Transchondral and impaction injuries of the femoral head are rare but significant injuries often associated with high-energy trauma such as hip dislocations. These fractures, which may involve chondral or subchondral bone, are challenging to diagnose due to their subtle presentation and frequent association with other injuries. Advanced imaging techniques like high-resolution CT scans and MRI arthrograms are crucial for accurate diagnosis and treatment planning. Management strategies range from conservative treatment for minor, non-weight-bearing lesions to joint preservation surgeries, including chondroplasty, microfracture, autologous chondrocyte implantation, and osteochondral grafting, for larger or symptomatic defects. In severe cases, especially those involving a large area and where the disease has progressed to osteonecrosis or advanced arthrosis, total hip arthroplasty is indicated. Early detection and tailored treatment are critical to prevent complications such as posttraumatic osteoarthritis and ensure optimal joint function. Continued advancements in hip preservation techniques promise improved outcomes with reduced morbidity and enhanced quality of life for affected patients.