Journal of

Orthopaedic
Article Surger y
Journal of Orthopaedic Surgery
25(1) 1–5
ª Journal of Orthopaedic Surgery 2017
Proposal of new classification Reprints and permissions:
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of femoral trochanteric fracture DOI: 10.1177/2309499017692700
journals.sagepub.com/home/osj

by three-dimensional computed
tomography and relationship
to usual plain X-ray classification

Etsuo Shoda1, Shimpei Kitada1, Yu Sasaki1, Hitoshi Hirase1,

Takahiro Niikura2, Sang Yang Lee2, Atsushi Sakurai3,
Keisuke Oe3, and Takeharu Sasaki4

Abstract
Purpose: Classification of femoral trochanteric fractures is usually based on plain X-ray findings using the Evans,
Jensen, or AO/OTA classification. However, complications such as nonunion and cut out of the lag screw or blade are
seen even in stable fracture. This may be due to the difficulty of exact diagnosis of fracture pattern in plain X-ray.
Computed tomography (CT) may provide more information about the fracture pattern, but such data are scarce. In the
present study, it was performed to propose a classification system for femoral trochanteric fractures using three-
dimensional CT (3D-CT) and investigate the relationship between this classification and conventional plain X-ray
classification. Methods: Using three-dimensional (3D)-CT, fractures were classified as two, three, or four parts using
combinations of the head, greater trochanter, lesser trochanter, and shaft. We identified five subgroups of three-part
fractures according to the fracture pattern involving the greater and lesser trochanters. In total, 239 femoral trochanteric
fractures (45 men, 194 women; average age, 84.4 years) treated in four hospitals were classified using our 3D-CT clas-
sification. The relationship between this 3D-CT classification and the AO/OTA, Evans, and Jensen X-ray classifications was
investigated. Results: In the 3D-CT classification, many fractures exhibited a large oblique fragment of the greater
trochanter including the lesser trochanter. This fracture type was recognized as unstable in the 3D-CT classification but
was often classified as stable in each X-ray classification. Conclusions: It is difficult to evaluate fracture patterns involving
the greater trochanter, especially large oblique fragments including the lesser trochanter, using plain X-rays. The 3D-CT
shows the fracture line very clearly, making it easy to classify the fracture pattern.

Keywords
computed tomography (CT), classification, femoral trochanteric fracture, X-ray

1
Department of Orthopaedic Surgery/Trauma Center, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Hyogo, Japan
2
Department of Orthopaedic Surgery, Kobe University School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
3
Department of Orthopaedic Surgery, Hyogo Prefectural Awaji Medical Center, Sumoto, Hyogo, Japan
4
Department of Orthopaedic Surgery, Nishinomiya Watanabe Hospital, Nishinomiya, Hyogo, Japan

