Franck Mabesoone

Department of Orthopaedics and Traumatology,

Hôpital Pitié-Salpétrière- F-75013 Paris, France
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Over the past 50 years, much has been published on the different methods for the fixation of
trochanteric fractures. In order to appreciate the results, one needs to understand the fracture patterns
involved. Many classification systems have been devised; however, since each has had a different
object, none has been unanimously adopted by the orthopaedic comm unity. Some of the systems
proposed have confined themselves to a simple anatomical description of the patterns observed (Evans;
Ramadier; Decoulx and Lavarde). Other, more recent, systems were designed to provide prognostic
information on the prospect of achieving and maintaining reduction of the different types of fractures
(Tronzo; Ender; Jensen's modification of the Evans grading; Müller et al.).
In present-day surgical practice, it is important to know whether a fracture is stable or unstable: The
answer to this question will guide the reduction technique, the type of fixation to be used, and the
postoperative management. A good classification must provide information on the fracture's potential of
being anatomically reduced, with good apposition of the fragments. Also, it should be possible to tell, in
the light of the classification, whether a particular fracture is likely to become secondarily displaced after
fixation; this information must be available before the patient is allowed to weight -bear. This new
approach has made it possible to develop fixation hardware whose design takes account of the
biomechanical properties of fractures, in order to arrive at more dynamic modes of fixation. Finally, any
classification system that aspires to universal adoption must be easy to use and reproducible; only if
these criteria are met can it facilitate communication among surgeons.
After the first papers showing the superiority of the surgical treatment of trochanteric fractures over
other management modalities, attempts were made to classify the different fracture types in the light of
the various authors' first experience with internal fixation. A review 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.

 
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 Figure 1 Evans' classification
Type I: Undisplaced 2-fragment fracture
Type II: Displaced 2-fragment fracture
Type III: 3-fragment fracture without posterolateral support, owing to
displacement of greater trochanter fragment
Type IV: 3-fragment fracture without medial support, owing to displace d
lesser trochanter or femoral arch fragment
Type 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 merits of reproducibility and ease of use. It ha s 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 running parallel to the intertrochanteric line, without separation of the
trochanters. The fractures may be undisplaced º
 or displaced º
.
 is a three-fragment fracture, without
posterolateral support owing to displacement of the greater trochanter.
 also has three fragments; however, in this type,
there is no medial support, because of displacement of the lesser trochanter or fracture of the medial arc h. In the four-fragment
fracture º
, 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 obliquely upwards and inwards; he called this pattern a
reversed obliquity fracture. The mechanical properties of this pattern are worth noting: Reversed obliquity fractures are inh erently
unstable. The femoral shaft tends to displace medially by the downward 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 to improve 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 patients managed with sliding screw-plate internal fixation made
it possible for the number of patterns to be reduced to three, the criterion being reducibility. 
 includes 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. 
 contains Evans
 and
 fractures, which are difficult to reduce in either the coronal or the sagittal
plane; while 
 (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 valu e
regarding the reduction potential, and would, therefore, also indicate the likely risk of secondary displacement of the different
fractures.

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 Figure 2 Ramadier's classification
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
9ecoulx 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 in France. He described four basic patterns, under four
main headings, as a function of the fracture line. He recognized cervico-trochanteric fractures º
, with a fracture line at the base of
the femoral neck. According to Ramadier and Bombard, these fractures account for 27% of all the fractures in the trochanteric
region. The fractures are usually impacted, and the displacement of the fragments produces a coxa vara deformity and internal
rotation. Simple pertrochanteric fractures º account for 24% of trochanteric fractures; they have a fracture line that runs parallel to
the intertrochanteric line; frequently, the lesser trochanter is broken off. The greater trochanter is not, or only marginally, involved.
Complex pertrochanteric fractures º , 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 º, with a fracture line that begins on the greater trochanter and finishes below the lesser trochanter; and low
pertrochanteric fractures º. Trochantero-diaphyseal fractures º, which make up 10% of all fractures in the region, have a fracture
line that follows a spiral line through the greater trochanter and into the proximal shaft. Often, the pattern contains a third fragment;
there may be major displacement. Subtrochanteric fractures º have a more or less horizontal fracture line that runs below the two
trochanters. Displacement may be substantial: 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 an intertrochanteric fracture, and made it part of a
five-grade classification: cervico-trochanteric fractures; pertrochanteric fractures; intertrochanteric fractures; subtrochantero -
diaphyseal fractures; and subtrochanteric fractures º.

