Femoral head fractures are complex injuries at the hip joint, named after Sir Frank Jefferson Pipkin, who extensively studied them in 1957. The initial documented report of such fractures dates back to 1869 by Birkett ^[1]. Pipkin subsequently classified femoral head fractures into four types: Type I below the fovea, Type II above the fovea, Type III associated with a femur neck fracture alongside Type I or Type II, and Type IV associated with acetabular fractures ^[2]. Notably, Type III fractures demonstrate the poorest outcomes, as reported by the Orthopedic Trauma Association ^[3]. High-velocity motor vehicle accidents or falls from significant heights are common causes of femoral head fractures ^[4]. In this case report, we present an intriguing case of a patient sustaining a Type III Pipkin’s injury.

A 35-year-old male was involved in a road traffic accident, after which he experienced an inability to mobilize himself along with severe pain in his right hip. Upon arrival at the local hospital, a plain radiograph revealed a right hip intracapsular fracture with a femur head fracture suggestive of Pipkin Type III injury (Fig. 1). He was subsequently transferred to our center for further care, arriving 24 h after the injury. An urgent computed tomographic scan was performed, revealing a Pipkin Type III fracture of the right hip. On the same day, he underwent an open surgical dislocation of the hip and internal fixation of the femoral head and neck.

The surgical dislocation of the right hip was performed with the patient in a left lateral position using a standard posterior approach ^[5]. Upon reaching the fracture site, the fracture ran subfoveal, and the second fracture line corresponded to that seen in the computed tomography at the neck with the head being dislodged inferiorly and rotated. The head and fracture fragment were removed from the surgical field carefully. The femoral head was fixed with two 3.5 mm headless compression screws, while the neck was fixed with three 6.5 mm cancellous cannulated screws (Fig. 2 and 3).

Post-operative X-rays (Fig. 4) of the hip demonstrated a good reduction of the femoral head and neck. The patient was advised non-weight-bearing on the operated limb for 6 weeks, with a gradual increase in weight-bearing thereafter and eventual full weight-bearing status at 3-month post-surgery (Fig. 5, 6, 7), as tolerated by the patient.

Birkett initially reported femoral head fractures in case reports, after which Pipkin categorized them into four types. In Pipkin’s original series, only 3 out of 25 (12%) patients had a Type III fracture. The posterior approach to the hip is recommended by many experienced surgeons as it does not disrupt the blood supply to the femoral head [6, 7]. Several studies have been conducted on Pipkin subtypes, indicating poor results and high complications, often requiring reoperations [8-10]. Scolaro et al. investigated a series of 147 Pipkin injuries, where all 13 Type III fractures underwent open reduction and internal fixation, later requiring revision to arthroplasty. In addition, 10% of Pipkin I, II, and IV cases ended up requiring arthroplasty ^[11]. Park et al. also noted the necessity for arthroplasty after closed reduction in Pipkin fractures ^[12]. Giannoudis et al. reported significant complications such as infection, avascular necrosis, and heterotrophic ossification. Scolaro et al. observed a 9% rate of avascular necrosis in their study ^[11]. Considering poorer functional outcomes compared to Type I and II fractures and a high risk of avascular necrosis, arthroplasty may be a preferable option over fixation in Type III fractures. However, the authors of this study acknowledge the importance of preserving the joint in younger patients, with arthroplasty being a more viable option for the elderly. There is limited evidence for the use of total hip replacement in treating Pipkin fractures in young individuals.

Femoral head fractures involving the neck present varied outcomes. Thorough pre-operative planning for surgical fixation is crucial. The timing of reduction and the selection of a surgical approach are both substantial factors influencing the ultimate outcomes and aiding in reducing the risk of complications. However, a deeper understanding of such situations requires extended and multicentric studies.

Despite the challenges of surgery, early intervention and meticulous surgical techniques are crucial to optimize outcomes and minimize the risk of complications, including avascular necrosis of the femoral head.