Corresponding author:
Etsuo Shoda, Department of Orthopaedic Surgery/Trauma Center, Hyogo Prefectural, Nishinomiya Hospital, 13-9 Rokutanji-cho, Nishinomiya, Hyogo
662-0918, Japan.
Email: shodafx@yahoo.co.jp
2 Journal of Orthopaedic Surgery 25(1)
Figure 1. Fracture is classified using a combination of four major
fragments. (a): anterior aspect; (b): posterior aspect; H: head; G:
greater trochanter; L: lesser trochanter; S: shaft. three-dimensional
computed tomography (3D-CT) classification is also based on the
combination of four major fragments.
Introduction
The incidence of femoral trochanteric fractures is rapidly
increasing with the growth of the elderly population. Clas-
sification of femoral trochanteric fractures is usually based
on plain X-ray findings1 using systems such as the Evans
classification,2 Jensen classification,3 and AO/OTA classi-
fication.4 However, complications such as delayed union,
nonunion, malunion, and cut out of the lag screw or blade
are sometimes seen in fractures classified using X-rays,
even in stable fractures.5,6 These complications are partly
caused by technical problems associated with surgery.
Another factor that may hinder diagnosis is a misunder-
standing of the fracture pattern by plain X-rays because
femoral trochanteric fractures are sometimes very difficult
to precisely diagnose, especially those involving the tro-
chanteric fragment. Computed tomography (CT) may pro-
vide more information about the fracture pattern, especially
in the trochanteric area; however, no fracture classification
systems using CT have been established.
The first objective of this study was to propose a clas-
sification of femoral trochanteric fractures using three-
dimensional CT (3D-CT). The second objective was to
investigate the relationship between this classification and
conventional plain X-ray classification.
Materials and methods
The 3D-CT classification was based on the combination
of four major fragments: the head (H), greater trochanter
(G), lesser trochanter (L), and shaft (S) (Figure 1). Each
fracture was classified as a two-, three-, or four-part
fracture according to the classification reported by
Nakano7 in Japan. A schema of our 3D-CT classification
is shown in Figure 2 and actual images of 3D-CT of
each type are shown in Figure 3.
A two-part fracture is a simple fracture, similar to an
Evans type 1, group 1 fracture; the anterior fracture line is
on the intertrochanteric line, the posterior fracture line is in
the intertrochanteric fossa, and the lesser trochanter is
intact. In a four-part fracture, both the greater trochanter
and lesser trochanter are fractured and displaced. Such
fractures are consistent with an Evans type 1, group 4 frac-
ture or Jensen type 5 fracture.
In this study, we identified five subgroups of three-part
fractures according to the fracture pattern of the greater and
lesser trochanters. The first subgroup involved a small frag-
ment of the greater trochanter in addition to a two-part
fracture: 3-part G(S), where S indicates small. The second
subgroup involved a big oblique fragment of the greater
trochanter that does not include the lesser trochanter:
3-part G(B), where B indicates big. The third subgroup
involves a large oblique fragment of the greater trochanter
including the lesser trochanter: 3-part G-L. In this type, the
large trochanteric fragment is sometimes divided into two
fragments between the greater and lesser trochanter. The
fourth subgroup involves a fragment of the whole greater
trochanter, but the lesser trochanter is intact: 3-part G(W),
where W indicates whole. This type includes some Evans
type 2 fractures and AO/OTA A-3 fractures. Finally, the
fifth subgroup comprises fractures of the lesser trochanter
in addition to two-part fractures: 3-part L. These fractures
do not involve the greater trochanter.
According to the classification described by Nakano,7
2-part, 3-part G(S), and 3-part G(B) fractures are consid-
ered stable and 3-part G-L, 3-part G(W), 3-part L, and
4-part fractures are considered unstable.
In total, 239 femoral trochanteric fractures (45 men, 194
women; average age 84.4 years) treated with the Asian
proximal femur intramedullary nail antirotation system:
PFNA-II (DePuy Synthes Trauma, PA, USA) from April
1, 2011, to December 31, 2014, in four hospitals were
investigated and classified with this 3D-CT classification.
Each fracture was also classified by the AO/OTA, Evans,
and Jensen classifications. First author, one orthopedic spe-
cialist and two residents classified these fractures. The rela-
tionship between each of these classifications and our
3D-CT classification was investigated.
Results
Using our 3D-CT classification, the numbers of each frac-
ture type were as follows: 2-part, n ¼ 49; 3-part G(S),
n ¼ 30; 3-part G(B), n ¼ 37; 3-part G-L, n ¼ 82; 3-part
G(W), n ¼ 17; 3-part L, n ¼ 8; and 4-part, n ¼ 16 (Table 1).
We identified 116 stable fractures in the 3D-CT classifica-
tion (2-part, 3-part G(S), and 3-part G(B)) and 123 unstable
fractures (3-part G-L, 3-part G(W), 3-part L, and 4-part).
The relationship between the 3D-CT classification and the
AO/OTA, Evans, and Jensen classifications is shown in
Tables 2, 3, and 4. Fifty (41%) of 123 unstable fractures
in the 3D-CT classification were classified as stable in the
Shoda et al. 3

Figure 2. Fracture classification with three-dimensional computed tomography (3D-CT). Three-part fracture is divided into five
subgroups.

Figure 3. Actual images of three-dimensional computed tomography (3D-CT) in each group.

