Infra-foveal femoral head fractures, commonly referred to as Pipkin type I fractures, are rare but severe injuries typically resulting from high-energy trauma, such as motor vehicle accidents. These fractures often occur in conjunction with posterior hip dislocations and require prompt diagnosis and management to optimize outcomes. Imaging modalities, including radiography, computed tomography (CT), and, in select cases, magnetic resonance imaging (MRI), play a crucial role in assessment and treatment planning. Management options range from conservative treatment in select cases to surgical interventions, including open reduction and internal fixation (ORIF), fragment excision, arthroscopic-assisted techniques, and, in elderly patients with significant joint damage, total hip arthroplasty. Surgical approaches, such as anterior, anterolateral, posterior, and medial approaches, each have specific indications and risks, with selection guided by fracture morphology and surgeon expertise. Advances in arthroscopic management and minimally invasive techniques offer promising alternatives for preserving joint function while minimizing morbidity. Despite improvements in treatment strategies, complications such as avascular necrosis, heterotopic ossification, and posttraumatic osteoarthritis remain concerns. Early diagnosis, appropriate intervention, and individualized treatment strategies are crucial for optimizing functional outcomes and long-term prognosis. Future research should focus on refining management algorithms, enhancing arthroscopic techniques, and defining precise parameters for selecting between conservative and surgical approaches.