ORIGINAL ARTICLE
Irreducible Fracture–Dislocations of the Femoral Head
Without Posterior Wall Acetabular Fractures
Samir Mehta, MD* and M.L. Chip Routt, Jr., MD†
Objective: To define the unique clinical and radiographic features,
operative treatment, and complications of irreducible femoral head
fracture–dislocation without associated posterior wall fracture.
Design: Retrospective clinical study from a prospectively gathered
trauma database.
Setting: Level I trauma center.
Patients/Participants: During a 6-year period (from January 2000
until August 2006), 72 patients with fractures of the femoral head
(OTA 31C) were treated at a level I trauma center. Seven (9.7%)
patients had irreducible femoral head fracture–dislocations without
associated posterior wall acetabular fractures and underwent
operative management.
Intervention: Open reduction and internal fixation of the
irreducible femoral head fracture–dislocation with miniature frag-
ment screw fixation using a Smith-Petersen exposure.
Main Outcome Measures: Clinical and radiographic markers of
irreducibility, surgical findings, fixation methods, reduction accuracy,
and injury- and treatment-related complications.
Results: Standardized postoperative pelvic computed tomography
scans revealed that all 7 femoral head fractures were accurately
reduced. Two patients with delayed operative management developed
femoral head aseptic necrosis and underwent hip arthroplasty.
Conclusions: Irreducible femoral head fracture–dislocations
without associated posterior wall fractures occur rarely, but are
heralded by unique clinical and radiographic features. These patients
warrant special consideration in terms of recognition and manage-
ment. The physical examination findings and specific radiographic
markers should alert the surgeon to this injury pattern and its related
complications. Closed reduction of this fracture–dislocation should
not be attempted. Delayed operative management may be related to
femoral head aseptic necrosis. Accurate reduction and stable fixation
can successfully be performed through a Smith-Petersen surgical
exposure using small or miniature fragment cortical screws alone.
Accepted for publication August 19, 2008.
From the *Department of Orthopaedic Surgery, Hospital of the University of
Pennsylvania, Philadelphia, PA; and †Department of Orthopaedics &
Sports Medicine, Harborview Medical Center, Seattle, WA.
The study was performed at Harborview Medical Center, Seattle, WA.
The devices used in this study are approved by the Food and Drug
Administration.
Reprints: Samir Mehta, MD, Department of Orthopaedic Surgery, Hospital of
the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street,
Philadelphia, PA 19104 (e-mail: samir.mehta@uphs.upenn.edu).
Copyright Ó 2008 by Lippincott Williams & Wilkins
686 J Orthop Trauma  Volume 22, Number 10, November/December 2008
Key Words: femoral head fracture, irreducible hip fracture–
dislocation, Smith-Petersen exposure
(J Orthop Trauma 2008;22:686–692)
INTRODUCTION
Femoral head fractures occur in association with
traumatic hip dislocations and are rare.1–6 Hip dislocations
result from high-energy accidents and are displaced posteriorly
in 82% to 94% of reported series.4,7,8 Femoral head fractures
occur in patients with posterior hip dislocations ranging from
7% to 16%.2,5,9 Femoral head fractures in association with hip
dislocation have a significant effect on prognosis and treat-
ment.10–13 Emergent reduction of the femoral head is under-
taken to decrease the risk of aseptic necrosis, which is related
to ischemia caused by the compression or traumatic disruption
of the primary blood supply to the femoral head.13–15
Numerous classification systems define the femoral
head fracture–dislocation injury, but scant information is
published regarding irreducible injuries. Irreducible injuries,
also termed ‘‘locked or fixed’’ dislocations, should not follow
the typical clinical and therapeutic courses described for
routine femoral head fracture–dislocations. The purpose of our
study was to identify the unique clinical and radiographic
features defining irreducible femoral head fracture–dislocation
injury patterns and report on a consistent operative manage-
ment strategy and perioperative complications.
PATIENTS AND METHODS
After obtaining approval from the Institutional Review
Board, a prospectively gathered orthopaedic trauma database
at a level 1 trauma center was used to retrospectively review
data between January 2000 and August 2006. Seventy-two
adult patients with femoral head fracture–dislocations (OTA
31C) were identified. Seven (9.7%) patients failed routine
closed reduction maneuvers and underwent urgent operative
management using a standard protocol. There were no patients
in this group with pathologic or prosthetic hip fracture–
dislocations.
