Franck Mabesoone

7/21/2019 Franck Mabesoone

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Franck MabesooneDepartment of Orthopaedics and Traumatology,Hpital Piti-Salptrire- F-75013 Paris, France

INTRODUCTION

Over the past 50 years, much has been published on the different methods for the fixationof trochanteric fractures. In order to appreciate the results, one needs to understand thefracture patterns involved. Many classification systems have been devised; however, sinceeach has had a different object, none has been unanimously adopted by the orthopaediccommunity. Some of the systems proposed have confined themselves to a simpleanatomical description of the patterns observed (Evans; Ramadier; Decoulx and Lavarde).Other, more recent, systems were designed to provide prognostic information on theprospect of achieving and maintaining reduction of the different types of fractures (Tronzo;Ender; Jensen's modification of the Evans grading; Mller et al.).

In present-day surgical practice, it is important to know whether a fracture is stable orunstable: The answer to this question will guide the reduction technique, the type of fixationto be used, and the postoperative management. A good classification must provideinformation on the fracture's potential of being anatomically reduced, with good appositionof the fragments. Also, it should be possible to tell, in the light of the classification, whethera particular fracture is likely to become secondarily displaced after fixation; this informationmust be available before the patient is allowed to weight-bear. This new approach has madeit possible to develop fixation hardware whose design takes account of the biomechanicalproperties of fractures, in order to arrive at more dynamic modes of fixation. Finally, anyclassification system that aspires to universal adoption must be easy to use andreproducible; only if these criteria are met can it facilitate communication among surgeons.

After the first papers showing the superiority of the surgical treatment of trochantericfractures over other management modalities, attempts were made to classify the differentfracture types in the light of the various authors' first experience with internal fixation. Areview of the literature shows many proposed classification systems (see Table above).Some of these will discussed in greater detail in this review article, either because they are

widely used, or because they provide important anatomical or biomechanical information.

THE EVANS CLASSIFICATION(Fig. 1)
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Figure 1 Evans' classificationType I: Undisplaced 2-fragment fractureType II: Displaced 2-fragment fractureType III: 3-fragment fracture without posterolateral support, owing todisplacement of greater trochanter fragmentType IV: 3-fragment fracture without medial support, owing to displacedlesser trochanter or femoral arch fragmentType V: 4-fragment fracture without posterolateral and medial support(combination of Type III and Type IV)R: Reversed obliquity fracture

As early as 1949, EM Evans devised a classification system that had the twin meritsof reproducibility and ease of use. It has been widely used in the English-speaking

countries. In this system, fractures of the trochanteric region are subdivided into five

types. The first two types are two-fragment fractures, with a fracture line runningparallel to the intertrochanteric line, without separation of the trochanters. The

fractures may be undisplaced (Type I)or displaced (Type II). Type IIIis a three-fragment fracture, without posterolateral support owing to displacement of the greater

trochanter. Type IValso has three fragments; however, in this type, there is no medial

support, because of displacement of the lesser trochanter or fracture of the medialarch. In the four-fragment fracture (Type V), there is neither medial nor posterolateral

support, since the comminution involves the greater and the lesser trochanter.

Evans also described a fracture with a subtrochanteric fracture line that runs obliquelyupwards and inwards; he called this pattern a reversed obliquity fracture. The

mechanical properties of this pattern are worth noting: Reversed obliquity fractures

are inherently unstable. The femoral shaft tends to displace medially by the downward


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and outward sliding of the greater trochanter; fixation, especially by sliding screws, is

incapable of controlling this displacement.

The modified grading proposed by Jensen and Michaelson in 1975 was intended toimprove the predictive value of the Evans system, to indicate which fractures could be

reduced anatomically and which were at risk for secondary displacement after

fixation. An analysis, published in 1980, of the reduction of fractures in 234 patientsmanaged with sliding screw-plate internal fixation made it possible for the number of

patterns to be reduced to three, the criterion being reducibility. Class Iincludes two-fragment fractures, which are considered stable. A study of this pattern shows that

such fractures may readily be reduced in the coronal and the sagittal plane. Class

IIcontains Evans Type IIIand Type IVfractures, which are difficult to reduce ineither the coronal or the sagittal plane; while Class III(Evans Type V) consists of

very unstable fractures, which are difficult to reduce in both planes. In the light of a

comparison with four other grading systems, the authors showed that this modified

Evans system had the best predictive value regarding the reduction potential, andwould, therefore, also indicate the likely risk of secondary displacement of the

different fractures.

