September 17, 2025
4 min read
A 36-year-old man presented to the ED as a level 1 trauma activation with a gunshot injury to the right thigh involving the femoral neck, head and acetabulum.
The patient reported being shot by an unknown assailant, with immediate severe right hip pain and inability to bear weight on his right lower extremity. The patient had no known medical or surgical history. His urine drug screen was positive for cocaine use. A comprehensive physical exam was notable for a Glasgow Coma Scale score of 15 and stable vital signs, and he had a ballistic entry wound along his lateral thigh with no exit wound. Right hip range of motion was limited by pain; otherwise, the right lower extremity was unremarkable, and he was neurovascularly intact distally. No gross pelvic instability was identified on manual stress testing. Pelvis radiographs showed a displaced right femoral neck fracture and a retained bullet in the sacral region. CT of the pelvis showed a displaced femoral neck fracture, comminuted femoral head fracture and nondisplaced posterior column acetabulum fracture (Figure 1).
Source: Joseph Wahl; Hayden Flume; Jennifer W. Liu, MD; and Edgar T. Araiza, MD
What are the best next steps in management of this patient?
See answer below.
Open reduction and internal fixation, closed reduction percutaneous fixation
After discussion of risks and benefits, the decision was made to proceed with open reduction internal fixation of the femoral neck and closed reduction percutaneous fixation of the acetabulum.
Source: Joseph Wahl; Hayden Flume; Jennifer W. Liu, MD; and Edgar T. Araiza, MD
Surgical technique
The patient was positioned supine on a radiolucent fracture table. Necrotic tissue around the gunshot wound was debrided. A subvastus approach was used to gain access to the proximal femur. Traction and manipulation with a Cobb elevator achieved anatomic reduction of the femoral neck, and the neck-shaft angle was compared with the contralateral limb. Five cannulated compression screws were then placed across the femoral neck and into the femoral head (Figure 2). The wound was copiously irrigated with normal saline solution, followed by layered closure and sterile dressing application.
Source: Joseph Wahl; Hayden Flume; Jennifer W. Liu, MD; and Edgar T. Araiza, MD
Next, attention was turned to the acetabulum fracture. A small incision along the ischial tuberosity was made. Blunt dissection was performed down to the ischium. Anteroposterior, outlet and iliac oblique views were used to place a retrograde posterior column screw (Figure 3). Proper reduction was confirmed on multiple views. We drilled and placed a 6.5-mm partially threaded screw across the column. The wounds were copiously irrigated with normal saline solution using gravity lavage. A layered closure was performed, and sterile dressings were applied.
Postoperative course
The patient was made non-weight-bearing to his right lower extremity with posterior hip precautions for 3 months postoperatively. The patient was ambulatory with a walker. After 3 months, radiographs showed interval fracture healing, though we did also see some mild varus collapse and early signs of avascular necrosis (Figure 4). The patient was advanced to weight-bearing as tolerated, and hip precautions were discontinued. At 6 months postoperatively, the patient was able to wean off using a walker and returned to work in construction as a machine operator. At 9 months postoperatively, radiographs demonstrated progression of femoral neck varus collapse and avascular necrosis of the femoral head. Revision options, including valgus-producing osteotomy or conversion to total hip arthroplasty, were discussed. However, the patient remained pain free with a return to baseline function and, therefore, declined further surgery. We plan to continue following our patient every 6 months with repeat clinical evaluation and radiographs.
Discussion
Combined displaced femoral neck and ipsilateral femoral head fractures are rare and devastating injuries, usually resulting from high-energy trauma. Displaced femoral neck fractures disrupt the vascular supply of the femoral head, while femoral head fractures further compromise viability and stability. Reported rates of avascular necrosis in these injuries are as high as 50% to 75%. In our case, the injury was further complicated by a posterior column acetabulum fracture. Acetabular involvement increases both surgical complexity and the risk for long-term degenerative changes.
Source: Joseph Wahl; Hayden Flume; Jennifer W. Liu, MD; and Edgar T. Araiza, MD
Despite appropriate surgical management, our patient developed avascular necrosis of the femoral head and varus collapse of the femoral neck. These are, unfortunately, well-described complications of this injury pattern. However, interestingly, our patient has thus far remained pain free and fully functional. He has declined offers of revision surgery or conversion to a total hip arthroplasty. This finding underscores the observation that clinical outcomes do not always parallel radiographic findings.
Source: Joseph Wahl; Hayden Flume; Jennifer W. Liu, MD; and Edgar T. Araiza, MD
Treatment strategy in these complex injuries remains debated. Primary arthroplasty may be favored in older patients, but in younger individuals, joint preservation is often attempted despite the high risk for failure. Our case highlights the difficulty of balancing these options, as well as the possibility of good functional adaptation even in the setting of structural collapse.
Source: Joseph Wahl; Hayden Flume; Jennifer W. Liu, MD; and Edgar T. Araiza, MD
In summary, combined femoral neck, femoral head and posterior column acetabular fractures carry a high risk for avascular necrosis and collapse despite fixation. Functional outcomes, however, may be better than radiographs suggest.
Key Points:
- Combined femoral neck, femoral head and acetabular fractures are rare injuries that carry a high risk for avascular necrosis and mechanical collapse despite anatomic fixation.
- Radiographic failure does not always correlate with patient function, and good clinical outcomes may still be achieved even in the presence of avascular necrosis and varus collapse.
- Management decisions should be individualized, balancing the risks for fixation failure with the potential benefits of preserving the native hip, particularly in younger patients.
References:
For more information:
Edgar T. Araiza, MD, can be reached at the Methodist Dallas Medical Center in Dallas. Hayden Flume and Joseph Wahl can be reached at the University of North Texas Health Science Center in Fort Worth, Texas. Jennifer Liu, MD, can be reached at Houston Methodist Hospital in Houston, Texas. Araiza’s email: edgararaiza@mhd.com.
Edited by Mitchell F. Bowers, MD, and Jennifer Liu, MD. Bowers is a chief resident in orthopedic surgery at Vanderbilt University Medical Center. He will be pursuing a spine surgery fellowship at the Leatherman Spine Institute following residency completion. Liu is a chief resident in orthopedic surgery at Houston Methodist Hospital. She will be pursuing an adult reconstruction fellowship at the University of California San Francisco following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
