Acta Orthopaedica Scandinavica

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Classification of Trochanteric Fractures

J. Steen Jensen

To cite this article: J. Steen Jensen (1980) Classification of Trochanteric Fractures, Acta
Orthopaedica Scandinavica, 51:1-6, 803-810, DOI: 10.3109/17453678008990877

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Actaorthop. scand. 51,803-810,1980

CLASSIFICATION OF TROCHANTERIC FRACTURES

J. STEENJENSEN

Department of Orthopaedic Surgery T-2, Gentofte Hospital,

Hellerup, Denmark

A comparative analysis of the information contained in five different

classification systems was performed.
The system classifying the fractures into five types in relation to the
comminution of the calcar femorale or greater tmhanter was found to be
superior to the others, as it contained the most reliable information about
the possibility of obtaining stable fracture reduction and gave the most
accurate prediction of the risk of secondary fracture dislocation.
Key words: femoral neck fractures; fractures, classification
Accepted 21.i.80

In a comparison of the results obtained with
different methods of internal fixation in
trochanteric fractures it is essential to take
into consideration how the fractures have
been assessed, as misleading conclusions
might otherwise be drawn.
Numerous follow-up studies have not
classified the fractures at all (Cleveland et al.
1947, 1959, Kennedy et al. 1957, Petersen et
al. 1974, Sahlstrand 1974, Sarmiento 1963,
Taylor et al. 1944, 1955), whereas some series
have divided the fractures into displaced and
undisplaced (Hafner 1951, Rasmussen 1953,
Wade et al. 1959). Another system was based
on the fracture mechanism (Ender 1970,
Ender & Simon-Weidner 1970). As many as
three systems have been developed in which
the fractures are assessed as stable or
unstable in an attempt to describe the
mechanical fixation problems involved in con-
nection with internal fixation procedures.
The first demand on a classification system
is that it should contain valid information
concerning the possibility of obtaining a
primary stable and anatomical fracture reduc-
tion. The second demand is a prediction of
the risk of secondary fracture dislocation
following internal fixation.
0001-6470/80/050803~8$02.50/0
From these premises an evaluation and
comparison of the existing classification
systems was undertaken with the purpose of
selecting the system which most accurately
predicted the prognosis of the fracture treat-
ment.
PATIENTS AND METHODS
During the period January 1st 1978 to June 30th
1979, 234 patients with trochanteric fractures
were treated with the sliding screw-plate internal
fixation system (Clawson 1964, Jensen et al. 1978).
With this type of internal fixation technical failure
as well as secondary impaction of the fractures
following telescoping of the screw are
encountered. Both situations lead to bony support
between the fracture surfaces.
The fractures were assessed from the pre-
operative X-rays using the five classification
systems described in Table 1. The Evans
classification system (1949) as slightly modified by
Jensen & Michaelsen (1975) is illustrated in
Figure 1.
The fracture reduction was evaluated from the
immediate postoperative X-rays. Anatomical
reduction was defined as a maximum diastasis
over the fracture line of 4mm. Fracture diastasis
exceeding the 4mm was looked for medially and
laterally in the AP projection and anteriorly or
posteriorly in the lateral projection.
G! 1980 Munksgaard, Copenhagen
 804 J. STEEN JENSEN

Table 1. Class$cation systems for trochanteric fractures

~~ ~

Primay Dislocation
Type 1: undisplaced
Type 2: displaced
Presence of Medial Comminution
Type 1: stable, i.e. no medial comminution
Type 2: unstable, i.e. dislocated lesser trochanter or larger femoral arch fragment
Enders System (1970)
Type 1: eversion fracture, i.e. posteromedial rotational wedge
Type 2: impaction fracture, i.e. inversion and adduction of neck fragment with varus collapse of the
fracture
Type 3: diatrochanteric fracture, i.e. fracture line extending subtrochanterically or being reversed
Tronoos System (1973)
Type 1: incomplete fracture only involving greater trochanter
Type 2: uncomminuted fracture, with or without slight displacement. Intact posterior wall and
relatively small lesser trochanter fragment
Type 3: comminuted posterior wall with telescoping of neck spike into shaft fragment. Lesser
trochanter fragment large
Type 4: like Type 3, but greater trochanter totally broken off
Types: comminuted posterior wall without telescoping of the two major fragments. Neck spike
displaced outside shaft. Most posterior wall lost medially
Type 6: reversed oblique fracture with medial displacement of shaft. Greater trochanter attached or not
to neck fragment
Evans System (1949)
Type 1: undisplaced 2-fragmentary fracture
Type 2: displaced 2-fragmentary fracture
Type 3: 3-fragmentary fracture without postemlateral support due to dislocated greater trochanter
fragment
Type 4: 3-fragmentary fracture without medial support due to dislocated lesser trochanter or femoral
arch fragment
Type 5 : +fragmentary fracture without medial and postemlateral support. Combination of Types
3 and 4

