What is the management of a Pipkin 3 fracture of the femoral head?

Management of Pipkin Type III Femoral Head Fractures

For Pipkin type III femoral head fractures (fracture with associated femoral neck fracture), surgical intervention with open reduction and internal fixation (ORIF) is recommended for younger patients, while primary total hip arthroplasty (THA) should be considered for older patients due to the high risk of complications. 1

Understanding Pipkin Type III Fractures

Pipkin type III femoral head fractures are characterized by:

• Femoral head fracture combined with femoral neck fracture 1, 2
• Extremely rare injury pattern compared to other hip fractures 3, 2
• High risk of avascular necrosis (AVN) of the femoral head 3, 1
• Poor prognosis, especially when combined with acetabular fractures 3

Treatment Algorithm

Initial Management

• Expedited surgical intervention is crucial for improved outcomes 3
• Patients should be admitted to an appropriate clinical ward area with orthogeriatric, nursing, and surgical expertise within 4 hours of hospital arrival 4
• Surgical fixation should not be delayed more than 48 hours from admission unless there are clear reversible medical conditions 4

Surgical Approach Options

• Combined anterior and posterior approaches may be necessary for complex cases 3
• Anterior approach is commonly used for fragment excision or fixation using mini-fragment screws 5
• Surgical approach should be determined based on fracture pattern and surgeon expertise 1

Fixation Methods

• For younger patients (typically under 50-60 years):

  • ORIF with countersunk head screws, hollow screws, and/or reconstruction plates 3, 1
  • Headless compression screws for femoral head and cortical screws for femoral neck 2
  • Mini-fragment screws are commonly used 5

• For older patients or those with poor bone quality:

  • Primary THA should be considered due to high complication rates with ORIF 1
  • All Pipkin III fractures in one study failed operative fixation, suggesting THA may be preferred 5

Anesthetic Considerations

• Regional anesthesia (spinal/epidural) should be considered for all patients undergoing hip fracture repair unless contraindicated 4
• If general anesthesia is used:
  • Reduced doses of intravenous induction agents should be administered 4
  • Consider peripheral nerve blockade (femoral, obturator, lateral cutaneous nerve of thigh) for perioperative analgesia 4
• Appropriate monitoring including pulse oximetry, capnography, ECG, and blood pressure is essential 4

Expected Outcomes and Complications

Major Complications

• Osteonecrosis of the femoral head (42-50% of cases) 1, 2
• Nonunion (8% of cases) 1
• Post-traumatic arthritis 1, 5
• Heterotopic ossification (40.6% of cases) 1, 5

Functional Outcomes

• Approximately 50% of patients may require conversion to THA due to complications 1
• According to Thompson-Epstein criteria, only 41% of patients achieve excellent or good outcomes after ORIF 1
• Early surgical treatment with appropriate approach and fixation can improve results 3

Special Considerations

• For younger patients (under 50 years), ORIF may be attempted despite high complication rates, considering the limited survivorship of prostheses 1
• Patients must be fully informed of the high complication rate associated with ORIF 1
• Multidisciplinary approach involving trauma coordinators, orthopaedic surgeons, anaesthetists, and rehabilitation services is essential 4
• Thromboembolism prophylaxis with fondaparinux or low molecular weight heparins should be administered 4
• Antibiotics should be administered within one hour of skin incision 4

Emerging Techniques

• Hip arthroscopy has been described for Pipkin I fractures but has limited application in the more complex Pipkin III fractures 6
• This technique may evolve to have applications in selected Pipkin III cases in the future 6