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IMAGE QUIZ ARCHIVE
Image Quiz
A Dashboard Injury1
(continued)
Answer: Posterior hip dislocation with Pipkin type-I fragment

Fig. 1-B		 Fig. 1-B. Anteroposterior radiograph, made after closed reduction in the emergency room, showing the Pipkin type-I fragment. There is widening of the joint space with an osteochondral fragment interposed between the femoral head and the acetabulum.

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Discussion
With a traumatic dislocation of the hip associated with a femoral head fracture, emergency reduction of the hip is imperative, regardless of the type or extent of the fracture2,3. Once reduction is accomplished, further evaluation, including computed tomography, is indicated to assess the congruity and stability of the joint. Treatment options include nonoperative treatment, excision of fracture fragments, open reduction and internal fixation, arthroplasty, and arthrodesis. Complications associated with these injuries are osteonecrosis of the femoral head, nonunion of the femoral head fragment, and posttraumatic arthritis2-14.
Fracture-dislocations of the femoral head, so-called dashboard injuries, are usually sustained in a motor-vehicle accident when the knee of a passenger who is not wearing a seat belt strikes the dashboard with the hip flexed at approximately 90° and slightly adducted.
In 1957, femoral head fractures were classified by Pipkin into four types11, earning him this fracture eponym. A Pipkin type-I fracture is a femoral head fracture distal to the fovea, a type-II fracture is proximal to the fovea, a type-III fracture is a type-I or II fracture associated with a femoral neck fracture, and a type-IV fracture is a type-I or II fracture associated with an acetabular-rim fracture.
Traumatic dislocations of the hip with a femoral head fracture are uncommon. The infrequency of this injury is reflected in the literature, where roughly 200 of these fractures, with an adequate description of the type and with more than one year of follow-up, have been reported. The Pipkin type-II fracture represents the largest group. Although there is no consensus on the treatment of these fractures, it seems that types I and II can be treated conservatively if alignment after reduction of the hip dislocation is anatomical and there are no loose fragments in the joint. Computed tomographic evaluation is indicated to confirm the adequacy of the fracture reduction. If open reduction and internal fixation is chosen, an anterior approach has been reported to be preferable to the Kocher-Langenbeck approach14. If internal fixation is not possible due to extensive comminution, then type-I and II fractures can be treated with excision of the fragments if they make up less than 30% of the femoral head7. Type-III fractures are most often treated with a hemiarthroplasty because they are typically associated with a high rate of osteonecrosis. In young, active patients with a type-III injury, an attempt at open reduction and internal fixation seems warranted. Type-IV injuries (associated with acetabular fracture) are treated with open reduction and internal fixation of the acetabulum and excision or internal fixation of the femoral head fragment.
References

1. Marti RK, Kloen P. Chronic recurrent posterior dislocation of the hip after a Pipkin fracture treated with intertrochanteric osteotomy and acetabuloplasty. A case report. J Bone Joint Surg Am. 2000;82:867-72.
2. Stewart MJ. Management of fractures of the head of the femur complicated by dislocation of the hip. Orthop Clin North Am 1974;5:793-8.
3. Thompson VP, Epstein HC. Traumatic dislocation of the hip. A survey of two hundred and four cases covering a period of twenty-one years. J Bone Joint Surg Am 1951;33:746-78.
4. Brumback RJ, Kenzora JE, Levitt LE, Burgess AR, Poka A. Fractures of the femoral head. In: The hip. Proceedings of the Fourteenth Open Scientific Meeting of the Hip Society. St. Louis: C. V. Mosby; 1987. p 181-206.
5. Butler JE. Pipkin type-II fractures of the femoral head. J Bone Joint Surg Am 1981;63:1292-6.
6. Dreinhofer KE, Schwarzkopf SR, Haas NP, Tscherne H. [Femur head dislocation fractures. Long-term outcome of conservative and surgical therapy.] Unfallchirurg. 1996;99:400-9. German.
7. Epstein HC, Wiss DA, Cozen L. Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop. 1985;201:9-17.
8. Hougaard K, Thomsen PB. Traumatic posterior fracture-dislocation of the hip with fracture of the femoral head or neck, or both. J Bone Joint Surg Am 1988;70:233-9.
9. Lang-Stevenson A, Getty CJ. The Pipkin fracture-dislocation of the hip. Injury. 1987;18:264-9.
10. Maroske D, Thon K, Fischer M. [Hip dislocation with femur head fracture.] Chirurg 1983;54:400-5. German.
11. Pipkin G. Treatment of grade IV fracture-dislocation of the hip. A review. J Bone Joint Surg Am 1957;39:1027-42.
12. Stewart MJ, Milford LW. Fracture-dislocation of the hip. An end-result study. J Bone Joint Surg Am 1954;36:315-42.
13. Stockenhuber N, Schweighofer F, Seibert FJ. [Diagnosis, therapy and prognosis of Pipkin fractures (femur head dislocation fractures).] Chirurg 1994;65:976-82. German.
14. Swiontkowski MF, Thorpe M, Seiler JG, Hansen ST. Operative management of displaced femoral head fractures: case-matched comparison of anterior versus posterior approaches for Pipkin I and Pipkin II fractures. J Orthop Trauma. 1992;6:437-42.
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