Gathered clinical data included patient age at pre-
sentation, mechanism of injury, distinct physical examination
findings, time to attempted closed reduction, number of closed
reduction attempts, and time to operative reduction and
fixation. The operative reports confirmed the uniform surgical
approach, detailed location of the fracture components,
anatomic features obstructing reduction, intraoperative re-
duction techniques, time of anterior surgical dislocation for
J Orthop Trauma  Volume 22, Number 10, November/December 2008
reduction and fixation, and fixation details. Radiographic
evaluations included review of the screening, postoperative
anteroposterior (AP) and oblique pelvic films, most recent AP
and oblique pelvic films, and both preoperative and post-
operative pelvic computed tomography (CT) scans. A similar
radiographic and clinical review of the remaining 65 reducible
fracture–dislocations was performed.
After surgical intervention, all patients were placed on
deep venous thrombosis prophylaxis and received intravenous
antibiotics. Standard protocol postoperative pelvic CT scans
were obtained. There were no active hip motion restrictions
applied, but gait training using 8 weeks of injured hip protected
weight bearing was monitored by a licensed physical therapist
beginning after surgery. Oral indomethacin was administered
without incident for 6 weeks after operation to prevent ectopic
bone formation. Follow-up clinical and radiographic evalua-
tions were performed for a minimum of 6 months in all patients.
Surgical Technique and Technique
of Reduction
After being medically cleared for surgical intervention,
the patients were taken to the operating room, administered
general anesthesia including muscle relaxation, and positioned
supine on an operating room table (OSI, Union City, CA). A
folded blanket placed posterior to the lumbosacral region
elevated the pelvic area from the table. The hairs of the
perineum and anticipated surgical site were shaved, then the
perineal area was cleansed thoroughly with isopropyl alcohol
and isolated using barrier drapes from the planned surgical
field. The entire injured lower extremity, hip region, and
ipsilateral flank were next prepared sequentially with iodine
and then with isopropyl alcohol solutions. Skin preparation
and draping were complicated especially for the inguinal and
posterior thigh regions due to the fixed flexion position of the
injured hip. A Smith-Petersen exposure was used after intrave-
nous antibiotic administration and patient-specific identifica-
tion, and treatment plan details were confirmed. The incision
extended from the anterior superior iliac spine distally approx-
imately 12 cm between the retracted tensor fascia lata and the
sartorius muscles. The common rectus femoris muscle tendon
was incised, tagged, and then retracted distally. The iliopsoas
muscle was elevated and retracted medially from the anterior
hip joint capsule, which was completely intact for all patients.
Next, an obliquely oriented T-shaped capsulotomy was
made with the upper limb paralleling and sparing the anterior
acetabular labrum while the perpendicular capsulotomy limb
paralleled the femoral neck, an essential step to dislocate the
hip. The hip joint hematoma, the femoral head fracture
fragments within the acetabulum, and the residual osteochon-
dral debris were removed. In all 7 patients, the dislocated
proximal femoral component had exited the acetabulum
through a posterior–superior labral–bone interval, and the torn
yet extremely taut posterior–superior labral and capsular
tissues severely limited any movements of the dislocated
proximal femur. The proximal femur’s sagittal head fracture
plane extended from the superior femoral head to its caudal exit
adjacent to the head–neck junction. The cancellous bone of this
proximal femoral fracture surface was forcefully impacted
against the supra-acetabular lateral iliac cortical bone.
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Femoral Head Fracture–Dislocation
To liberate the proximal femur, the taut posterior–
superior capsular–labral obstructing lesion was incised sharply
with a scalpel from cranially to caudally under direct
visualization. Residual local debris was excised. Assuring
anesthetic skeletal relaxation, the manipulative hip reduction
was then possible using proximal femoral flexion, adduction,
internal rotation, and anterior translation. No additional
instrumentation, surgical table attachments, or special devices
were necessary for reduction of the femoral head. This
maneuver also allowed for reduction of the femoral head in the
patient with iatrogenic femoral neck fracture. The surgical
wound was then packed with a saline-moistened sponge.