The fractures were X-rayed regularly until RESULTS

fracture union or technical failure of fixation was
experienced. The occurrence of technical failure as A review of the different classification
well as telescoping of the implant with secondary systems is presented in Table 2. T h i s is
impaction were registered. Technical failure was
defined as bending or loosening of the implant and based on the preoperative X-rays and related
cutting or penetration of the screw through the to the quality of fracture reduction as seen in
bone. Secondary dislocation was defined as the immediate postoperative X-rays.
impaction or varus displacement due to technical Applying a step-wise information analysis
failures or impaction due to telescoping of the the Evans classification system was found to
implant.
Statistical analysis of the data was applied. An contain the most reliable information
information analysis was performed by multi- (P < 0.00005) about the possibility of
dimensional contingency tables adding variables in achieving anatomical reduction of the
steps and comparing in relation to Kullbacks in- different fracture types. Having excluded the
formation measure (1959). For each step of the Evans system the next step of the analysis
analysis the significance of the information
contained was calculated. In addition a multiple revealed that the second best system was one
contingency table analysis was performed with considering only the primary dislocation of
successive testing as described by Madsen (1976). the fracture (P< 0.00005). The remaining
 CLASSIFICATION OF TR(3CHANTERIC FRACTURES 805
STABLE reduced in both planes. The instability of this
fracture type is caused mainly by the
difficulty of obtaining reduction in the lateral
plane, which was the case in 64 per cent
(61/95). In 28 per cent (27/95) this was
combined with a medial diastasis. Among
fractures with detachment from the calcar
femorale (Type 4) only 21 per cent (6/28)
could be anatomically reduced in both planes.
undisplaced displaced
The main problem is the postoperative
2-fragmentary fract 2-fragmentary fract
medial diastasis encountered in 64 per cent
(18/28) of cases. Type 5 fractures with
UNSTABLE detachment of both trochanters could be
anatomically reduced in only 8 per cent (6/77)
of cases, whereas fracture diastasis was
encountered in 69 per cent (53/77) in both
planes.
Table 3 compares the preoperative
classification according to the different
systems with the secondary fracture disloca-
, . tion, as evaluated from the h a l X-rays. The
3-fragmentary fract. without posterolatcral support
step-wise information analysis was repeated
and confirmed that the Evans classification
system was significantly the most informative
also in this respect (P<O.O18). In the second
step of the analysis the second best system
was again that based on the primary fracture
dislocation (P<0.00005). No additional in-
formation was contained in the remaining
systems (P<0.1335) according to the subse-
I '
quent steps of the analysis.
3-fragmentary fract.
without medial support &-fragmentary fract.
Stable 2-fragmentary fractures (Types 1
and 2 in the Evans system) were followed by
Figure 1. Class$cation of trochanteric fractures secondary dislocation in 9 per cent (3/34) of
according to Evans (1949) as modijied by Jensen cases, whilst Type 3 fractures dislocated in
W Michaelsen (1975). 58 per cent (55/95), mainly due to fracture
diastasis in the lateral plane or bi-plane
systems did not give any significant informa- diastasis. Lack of medial support (Type 4) led
tiOn in the subsequent steps of the analysis to secondary dislocation in 61 per cent
(P=O.3539). (17/28) of cases. This was caused by medial
It appears from Table 2 that the stable 2- or bi-plane diastasis in 83 per cent (15/17).
fragmentary fractures (Types 1 and 2 Secondary dislocation occurred eventually in
according to Evans) can be anatomically 78 per cent (60/77) of the highly comminuted
reduced in both planes in 94 per cent (32/34) &fragmentary fractures (Type 5). In 80 per
of cases. The remaining three fracture types cent (48/60) of cases these dislocations were
in the Evans system are all considered caused by fracture diastasis in both planes.
unstable. Of the fractures with detachment of The Evans classification system thus
a greater trochanter fragment (Type 3) only revealed a grading which included a decreas-
33 per cent (31/95) could be anatomically ing possibility of anatomical reduction and an
806 J. STEEN JENSEN

Table 2. Classijication of trochanteric fractures in relation to the quality of reduction

