International Orthopaedics (SICOT) DOI 10.1007/s00264-015-2730-x
ORTHOPAEDIC HERITAGE
History of femoral head fracture and coronal fracture of the femoral condyles Jan Bartoníček & Stefan Rammelt
Received: 26 February 2015 / Accepted: 27 February 2015 # SICOT aisbl 2015
Abstract The first known description of the coronal fracture of the lateral femoral condyle was published by Busch in 1869. Hoffa used Busch’s drawing in the first edition of his book in 1888 and accompanied it only with one sentence. A full case history of this fracture pattern was described by Braun in 1891. However, Braun’s article fell into oblivion and so the fracture was popularized only in the fourth edition of Hoffa’s textbook, particularly thanks to the drawing, rather than the brief description. Therefore, a fracture of the posterior femoral condyle, or more specifically, of the lateral condyle, could properly be called BBusch-Hoffa fracture^. Femoral head fracture was initially described by Birkett in 1869. Of essential importance in this respect were the publications by Christopher in 1924 and, particularly, Pipkin’s study of 1957, including his classification that is still in use today. A historically correct eponym for a femoral head fracture would therefore be BBirkitt-Pipkin fracture^.
Keywords History of orthopaedics . Hoffa’ fracture . Pipkin’ fracture . Fracture of femoral head . Coronal fracture of femur condyles
J. Bartoníček (*) Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, U Vojenské nemocnice 1200, 169 02 Prague 6, Czech Republic e-mail: [email protected] S. Rammelt University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany e-mail: [email protected] S. Rammelt UniversitätsCentrum für Orthopädie & Unfallchirurgie , Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
Introduction Femoral head fractures and coronal fractures of the femoral condyles are rare intra-articular injuries to the femur. They were both described in 1869 and sometimes they are eponymously referred to as Pipkin and Hoffa fractures. However, little is currently known about their true and very interesting history [9, 31]. BHoffa^ fracture Most authors state that the first description of the coronal fracture of the posterior condyle of the femur was reported by Albert Hoffa in 1904 [15]. However, this is a double error. Although Hoffa described this fracture, he was neither the first to do so, nor did he publish this description in 1904. The first known description of this fracture pattern dates back to 1869. It was published by Busch [5] who found a specimen of a knee joint in the anatomical collections of the Department of Surgery in Berlin, which, according to the available information, came from the corpse of a muscular man, who died of the consequences of a severe injury sustained several years before his death. After maceration of the distal femur, a fissure separating the posterior lateral femoral condyle became visible (Fig. 1). Friedrich Busch (1844– 1916) was a pupil of Recklinghausen, Virchow and Langenbeck. In 1875, he was appointed Associate Professor of Surgery and, in 1884, head of the newly opened Institute of Dental Medicine at the Friedrich-Wilhelms-Universität in Berlin. Busch’s drawing was used by Albert Hoffa (1859–1907) in the first edition of his textbook in 1888 [14], without citing the source (Fig. 2). The fracture itself was mentioned by Hoffa in his book in one sentence only and quite vaguely. Twenty years after Busch, at the Congress of the German Surgical Society in 1889, Ludwig Wilhelm Carl Rehn (1849–
International Orthopaedics (SICOT)
Fig. 1 Original drawing of a fracture of the lateral condyle of distal femur published by Busch in 1869 [5]
Fig. 2 Original drawing of a fracture of the lateral condyle of distal femur published by Hoffa in 1888 [14]
1930) presented the case of a 45-year-old man who died of Bphlegmon^ [25]. He had sustained an injury to the knee 16 years before he died. Autopsy revealed an avulsion of the lateral femoral condyle in the coronal plane. A fragment with osteoarthritic changes was displaced posteriorly and proximally. The cruciate ligaments were intact, but the lateral meniscus was severely damaged, as was the posterior lateral condyle of the tibia. During a debate about Rehn’s case, Christian Heinrich Braun (1847–1911) mentioned a similar case, which he subsequently published two years later (1891) [4]. A 48-year-old man sustained an open injury to the left knee joint in a stone quarry. Due to infection, the limb had to be amputated ten days after the injury, which saved the patient’s life. Autopsy of the specimen showed a minimally displaced twofragment fracture of the lateral femoral condyle (Fig. 3). The posterior capsule and the cruciate ligament remained intact. Thus it was Braun [4] who, for the first time, presented details of the injury based on autopsy performed early after injury. In the previous two cases, either basic information was missing (Busch), or the injury was not acute (Rehn), but the common feature of all the three cases was injury to the lateral femoral condyle.