The femoral head fracture components and debris previ-
ously removed from the acetabulum were cleansed of clot,
cancellous debris, and chondral flap fragments on the surgical
nurse’s sterile table. The femoral head fracture fragment was
then prepared with glide holes using an appropriate sized
miniature fragment drill. The 2 glide holes were positioned
caudally on the head fragment to avoid the weight-bearing area
and were oriented perpendicular to the fracture plane. A
corresponding countersink of appropriate size was used to the
remove surrounding cartilage to the level of subchondral bone.
The proximal femur, which had been dislocated at injury
and then surgically reduced into the acetabulum after soft
tissue release as described above, was then surgically
dislocated anteriorly from the joint manually using a figure-
of-four maneuver and slight traction. Although caudal anterior
femoral head fractures could be reduced accurately without
anterior surgical dislocation, none of our patients had such
a fracture pattern. All our patients had fractures involving their
superior femoral heads and required direct visualization to
accurately reduce the fracture. The predrilled femoral head
chondro-cancellous articular fracture fragments were reduced
and secured to the proximal femur fragment initially using
thin-diameter wire remote from the cartilage whenever
possible and then definitively with 2 miniature cortical lag
screws after drilling and accurate depth assessments. The wires
were removed, and the hip was then atraumatically manually
re-reduced into the acetabulum. The injured hip was examined
through a full passive range of motion to assure stability and
congruency. Fluoroscopic orthogonal views and also real-time
fluoroscopy through a 180-degrees passive motion arc
confirmed the hip congruency, reduction accuracy, and implant
safety before wound closure. The wound was irrigated. The
anterior surgical capsulotomy and rectus femoris tenotomy
were repaired directly, and the fascial and dermal layers and
skin closed primarily.
RESULTS
There were 5 men and 2 women, with an average age of
42.1 years (range 21–82 years). Five patients were involved in
motor vehicle collisions, 1 was injured in a snowboarding
accident, and 1 was crushed in an industrial accident (Table 1).
Evaluation of the hip injury included a physical examination,
AP pelvic radiograph, and standard protocol pelvic CT after
thorough resuscitation and evaluation.
All patients had uniquely similar and distinct physical
examination findings of the involved limb. The involved
extremity was locked in slight flexion at the hip, and the limb
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TABLE 1. Clinical Data Regarding Patients With Irreducible Fracture–Dislocations of the Femoral Head Without Posterior
Wall Fracture
Patient Age Time to Attempted Attempted Time to Operative Intraoperative Dislocation Length of
ID Sex (yr) Mechanism Side Reduction (h) Reductions Reduction (h) Time (min) Follow-up (mo) Complications
5 M 39 Crush R 5 2 6 17 20 —
4 M 21 Snowboard L 2 1 4 14 9 Femoral neck fracture
2 F 29 HSMVC L 6 2 12 12 41 —
3 M 82 HSMVC L 5 1 8 11 10 —
7 F 29 HSMVC R 12 2 32 14 6 AVN
6 M 56 HSMVC R 8 4 14 11 6 AVN
1 M 39 HSMVC L 4 2 6 12 9 —
AVN, avascular necrosis; F, female; HSMVC, high-speed motor vehicle collision; L, left; M, male; R, right.

was in neutral rotation with obvious leg length discrepancy
(Figs. 1A, B).
As part of their evaluations, all patients had an AP plain
pelvic radiograph performed at presentation. The radiograph
showed consistently unique findings—the sagittal plane femoral
head fracture fragment remained in the acetabulum, the
proximal femoral fracture component was dislocated poster-
osuperiorly relative to the acetabulum, and the dislocated
proximal femoral component was tightly approximated to the
supra-acetabular lateral iliac cortical bone (Fig. 2).
All patients received a standardized pelvic CT scan, with
coronal and sagittal reconstructions, confirming and detailing
the findings seen on radiographs (Figs. 3A, B).
The first closed reduction attempt was made within
6 hours on average (range 2–12 hours). Also on average,
2 (range 1–4) closed reduction attempts failed before pro-
ceeding to operative management (Table 1). In an instance, the
initial routine attempted closed reduction maneuver resulted in
an iatrogenic femoral neck fracture (Figs. 4A, B).
