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Hip dislocation and femoral neck fracture:

Decision-making for head preservation

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 Injury, Int. J. Care Injured 40 (2009) 11181124
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Case report
Hip dislocation and femoral neck fracture: Decision-making for head preservation
Moritz Tannast a,*, Philip W. Mack b, Bernd Klaeser c, Klaus A. Siebenrock a
a
Department of Orthopaedic Surgery, Inselspital, University of Bern, Murtenstrasse, 3010 Bern, Switzerland
b
Shriners Hospital for Children, Springeld, MA, USA
c
Department of Nuclear Medicine, Inselspital, University of Bern, Switzerland
A R T I C L E I N F O
Article history:
Accepted 22 June 2009
Introduction
Hip dislocation with femoral neck fracture is a rare injury in
young adults and is a challenging problem. It is fraught with
potentially devastating consequences including avascular necrosis
and subsequent early secondary osteoarthritis.
We identied only 30 cases reported in literature that bear this
fracture pattern (Table 1). Of note 17/30 cases were treated by
open reduction and internal xation and 9 of these 17 have
developed avascular necrosis leading to eventual prosthetic
replacement. Based on this evidence in literature many authors
have even proposed primary hemi- or total hip arthroplasty.
Although femoral head viability and risk of subsequent
avascular necrosis were of major concern in all prior reports none
of the previous reports or discussions has alluded to decision-
making based on intraoperative integrity of the medial femoral
circumex artery (MCFA) and retinacular vessels for deciding
between osteosynthesis versus joint replacement. The precise
knowledge of the MFCA topography and surgical anatomy has led
to the development of the safe surgical hip dislocation, a technique
developed at our institution for complete dislocation of the femoral
head without the risk of avascular necrosis by protecting the
MFCA.8,9 Accurate knowledge of anatomy and intraoperative
assessment of its integrity is an essential step for hip-joint
preserving surgery.
The purpose of this article is to use evidence-based medicine to
give current perspective in modern orthopaedic management of
this devastating injury pattern. We have presented an illustrative
case report to outline the steps in decision-making. We further
provide an algorithm for the management of this injury that will
hopefully aid clinicians in approaching these patients.
* Corresponding author. Tel.: +41 31 632 2222; fax: +41 31 632 3600.
E-mail address: moritz.tannast@insel.ch (M. Tannast).
00201383/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2009.06.166
Illustrative case example
Written consent was obtained from the patient for the
publication of this case report. A 31-year-old man presented to
our level I trauma centre as a transfer from a rural centre 3 h after
being involved in a motor vehicle accident. The patient was healthy
and had no previous medical issues.
On primary survey the patient was haemodynamically stable.
Physical examination revealed a stable pelvis with abduction,
external rotation and shortening of his right lower extremity.
Distal pulses were palpable with sciatic, femoral and obturator
nerve function grossly intact. Pelvic exam was stable. A routine
anteroposterior pelvic radiograph, Judet views13 and additional
computed tomography showed a completely displaced trans-
cervical femoral neck fracture with posterior hip dislocation in
addition to a transverse acetabular fracture (Fig. 1). The only other
orthopaedic injury noted was an intraarticular distal phalanx
fracture of the thumb. There were no additional systemic injuries.
The patient was taken to the operating room with in an hour of
presenting to the emergency room (5 h after the primary injury).
He was placed in a lateral decubitus position with his right hip
exposed through a previously described modied Kocher Langen-
beck approach.31 After splitting of the fascia latae and the gluteus
maximus muscle, the femoral head was found lying posterior to
the greater trochanter (Fig. 2A). The tendon of the piriformis
muscle was partially torn as were the triceps coxae and the inferior
portion of the gluteus minimus muscle. A trochanteric ip
osteotomy was performed and a z-shaped capsulotomy was
completed. By means of a retrograde-inserted Schanz screw, the
head was gently reduced. Careful inspection at this point revealed
an intact vessel bundle of the MFCA in the posterior aspect of the
femur with a preserved retinaculum in the posterosuperior
femoral neck leading to the femoral head (Fig. 2B). By lifting up
the femur with a bone hook, the intact tendon of the obturator
externus was evident, thus suggesting a preserved extracapsular
course of the MFCA.9 Based on the structural integrity of the
retinaculum and the intact obturator externus muscle/tendon a
 M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 11181124 1119

Table 1
Overview of the literature of hip dislocations associated with femoral neck fractures (ORIF = open reduction and internal xation, AVN = avascular necrosis of the femoral
head, THA = total hip arthroplasty, TO = trochanter osteotomy).