In the following decades, a coronal fracture of posterior condyle of the distal femur was repeatedly mentioned in a number of textbooks on bone and joint trauma [3, 29, 30], but the fracture was not associated with Hoffa’s name. The term Hoffa fracture began to appear at the turn of the 1970s, primarily in the German and French literature, together with descriptions of its modifications. One of the outstanding publications in this respect is the article by Letteneur et al. of 1977 [17] under the title BFractures de Hoffa^, evaluating 20 cases of this fracture and presenting probably its first prognostic classification. The term Hoffa fracture was used also in the second edition of the AO Manual of Internal Fixation, published in 1979 [21]. In the English literature, Letteneur’s classification was popularized by Lewis et al. [18]. The term Hoffa fracture is again mentioned in the English version of AO Classification of Fractures, published in 1990 [22]. In 1996, the AO classification was adopted by the OTA. Since then, this term has been used almost systematically. All publications without exception cite the 4th edition of Hoffa’s book of 1904, presenting this date as the year when fracture of the posterior femoral condyle was initially described. Only in 1994, did Heuschen et al. [12], and more recently Jain et al. [16] in 2015, point out
International Orthopaedics (SICOT) Fig. 3 Original drawings published by Braun in 1891 [4]. Figs. 1 and 2 fracture of the lateral condyle of right distal femur, Fig. 3 fracture of the femoral head, Fig. 4 fracture of the glenoid fossa, Fig. 5 longitudinal fracture of the first cuneiform bone
that it was Busch who first described this fracture in 1869, but they also incorrectly dated Hoffa’s description at 1904.
Pipkin fracture The first to describe a femoral head fracture was John Birkett in 1869 [2]. He presented a case of a 35-year-old woman who sustained a severe injury, after a fall from a window, and died. Autopsy revealed dislocation of the hip in combination with a femoral head fracture. The avulsed fragment of the femoral head, carrying Bthe attachment of the ligament of head of femur (ligamentum capitis femoris, ligamentum teres) remained in the acetabulum^ (Fig. 4). John Birkett (1815– 1904) was an outstanding surgeon and an early specialist in breast diseases, including breast cancer, as well as being an early advocate of histology. In 1850, he published his book on BThe Diseases of the Breast and Their Treatment^. Three years later, in 1872, Moxon [20] described a similar injury in a man hit by a train. Autopsy confirmed iliac dislocation of the hip with partial avulsion of the femoral head
carrying the Battachment of the ligament of the head of the femur^. This fragment remained in the acetabulum. In 1885, Bernhard Moritz Carl Ludwig Riedel (1846– 1916) reported a case of a 15-year-old boy with an injury to the hip [26]. The boy was admitted to the hospital as late as three months after the injury, namely, for persisting iliac dislocation of the hip associated with crepitation. Attempts at closed reduction failed and the boy had to be operated on. After detachment of the greater trochanter, a dislocated femoral head was found, that was split into two parts, both of them outside the acetabulum. An impression was seen at the posterior rim of the acetabulum. A loose fragment was removed and the rest of the femoral head reduced into the acetabulum. The fracture healed but the patient subsequently developed an ankylosis of the hip with a limb shortening of 2 cm. In 1891, Braun [5] described a case of a man hit by a train, who sustained among other injuries an ischial dislocation of the right hip. Reduction was performed easily, but the man died within a few hours. Autopsy revealed a fracture of the femoral head, running across the Bfovea for the ligament of the
International Orthopaedics (SICOT)
Fig. 5 a Fracture of the posterior acetabular rim in the case published by Crile in 1891 [7]. b Fracture of the femoral head in the case published by Crile in 1891 [7]
Fig. 4 a Fracture of femoral head published by Birkett in 1869 [2]. Original legend: BFig. 1.–a. Part of capsular ligament, b. Cotyloid ligament [ligamentum teres, ligamentum capitis femoris], c. Fragment of head of femur in the acetabulum, d. A few fibres of the ligamentum teres^. b Fracture of femoral head published by Birkett in 1869 [2]. Original legend: BFig. 2.–a. Capsular ligament, b. Acetabulum, its bare edge (1) exposed, and the bare surface (2) of os innominatum, c. Fragment of head of femur, d. Cancellous tissue of the head of the femur, e. Cotyloid ligament torn off from edge of acetabulum (1)^
head of the femur and splitting the ligament into two parts^ (Fig. 3), as well as fractures of the glenoid and of the first cuneiform bone. In fact, Braun was the only author to describe a femoral head fracture and coronal fracture of the femoral condyle in one article [5]. In the same year, i.e., in 1891, Crile [7] published a case of a man who sustained fracture of the femoral head and of the posterior rim of the acetabulum after a fatal fall from a height (Fig. 5). In 1896, Roberts [27] described a case of a man who got squeezed between railway carriages and sustained an iliac
dislocation of the hip. Non-operative treatment failed and a fracture of the femoral neck occurred, probably during closed reduction manoeuvre. The fracture was confirmed during surgery that was performed three months after the injury, which also revealed a fracture of the femoral head, which was dislocated outside the acetabulum. As the acetabulum was completely filled with fibrous tissue at the time of surgery, the femoral head had to be resected. The patient died several days after the operation. Autopsy confirmed the intraoperative finding of an additional avulsion of the posterior rim of the acetabulum. Durant and Destot [8], in 1904, were probably the first to diagnose a femoral head fracture using radiographs, namely, in three cases. In 1912, Morávek [19] described a case of a railway worker who, in 1905, fell onto the wheel drag during track maintenance and sustained an injury to the left hip. The injury was treated as a contusion. A radiograph taken as late as seven years after the injury showed that it was a femoral head fracture. In 1923, Hinsdale [13] recorded a case of a woman with an iliac dislocation of the hip, combined with a femoral head