Patients were taken to the operating room in a mean time
of 12 hours from their presentation (range 4–32 hours) for
open reduction and internal fixation of the femoral head
fracture–dislocation. Two patients had associated primary
organ system injuries that prevented urgent surgery until
14–32 hours after presentation. The remaining patients were
treated within 8 hours.
Because no acetabular fractures occurred in conjunction
with the femoral head fracture–dislocation, a Smith-Petersen
surgical exposure was used. In all cases, the displaced proximal
femur had herniated through a posterior–superior labral–bone
traumatic interval. The displaced and taut labral band tethered
the displaced proximal femoral component and blocked
reduction. The tight labral tissue was then incised to allow
the proximal femoral reduction into the acetabulum. After
incision of the tethering labral band, hip flexion, adduction,
internal rotation, and manual traction were required to reduce
the hip. After preparation of the femoral head fragments, the hip
was surgically dislocated anteriorly averaging 13 minutes (range

FIGURE 1. A, Lateral view of a patient with a left irreducible femoral head fracture–dislocation. The entire limb is prepped into the
field. The limb is typically slightly flexed at the knee and the hip (solid arrows) in neutral rotation. B, Anterior view of a patient with
a left irreducible femoral head fracture–dislocation. The ipsilateral torso and entire limb are prepped into the field. The limb is in
neutral rotation and has a leg length discrepancy, with the involved side being shorter (solid arrow). There is no adduction or
internal rotation component noted on the physical examination, as would be expected in the typical posterior hip dislocation.

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J Orthop Trauma  Volume 22, Number 10, November/December 2008
FIGURE 2. AP projection of the left hip revealing a portion of
the femoral head retained in the acetabulum (black arrow)
with the remaining intact femoral head–neck–shaft compo-
nent posterior and superior relative to the acetabulum (white
arrow).
4–32 minutes) while the reduction, and then fixation was
performed using miniature (either 2.0 or 2.7 mm) cortical
screws. The hip was easily relocated after fixation and then
stressed through a full passive range of motion to assure stability
and smooth, congruent movement.
Intraoperative real-time multiplanar fluoroscopy con-
firmed the hip congruity and reduction quality and proved that
none of the screws protruded through the femoral head. All
patients underwent routine plain pelvic radiographs (Fig.5A)
and standardized pelvic CT scans (Fig. 5B) postoperatively.
There were 4 perioperative complications. There was
1 iatrogenic femoral neck fracture, 1 deep vein thrombus in
the operative limb that was managed medically, and 2 patients
developed symptomatic femoral head aseptic necrosis within
6 months after injury requiring uncomplicated hip replace-
ments. Both patients with femoral head necrosis had operative
treatment delays greater than 8 hours. The remaining injuries
healed uneventfully with no radiographic or clinical signs of
aseptic necrosis in early follow-up evaluation. The average
duration of clinical and radiographic follow-up was 14 months
(range 6–41 months).
One patient sustained an iatrogenic femoral neck fracture
during attempted closed reduction. There was no occult femoral
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Femoral Head Fracture–Dislocation
FIGURE 3. Axial (A) and coronal (B) views of the pelvis on CT
scan in a patient with an irreducible femoral head fracture–
dislocation. There is no posterior wall or other acetabular
component to this injury. The femoral head–neck–shaft
component ‘‘locked’’ in a posterior and superior position
relative to the acetabulum.
neck fracture on the initial imaging studies. The patient’s
fractures were reduced through a Smith-Petersen exposure. The
femoral neck fracture was initially reduced and stabilized with
percutaneously inserted screws using fluoroscopy to guide the
precise implant locations. The femoral neck fixation screws
were positioned to avoid the femoral head fracture fragment.
Then, the reconstructed proximal femur was surgically
dislocated anteriorly through the wound, and the remaining
femoral head was reduced and secured with miniature screws as
for the other 6 patients (Figs. 6A, B). The patient ultimately
healed and had no clinical or radiographic signs of osteonec-
rosis after 9 months of early follow-up evaluation. We attribute
the patient not developing aseptic necrosis of the femoral head
(after femoral neck fracture) due to timely and accurate
reduction of the femoral neck.