Anatomical Fracture Fracture Fracture

reduction diastasis diastasis diastasis
in both in lateral in AP- in both
Type Number planes plane plane planes
Primary Dislocation
1 41 (18%) 30 (73 90) 7 4 0
2 193 (82 %) 45 (23 7%) 43 18 87 (45 lo)
Medial Comminution
1 139 (59 %) 63 (45 %) 39 6 3 1 (22 90)
2 95 (41 %) 12(13%) 11 16 56 (59 %)
Ender system
1 114 (49 90) 49 (43 %) 18 13 34 (30 70)
2 106 (45 %) 23 (22 %) 31 6 46 (43 l o )
3 14( 6%) 3 (21 90) 1 3 7 (50 7 0 )
Tronao system
1 2 1 1 0 0
2 106 (45 %) 59 (56 90) 23 10 14(13 90)
3 33 (14%) 4(12%) 4 4 21 (64 5%)
4 52 (22 %) 6(12%) 18 5 23 (44%)
5 a(17%) 5 (13 %) 4 3 28 (70 l o )
6 1 0 0 0 1
Evans system
1 25 (11 %) 24 (96 %) 1 0 0
2 9( 490) 8 (89 %) 1 0 0
3 95 (41 %) 31 (33 %) 34 3 27 (28 70)
4 28 (12 %) 6(21%) 4 11 7 (25 l o )
5 77 (33 %) 6 ( 8%) 10 8 5 3 (69 %)

increasing risk of secondary dislocation Rasmussen 1953, Wade et al. 1959). This
(P< 0.01, Spearman-test). leads to fairly reliable information about the
A multiple contingency table analysis was fracture reduction and the risk of secondary
applied and revealed that the fracture types dislocation. More than 80 per cent of the
according to Evans determined the quality of fractures will be in the risk group, however,
reduction (P< 0.00005). The comminuted and consequently the system does not give
fractures were thus more difficult to reduce. sufficient grading.
In the continuation of the analysis it Ender (1970) described a system based on
appeared that secondary dislocation was the fracture mechanism in connection with
determined by the quality of the reduction his own method of internal fixation with
(P< 0.00005). This meant that secondary dis- condylocephalic nails (Ender 1970, Ender &
location depended solely on the quality of Simon-Weidner 1970, Kapral 1976,
reduction and not on the fracture type as Poigenfiirst & Schnabl 1977). According to
such. the present analysis this system does not give
any reliable prediction of the instability of
DISCUSSION reduction or secondary fracture dislocation as
it does not differentiate sufficiently.
The simplest possible method of classifying The mechanical importance of the calcar
trochanteric fractures is to divide them into femorale has been pointed out in numerous
displaced and undisplaced (Hafner 1951, reports, leading to a classification based on
 CLASSIFICATION OF TROCHANTERIC FRACTURES 807
Table 3. Class$cation of trochanteric fractures in relation to secondary fracture dislocation

Secondary Dislocation in Relation to Reduction

Anatomical Diastasis Secondary
reduction lateral Diastasis Diastasis Technical dislocation
Type both planes plane AP-plane both planes Telescoping failure total
Primary Dislocation
1: 41 1( 3%) 5( 71%) 4(100%) 0 9 1 10( 24%)
2:193 5 (11%) 27( 63%) 12( 67%) 81( 93%) 118 13 125 ( 65 %)
Medial Comminution
1:139 3( 5%) 28( 72%) 5( 83%) 29( 94%) 61 7 65( 47 70)
2: 95 3 (25%) 4( 36%) 11( 69%) 52( 930/0) 66 7 70( 74%)
Ender system
1:114 4( 8 % ) 10( 5670) 10( 77%) 31( 91%) 50 8 55( 4870)
2:106 0 21( 68%) 4( 67%) 44( 96%) 66 6 69 ( 65 %)
3: 14 2 (6770) 1 2( 67%) 6( 86%) 11 0 11( 79%)
Tronso system
1: 2 - 1 - - 1 - 1( 50%)
2:106 5( 8%) 16( 70%) 9(90%) 13( 93%) 41 4 43 ( 41 %)
3: 33 1 (25 70) 1 ( 25%) 3(75%) 19( 90%) 23 2 24 ( 73 %)
4: 52 - 11(61%) 3(60%) 22( 96%) 32 5 36( 6970)
5: 40 - 3( 75%) 1(33%) 26( 93%) 29 3 30( 75 70)
6: 1 - - - 1 1 - 1 (100%)
Evans system
1: 25 1( 4%) 1(100%) - - 1 1 2( 8%)
2: 9 - 1(100%) - - 1 - 1( 11%)
3: 95 2( 6%) 24( 71%) 3(100%) 26( 96%) 51 7 55( 5670)
4: 28 1 (17%) 1( 25%) 8 ( 73%) 7(100%) 16 1 17( 61 70)
5: 77 2 (33 70) 5( 63%) 5( 63%) 48( 91%) 58 5 60( 78%)