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Figure 3 Briot's
grading of
diaphyseo-
trochanteric
fractures
A Evans' reversed
obliquity fracture
B "Basque roof"
fractures
C Boyd's "steeple"
 fracture
D Fractures with an
additional fracture line
ascending to the
intertrochanteric line
E Fractures with
additional fracture
lines radiating
through the greater
trochanter
In 1980, Briot tried to simplify the Ramadier system and to introduce biomechanical concepts. He merged the cervico -trochanteric
and the pertrochanteric fractures. In his opinion, 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 fixate and 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 and
inwards; however, by definition, he excluded subtrochanteric fractures, because they do not affect the trochanters, and because the
mechanical problems involved in this pattern are totally different, even where these fractures are associated with undisplaced
fractures of the greater trochanter or a detachment of the lesser trochanter. In this way, Briot established three well -defined patterns
of trochanteric region fractures:
º pertrochanteric fractures with a fracture line running parallel to the intertrochanteric line, which may detach a posterior c ortical
fragment (this lesion will be discussed further below). Under the same heading, Briot consider s pertrochantero-diaphyseal fractures
with a downward and inward slanting line that continues distal to the lesser trochanter.
º the intertrochanteric fractures described by Decoulx;
º diaphyseo-trochanteric fractures º 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 al so turn
back and continue downwards along the intertrochanteric line, to produce the steeple-shaped pattern described by Boyd.

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 Figure 4 Ender's classification
rochanteric eversion fractures
-1 Simple fractures
-2 Fractures with a posterior fragment
-3 Fractures with lateral and proximal displacement
rochanteric inversion fractures
-4 With a pointed proximal fragment spike
-5 With a rounded proximal fragment beak
-6 Intertrochanteric fractures
Subtrochanteric 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, gave a fracture grading system based upon the
fracture mechanism. The first type is represented by eversion fractures, with an anterior opening of the fracture site º, sometimes
involving the separation of a posterior fragment º. In this group, Ender described fractures with substantial lateral and posterior
displacement of the distal fragment º, which shows that major soft tissue damage has occurred, resulting in severe 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 º
.
The last two groups are intertrochanteric fractures º and subtrochanteric fractures º
.
Ender felt that a knowledge of the fracture mechanism was useful when it came to performing external reduction manoeuvres bef ore
doing closed nailing using his hardware. As a result, the Ender grading system has been applied only in conjunction with Ender's
condylocephalic nailing system.

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 Figure 5 AO classification
A1: Simple (2-fragment) pertrochanteric area fractures
A1.1 Fractures along the intertrochanteric line
A1.2 Fractures through the greater trochanter
A1.3 Fractures below the lesser trochanter
A2: Multifragmentary pertrochanteric fractures
A2.1 With one intermediate fragment (lesser trochanter detachment)
A2.2 With 2 intermediate fragments
A2.3 With more than 2 intermediate fragments
A3: Intertrochanteric fractures
A3.1 Simple, oblique
A3.2 Simple, transverse
A3.3 With a medial fragment
The AO classification, proposed by Müller 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 the trochanteric area. These
fractures are divided into three groups.
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 medi al fracture
line: A1.1 fractures run above the lesser trochanter; A1.2 fractures have calcar impaction in the metaphysis; while A1.3 frac tures 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 A2.1 fractures, 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 th e
proximal border of the lesser trochanter; often there is also an undisplaced fracture separating the gr eater trochanter. A3.1 fractures
are reverse intertrochanteric fractures (with an oblique fracture line); while A3.2 fractures are transverse (intertrochanter ic). A3.3
fractures involve the detachment of the lesser trochanter, and are notoriously difficult to reduce and stabilize.
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The mechanical rôle of the medial arch, and the implications of its failure in trochanteric 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 an d V
are the most unstable patterns. If the calcar is involved, there will be instability 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 lesser trochanter 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 º.

Figure 6
Extradigital fracture line (Ottolenghi)
posterior opening
From above
The latter, whose line is more lateral than in the usual patterns, will leave all the rotator 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 b e
achieved by external rotation of the shaft fragment.
The detachment of the posterior portion of the greater trochanter may also pose major problems. It has been held responsible for
difficult reduction in the sagittal plane. Boyd and Griffin (1949) were the first to consider the instability of trochanteric fractures in
the coronal as well as the sagittal plane. This concept was also embodied in the classification established by Tronzo in 1973 . Among
Tronzo's patterns, there are three involving an explosion of the posterior wall º:

Figure 7
Tronzo's classification
Posterior view
Type 3 | Type 3 Variant | Type 4
Fractures with posterior comminution
In the first, the neck spike is telescoped into the shaft fragment, and there is a large lesser trochanter fragment. In the s econd, the
greater trochanter is also totally broken off; while, in the third, the neck spike is not telescoped into the shaft, but is dis placed medial
to the shaft. This grading system gives a good indication of the degree of instability 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 of sagittal instability, and, in particular, external rotation. From cadaver studies, Br iot found that
the fracture may detach a posterior plate, situated between the lateral lip of the linea asper a and the spiral line, comprising the
intertrochanteric crest and the lesser trochanter. This plate may be completely avulsed, sometimes with additional fractures lines;
equally, it may be separated from the femur in its upper part º.
 Figure 8
Briot's posterior plate fractures
Briot's posterior plate fractures
a Boundaries of posterior plate
b Maximum extent of plate
c 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 his Type 2 fractures in external rotation; however, he stressed the rôle of the soft tissue lesio ns in his
Type 3 fractures.
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The different classification systems devised to date for the grading of trochanteric fractures contain several points that ar e of
importance in the analysis of radiographs of such fractures.
Stable two-fragment fractures, with a pertrochanteric or a paratr ochanteric (basicervical) line, may be considered as one category,
since their grading, reduction, and stabilization are straightforward.
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 as sociated
with a separation of the greater trochanter. The fracture must be reduced in internal rotation, to close the an terior gap and to replace
the posterior cortical fragments.
One fracture pattern warrants separate consideration - the reversed obliquity fracture described 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 attempt would not be very productive, since there is no
such thing as a perfect system for the grading 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 informatio n regarding the stability potential of the
various fracture patterns.
Evans' classification (1949)
Type I: Undisplaced 2-fragment fracture
Type II: Displaced 2-fragment fracture
Type III: 3-fragment fracture without posterolateral support
Type IV: 3-fragment fracture without medial support,
Type V: 4-fragment fracture without posterolateral and medial
support
Reversed obliquity fracture

Boyd and Griffin's classification (1949)

Linear intertrochanteric line fractures
Intertrochanteric line fractures with comminution
Subtrochanteric fractures
Fractures 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

9ecoulx & Lavarde's classification (1969)

Cervico-trochanteric fractures
Pertrochanteric fractures
Intertrochanteric fractures
Subtrochanteric fractures
Subtrochantero-diaphyseal fractures

Ender's classification (1970)

Trochanteric eversion fractures
Type 1: Simple fractures
Type 2: Fractures with a posterior fragment
Type 3: Fractures with lateral and proximal displacement
Trochanteric inversion fractures
Type 4: With a pointed proximal fragment spike
Type 5: With a rounded proximal fragment beak
Intertrochanteric fractures :Type 6
Subtrochanteric fractures
Types 7 and 7a: Transverse or reversed obliquity fractures
Types 8 and 8a: Spiral fractures

ronzo's classification (1973)

Type 1: Incomplete fractures
Type 2: Uncomminuted fractures, with or without displacement;
both trochanters fractured
Type 3: Comminuted fractures, large lesser trochanter fragment;
posterior wall exploded; neck beak impacted in shaft
Type 3 Variant: As above, plus greater trochanter fractured off
and separated
Type 4: Posterior wall exploded, neck spike displaced outside
shaft
Type 5: reverse obliquity fracture, with or without greater
trochanter separation

Jensen's classification (1975)

Displaced or undisplaced stable 2-fragment fractures
Unstable 3-fragment fractures with greater or lesser trochanter
fracture
4-fragment fractures

9eburge's classification (1976)

Cervico-trochanteric fractures
Pertrochanteric fractures
Intertrochanteric fractures
Subtrochanteric fractures
Trochantero-diaphyseal fractures

Briot's classification (1980)

º
Pertrochanteric fractures
- simple
- with posterior wall explosion
- extending into the shaft
º
Intertrochanteric fractures
º
Diaphyseo-trochanteric fractures
- Evans' reversed obliquity fracture
- "Basque roof" fractures
- Boyd's "steeple" fracture
- fractures with an additional line ascending to th e
intertrochanteric line
- Fractures with additional fracture lines radiating through the
greater trochanter

AO classification (1981)
´roup A  Simple º-fragment
pertrochanteric area
fractures
A1.1 Fractures along the intertrochanteric line
A1.2 Fractures through the greater trochanter
A1.3 Fractures below the lesser trochanter
´roup A Multifragmentary pertrochanteric fractures
A2.1 With one intermediate fragment
A2.2 With 2 intermediate fragments
A2.3 With more than 2 intermediate fragments
´roup A Intertrochanteric fractures
A3.1 Simple, oblique
A3.2 Simple, transverse
A3.3 With a medial fragment
c