DISCUSSION
Little information exists in the literature regarding
irreducible femoral head fracture–dislocations without
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FIGURE 4. A, AP radiograph of the pelvis showing an
irreducible right femoral head fracture–dislocation. This
radiograph has the same characteristics as the patient’s in
Figure 2. B, Iatrogenic femoral neck fracture in the same
patient after closed reduction attempt.
associated acetabular fracture.7,12,16–18 Several published
clinical series describe irreducible hip dislocations and their
prognosis after treatment.10,17,19 Hip fracture–dislocations are
associated with poor results, presumably due to the
displacement of and energy imparted to the femoral head at
the time of impact.10,20,21 However, none of these articles
describe the unique yet consistent physical examination and
radiographic markers that should alert physicians to an
irreducible femoral head fracture–dislocation.
The clinical presentation for each patient in our series
was uniform. Each patient had the injured lower limb
positioned at the hip joint in slight but fixed flexion, in
immobile neutral rotation, and with obvious anisomelia. This
hip position is not typical of routine posterior hip dislocations
and fracture–dislocations. Rather, patients with standard
posterior hip dislocations and fracture–dislocations have
residual passive hip mobility, although similarly symptomatic.
690
FIGURE 5. Postoperative radiograph of the pelvis (A) showing
a concentric reduction of the femoral head with no residual
deformity. Axial imaging on CT scan (B) shows no loose bodies
in the hip joint, concentric reduction, and restoration of the
femoral head contour.
Patients with routine posterior hip dislocation demonstrate the
injured limb to be shortened but the hip is also adducted, flexed
but flexible, and internally rotated but somewhat mobile to
examination. Patients with irreducible femoral head fracture–
dislocations have a different clinical appearance at pre-
sentation that should be discriminated from that of a standard
posterior dislocation. The hip area’s essential immobility is
unique and must be identified. Numerous physicians were
involved in the acute evaluation and management of all
patients with femoral head fracture–dislocations, and a single
attending faculty member was responsible for their definitive
management. This surgeon observed the common radio-
graphic and clinical characteristics of the irreducible subset
patients. These unique clinical findings did not occur in the
65 patients with a routine posterior hip dislocation or a
fracture–dislocation.
Imaging studies for this unusual injury pattern are
routine and include plain pelvic radiographs and CT
scanning.2,8,9 The irreducible injuries are easily identified on
the plain pelvic radiographs by the close apposition of the
dislocated proximal femoral component’s cancellous head
surface against the lateral iliac cortical bone of the supra-
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J Orthop Trauma  Volume 22, Number 10, November/December 2008
FIGURE 6. Postoperative AP (A) and
lateral (B) radiograph of surgical
fixation in a patient sustaining an
iatrogenic femoral neck fracture after
failed reduction of an irreducible
femoral head fracture–dislocation.
acetabular region, which were findings not present in the
65 patients who had a reducible fracture. In all our patients,
there was a sagittal plane femoral head fracture fragment within
the acetabulum, but none of the patients had acetabular fracture.
The plain pelvic radiographs and CT scan should be inspected
for concomitant femoral neck fracture or other injuries. The
pelvic CT scan details the locations of the fragments, rules out
acetabular fracture, and identifies joint debris.
It is relevant that none of these patients had a posterior
wall acetabular fracture. Perhaps, this finding alone is
responsible for the proximal femoral irreducibility. Because
the posterior wall remains intact, the proximal femoral
component exits the joint through the traumatic labral interval.
This torn labral interval then captures the displaced com-
ponent at the narrower femoral neck region (Fig. 7, inset). The
planar cancellous femoral head surface is then crushed
tightly against the lateral cortical bone of the supra-acetabular
area as a result (Fig. 7). Perhaps this is the reason that no
patients with posterior wall acetabular fracture–dislocations
or posterior hip dislocations without fracture were noted
with this clinical scenario. Irreducibility may occur in
patients with concomitant posterior wall fracture–dislocation
due to obstructing fragments of bone within the acetabulum,
but perhaps not due to a taut constrictive traumatic labral
interval.