the medial comminution (Harrington 1975,
Jacobs et al. 1976, Johnson et al. 1968,
Kumar 1973, Laros & Moore 1974, Massie
1962, 1964, Murray & Frew 1949, Niemann
& Mankin 1968, Rennie & Mitchell 1976,
Sarmiento 1967, Sarmiento & Williams 1970,
Scott 1951). This classification does not take
into account the postero-lateral instability
caused by the difficulty obtaining sufficient
reduction of the fractures in the lateral plane.
Consequently this system was not found to
be sufficiently reliable.
The classification system originally
described by Boyd & Griffin (1949) and later
modified by Tronzo (1973) has only been
used in a few publications (Bosacco et al.
1973, Boyd & Andersson 1961, Ecker et al.
1975). Tronzo considered both the medial and
the postero-lateral instability. The gradings
involve an increasing degree of instability but
35
the system is rather complicated and in the
present analysis the Tronzo system did not
prove to be reliable enough in the prediction
of the risk of unstable fracture reduction and
secondary fracture dislocation.
The classification of Evans (1949) is rather
simple and based on the presence of
mechanical instability as related to
detachments from the lesser or greater
trochanter. This system has been used in
numerous publications (Bremner & Graham
1958, Clawson 1957, 1964, Cram 1955,
Cuthbert & Howat 1976, Dimon 1973,
Dimon & Hughston 1967, Evans 1949, 1951,
Foster 1958, Friedenberg et al. 1972,
Hamngton & Johnston 1973, Horn & Wang
1964, Jensen & Michaelsen 1975, Jensen et al.
1978, Jensen & Some-Holm 1980, Kuderna
et al. 1976, Kyle et al. 1979, Lowell 1966,
Morrison et al. 1978, Parker 1955, Robey
808 J. STEEN JENSEN
1956). The Evans classification system has
been slightly modified by Jensen &
Michaelsen (1975) who based the assessment
on the primary X-rays after the accident and
reduced the number of types from 6 to 5 by
including the extremely rare fracture with a
reversed oblique fracture line and large
greater trochanter fragment into Type 3.
The essential result of the present com-
parison of the classification systems is that
the modification of the Evans system offers
the best prediction of the possibility of
obtaining reliable anatomical reduction and
the risk of secondary fracture dislocation.
From the present series a new classification
system could be invented based on three
classes. The first class would include the
stable 2-fragmentary fractures (Types 1 and 2
according to Evans), which can be
anatomically reduced in both planes. The
second class would contain fractures (Types 3
and 4 according to Evans) in which it is
difficult to obtain reduction in one plane and
the third class those with difficulty of
reduction in both planes (Type 4 according to
Evans). Such a classification system would be
consistent with the present analysis which
revealed a clear correlation between the
fracture type and the possibility of fracture
reduction and that mechanically unreliable
fracture reduction was significantly related to
secondary fracture dislocation. With five
existing classification systems, however, there
is no need for a new system. It is considered
of greater importance to apply one of the
existing systems so that the results of the
fracture treatment can be compared. In this
respect the classification system described by
Evans with slight modifications (Figure 1) is
the system of choice.
Only the sliding screw plate system
(Clawson 1964, Jensen et al. 1978) which
allows secondary impaction was considered in
the present series. With this fixation method
secondary fracture dislocation is possible in
all cases with fracture diastasis, leading to the
establishment of bony support. In other
methods of internal fixation a secondary
fracture dislocation always involves either
failure of the osteoporotic bone of the femoral
head or neck or technical failure of the
implant. A fairly true picture of the instability
of the fracture is assumed to be encountered
in the present series, although a fracture
diastasis of up to 4mm was accepted in the
definition of anatomical reduction. This
might explain why 8 per cent (6/75)of the
anatomically reduced fractures dislocated
secondarily.
In conclusion, the Evans classification
system (1949)in the present modification was
found to give the most reliable prediction of
the instability of reduction and the risk of
secondary fracture dislocation of trochanteric
fractures and should thus be mandatory in
any analysis of the internal fixation of these
fractures.
ACKNOWLEDGEMENTS
This study was kindly supported by Nordisk
Gjenforsikrings Jubilaeumsfond. Gratitude is
expressed to Sv. Kreiner-Meller (cand. stat.),
Department for Data Processing, Herlev Hospital,
for the statistical aid.
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