THE RAMADIER CLASSIFICATION(Fig. 2)


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Figure 2 Ramadier's classificationa: Cervico-trochanteric fracturesb: Simple pertrochanteric fracturesc: Complex pertrochanteric fracturesd: Pertrochanteric fractures with valgus displacemente: Pertrochanteric fractures with an intertrochanteric fracture linef: Trochantero-diaphyseal fractures

g: Subtrochanteric fractures

Decoulx and Lavarde's classification (1969)Cervico-trochanteric fractures (a)Pertrochanteric fractures (b,c,d)Subtrochanteric fractures (e)Subtrochantero-diaphyseal fractures (f)

In 1956, Ramadier established a grading system that came to be widely used inFrance. He described four basic patterns, under four main headings, as a function ofthe fracture line. He recognized cervico-trochanteric fractures (a), with a fracture line

at the base of the femoral neck. According to Ramadier and Bombard, these fracturesaccount for 27% of all the fractures in the trochanteric region. The fractures areusually impacted, and the displacement of the fragments produces a coxa vara

deformity and internal rotation. Simple pertrochanteric fractures (b)account for 24%

of trochanteric fractures; they have a fracture line that runs parallel to theintertrochanteric line; frequently, the lesser trochanter is broken off. The greater

trochanter is not, or only marginally, involved. Complex pertrochanteric fractures (c),which account for 31% of all fractures in the region, have an additional fracture line

that separates most of the greater trochanter from the femoral shaft; the lesser

trochanter is often fractured. There will be a greater or lesser amount of displacement.Ramadier described two infrequently encountered patterns: Pertrochanteric fractures

impacted in a valgus displacement (d), with a fracture line that begins on the greater

trochanter and finishes below the lesser trochanter; and low pertrochantericfractures (e). Trochantero-diaphyseal fractures (f), which make up 10% of all fractures

in the region, have a fracture line that follows a spiral line through the greatertrochanter and into the proximal shaft. Often, the pattern contains a third fragment;

there may be major displacement. Subtrochanteric fractures (g)have a more or less

horizontal fracture line that runs below the two trochanters. Displacement may besubstantial: The proximal fragment is put into flexion by the action of the iliopsoas,

and the shaft fragment tends to drop backwards.

Decoulx and Lavarde (1969) enhanced the above system by the addition of a further

pattern that had previously been described by Ehalt - a trochanteric fracture with a

more distal fracture line, which is slightly concave proximally and which crosses the

intertrochanteric line just above the lesser trochanter. They called this pattern anintertrochanteric fracture, and made it part of a five-grade classification: cervico-trochanteric fractures; pertrochanteric fractures; intertrochanteric fractures;

subtrochantero-diaphyseal fractures; and subtrochanteric fractures (Fig. 2).

THE BRIOT CLASSIFICATION(Fig. 3)


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Figure 3 Briot's

grading ofdiaphyseo-trochanteric

fracturesA Evans' reversed

obliquity fractureB "Basque roof"fracturesC Boyd's "steeple"fractureD Fractures with anadditional fractureline ascending to theintertrochanteric lineE Fractures withadditional fracturelines radiating

through the greatertrochanter

In 1980, Briot tried to simplify the Ramadier system and to introduce biomechanicalconcepts. He merged the cervico-trochanteric and the pertrochanteric fractures. In hisopinion, a fracture at the base of the neck, with a line running parallel to the

intertrochanteric line and medial to the iliofemoral ligaments, was as difficult to fixateand reduce as were pertrochanteric fractures with a line lateral to these ligaments. To

the previous system, Briot added fractures with an oblique line running upwards andinwards; however, by definition, he excluded subtrochanteric fractures, because they

do not affect the trochanters, and because the mechanical problems involved in thispattern are totally different, even where these fractures are associated withundisplaced fractures of the greater trochanter or a detachment of the lessertrochanter. In this way, Briot established three well-defined patterns of trochanteric

region fractures:

(1)pertrochanteric fractures with a fracture line running parallel to the

intertrochanteric line, which may detach a posterior cortical fragment (this lesion willbe discussed further below). Under the same heading, Briot considers pertrochantero-

diaphyseal fractures with a downward and inward slanting line that continues distal to

the lesser trochanter.