Unfortunately, these unique clinical and radiographic
markers were not noted early in this series so an average of
2 closed reduction attempts were made before operative
reduction. Even using complete muscle relaxation, each
patient’s injured hip position was notably rigid on examination
and could not be dissociated from its ‘‘locked’’ position.
Although prompt reduction is thought to decrease risk of
femoral head avascular necrosis and improve outcomes,
multiple manipulative closed reduction attempts actually have
poorer results.2,5–7,10,17 Furthermore, multiple or forceful
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Femoral Head Fracture–Dislocation
closed manipulative reduction attempts at closed reduction
can result in iatrogenic injury. In our series, 1 (14%) patient
sustained an iatrogenic femoral neck fracture as a result of
a routine reduction maneuver. That patient had all the clinical
and radiographic markers for irreducibility. Prompt recogni-
tion of the irreducible injury most likely could have prevented
this from occurring. At this patient’s last follow-up clinic visit,
she displayed no signs or symptoms of osteonecrosis and had
healed her fractures uneventfully.
Open reduction and internal fixation was performed
within 8 hours for 5 patients and for more than 14 hours for
2 other patients. These 2 delayed treatment patients had
associated medical conditions that prevented more urgent
surgical intervention. Symptomatic aseptic necrosis occurred
in both of these patients within 6 months after injury.
The anterior Smith-Petersen surgical exposure has been
shown to be effective in treatment of femoral head fracture–
dislocations.16–18 Anterior capsular blood flow has been shown
to have minimal contribution to the femoral head.22 Despite
posterior injury, due to the dislocation, and an anterior
exposure, we did not attribute the aseptic necrosis in our series
as a result of the surgical exposure.18
This clinical series describes the unique and reliable
clinical and radiographic hallmarks of irreducible femoral
head fracture–dislocations without associated acetabular
fracture. These injuries are an atypical variant of the more
common reducible femoral head fracture–dislocations that
have been previously reported in numerous series.2,5,6,10,16–19
Early recognition of the irreducible injury pattern by clinical
and radiographic hallmarks is essential to provide appropriate
and timely treatment while avoiding related complications.
Emergency room physicians and orthopaedic surgeons should
be more alert when treating an injured patient who presents
with hip pain after a high-energy traumatic event, especially if
the physical examination reveals fixed hip flexion with neutral
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Mehta and Routt J Orthop Trauma  Volume 22, Number 10, November/December 2008
FIGURE 7. Fractured femoral head–neck–shaft component
dislocated posterosuperiorly through constricting capsulola-
bral defect. The cancellous surface of the femoral head is
crushed against the lateral cortical bone of the supra-
acetabular area.
rotation and obvious limb length discrepancy. Routine pelvic
imaging confirms femoral head fracture, the posterior–
superior displacement, and close approximation of the
proximal femoral component relative to the acetabulum and
the lack of an acetabular fracture. Closed reduction should not
be attempted in such patients to avoid iatrogenic fracture or
other problems including pain, unnecessary sedation, failed
reduction attempts, increased time to definitive reduction and
management, and patient/surgeon/family member stress.
Urgent operative reduction using a Smith-Petersen exposure
is accomplished by releasing the constrictive traumatic labral
interval.23 In none of these patients was the irreducibility due
to other soft tissues such as the piriformis muscle tendon or
obturator internus muscle tendon. It is possible to visualize and
release these potentially constrictive structures using the
Smith-Petersen exposure if necessary, but it is not possible to
subsequently repair them after their release. Prophylaxis for
heterotopic ossification with indomethacin should be consid-
ered by the surgeon postoperatively.
Although this is a small clinical series with limited
follow-up data, we have identified and described consistent
and distinct clinical and radiographic markers of irreducible
femoral head fracture–dislocations without associated poste-
rior wall acetabular fractures. Our intraoperative findings and
692
treatments were likewise uniform. Based on these findings, we
recommend urgent open reduction and internal fixation for
such injuries without closed manipulative reduction attempts.
This should avoid iatrogenic femoral neck fracture. Delays to
surgery seem to correlate with the development of aseptic
necrosis.
ACKNOWLEDGMENTS
The authors thank Julie Agel for her help in data
collection and manuscript preparation.
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