CASE REPORT

Non-traumatic femoral head fracture forming bone fragments

Hiroyuki Tsuchie • Shin Yamada • Moto Kobayashi •

Hiroshi Tazawa • Takashi Minato • Gota Ohi •

Hidetomo Saito • Yoichi Shimada

Received: 19 November 2012 / Accepted: 12 March 2013

� The Japanese Orthopaedic Association 2013

Introduction

Femoral head fracture generally occurs due to high-energy

injury such as dislocation of the hip joint. However, fem-

oral head fracture forming bone fragments without appar-

ent trauma has not previously been reported. We describe

herein a unique case of non-traumatic femoral head frac-

ture leading to rapid destruction of the femoral head and

osteoarthritic changes in the hip joint, along with a review

of the literature. The patients and their families were

informed that data from the case would be submitted for

publication, and gave their consent.

Case report

A 73-year-old woman presented to our outpatient clinic

with pain around the right thigh with a 1-month history.

There was no history of trauma nor glucocorticoid use, nor

habit of alcohol drinking, and only hypotensive drugs were

prescribed. Her pain was insidious at onset and gradually

increased. She had been treated only with rest of lower

extremity for 6 months for right pubic synovial bursitis

diagnosed by magnetic resonance imaging (MRI) 2 years

before, but plain radiographs of the right hip joint had

shown no abnormality at that time (Fig. 1a). Physical

examinations demonstrated no tenderness of the right hip

and thigh. Although she had pain while walking, she could

walk without a cane. The flexion range of motion was 100

degrees in her right hip. Plain radiographs and computed

tomography (CT) showed fracture of the right femoral head

including small bone fragments and osteoarthritic change

of the right hip joint (Figs. 1b, 2a, b). On MRI, the right

femoral head and lateral acetabular roof showed dappled

low signal intensities on T1-weighted images and high

signal intensities on T2-weighted images, and mild liquid

retention was shown in the right hip joint (Fig. 3a, b). Also,

the ligamentum teres connecting to a large bone fragment

was shown on T2-weighted images (Fig. 3c).

There was no abnormal value on laboratory examinations,

including rheumatoid arthritis and tuberculosis. Bone mineral

density (BMD) of the lumbar spine (L1-4, 0.693 g/cm2,

T-score: -2.64 S.D.) by dual energy X-ray absorptiometry

(QDR-4500, Hologic Inc. Waltham, MA, USA) confirmed the

presence of associated osteoporosis. Yellow and clear liquid

(1.2 ml) was aspirated by right hip puncture, but there was no

abnormality on examination. Nonsteroidal anti-inflammatory

drugs (NSAIDs) was prescribed, and we instructed her to rest

her right lower extremity by using a cane.

However, her pain gradually increased, and she needed a

cane to walk 1 month after the initial visit. The range of

motion of her right hip deteriorated to 70 degrees flexion

4 months after the initial visit. Plain radiographs and

computed tomography (CT) showed the rapid destruction

H. Tsuchie (&)

Ugo Municipal Hospital, 44-5 Otomichi,

Nishomonai, Ugo 012-1131, Japan

e-mail: tuchikiti@yahoo.co.jp

S. Yamada � H. Tazawa � G. Ohi � H. Saito � Y. Shimada

Department of Orthopedic Surgery,

Akita University Graduate School of Medicine,

1-1-1 Hondo, Akita 010-8543, Japan

M. Kobayashi

Division of Orthopedic Surgery, Nakadori General Hospital,

3-15 Misono-cho, Minami-dori,

Akita 010-8577, Japan

T. Minato

Sannoh Orthopedic and Plastic Surgery Clinic,

15-18 Nakajima-cho, Sannoh, Akita 010-0955, Japan

123

J Orthop Sci

DOI 10.1007/s00776-013-0386-1

of the right femoral head and osteoarthritic change of the

right hip joint (Figs. 1c, d, 2c). Although we examined

brain and spinal MRI, and laboratory examinations of

infectious disease including syphilis, there was no abnor-

mal findings suspecting Charcot arthropathy.

