What is the best course of treatment for a patient with a femoral head fracture, considering factors such as age, energy of trauma, and medical history, including potential osteoporosis?

Femoral Head Fracture Treatment

For femoral head fractures, surgical treatment with open reduction and internal fixation using screw fixation is the definitive treatment for most patients, particularly those who are young and active, with the goal of achieving anatomic reduction to minimize complications including avascular necrosis and post-traumatic osteoarthritis. 1, 2, 3

Initial Management

Immediate hip dislocation reduction is critical - when femoral head fractures occur with hip dislocation (the most common presentation), manual reduction under anesthesia should be performed emergently, as earlier reduction correlates with better outcomes 1, 2. The average time to definitive surgical treatment after admission is approximately 2-3 days once the patient is medically stabilized 1.

Treatment Algorithm Based on Patient Factors

Young, Active Patients (Typical High-Energy Trauma Victims)

• Open reduction and internal fixation with screws is the treatment of choice for most young patients with femoral head fractures 1, 2, 3
• Anatomic reduction of all fracture fragments is the major factor determining outcome quality 4
• All 35 femoral head fractures treated surgically in one series achieved fracture healing with screw fixation 1

Elderly or Low-Demand Patients

• Total hip arthroplasty should be performed in elderly patients or those with severe femoral head impaction 2
• This approach avoids the high complication rates associated with attempting to salvage severely damaged femoral heads in this population 2

Fragment-Specific Considerations

• Very small fragments located below the fovea should be excised rather than fixed 2
• Large fragments require stable internal fixation for optimal outcomes 1, 3

Surgical Approach Selection

The choice of surgical approach depends on fracture location and associated injuries 5, 3:

• Anterior (Smith-Petersen) approach: Used for anterior or superior femoral head fractures 3
• Posterior (Kocher-Langenbeck) approach: Used for posterior fractures, especially with posterior hip dislocation 3
• Surgical hip dislocation (trochanteric flip/digastric osteotomy): Provides superior visualization of the entire hip joint and allows accurate anatomic reduction under direct visual control, with 83.3% good-to-excellent results 4

Critical Complications to Anticipate

Avascular Necrosis (AVN)

• Occurs in approximately 23% of surgically treated patients 1
• Stress fractures of the femoral head in healthy patients are high-risk injuries with increased rates of delayed union, nonunion, displacement, and AVN if not recognized promptly 6
• Six of 30 patients (20%) required conversion to hip arthroplasty for advanced AVN 1

Heterotopic Ossification

• Develops in 43% of patients after surgical treatment 1
• Most cases do not limit range of motion (only 1 of 13 patients had functional limitation) 1
• Highest risk in patients with multiple injuries including brain injury (Brooker III-IV classification) 4

Post-Traumatic Osteoarthritis

• Remains a significant long-term complication despite optimal surgical management 4
• Risk minimized by achieving anatomic reduction 4

Postoperative Management

Comprehensive postoperative care must include 6:

• Appropriate pain management
• Antibiotic prophylaxis
• Correction of postoperative anemia
• Assessment of cognitive function
• Pressure sore prevention
• Nutritional assessment
• Early mobilization protocols

Secondary Fracture Prevention

All patients aged 50 years and over with femoral head fractures require systematic evaluation for osteoporosis 6:

• Adequate calcium and vitamin D supplementation 6
• Pharmacological treatment with drugs proven to reduce vertebral, non-vertebral, and hip fractures 6
• Fracture Liaison Service coordination for comprehensive secondary prevention 6

Key Pitfalls to Avoid

• Delaying hip reduction: Emergency reduction is essential; delays worsen outcomes 1, 2
• Attempting fixation of severely impacted femoral heads in elderly patients: Primary arthroplasty is preferable 2
• Inadequate visualization during surgery: Poor visualization leads to non-anatomic reduction and worse outcomes 4
• Ignoring associated injuries: Assess for other skeletal injuries that may compromise rehabilitation 6

Despite optimal management, complication rates may reach 50%, emphasizing the severity of this injury pattern and the importance of meticulous surgical technique and patient selection 2.