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To define the unique clinical and radiographic features, operative treatment, and complications of irreducible femoral head fracture-dislocation without associated posterior wall fracture.Retrospective clinical study from a prospectively gathered trauma database.Level I trauma center.During a 6-year period (from January 2000 until August 2006), 72 patients with fractures of the femoral head (OTA 31C) were treated at a level I trauma center. Seven (9.7%) patients had irreducible femoral head fracture-dislocations without associated posterior wall acetabular fractures and underwent operative management.Open reduction and internal fixation of the irreducible femoral head fracture-dislocation with miniature fragment screw fixation using a Smith-Petersen exposure.Clinical and radiographic markers of irreducibility, surgical findings, fixation methods, reduction accuracy, and injury- and treatment-related complications.Standardized postoperative pelvic computed tomography scans revealed that all 7 femoral head fractures were accurately reduced. Two patients with delayed operative management developed femoral head aseptic necrosis and underwent hip arthroplasty.Irreducible femoral head fracture-dislocations without associated posterior wall fractures occur rarely, but are heralded by unique clinical and radiographic features. These patients warrant special consideration in terms of recognition and management. The physical examination findings and specific radiographic markers should alert the surgeon to this injury pattern and its related complications. Closed reduction of this fracture-dislocation should not be attempted. Delayed operative management may be related to femoral head aseptic necrosis. Accurate reduction and stable fixation can successfully be performed through a Smith-Petersen surgical exposure using small or miniature fragment cortical screws alone.