Pipkin type IV fractures are complex injuries involving the femoral head and acetabulum, often requiring a multifaceted treatment approach due to their intricate nature. Management strategies can be either operative or nonoperative, with nonoperative management considered when anatomic reduction of the femoral head fragment is achieved and the hip joint remains stable. Current evidence suggests that these injuries have relatively poor outcomes compared to other Pipkin types. Complications such as infection, sciatic nerve injury, avascular necrosis (AVN) of the femoral head, and heterotrophic ossification are frequently encountered. Surgical techniques emphasize the importance of preserving vascular supply to the femoral head, particularly during capsulotomy, to minimize the risk of AVN. The current chapter delves into the intricacies of Pipkin type IV fractures, encompassing their anatomy, classification, mechanisms, clinical presentation, diagnostic approaches, treatment strategies, potential complications, and prognostic factors, along with relevant case examples.