International Orthopaedics (SICOT)
fracture. Closed reduction failed and therefore open reduction was performed and the femoral head fragment, Bcarrying the attachment of the ligament of the head of the femur^, was removed. The patient healed with a very good hip function. Christopher [6] in 1924 published a case of a woman who sustained posterior dislocation of the hip associated with avulsion of the inferior part of the femoral head (Fig. 6). Closed reduction under general anaesthesia was successful. The patient healed with a very good functional result, except for a temporary palsy of the common peroneal nerve, probably caused by the hip dislocation. In his article Christopher also provided a detailed analysis of 14 femoral head fractures published hitherto, to which he added his own case. This analysis substantially contributed to a better understanding of this injury. The patients were divided into two groups. One group comprised nine classical cases with posterior dislocation of the hip and the other group six cases without dislocation of the hip. Of these 15 cases, four injuries were caused by railway accidents. Based on autopsy, radiographs and intraoperative findings, different femoral head fracture patterns were described, namely, in combination with an acetabular fracture, femoral neck fracture during reduction, palsy of the sciatic nerve, etc. Of these 15 patients, six died, four of them immediately after the injury. In total, four
Fig. 6 Fracture of the femoral head in the case published by Christopher in 1924 [6]
patients were operated on, two immediately [13, 28] and the other two, three months after the injury [26, 27]. In three cases the avulsed femoral head fragment was removed and the hip reduced. One case involved resection of the femoral head [27]. Of all the operated patients, one died immediately after surgery [26], two of them [26, 28] developed ankylosis of the hip and in one case [6] the function of the hip was very good. A good functional result in non-operatively treated patients was achieved only by Christopher [13]; in Morávek’s case the function was satisfactory [19], and in the three cases treated by Durand and Destot [8] all patients developed painful incomplete ankylosis. A similar overview was published ten years later (1934) by Henry and Bayumi [10]. In an extensive study focused on hip dislocations associated with ipsilateral femoral fractures, they also dealt with femoral head fractures. They based their work primarily on the study by Christopher, to which they added only one new case described by Nicharelli. The resulting overview presented a comprehensive summary of the current information and knowledge concerning this injury. The first author of this overview, Arnold Kirkpatrick Henry (1886– 1982), later became famous for his book on extensile surgical approaches [11]. Femoral head fracture was mentioned also in some textbooks on bone traumatology, for the first time, most probably, in the book by Tanton [30], in 1916 and then in the book by Znojemský [32], in 1922. On the contrary, a description of femoral head fractures was missing completely in the 9th to 11th editions of Böhler’s textbook that was respected worldwide [3]. In the post-war period, in 1948, Armstrong [1] reported on a total of five patients, all initially treated non-operatively. Good function of the hip was restored in one case only. Two patients required surgery, one and three months after the injury, respectively. However, both of them finally had to be treated by hip arthrodesis. In 1954, Palin and Richmond [23] recorded three cases, all of them associated with posterior hip dislocation and operated on. In one case the femoral head was replaced by the Judet endoprosthesis. In the remaining two cases, excision of the fragment and reduction of the hip joint resulted in development of post-traumatic osteoarthritis, or ankylosis. Garret Pipkin [24] used his own cases and cases of his colleagues to form a group of 25 patients with the follow-up of up to 18 years. In 1957, based on the analysis of this group, he developed the following classification of these fractures: Type 1 Dislocation with fracture of the femoral head caudad to the fovea capitis femoris. Type 2 Dislocation with fracture of the femoral head cephalad to the fovea capitis femoris. Type 3 Type 1 or type 2 injury associated with fracture of the femoral neck.
International Orthopaedics (SICOT)
Type 4 Type 1 or type 2 injury associated with fracture of the acetabular rim. In patients treated operatively, the procedure included excision of the fragment, replacement of the femoral head, and in certain fracture patterns of types 2 and 3 even internal fixation. We have not found any description of internal fixation of the femoral head in older sources. Also, thanks to its publication in the Journal of Bone and Joint Surgery, Pipkin’s study has substantially contributed to the understanding of femoral head fractures. The Pipkin classification has been applied ever since and sometimes his name is used eponymously for these fractures.
Conclusion Based on the above, the first known description of the coronal fracture of the lateral femoral condyle was published by Busch in 1869. Hoffa used Busch’s drawing in the 1st edition of his book in 1888 and accompanied it only with one sentence. A full case history of this fracture pattern was described by Braun in 1891. However, the Braun’s article fell into oblivion and so the fracture was popularized only in the 4th edition of the Hoffa’s textbook, particularly thanks to the drawing, rather than the brief description. Therefore, a fracture of the posterior femoral condyle, or more specifically, of the lateral condyle could properly be called BBusch-Hoffa fracture^. Femoral head fracture was initially described by Birkett in 1869. Of essential importance in this respect were the publications by Christopher of 1924 and, particularly, Pipkin’s study of 1957, including his classification that is still in use today. A historically correct eponym for a femoral head fracture would therefore be BBirkitt-Pipkin fracture^. Acknowledgments The authors would like to express their special gratitude to Prof. Chris Colton, MD and Ms Ludmila Bébarová, PhD for their assistance in editing the manuscript and Ms Ludmila Frajerová, Ms Mirka Plecitá and As. Prof. Patrick Cronier, MD for tracing the original source documents.
