Management and functional outcomes of a pipkin type II fracture: A case report

Abstract

Introduction

Femoral head (Pipkin) fractures are rare injuries typically caused by high-energy trauma. Classified into four types, their management remains debated, particularly for Pipkin type II fractures. This case report provides insights into surgical treatment, rehabilitation, and associated complications.

Case presentation

A 22-year-old male sustained a Pipkin type II femoral head fracture from a dashboard injury in a car accident. He presented with a posterior hip dislocation and a fracture involving the weight-bearing surface. Closed reduction was performed within 40 min, followed by open reduction and internal fixation (ORIF) using two Herbert screws via an anterior approach. The patient was discharged after three days and began structured rehabilitation. At six months, he showed significant functional recovery with minimal restrictions.

Discussion

The management of Pipkin type II fractures remains controversial, particularly regarding fragment fixation versus excision. Early surgical intervention and stable fixation are key to reducing complications such as avascular necrosis (AVN) and post-traumatic arthritis. In this case, ORIF with early rehabilitation, including gradual weight-bearing and range of motion exercises, contributed to a favorable outcome.

Conclusion

Prompt surgical intervention and a structured rehabilitation program are essential for optimal recovery in Pipkin type II fractures. This case highlights the importance of individualized treatment strategies and adds to the growing literature on managing this rare injury.

Highlights

• •Discussion on the rarity of Pipkin type II femoral head fractures, highlighting the challenges in managing such cases.
• •Use of CT scan for accurate diagnosis, guiding effective treatment planning.
• •Adoption of ORIF via anterior approach, ensuring precise alignment and stable fixation.
• •Implementation of structured postoperative physical therapy, facilitating improved mobility and recovery.

1. Introduction and importance

Femoral head fractures (pipkin fractures) are uncommon, usually caused by high energy trauma and were first discovered by Birkett, in 1869. Thereafter, many classifications were recommended including pipkin's, which is the most used nowadays. Moreover, 2 cases per million presents with pipkin fractures. Recently, the incidence of pipkin fractures has increased proportionally to the high rate of traffic accidents [1]. Pipkin classified these injuries into 4 types according to its size and its association with acetabulum or femoral neck fractures [2]. Therefore, in this case, we are presenting a fracture that affects the weight-bearing part of the femoral head (type 2) [3]. For diagnosis, CT scan is the most effective tool and is recommended prior to any surgical approach [2]. On account of the ongoing controversy about the best surgical choice to improve femoral head fractures prognosis, [1] poor functional outcomes and high complication rates have been highly reported [3]. In addition, the most associated consequence of such injuries is avascular necrosis (AVN) and post- traumatic arthritis [3].

In conclusion, the aim of this case was to enhance the literature data with more information about what could be the best surgical choices in such cases by demonstrating the effect of our approach and its complications.

This case report was prepared in accordance with SCARE guidelines [4].

2. Case presentation

A 22-year-old Caucasian male, who got exposed to a car accident (dashboard injury), was presented to the Emergency Department. He had a Glasgow Coma Score (GCS) of 15/15. The patient had pain in his left lower limb. His left lower limb was shortened, internally rotated, flexed at the hip with abduction. Neurological examination of the patient was normal.

Preoperative pain management was achieved with IV analgesics and muscle relaxants to stabilize the limb and reduce discomfort.

A pelvic X-ray showed a posterior dislocation of the left hip associated with femoral head fracture. (Fig. 1).

Fig. 1.

AP Preoperative X-ray of the pelvis shows the dislocation of the left hip joint.

A Computed Tomography (CT) scan of the hip showed a femoral head fracture involving the weight-bearing portion, with a large femoral head fragment superior to the fovea capitis. (Fig. 2).

Fig. 2.

Preoperative CT scan of the pelvis shows the dislocation with the fracture of the femoral head, Pipkin fracture type 2.

All blood tests were within the normal range. A diagnosis of a posterior dislocation of the left hip with Pipkin type 2 fracture was established.

The patient was admitted to the operations room and an urgent closed reduction was achieved within 40 min of being presented to the Emergency Department and 6 h after the injury. There was no associated neurovascular deficit after the reduction. Then, a decision of performing an open reduction and internal fixation (ORIF) for the fractured fragment was made with an anterior approach. Intraoperatively, an anatomical reduction was done followed by fixation of the fragment using two Herbert screws, and the capsule was closed with Vicryl 2 suture. (Fig. 3, Fig. 4).

Fig. 3.

Intraoperative image showing the large femoral head fragment.

Fig. 4.

Reduced fragment fixed with Herbert screws.

The patient was discharged 3 days after the surgery with a good condition and good post operational physical status. The postoperative pelvic X-ray showed a good anatomical. (Fig. 5).