Author, Number Age of Direction Intraoperative Treatment Associated fractures AVN Surgical approach
year of cases patient dislocation bleeding of of the pelvis/hip
(years) the head

Baba 1 36 Anterior ORIF Pelvic ring fracture, Yes Lateral

et al., 20021 acetabular fracture transtrochanteric
Dummer 2 48 Obturator THA Posterolateral
et al., 19992
50 Posterior THA Posterior
Duygulu 1 52 Posterior ORIF Pelvic ring injury, No Posterolateral
et al., 20063 acetabular fracture,
femoral shaft fracture
Esenkaya 1 39 Anterior THA Lateral
et al., 20025
Fernandes, 1 60 Posterior Unipolar Femoral head fracture Posterolateral
19816 hemiprosthesis
Fina 5 65 Posterior Unipolar
et al., 19707 hemiprosthesis
36 Posterior Unipolar
hemiprosthesis
10 Anterior ORIF Yes
50 Posterior ORIF Acetabular fracture Yes
57 Posterior ORIF Femoral head and Yes
shaft fracture
Hougaard 2 62 Conservative No surgery
et al., 198811
63 Unipolar
hemiprosthesis
Izquierdo 1 17 Obturator ORIF Fragment at the Yes Lateral
et al., 199412 posterosuperior neck transtrochanteric
Klasen 2 19 Posterior No ORIF Acetabular fracture Yes
et al., 198414 bleeding
41 ORIF Acetabular fracture No
Kumar 1 33 Posterior ORIF No
et al., 198515
Maini 1 25 Posterior ORIF Greater trochanter fracture Yes Posterolateral
et al., 200416
McClelland 1 28 Obturator Bipolar Indentation fracture Posterolateral
et al., 198717 hemiprosthesis of the femoral head
Mehara 1 45 Posterior Unipolar Indentation fracture of Posterior
et al., 199518 hemiprosthesis the femoral head
Meinhard 1 27 Central ORIF Acetabular fracture No Posterolateral with TO
et al., 198719
Meller Y 1 24 Posterior Unipolar Femoral head fracture Posterolateral
et al., 198220 hemiprosthesis
Mestdagh 1 52 Central Traction, Pelvic ring injury, No Posterolateral with TO
et al., 199122 secondary THA acetabular fracture
Newman, 197423 1 40 Posterior Conservative Acetabular fracture No No surgery
Peterson 1 33 Posterior Bone grafting, Yes SmithPetersen
et al., 195025 traction
Polesky 1 81 Anterior Unipolar Acetabular fracture Anterolateral
et al., 197226 hemiprosthesis
Sadler 1 77 Anterior ORIF Yes WatsonJones
et al., 198527
Saragaglia 3 41 Posterior ORIF No Kocher Langenbeck
et al., 198728
22 Posterior ORIF Acetabular fracture No Kocher Langenbeck
38 Posterior ORIF Acetabular fracture No Kocher Langenbeck
Present study 1 31 Posterior No ORIF Acetabular fracture No Surgical dislocation
bleeding

decision was taken to perform osteosynthesis with 6.5 mm
cancellous screw xation. Additionally, the defect in the ante-
roinferior femoral neck was grafted with autologous cancellous
bone obtained from the greater trochanter. The acetabular fracture
was anatomically reduced and xed with a 7-hole-3.5 mm
reconstruction plate (Fig. 3B).
The initial postoperative course was uneventful. Due to the rare
nature if the injury in this patient, to conrm the integrity of the
MFCA and the femoral head blood supply, a selective femoral
angiography and a bone scan were performed postoperatively
(although this is not a routine for our institution). The femoral
angiography demonstrated the integrity of the extracapsular
course of the MFCA (Fig. 4A). The 2-phase bone scan conrmed
that there was perfusion to the femoral head and showed a
posttraumatic increase of bone metabolism in the femoral neck
and head (Fig. 4B). The patient was kept NWB on crutches. A
follow-up bone scan 3 weeks postoperatively (again performed in
this case as an exception due to the rare nature of the injury and
femoral head preservation that was performed) re-conrmed the
preserved perfusion and viability of the femoral head (Fig. 4C).
At the 8-week follow-up, radiographs unfortunately partial loss
of reduction and early signs of implant failure. The compliance of
weight-bearing status of the patient remained questionable.
Nevertheless, a prompt decision was taken to revise the xation
1120 M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 11181124

Fig. 1. The preoperative anteroposterior pelvic radiograph (A), Judet views (B, C) and computed tomography show the severely displaced lateral femoral neck fracture with
posterior dislocation of the femoral head in combination with a transverse acetabular fracture.