References 1. Armstrong JR (1948) Traumatic dislocation of the hip joint. Review of one hundred and one dislocations. J Bone Joint Surg (Br) 30-B: 430–445 2. Birkitt J (1869) Description of a dislocation of the head of the femur, complicated with its fracture. Med Chir Trans 52:133–138 3. Böhler L (1943) Technik der Knochenbruchbehandlungen im Frieden und im Kriege 9.-11. Auflage. Maudrich, Wien 4. Braun H (1891) Seltenere Fracture des Oberschenkels. Arch Klin Chir 42:107–111
5. Busch F (1869) Mehrere Fälle seltener Knochenverletzungen. Arch Klin Chir 10:703–719 6. Christopher F (1924) Fractures of the head of the femur. Arch Surg 12:1049–1061 7. Crile GW (1891) Report of three cases of fractures with fatal termination. Ann Surg 13:373–377 8. Durand D (1903) Les fractures de la tête fémorale. Bul Soc Chir Lyon 6:376–382 9. Guimaräes RP, de Souza GS, da Silva RS, Ono NK, Honda EK, Polesello GC, Riccioli W (2010) Study of the treatment of femoral head fractures. Rev Bras Ortop 45:355–361 10. Henry AK, Bayumi M (1934) Fracture of the femur with luxation of the ipsilateral hip. Br J Surg 22:204–230 11. Henry AK (1945) Extensile exposure. Livingstone, Edinburgh 12. Heuschen UA, Göhring U, Meeder PJ (1994) Die beidseitige HoffaFraktur – eine Rarität. Aktuelle Traumatol 24:83–86 13. Hinsdale G (1923) Fracture of head of femur, with dislocation on dorsum of ilium. J Am Med Assoc 80:469 14. Hoffa A (1888) Lehrbuch der Frakturen und Luxationen für Ärzte und Studierende, Ith edn. Verlag der Stahel'schen Universitäts-Buch& Kunsthandlung, Würzburg 15. Hoffa A (1904) Lehrbuch der Frakturen und Luxationen für Ärzte und Studierende, IVth edn. Enke, Stuttgart 16. Jain SK, Jadaan M, Rahall E (2015) Hoffa’s fracture—lateral mensicus obstructing the fracture reduction—a case report. Injury 46:419–421 17. Letteneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV (1977) Fractures de Hoffa—A propos de 20 observations. Ann Chir 32: 213–219 18. Lewis SL, Pozo JL, Muirhead-Allwood WFG (1989) Coronal fractures of the lateral femoral condyle. J Bone Joint Surg (Br) 71-B:118– 120 19. Morávek A (1912) Odštěpná zlomenina hlavice kosti stehenní [Split fracture of the femoral head]. Cas Lek Cesk 51:106–108 20. Moxon (1872) Compound dislocation of hip-joint, the bone thrust through skin. Med Times Gaz 1:96 21. Müller ME, Allgöwer M, Schneider R, Willeneger H (1979) Manual of internal fixation, Secth edn. Springer, Berlin 22. Müller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive classification of fractures of long bones. Springer, Berlin 23. Palin HC, Burnley AR (1954) Dislocation of the hip with fracture of the femoral head. J Bone Joint Surg (Br) 36-B:442–444 24. Pipkin G (1957) Treatment of grade IV fracture-dislocation of the hip. J Bone Joint Surg Am 39-A:1027–1042 25. Rehn (1889) Präparat von Querbruch des Condylus externus femoris. Verh Dtsch Ges Chir XVIII Congres, pp 136–137 26. Riedel B (1885) Längsfraktur von Schenkelkopf und –Hals. Bericht über die Verh Dtsch Ges Chir XIV. Congr Beilage Zbl Chir 12(24): 92–93 27. Roberts JB (1896) Iliac dislocation complicated with fracture of the head and neck of the femur and the edge of the acetabulum. Ann Surg 23:207–212 28. Satta F. Cited by Christopher [Christopher F (1924) Fractures of the head of the femur. Arch Surg 12:1049–1061] 29. Smillie IS (1946) Injuries of the knee joint. Livingstone, Edinburgh 30. Tanton J (1916) Fractures en général - Fractures des membres – membre inférieur. JB Baillière, Paris 31. White EA, Matcuk GR, Schein A, Skalski M, Maracek GS, Forrester DM, Patel DB (2015) Coronal plane fracture of the femoral condyles: anatomy, injury patterns, and approach to management of the Hoffa fragment. Injury 44:37–43 32. Znojemský J (1922) Zlomeniny a vymknutí (fracturea et luxationes) pro lékaře a studující [Fractures and dislocations for physicians and students]. Praha, Unie
ORTHOPAEDIC HERITAGE
History of femoral head fracture and coronal fracture of the femoral condyles Jan Bartoníček & Stefan Rammelt
Received: 26 February 2015 / Accepted: 27 February 2015 # SICOT aisbl 2015
Abstract The first known description of the coronal fracture of the lateral femoral condyle was published by Busch in 1869. Hoffa used Busch’s drawing in the first edition of his book in 1888 and accompanied it only with one sentence. A full case history of this fracture pattern was described by Braun in 1891. However, Braun’s article fell into oblivion and so the fracture was popularized only in the fourth edition of Hoffa’s textbook, particularly thanks to the drawing, rather than the brief description. Therefore, a fracture of the posterior femoral condyle, or more specifically, of the lateral condyle, could properly be called BBusch-Hoffa fracture^. Femoral head fracture was initially described by Birkett in 1869. Of essential importance in this respect were the publications by Christopher in 1924 and, particularly, Pipkin’s study of 1957, including his classification that is still in use today. A historically correct eponym for a femoral head fracture would therefore be BBirkitt-Pipkin fracture^.