(2)the intertrochanteric fractures described by Decoulx;


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(3)diaphyseo-trochanteric fractures (Fig. 3)with a fracture line running upwards and

outwards that extends to, but not beyond, the intertrochanteric line. One pattern in this

group would be Evans' reversed obliquity fracture; while the fracture line may also

turn back and continue downwards along the intertrochanteric line, to produce thesteeple-shaped pattern described by Boyd.

THE ENDER CLASSIFICATION(Fig. 4)


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Figure 4 Ender's classificationTrochanteric eversion fractures-1 Simple fractures-2 Fractures with a posterior fragment-3 Fractures with lateral and proximal displacementTrochanteric inversion fractures-4 With a pointed proximal fragment spike-5 With a rounded proximal fragment beak-6 Intertrochanteric fracturesSubtrochanteric fractures-7 and 7a Transverse or reversed obliquity fractures-8 and 8a Spiral fractures

Some authors have adopted a more pragmatic approach: Instead of merely describing

the patterns of trochanteric fractures, they have analysed the potential for achieving

reduction potential and for the maintenance of reduction following fixation.

In 1970, HG Ender, in his description of a technique for condylocephalic nailing, gavea fracture grading system based upon the fracture mechanism. The first type is

represented by eversion fractures, with an anterior opening of the fracture site (1),sometimes involving the separation of a posterior fragment (2). In this group, Ender

described fractures with substantial lateral and posterior displacement of the distal

fragment (3), which shows that major soft tissue damage has occurred, resulting insevere instability.

The second group consists of impaction (inversion and adduction) fractures ;

typically, the distal medial beak of the neck fragment is impacted in the metaphysis (4

and 5).

The last two groups are intertrochanteric fractures (6)and subtrochanteric fractures (7and 8).

Ender felt that a knowledge of the fracture mechanism was useful when it came to

performing external reduction manoeuvres before doing closed nailing using hishardware. As a result, the Ender grading system has been applied only in conjunction

with Ender's condylocephalic nailing system.

THE AO CLASSIFICATION(Fig. 5)


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Figure 5 AO classificationA1: Simple (2-fragment) pertrochanteric area fracturesA1.1 Fractures along the intertrochanteric lineA1.2 Fractures through the greater trochanterA1.3 Fractures below the lesser trochanter

A2: Multifragmentary pertrochanteric fracturesA2.1 With one intermediate fragment (lesser trochanter detachment)A2.2 With 2 intermediate fragmentsA2.3 With more than 2 intermediate fragmentsA3: Intertrochanteric fracturesA3.1 Simple, obliqueA3.2 Simple, transverseA3.3 With a medial fragment

The AO classification, proposed by Mller et al. in 1980-1987, attempts to be

descriptive and to provide prognostic information, in the light of what can be done

with present-day fixation techniques. Type A fractures are fractures of thetrochanteric area. These fractures are divided into three groups.


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Group A1 contains the simple (two-fragment) pertrochanteric fractures whose fracture

line runs from the greater trochanter to the medial cortex; this cortex is interrupted in

only one place. There are three subgroups, reflecting the pattern of the medial fracture

line: A1.1 fractures run above the lesser trochanter; A1.2 fractures have calcarimpaction in the metaphysis; while A1.3 fractures are trochantero-diaphyseal fractures

that finish up distal to the lesser trochanter.