4 Journal of Orthopaedic Surgery 25(1)

Table 1. Numbers of each type of fracture.a Table 4. Relationship between 3D-CT classification and Jensen
classification.a
Fracture type No. of cases
Type 1 Type 2 Type 3 Type 4 Type 5
2 part 49
3 part 2 part 41 8 0 0 0
G(S) 30 3 part G(S) 22 7 1 0 0
G(B) 37 3 part G(B) 25 7 4 1 0
G-L 82 3 part G-L 30 10 10 31 1
G(W) 17 3 part G(W) 4 1 4 3 5
L 8 3 part L 1 0 0 7 0
4 part 16 4 part 0 3 12
1 0
G: greater trochanter; L: lesser trochanter; S: small; B: big; W: whole.
a G: greater trochanter; L: lesser trochanter; S: small; B: big; W: whole.
Numbers of each group in 3D-CT fracture classification.
&aRelationship between 3D-CT classification and Jensen classification
stable fracture in Jensen classification but unstable in 3D-CT.
Table 2. Relationship between three-dimensional computed
tomography (3D-CT) classification and AO/OTA classification.a
Jensen: 85%). Conversely, only 1 of 116 stable fractures
A1-1 A1-2 A2-1 A2-2 A2-3 A3 according to the 3D-CT classification was classified as
2 part 46 3 0 0 0 0 unstable in the AO/OTA classification. Similarly, one frac-
3 part G(S) 27 3 0 0 0 0 ture was unstable in the Evans classification and six were
3 part G(B) 30 6 0 1 0 0 unstable in the Jensen classification.
3 part G-L 32 12 22 10 6 0
3 part G(W) 3 1 0 0 0 13
3 part L 1 0 6 0 1 0
Discussion
4 part 1 0 2 6 0 7 Several plain X-ray-based classification systems for
femoral trochanteric fractures are available. The Evans,
G: greater trochanter; L: lesser trochanter; S: small; B: big; W: whole. Jensen, and AO/OTA classifications have been widely used
&aRelationship between 3D-CT classification and AO/OTA classifica-
in clinical practice. In 1949, Evans2 developed a classifi-
tion stable fracture in AO/OTA classification but unstable in 3D-CT.
cation system based on the direction of the fracture line and
the assessment of stability, determined according to the
likelihood of fracture reduction and displacement. In
Table 3. Relationship between three-dimensional computed
tomography (3D-CT) classification and Evans classification.a 1980, Jensen3 added evaluation of plain lateral X-rays to
this classification system. Finally, the AO/OTA classifica-
T1-G1 T1-G2 T1-G3 T1-G4 T2 tion system4 was introduced. These classification systems
2 part 48 1 0 0 0 have been used for treatment planning and outcome pre-
3 part G(S) 29 1 0 0 0 diction. In each classification system, fractures are mainly
3 part G(B) 34 2 1 0 0 divided into two groups: stable or unstable. In the Evans
3 part G-L 41 35 5 1 0 classification, groups 1 and 2 of type 1 fractures are stable,
3 part G(W) 4 0 0 0 13 and others are unstable. In the Jensen classification, types 1
3 part L 1 4 3 0 0 and 2 are stable and types 3, 4, and 5 are unstable. In the
4 part 1 1 2 7 5 AO/OTA classification, type 31-A1 is stable and types A2
and A3 are unstable. However, complications including
G: greater trochanter; L: lesser trochanter; S: small; B: big; W: whole. delayed union, nonunion, malunion, and cut out of the lag
&aRelationship between 3D-CT classification and Evans classification screw or blade are sometimes seen on plain X-rays, even in
stable fracture in Evans classification, but unstable in 3D-CT.
stable fractures. This may make it difficult to distinguish
stable versus unstable fractures on plain X-rays. CT may
AO/OTA classification (Table 2). Forty-four (88%) of provide more information about the fracture pattern, espe-
these 50 fractures were of the 3-part G-L type. Addition- cially in the trochanteric area.
ally, 87 (71%) of 123 unstable fractures according to the CT is usually used for femoral neck fractures or for
3D-CT classification were classified as stable in the Evans diagnosis of occult fractures of the proximal femur.8,9
classification (76 were 3-part G-L fracture: 87%) (Table 3), However, there are only a few reports of CT for evaluation
and 47 (38%) of 123 unstable fractures according to the of femoral trochanteric fractures.10,11 Nakano7 proposed a
3D-CT classification were classified as stable in the Jensen 3D-CT classification system in Japan. Our classification is
classification (40 were 3-part G-L fracture: 85%) (Table 4). a modification of his classification. In his classification,
Almost all mismatched fractures between the 3D-CT and two-part fractures are the most stable, and four-part and
X-ray classifications (unstable in 3D-CT, stable in X-ray) type II (reverse oblique type) are the most unstable. Nakano
were 3-part G-L fracture (AO/OTA: 88%, Evans: 87%, also pointed out that many fractures have a large oblique
Shoda et al.
fragment that includes the lesser trochanter on 3D-CT (our
3-part G-L fracture) and this type is equally as unstable as a
four-part or type 2 fracture.
Unstable trochanteric fractures may exhibit (1) poster-
omedial large separate fragmentation, (2) a basicervical
pattern, (3) a reverse obliquity pattern, (4) a displaced
greater trochanter (lateral wall fracture), or (5) the inability
to be reduced before internal fixation. Of the above char-
acteristics, 3-part G-L type fracture is considered to have
posteromedial large separate fragmentation. So 3-part G-L
type is recognized as unstable type because of this defini-
tion and Nakano’s article. However, classification of this
fracture is impossible using plain X-rays. In the present
study, 50, 87, and 47 fractures that were classified as stable
using the AO/OTA (41%), Evans (71%), and Jensen clas-
sifications (38%) were classified as unstable using the
3D-CT classification. Additionally, almost all fractures in
each group were 3-part G-L fractures using 3D-CT
(AO/OTA: 88%, Evans: 87%, Jensen: 85%). This result
shows that 3-part G-L fractures tend to be misdiagnosed
as stable fractures on plain X-rays. However, there is no
study on how to manage this fragment.
Overall, our findings indicate that it is very difficult to
evaluate the fracture pattern of the greater trochanter on
plain X-rays and that our 3D-CT classification system may
be necessary for more precise diagnosis of trochanteric
fractures. There is no clinical results relation to this
3D-CT classification in this article. Another study on how
to treat this fragment and clinical investigation based on
this classification is necessary in next stage. However,
whether this classification system has acceptable reliability
when applied by all orthopedic surgeons remains to be
determined, because intra- and interobserver variations are
not measured in this study.
After solution of these problems, this 3D-CT classifica-
tion should be one of the treatment guidelines.
Conclusion
3D-CT classification system for femoral trochanteric frac-
tures has been proposed in this study. This study has shown
that it is difficult to evaluate the fracture pattern of the
greater trochanter, especially large oblique fragments that
include the lesser trochanter, on plain X-rays. 3D-CT
shows the fracture line very clearly, making it easy to clas-
sify the fracture pattern.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
5
Funding
This study was supported by AOTAP Research Seed Grants 2010.
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Ethics statement
This project was approved by the ethical committee of Hyogo
Prefectural Nishinomiya Hospital.
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