Keywords History of orthopaedics . Hoffa’ fracture . Pipkin’ fracture . Fracture of femoral head . Coronal fracture of femur condyles
J. Bartoníček (*) Department of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital Prague, U Vojenské nemocnice 1200, 169 02 Prague 6, Czech Republic e-mail: [email protected] S. Rammelt University Center of Orthopaedics and Traumatology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany e-mail: [email protected] S. Rammelt UniversitätsCentrum für Orthopädie & Unfallchirurgie , Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
Introduction Femoral head fractures and coronal fractures of the femoral condyles are rare intra-articular injuries to the femur. They were both described in 1869 and sometimes they are eponymously referred to as Pipkin and Hoffa fractures. However, little is currently known about their true and very interesting history [9, 31]. BHoffa^ fracture Most authors state that the first description of the coronal fracture of the posterior condyle of the femur was reported by Albert Hoffa in 1904 [15]. However, this is a double error. Although Hoffa described this fracture, he was neither the first to do so, nor did he publish this description in 1904. The first known description of this fracture pattern dates back to 1869. It was published by Busch [5] who found a specimen of a knee joint in the anatomical collections of the Department of Surgery in Berlin, which, according to the available information, came from the corpse of a muscular man, who died of the consequences of a severe injury sustained several years before his death. After maceration of the distal femur, a fissure separating the posterior lateral femoral condyle became visible (Fig. 1). Friedrich Busch (1844– 1916) was a pupil of Recklinghausen, Virchow and Langenbeck. In 1875, he was appointed Associate Professor of Surgery and, in 1884, head of the newly opened Institute of Dental Medicine at the Friedrich-Wilhelms-Universität in Berlin. Busch’s drawing was used by Albert Hoffa (1859–1907) in the first edition of his textbook in 1888 [14], without citing the source (Fig. 2). The fracture itself was mentioned by Hoffa in his book in one sentence only and quite vaguely. Twenty years after Busch, at the Congress of the German Surgical Society in 1889, Ludwig Wilhelm Carl Rehn (1849–
International Orthopaedics (SICOT)
Fig. 1 Original drawing of a fracture of the lateral condyle of distal femur published by Busch in 1869 [5]
Fig. 2 Original drawing of a fracture of the lateral condyle of distal femur published by Hoffa in 1888 [14]
1930) presented the case of a 45-year-old man who died of Bphlegmon^ [25]. He had sustained an injury to the knee 16 years before he died. Autopsy revealed an avulsion of the lateral femoral condyle in the coronal plane. A fragment with osteoarthritic changes was displaced posteriorly and proximally. The cruciate ligaments were intact, but the lateral meniscus was severely damaged, as was the posterior lateral condyle of the tibia. During a debate about Rehn’s case, Christian Heinrich Braun (1847–1911) mentioned a similar case, which he subsequently published two years later (1891) [4]. A 48-year-old man sustained an open injury to the left knee joint in a stone quarry. Due to infection, the limb had to be amputated ten days after the injury, which saved the patient’s life. Autopsy of the specimen showed a minimally displaced twofragment fracture of the lateral femoral condyle (Fig. 3). The posterior capsule and the cruciate ligament remained intact. Thus it was Braun [4] who, for the first time, presented details of the injury based on autopsy performed early after injury. In the previous two cases, either basic information was missing (Busch), or the injury was not acute (Rehn), but the common feature of all the three cases was injury to the lateral femoral condyle.