Fig. 5.

Postoperative pelvic X-ray showing screw fixation of the fractured fragment of the femoral head using tow Herbert Screws. It is showing a good anatomical reduction.

During periodic reviews for 6 months, the patient showed remarkable improvement. Gradually regaining the normal range of motion of the hip joint Weight bearing was permitted after six weeks of the operation. A clinical examination after 6 months of surgery showed good functional results with good axial weight bearing, there was a simple restriction in external rotation and abduction, the rest of the joint's movements were normal.

The timeline of the main events can be noted. (Table 1) and The rehabilitation stages can be noted (Table 2).

Table 1.

Timeline of key events.

Even Date
Accident and initial assessment	Day 1
Surgery	Day 1(40 min of being presented to the Emergency Department and 6 h after the injury)
Patient discharged from hospital	Day 3
Follow-up and rehabilitation	Month 6

Table 2.

The rehabilitation stages included.

Phase 1 (0–6 weeks):	Limited weight-bearing (partial weight-bearing with crutches) and range of motion (ROM) exercises to maintain joint mobility.
Phase 2 (6–12 weeks):	Gradual weight-bearing with increasing physical activity, strengthening exercises, and proprioception training.
Phase 3 (12+ weeks):	Return to full activity with functional training and sport-specific exercises.

3. Clinical discussion

Managing Pipkin type II femoral head fractures presents complex challenges due to their rarity and intricate nature, often compounded by their association with traumatic posterior hip dislocation. [5] The literature documented that early surgical intervention and rigid fixation improve the prognosis and reduce the complication rates. [6]

A key consideration in managing these fractures is timing—the sooner the fracture is reduced, the better the outcome. As highlighted in previous studies, delays in reduction significantly increase the risk of complications, including Avascular Necrosis (AVN), Osteoarthritis and Heterotopic Ossifications (HO) and post-traumatic arthritis. In our case, early reduction within six hours of injury was a critical factor in the patient's positive outcome. [7]

In our case we used an anterior approach because the fractured fragment was located anteriorly and this approach was familiar to the chief surgeon and it allowed better visualization and fixation of the femoral head while avoiding the complications associated with posterior dislocations, such as sciatic nerve injury or instability.

We opted for fixation with Herbert screws instead of fragment excision to preserve joint congruity and maintain femoral head integrity. Excising the fragment could have led to joint instability, altered biomechanics, and an increased risk of post-traumatic arthritis. Herbert screws were chosen because their headless, compression-based design allows for stable fixation while minimizing the risk of hardware prominence and secondary complications. [8]

The guidelines recommend surgery in case of type II pipkin fractures especially with large fragments associated with the weight – bearing area of the femoral head. [9] Time between the injury and reduction proved in a lot of conducted studies to be a crucial factor in getting a good functional result and decrease the rate of necrosis in the femoral head along with other complications, however, there is a wide controversy on the most optimal procedure whether to fixate or remove the fractured fragment. [10]

In our case we choose to fixate the fragment because it was displaced after reduction and was large in size for removal or conservative therapy.

Structured physical therapy as part of postoperative rehabilitation is essential for optimizing functional recovery and restoring mobility to patients. [11] In our case the reduction was performed within the first six hours of the injury.

Due to young age, the patient underwent a physical therapy program 3 months after the surgery, in average of two sessions per week, which increased the range of motion and made the patient return to the daily activity faster.

4. Conclusion

In summary, this case report underscores the importance of early intervention and a structured rehabilitation protocol in managing rare and complex injuries such as Pipkin type II femoral head fractures. Our findings emphasize that surgical fixation with an anterior approach, using Herbert screws for fragment stabilization, combined with a well-structured rehabilitation program, leads to good functional recovery in young, active patients.

By contributing to the limited literature on Pipkin type II fractures, this case highlights the ongoing need for personalized treatment strategies, considering the unique characteristics of each injury and patient. Continued refinement of surgical techniques and rehabilitation protocols is crucial to improving patient outcomes and minimizing long-term complications such as avascular necrosis and post-traumatic arthritis.

Consent

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Given the nature of the article, a case report, no ethical approval was required.

Guarantor

Dr. Ali Youssef

Research registration number

Not needed.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Funding

None.

Author contribution

All authors contributed to this manuscript:

Jafar Sallameh and Majd Mansour: collected the data, drafted, discussed and edited the manuscript.

Abdallah N. Mansour: wrote the final draft, reviewed the manuscript and edited it.

Bashaar Assad and Ali Afif: drafted and searched for similar cases in the literature.

Ali Youssef: supervisors, critically revised the article and approved the final manuscript.

Declaration of competing interest

The authors have disclosed that they do not have any conflicts of interest to declare.