Femoral head fractures are infrequent injuries, resulting in limited exposure and experience among individual surgeons. While open reduction and internal fixation (ORIF) is generally the preferred treatment for Pipkin type II fractures, there is no universally accepted protocol for managing type I fractures. Treatment challenges include persistent cartilage defects in the weight-bearing zone, particularly in cases with comminution, which may negatively impact long-term outcomes. Additionally, morbidity associated with surgical approaches can influence clinical results. In this context, adjunctive cartilage reconstruction techniques and minimally invasive strategies, such as arthroscopic-assisted fixation, have emerged as promising options to enhance outcomes. This chapter discusses the current landscape of osteochondral repair and the evolving role of arthroscopy in the management of femoral head fractures.