In the following decades, a coronal fracture of posterior condyle of the distal femur was repeatedly mentioned in a number of textbooks on bone and joint trauma [3, 29, 30], but the fracture was not associated with Hoffa’s name. The term Hoffa fracture began to appear at the turn of the 1970s, primarily in the German and French literature, together with descriptions of its modifications. One of the outstanding publications in this respect is the article by Letteneur et al. of 1977 [17] under the title BFractures de Hoffa^, evaluating 20 cases of this fracture and presenting probably its first prognostic classification. The term Hoffa fracture was used also in the second edition of the AO Manual of Internal Fixation, published in 1979 [21]. In the English literature, Letteneur’s classification was popularized by Lewis et al. [18]. The term Hoffa fracture is again mentioned in the English version of AO Classification of Fractures, published in 1990 [22]. In 1996, the AO classification was adopted by the OTA. Since then, this term has been used almost systematically. All publications without exception cite the 4th edition of Hoffa’s book of 1904, presenting this date as the year when fracture of the posterior femoral condyle was initially described. Only in 1994, did Heuschen et al. [12], and more recently Jain et al. [16] in 2015, point out
International Orthopaedics (SICOT) Fig. 3 Original drawings published by Braun in 1891 [4]. Figs. 1 and 2 fracture of the lateral condyle of right distal femur, Fig. 3 fracture of the femoral head, Fig. 4 fracture of the glenoid fossa, Fig. 5 longitudinal fracture of the first cuneiform bone
that it was Busch who first described this fracture in 1869, but they also incorrectly dated Hoffa’s description at 1904.
Pipkin fracture The first to describe a femoral head fracture was John Birkett in 1869 [2]. He presented a case of a 35-year-old woman who sustained a severe injury, after a fall from a window, and died. Autopsy revealed dislocation of the hip in combination with a femoral head fracture. The avulsed fragment of the femoral head, carrying Bthe attachment of the ligament of head of femur (ligamentum capitis femoris, ligamentum teres) remained in the acetabulum^ (Fig. 4). John Birkett (1815– 1904) was an outstanding surgeon and an early specialist in breast diseases, including breast cancer, as well as being an early advocate of histology. In 1850, he published his book on BThe Diseases of the Breast and Their Treatment^. Three years later, in 1872, Moxon [20] described a similar injury in a man hit by a train. Autopsy confirmed iliac dislocation of the hip with partial avulsion of the femoral head
carrying the Battachment of the ligament of the head of the femur^. This fragment remained in the acetabulum. In 1885, Bernhard Moritz Carl Ludwig Riedel (1846– 1916) reported a case of a 15-year-old boy with an injury to the hip [26]. The boy was admitted to the hospital as late as three months after the injury, namely, for persisting iliac dislocation of the hip associated with crepitation. Attempts at closed reduction failed and the boy had to be operated on. After detachment of the greater trochanter, a dislocated femoral head was found, that was split into two parts, both of them outside the acetabulum. An impression was seen at the posterior rim of the acetabulum. A loose fragment was removed and the rest of the femoral head reduced into the acetabulum. The fracture healed but the patient subsequently developed an ankylosis of the hip with a limb shortening of 2 cm. In 1891, Braun [5] described a case of a man hit by a train, who sustained among other injuries an ischial dislocation of the right hip. Reduction was performed easily, but the man died within a few hours. Autopsy revealed a fracture of the femoral head, running across the Bfovea for the ligament of the
International Orthopaedics (SICOT)
Fig. 5 a Fracture of the posterior acetabular rim in the case published by Crile in 1891 [7]. b Fracture of the femoral head in the case published by Crile in 1891 [7]
Fig. 4 a Fracture of femoral head published by Birkett in 1869 [2]. Original legend: BFig. 1.–a. Part of capsular ligament, b. Cotyloid ligament [ligamentum teres, ligamentum capitis femoris], c. Fragment of head of femur in the acetabulum, d. A few fibres of the ligamentum teres^. b Fracture of femoral head published by Birkett in 1869 [2]. Original legend: BFig. 2.–a. Capsular ligament, b. Acetabulum, its bare edge (1) exposed, and the bare surface (2) of os innominatum, c. Fragment of head of femur, d. Cancellous tissue of the head of the femur, e. Cotyloid ligament torn off from edge of acetabulum (1)^
head of the femur and splitting the ligament into two parts^ (Fig. 3), as well as fractures of the glenoid and of the first cuneiform bone. In fact, Braun was the only author to describe a femoral head fracture and coronal fracture of the femoral condyle in one article [5]. In the same year, i.e., in 1891, Crile [7] published a case of a man who sustained fracture of the femoral head and of the posterior rim of the acetabulum after a fatal fall from a height (Fig. 5). In 1896, Roberts [27] described a case of a man who got squeezed between railway carriages and sustained an iliac
dislocation of the hip. Non-operative treatment failed and a fracture of the femoral neck occurred, probably during closed reduction manoeuvre. The fracture was confirmed during surgery that was performed three months after the injury, which also revealed a fracture of the femoral head, which was dislocated outside the acetabulum. As the acetabulum was completely filled with fibrous tissue at the time of surgery, the femoral head had to be resected. The patient died several days after the operation. Autopsy confirmed the intraoperative finding of an additional avulsion of the posterior rim of the acetabulum. Durant and Destot [8], in 1904, were probably the first to diagnose a femoral head fracture using radiographs, namely, in three cases. In 1912, Morávek [19] described a case of a railway worker who, in 1905, fell onto the wheel drag during track maintenance and sustained an injury to the left hip. The injury was treated as a contusion. A radiograph taken as late as seven years after the injury showed that it was a femoral head fracture. In 1923, Hinsdale [13] recorded a case of a woman with an iliac dislocation of the hip, combined with a femoral head