We performed right total hip arthroplasty 5 months after

the initial visit. Histopathologic examination of the femoral

head fragments confirmed the bone necrosis, granulation

tissue, and fibrous tissue, and tissue damages of the bone

area superior to the cartilage area. She was rehabilitated

after the operation and could walk without a cane, with no

pain. She did not have any pain in the right hip at the most

recent follow-up 2 years post-operatively.

Discussion

Femoral head fracture generally occurs due to dislocation

of the hip joint, and patients usually have a history of high-

energy injury such as a traffic accident. On the other hand,

there is non-traumatic femoral head fracture, which is

subchondral insufficiency fracture of the femoral head

Fig. 1 Antero-posterior

radiographs of the right hip joint

at 2 years before the initial visit

(a), the initial visit (b),

2 months after the initial visit

(c), and 4 months after the

initial visit (d)

H. Tsuchie et al.

123

(SIF) [1]. Although SIF makes some small bone fragments

of the femoral head [2], there is no report of it causing a

large bone fragment connecting to the ligamentum teres.

So, there has been no report of femoral head fracture like in

the current case, involving no history of trauma and bone

fragment formation. In the current case, there were no

anamnesis or abnormal values on laboratory examinations,

and we could confirm only osteoporosis. So, we can sug-

gest that bone fragility of the femoral head strongly influ-

enced the current case.

The ligamentum teres has traditionally been viewed as

an embryonic remnant with no role in the biomechanics of

adult hips. However, ligamentum teres lesions are being

increasingly recognized as a cause of persistent hip pain,

and debridement and reconstruction have been conducted

by arthroscopy for such patients in recent years [3–5].

Some reports also mention the possibility that the liga-

mentum teres contributes to hip stability, particularly in the

hip posture of adduction, flexion, and external rotation [6,

7]. In the current case, although we could not confirm what

was the cause, femoral head fracture was probably due to

the traction force applied to the femoral head showing bone

fragility through the ligamentum teres.

The hip joint was rapidly destroyed in our case, and she

showed a course similar to rapidly destructive arthrosis of

the hip (RDA) [8]. Pipkin’s classification of femoral head

fracture in the current case is type 2 when applying this

classification, and the fracture site of femoral head includes

a part of the loading surface of the hip joint. This may be

one factor leading to rapid destruction of the hip joint.

Actually, lateral acetabular roof, not only the right femoral

head, showed abnormal signal changes on MRI, and this

may represent more load added to the acetabular roof.

Some SIF patients have a course similar to RDA [9]. So,

we can consider in our case that SIF occurred at the right

femoral head at first, and femoral head fracture was caused

by the ligamentum teres, and finally, the hip joint was

rapidly destroyed like RDA.

Fig. 2 Computed tomography

(CT) of the right hip joint at the

initial visit (a coronal section,

b transverse section) and

4 months after the initial visit

(c). CT showed bone fragments

and rapid destruction of the

femoral head and osteoarthritic

change of the hip joint

Non-traumatic femoral head fracture

123

In conclusion, the current patient is an extremely rare

case of non-traumatic femoral head fracture leading to

rapid destruction of the right femoral head and osteoar-

thritic change of the right hip joint. Non-traumatic femoral

head fracture forming bone fragments occurs due to bone

fragility, and the ligamentum teres functions in hip

stability.

Conflict of interest The authors declare that they have no conflict

of interest.

References

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Fig. 3 Magnetic resonance

imaging (MRI) of the bilateral

hip joint. The right femoral head

showed a dappled low signal

intensity on T1-weighted

images (a) and high signal

intensities on T2-weighted

images (b). The ligamentum

teres (arrow) connecting to a

large bone fragment was shown

on T2-weighted images (c)

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