and perform an additional valgus intertrochanteric osteotomy to
decrease the Pauwels angle and convert the shear forces to
compressive forces. Surgical approach was performed through the
original skin incision and the trochanteric ip osteotomy was used
again (Fig. 3C). Intraoperatively, brisk bleeding present after
drilling of the femoral head was a reassuring sign.10 Inserting the
2 mm laser-Doppler-owmetry24 probe demonstrated strong
pulsatile signals emanating from the femoral head (Fig. 4D). The
patient was carefully instructed to be compliant about NWB this
time and repeatedly reinforced that this was the nal salvage
procedure.
Radiographic examination, 8 weeks after the revision (4 months
after the accident), showed signs of healing in both the femoral
neck and the transverse acetabular fracture. Patient was eventually
progressed to PWB at 8 weeks and then with documented good
signs of healing, progressed to FWB at 12 weeks.
At the most recent follow-up, 4.7 years after injury, the patient
remained completely asymptomatic with full, symmetrical, and
unrestricted range of motion of the hip. According to the Medical
Research Council (MRC) muscle strength grading system, the hip
abductor strength was M5. The total Merle-dAubigne hip score21
was 18, depicting an excellent outcome. Routine roentgenograms
showed no radiographic evidence of avascular necrosis of the
femoral head or progression of arthritis (Fig. 3D). The patient has
returned to his full-time occupation as a forester without
restrictions.
Relevant surgical anatomy
A detailed knowledge of the vascular supply to the proximal
femur forms the essential basis for safe hip preserving surgery. The
medial circumex femoral artery (MFCA) provides the main and

Fig. 2. (A) Intraoperatively, after splitting of the fascia lata and the gluteus maximus muscle, the femoral head (*) was found lying posterior to the osteotomized greater
trochanter (OGT). (B) This gure shows the view from anterior after reduction and provisory xation with k-wires (KW). The retinaculum with the terminal branches of the
medial circumex femoral artery was intact (arrows).
 M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 11181124 1121

Fig. 3. (A) Osteosynthesis was performed using two 6.5 mm screws via a modied Kocher-Langenbeck approach with trochanteric osteotomy. The acetabular fracture was
xed with a 7-hole-3.5 mm reconstruction plate. (B) Eight weeks postoperatively, a delayed union with loss of reduction and screw breakage was observed. (C) A 20-degrees
valgus intertrochanteric osteotomy was subsequently performed using the same trochanteric ip osteotomy approach used previously. (D) At latest follow-up (4.7 years after
injury), no signs of avascular necrosis are present after partial hardware removal.

critical blood supply to the femoral head in an adult.9,29 The deep
branch of the MFCA runs towards the intertrochanteric crest
between the pectineus medially and the iliopsoas tendon laterally
(Fig. 5A) along the inferior border of the obturator externus muscle
(Fig. 5C). After crossing this tendon posteriorly, a constant
trochanteric branch is delivered adjacent to the proximal border
of the quadratus femoris (Fig. 5C). Thereafter, the deep branch of
the MFCA runs anterior to the tendon of the triceps coxae muscles
(gemelli and obturator internus muscles) to perforate the hip
capsule obliquely just cranial to the insertion of the tendon of the
superior gemellus and distal to the tendon of piriformis. It then
splits into two to ve retinacular vessels lying in a mobile layer of
connective tissue on the posterosuperior aspect of the femoral
neck and enters the femoral head lateral to the bonecartilage
junction (Fig. 5D).
Proposed algorithm
Management of femoral neck fractures by itself can be a
challenging problem. To add to it an associated hip dislocation can
make the situation more complex and therefore decision-making
becomes more a matter of experience than objectivity. Based on
the previous technique of safe surgical dislocation described at our
institution, we believe that an algorithmic approach can be used
for these difcult injuries. Our proposed algorithm is outlined in
Fig. 6.
Discussion
Femoral neck fractures with hip dislocation are a challenging
problem. By protecting the MCFA and its retinacular vessels
adjacent to the posterosuperior femoral neck, a safe and complete
dislocation of the femoral head is possible without the risk of
avascular necrosis. Knowledge of this topographic anatomy, the
anatomical course of the MCFA, and the importance of an intact
obturator externus muscle, are absolutely critical in the intrao-
perative decision-making for preservation of the native femoral
head.
Femoral neck fracture with hip dislocation is a rare injury. As
mentioned before, we could identify only 30 cases with this
fracture pattern upon a thorough review of the English literature
(Table 1). Treatment options based on literature review include
conservative treatment, traction, osteosynthesis, hemiarthroplasty
or primary total hip arthroplasty. The only reported case in which
successful conservative treatment was achieved was presented by
Newman.23 He suggested attempting closed reduction before
performing open surgery. However, closed reduction, even when
performed gently, may be proved to be very harmful and these
manoeuvres are hard to control. Such manipulation could create
additional damage to the frail bridge of preserved retinacular
vessels thereby causing denite devascularization.4,26 Some
authors who recommend immediate endoprosthetic replacement
justify their approach by pointing the high likelihood of ques-
tionable viability.7 These reports have failed to assess and report
the intraoperative integrity of the MFCA or the viability of the
femoral head. McClelland based his decision to abandon femoral
head preservation and osteosynthesis by the noted absence of
capsular bleeding and absent bleeding of the round ligament.17
However, we now know from anatomic studies that the medial
epiphyseal artery via the round ligament typically perfuses only
the area adjacent to the fovea and rarely supplies a signicant area
of the head in adults.9,29
Although intraoperative drilling of the femoral head is a reliable
sign of femoral head vascularization,10 it may be less reliable in
1122 M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 11181124