International Orthopaedics (SICOT)
fracture. Closed reduction failed and therefore open reduction was performed and the femoral head fragment, Bcarrying the attachment of the ligament of the head of the femur^, was removed. The patient healed with a very good hip function. Christopher [6] in 1924 published a case of a woman who sustained posterior dislocation of the hip associated with avulsion of the inferior part of the femoral head (Fig. 6). Closed reduction under general anaesthesia was successful. The patient healed with a very good functional result, except for a temporary palsy of the common peroneal nerve, probably caused by the hip dislocation. In his article Christopher also provided a detailed analysis of 14 femoral head fractures published hitherto, to which he added his own case. This analysis substantially contributed to a better understanding of this injury. The patients were divided into two groups. One group comprised nine classical cases with posterior dislocation of the hip and the other group six cases without dislocation of the hip. Of these 15 cases, four injuries were caused by railway accidents. Based on autopsy, radiographs and intraoperative findings, different femoral head fracture patterns were described, namely, in combination with an acetabular fracture, femoral neck fracture during reduction, palsy of the sciatic nerve, etc. Of these 15 patients, six died, four of them immediately after the injury. In total, four
Fig. 6 Fracture of the femoral head in the case published by Christopher in 1924 [6]
patients were operated on, two immediately [13, 28] and the other two, three months after the injury [26, 27]. In three cases the avulsed femoral head fragment was removed and the hip reduced. One case involved resection of the femoral head [27]. Of all the operated patients, one died immediately after surgery [26], two of them [26, 28] developed ankylosis of the hip and in one case [6] the function of the hip was very good. A good functional result in non-operatively treated patients was achieved only by Christopher [13]; in Morávek’s case the function was satisfactory [19], and in the three cases treated by Durand and Destot [8] all patients developed painful incomplete ankylosis. A similar overview was published ten years later (1934) by Henry and Bayumi [10]. In an extensive study focused on hip dislocations associated with ipsilateral femoral fractures, they also dealt with femoral head fractures. They based their work primarily on the study by Christopher, to which they added only one new case described by Nicharelli. The resulting overview presented a comprehensive summary of the current information and knowledge concerning this injury. The first author of this overview, Arnold Kirkpatrick Henry (1886– 1982), later became famous for his book on extensile surgical approaches [11]. Femoral head fracture was mentioned also in some textbooks on bone traumatology, for the first time, most probably, in the book by Tanton [30], in 1916 and then in the book by Znojemský [32], in 1922. On the contrary, a description of femoral head fractures was missing completely in the 9th to 11th editions of Böhler’s textbook that was respected worldwide [3]. In the post-war period, in 1948, Armstrong [1] reported on a total of five patients, all initially treated non-operatively. Good function of the hip was restored in one case only. Two patients required surgery, one and three months after the injury, respectively. However, both of them finally had to be treated by hip arthrodesis. In 1954, Palin and Richmond [23] recorded three cases, all of them associated with posterior hip dislocation and operated on. In one case the femoral head was replaced by the Judet endoprosthesis. In the remaining two cases, excision of the fragment and reduction of the hip joint resulted in development of post-traumatic osteoarthritis, or ankylosis. Garret Pipkin [24] used his own cases and cases of his colleagues to form a group of 25 patients with the follow-up of up to 18 years. In 1957, based on the analysis of this group, he developed the following classification of these fractures: Type 1 Dislocation with fracture of the femoral head caudad to the fovea capitis femoris. Type 2 Dislocation with fracture of the femoral head cephalad to the fovea capitis femoris. Type 3 Type 1 or type 2 injury associated with fracture of the femoral neck.
International Orthopaedics (SICOT)
Type 4 Type 1 or type 2 injury associated with fracture of the acetabular rim. In patients treated operatively, the procedure included excision of the fragment, replacement of the femoral head, and in certain fracture patterns of types 2 and 3 even internal fixation. We have not found any description of internal fixation of the femoral head in older sources. Also, thanks to its publication in the Journal of Bone and Joint Surgery, Pipkin’s study has substantially contributed to the understanding of femoral head fractures. The Pipkin classification has been applied ever since and sometimes his name is used eponymously for these fractures.
Conclusion Based on the above, the first known description of the coronal fracture of the lateral femoral condyle was published by Busch in 1869. Hoffa used Busch’s drawing in the 1st edition of his book in 1888 and accompanied it only with one sentence. A full case history of this fracture pattern was described by Braun in 1891. However, the Braun’s article fell into oblivion and so the fracture was popularized only in the 4th edition of the Hoffa’s textbook, particularly thanks to the drawing, rather than the brief description. Therefore, a fracture of the posterior femoral condyle, or more specifically, of the lateral condyle could properly be called BBusch-Hoffa fracture^. Femoral head fracture was initially described by Birkett in 1869. Of essential importance in this respect were the publications by Christopher of 1924 and, particularly, Pipkin’s study of 1957, including his classification that is still in use today. A historically correct eponym for a femoral head fracture would therefore be BBirkitt-Pipkin fracture^. Acknowledgments The authors would like to express their special gratitude to Prof. Chris Colton, MD and Ms Ludmila Bébarová, PhD for their assistance in editing the manuscript and Ms Ludmila Frajerová, Ms Mirka Plecitá and As. Prof. Patrick Cronier, MD for tracing the original source documents.
