Neck of Femur Fractures
Classification
 |
|||||||||
Neck of Femur fractures
|
Intracapsular
Classically when talking about intracapsular femoral neck fractures people start quoting the Garden classification (follow link). It however has a very poor Kappa ratio of inter and intra observer error, limiting its use. It has been shown that people can only reliably differentiate between Undisplaced (Garden 1&2) and displaced (Garden 3&4). This differentiation (displaced versus undisplaced) is clinically important regarding treatment algorhythms and prognosis of complications.
Pauwels Classification is of the fracture angle, it was thought a steeper angle had a worse prognosis and was less stable. It has been shown that fracture angle however has poor prognostic value.
Extracapsular
Broken down into Trochanteric and subtrochanteric (area up to 5cm below lesser trochanter). Confusing terms intertrochanteric and per trochanteric no longer of value.
Trochanteric
Several classification systems all however have poor Kappa correlations. Latest article 2002 suggests 3 groups (essentially AO system without sub groups)
- Stable (AO Classification A1)
- Unstable (involvement of lesser trochanter) (AO Classification A2)
- Transtrochanteric (reverse oblique, transverse at level of lesser trochanter) (AO Classification A3)
Subtrochanteric
Always consider that it may be a pathological fracture. Most important thing to take note is that it is a subtrochanteric fracture. Individual classification systems seldom affect treatment. Grey zone occasionally merges with with transtrochanteric fractures (reverse oblique fractures).
Treatment options for subtrochanteric fractures in personal order of preference:
- Intramedullary device that locks in the head (PFN proximal femoral nail, IMHS, Recon nail.)
- Fixed angle blade plate (Very rigid, Viz problems in osteoporotic bone, technically demanding)
- DCS (Dynamic condylar screw)
- DHS (Dynamic hip screw) (Not good for unstable subtrochanteric fractures)
Seinsheimer classification based on the number of major fragments and the location and shape of fracture lines. Seinsheimer classification
References
Injury 2002 Oct;33(8):713-5 - Classification of trochanteric fracture of the proximal femur: a study of the reliability of current systems. - Pervez H, Parker MJ, Pryor GA, Lutchman L, Chirodian N.
Injury 2002 December;33 Ostesynthesis of femoral neck fractures (Whole issue dedicated to femoral neck fractures)
JBJS (B) 2000:82 (7);937-941 - The Management of Intracapsular Fractures of the Proximal Femur - Martyn J. Parker
JBJS (B) 1998:80 (4);679-683 - Assessment of the AO classification of intracapsular fractures of the proximal femur - Chris M. Blundell; Martyn J. Parker; Glyn A. Pryor; James Hopkinson-Woolley; Sachin S. Bhonsle