Fig. 4. (A) A selective angiography of the femoral artery was performed postoperatively to conrm the integrity of the extracapsular course of the medial femoral circumex
artery (CFA = common femoral artery, SFA = supercial femoral artery, PFA = profund femoral artery, MCFA = medial femoral circumex artery, LCFA = lateral femoral
circumex artery, PV = perforating vessels). (B) This bone scan which was taken postoperatively after the rst operation shows posttraumatic changes with increased
perfusion and bone metabolism in the right femoral neck and head (arrow) indicate preserved viability of the femoral head. (C) The control scan three weeks after the index
operations shows persistent increase of perfusion and metabolism in the femoral neck and head as a sign of ongoing bone healing and preserved viability of the femoral head.
(D) At the time of revision, the laser Doppler owmetry shows a strong pulsatile signal emanating from the femoral head.

dislocated fractures for multiple reasons. Hip dislocation can lead
to traction, compression and spasm of the femoral, deep femoral
and their circumex arteries.30,32 These pathological factors may
be reversible by early reduction of the dislocation.30,32 Although
the blood ow of the MFCA during head dislocation might be
compromised, the perfusion of the head can be preserved due to
existing collaterals that are not under traction, e.g. the inferior
gluteal artery.9,32 The intactness of MCFA and the retinaculum as
such remains an import sign and decision-making point to proceed
with femoral head preservation despite presence or absence of
 M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 11181124 1123

Fig. 5. (A) The deep branch of the MFCA runs towards the intertrochanteric crest between the pectineus medially and the iliopsoas tendon laterally. (B) The MCFA then runs
along the inferior border of the obturator externus muscle. (C) After overcrossing the tendon of the obturator externus muscle, a constant trochanteric branch is given off
adjacent to the proximal border of the quadratus femoris. Then, the MFCA undercrosses the tendon of the triceps coxae muscles (gemelli and obturator internus muscles) to
perforate the hip capsule obliquely just cranial to the insertion of the tendon of the superior gemellus and distal to the tendon of piriformis. (D) It then splits up into 25
retinacular vessels lying in a mobile layer of connective tissue on the posterosuperior aspect of the femoral neck and enters the femoral head lateral to the bone-cartilage
junction.

Fig. 6. Proposed algorithm.

1124 M. Tannast et al. / Injury, Int. J. Care Injured 40 (2009) 11181124
femoral head bleeding upon intraoperative drilling in these
complex cases of femoral neck fracture with hip dislocation.
In our experience, femoral neck fracture associated with hip
dislocation does not represent an ultimate sign of irrevocable
avascularity to the femoral head. As shown in our illustrative case,
the retinaculum with its mobile layer of connective tissue on the
posterosuperior aspect of the femoral neck remained in continuity
and protected the terminal branches of the MFCA. Any attempts at
closed reduction could have denitely harmed the remaining
perfusion of the retinacular vessels and we would certainly not
recommend that. As mentioned in our proposed algorithm, we
suggest an open reduction and internal xation utilizing the MCFA
preserving trochanteric ip osteotomy as soon as possible and if
the patient is stable enough to undergo the anaesthesia and
surgical procedure. In our opinion, preservation of the dislocated
femoral head via osteosynthesis, the trochanteric ip osteotomy
surgical approach and assessment of the MCFA integrity provides a
safe and rationale strategy for attempted joint preservation.
Conict of interest statement
There are no conicts of interest.
Acknowledgements
The authors thank Dr. Harish Hosalkar for his help in manu-
script preparation.
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