References 1. Armstrong JR (1948) Traumatic dislocation of the hip joint. Review of one hundred and one dislocations. J Bone Joint Surg (Br) 30-B: 430–445 2. Birkitt J (1869) Description of a dislocation of the head of the femur, complicated with its fracture. Med Chir Trans 52:133–138 3. Böhler L (1943) Technik der Knochenbruchbehandlungen im Frieden und im Kriege 9.-11. Auflage. Maudrich, Wien 4. Braun H (1891) Seltenere Fracture des Oberschenkels. Arch Klin Chir 42:107–111
5. Busch F (1869) Mehrere Fälle seltener Knochenverletzungen. Arch Klin Chir 10:703–719 6. Christopher F (1924) Fractures of the head of the femur. Arch Surg 12:1049–1061 7. Crile GW (1891) Report of three cases of fractures with fatal termination. Ann Surg 13:373–377 8. Durand D (1903) Les fractures de la tête fémorale. Bul Soc Chir Lyon 6:376–382 9. Guimaräes RP, de Souza GS, da Silva RS, Ono NK, Honda EK, Polesello GC, Riccioli W (2010) Study of the treatment of femoral head fractures. Rev Bras Ortop 45:355–361 10. Henry AK, Bayumi M (1934) Fracture of the femur with luxation of the ipsilateral hip. Br J Surg 22:204–230 11. Henry AK (1945) Extensile exposure. Livingstone, Edinburgh 12. Heuschen UA, Göhring U, Meeder PJ (1994) Die beidseitige HoffaFraktur – eine Rarität. Aktuelle Traumatol 24:83–86 13. Hinsdale G (1923) Fracture of head of femur, with dislocation on dorsum of ilium. J Am Med Assoc 80:469 14. Hoffa A (1888) Lehrbuch der Frakturen und Luxationen für Ärzte und Studierende, Ith edn. Verlag der Stahel'schen Universitäts-Buch& Kunsthandlung, Würzburg 15. Hoffa A (1904) Lehrbuch der Frakturen und Luxationen für Ärzte und Studierende, IVth edn. Enke, Stuttgart 16. Jain SK, Jadaan M, Rahall E (2015) Hoffa’s fracture—lateral mensicus obstructing the fracture reduction—a case report. Injury 46:419–421 17. Letteneur J, Labour PE, Rogez JM, Lignon J, Bainvel JV (1977) Fractures de Hoffa—A propos de 20 observations. Ann Chir 32: 213–219 18. Lewis SL, Pozo JL, Muirhead-Allwood WFG (1989) Coronal fractures of the lateral femoral condyle. J Bone Joint Surg (Br) 71-B:118– 120 19. Morávek A (1912) Odštěpná zlomenina hlavice kosti stehenní [Split fracture of the femoral head]. Cas Lek Cesk 51:106–108 20. Moxon (1872) Compound dislocation of hip-joint, the bone thrust through skin. Med Times Gaz 1:96 21. Müller ME, Allgöwer M, Schneider R, Willeneger H (1979) Manual of internal fixation, Secth edn. Springer, Berlin 22. Müller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive classification of fractures of long bones. Springer, Berlin 23. Palin HC, Burnley AR (1954) Dislocation of the hip with fracture of the femoral head. J Bone Joint Surg (Br) 36-B:442–444 24. Pipkin G (1957) Treatment of grade IV fracture-dislocation of the hip. J Bone Joint Surg Am 39-A:1027–1042 25. Rehn (1889) Präparat von Querbruch des Condylus externus femoris. Verh Dtsch Ges Chir XVIII Congres, pp 136–137 26. Riedel B (1885) Längsfraktur von Schenkelkopf und –Hals. Bericht über die Verh Dtsch Ges Chir XIV. Congr Beilage Zbl Chir 12(24): 92–93 27. Roberts JB (1896) Iliac dislocation complicated with fracture of the head and neck of the femur and the edge of the acetabulum. Ann Surg 23:207–212 28. Satta F. Cited by Christopher [Christopher F (1924) Fractures of the head of the femur. Arch Surg 12:1049–1061] 29. Smillie IS (1946) Injuries of the knee joint. Livingstone, Edinburgh 30. Tanton J (1916) Fractures en général - Fractures des membres – membre inférieur. JB Baillière, Paris 31. White EA, Matcuk GR, Schein A, Skalski M, Maracek GS, Forrester DM, Patel DB (2015) Coronal plane fracture of the femoral condyles: anatomy, injury patterns, and approach to management of the Hoffa fragment. Injury 44:37–43 32. Znojemský J (1922) Zlomeniny a vymknutí (fracturea et luxationes) pro lékaře a studující [Fractures and dislocations for physicians and students]. Praha, Unie