The fractures in Group A2 have a fracture line pattern identical to that of Group A1

fractures; however, the medial cortex is comminuted. They are subdivided into A2.1fractures, with one intermediate fragment; A2.2 fractures, with two fragments; and

A2.3 fractures, with more than two intermediate fragments.

Group A3 fractures are characterized by a line that passes from the lateral femoral

cortex below the greater trochanter to the proximal border of the lesser trochanter;

often there is also an undisplaced fracture separating the greater trochanter. A3.1

fractures are reverse intertrochanteric fractures (with an oblique fracture line); whileA3.2 fractures are transverse (intertrochanteric). A3.3 fractures involve the

detachment of the lesser trochanter, and are notoriously difficult to reduce and

stabilize.

SOURCES OF INSTABILITY

The mechanical rle of the medial arch, and the implications of its failure introchanteric fractures, have been stressed in a number of papers. In particular, Evans

has drawn attention to medial arch compromise as a source of instability. His own

Types IV and V are the most unstable patterns. If the calcar is involved, there will beinstability in the coronal plane. There is less agreement on the extent to which

stability is affected by lesser trochanter fractures.

Some authors think that medial stability is usually preserved if only the lessertrochanter is fractured, since the structure described as a "massive cancellous

apophysis behind the calcar" does not have a major weight-bearing function.

In 1964, Ottolenghiin distinguished between intradigital fractures, whose fracture line

is medial to the digital fossa of the greater trochanter, and extradigital fractures (Fig.

6).


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Figure 6Extradigital fracture line (Ottolenghi)

posterior openingFrom above

The latter, whose line is more lateral than in the usual patterns, will leave all therotator insertions on the proximal fragment. Displacement of the neck and trochanter

fragment in external rotation will open up the fracture at the back; reduction must beachieved by external rotation of the shaft fragment.

The detachment of the posterior portion of the greater trochanter may also pose majorproblems. It has been held responsible for difficult reduction in the sagittal plane.

Boyd and Griffin (1949) were the first to consider the instability of trochantericfractures in the coronal as well as the sagittal plane. This concept was also embodiedin the classification established by Tronzo in 1973. Among Tronzo's patterns, there

are three involving an explosion of the posterior wall (Fig. 7):

Figure 7Tronzo's classification

Posterior viewType 3 | Type 3 Variant | Type 4Fractures with posterior comminution


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In the first, the neck spike is telescoped into the shaft fragment, and there is a largelesser trochanter fragment. In the second, the greater trochanter is also totally broken

off; while, in the third, the neck spike is not telescoped into the shaft, but is displaced

medial to the shaft. This grading system gives a good indication of the degree ofinstability of a given fracture, from lack of medial and/or posterior support. However,

the system may be somewhat too complex for wider use.

Briot studied the way in which the posterior wall of the trochanteric region affects the

stability of trochanteric fractures. Damage to the posterior wall is a major source ofsagittal instability, and, in particular, external rotation. From cadaver studies, Briot

found that the fracture may detach a posterior plate, situated between the lateral lip of

the linea aspera and the spiral line, comprising the intertrochanteric crest and thelesser trochanter. This plate may be completely avulsed, sometimes with additional

fractures lines; equally, it may be separated from the femur in its upper part (Fig. 8).

Figure 8Briot's posterior plate fracturesBriot's posterior plate fractures

a Boundaries of posterior plateb Maximum extent of platec Possible fracture lines

It is thought that this posterior comminution causes malunion in external rotation.

Ender described this fracture, with detachment of a posterior fragment, among hisType 2 fractures in external rotation; however, he stressed the rle of the soft tissuelesions in his Type 3 fractures.

CONCLUSION

The different classification systems devised to date for the grading of trochantericfractures contain several points that are of importance in the analysis of radiographs of

such fractures.

Stable two-fragment fractures, with a pertrochanteric or a paratrochanteric(basicervical) line, may be considered as one category, since their grading, reduction,

and stabilization are straightforward.


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Two factors must be considered in the assessment of stability: loss of medial support,

as a result of a separation of the lesser trochanter in association with a fracture of the

medial arch; and comminution of the posterior cortex, which is frequently associated

with a separation of the greater trochanter. The fracture must be reduced in internalrotation, to close the anterior gap and to replace the posterior cortical fragments.

