Progress in diagnosis and care of fractures of the femoral head

Abstract

Fractures of the femoral head (FFH) are mainly seen in young adults, and the majority mechanism is due to dashboard injury in crushing vehicles. FFH can be present with or without posterior dislocation of the hip joint. Except for periarticular pain and hip dysfunction, the typical signs include flexion, adduction and internal rotation of the hip and shortening of involved limb. CT and MRI get their popularity as diagnostic methods for FFH. An emergency open reduction should be indicated in the scenario of failed closed reduction in FFH with posterior dislocation, of FFH with femoral neck fractures, of unmatched head and acetabulum following closed reduction and of deteriorating sciatic nerve damage. Pipkin as well as Brumback classification is still the most popularly used methods, which have great significance for establishment of surgical strategy and prediction of prognosis. More and more clinical evidences show conservative care of FFH should only be indicated for non-displaced fractures or displacement less than 2 mm. These cases must meet the following criteria simultaneously, including stable hip joint, concentric head and acetabulum, no free fractured fragments in the joint space and no labrum entrapment. Operative care is naturally the treatment of choice. Surgical approaches for FFH are hot topics in recent years. In previous control studies to compare Kocher-Langenbeck (K-L) and Smith-Peterson (S-P) approach, it is revealed less operative time, less blood loss and better operative field you can get in S-P approach, however, the incidence of ectopic ossification is higher. Ganz approach, which is characterized by osteotomy of great trochanter, hip capsulotomy and surgical dislocation of the hip, is a novel pattern for operative care of FFH. Ganz approach can show the entire femoral head, while can not damage medial femoral circumflex artery (MFCA) and induce iatrogenic osteonecrosis of the femoral head (ONFH). Various screws are the main implants for the fixation of fractured femoral head. Osteoarthritis and ONFH are two principal complications following FFH, which not only closely associate with severity and mechanism of primary injury, but also correlate with reduction quality and iatrogenic factors. Artificial hip joint replacement is a rational choice for extremely comminuted femoral head and these FFH in the elderly.