One fracture pattern warrants separate consideration - the reversed obliquity fracturedescribed by Evans. This fracture is similar to subtrochanteric fractures, in that it is

difficult to reduce and causes major instability.

This review does not attempt to draw up yet another classification. Such an attemptwould not be very productive, since there is no such thing as a perfect system for thegrading of trochanteric fractures. Any system to be used in traumatology needs to be

simple, and precise enough to produce the same results when used by different

observers, or by the same observers at different points in time . Equally, it must be go

beyond a mere description, to provide predictive information regarding the stabilitypotential of the various fracture patterns.

Evans' classification (1949)Type I: Undisplaced 2-fragment fractureType II: Displaced 2-fragment fractureType III: 3-fragment fracture without posterolateral supportType IV: 3-fragment fracture without medial support,Type V: 4-fragment fracture without posterolateral and medialsupportReversed obliquity fracture

Boyd and Griffin's classification (1949)Linear intertrochanteric line fracturesIntertrochanteric line fractures with comminutionSubtrochanteric fracturesFractures of the trochanteric region and the proximal shaft

Ramadier's classification (1956)(a) Cervico-trochanteric fractures(b) Simple pertrochanteric fractures(c) Complex pertrochanteric fractures(d) Pertrochanteric fractures with valgus displacement(e) Pertrochanteric fractures with an intertrochanteric fracture

line(f) Trochantero-diaphyseal fractures(g) Subtrochanteric fractures

Decoulx & Lavarde's classification (1969)Cervico-trochanteric fracturesPertrochanteric fracturesIntertrochanteric fracturesSubtrochanteric fracturesSubtrochantero-diaphyseal fractures

Ender's classification (1970)

Trochanteric eversion fracturesType 1: Simple fracturesType 2: Fractures with a posterior fragment


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Type 3: Fractures with lateral and proximal displacementTrochanteric inversion fracturesType 4: With a pointed proximal fragment spikeType 5: With a rounded proximal fragment beakIntertrochanteric fractures :Type 6Subtrochanteric fracturesTypes 7 and 7a: Transverse or reversed obliquity fractures

Types 8 and 8a: Spiral fractures

Tronzo's classification (1973)Type 1: Incomplete fracturesType 2: Uncomminuted fractures, with or without displacement;both trochanters fracturedType 3: Comminuted fractures, large lesser trochanter fragment;posterior wall exploded; neck beak impacted in shaftType 3 Variant: As above, plus greater trochanter fractured offand separatedType 4: Posterior wall exploded, neck spike displaced outsideshaft

Type 5: reverse obliquity fracture, with or without greatertrochanter separation

Jensen's classification (1975)Displaced or undisplaced stable 2-fragment fracturesUnstable 3-fragment fractures with greater or lesser trochanterfracture4-fragment fractures

Deburge's classification (1976)Cervico-trochanteric fracturesPertrochanteric fractures

Intertrochanteric fracturesSubtrochanteric fracturesTrochantero-diaphyseal fractures

Briot's classification (1980)(1) Pertrochanteric fractures- simple- with posterior wall explosion- extending into the shaft(2) Intertrochanteric fractures(3) Diaphyseo-trochanteric fractures- Evans' reversed obliquity fracture- "Basque roof" fractures- Boyd's "steeple" fracture- fractures with an additional line ascending to theintertrochanteric line- Fractures with additional fracture lines radiating through thegreater trochanter

AO classification (1981)Group A1: Simple (2-fragment) pertrochanteric areafracturesA1.1 Fractures along the intertrochanteric lineA1.2 Fractures through the greater trochanterA1.3 Fractures below the lesser trochanterGroup A2: Multifragmentary pertrochanteric fracturesA2.1 With one intermediate fragmentA2.2 With 2 intermediate fragments


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A2.3 With more than 2 intermediate fragmentsGroup A3: Intertrochanteric fracturesA3.1 Simple, obliqueA3.2 Simple, transverseA3.3 With a medial fragment

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