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SYMPOSIUM: FRACTURE NECK OF FEMUR
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 5-7

Classification of fracture neck of femur


Department of Orthopaedics, AIIMS, Raipur, CG, India

Date of Web Publication28-Dec-2018

Correspondence Address:
Dr. Alok C Agrawal
Department of Orthopaedics, AIIMS, Raipur, CG 492013
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.JODP_15_18

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  Abstract 

There are numerous classification systems for fracture neck of femur in adults. A fracture classification is proposed either for taxonomical purpose, characterization, guiding intervention, or predicting outcomes of intervention. The classifications described in this chapter are needed to decide on choice of implant, stability, acceptability of reduction, vascularity and long term prognosis.

Keywords: Classification, fracture, neck of femur


How to cite this article:
Sahoo B, Agrawal AC, Kar BK, Sakale H, Yadav SK, Mittal S. Classification of fracture neck of femur. J Orthop Dis Traumatol 2018;1:5-7

How to cite this URL:
Sahoo B, Agrawal AC, Kar BK, Sakale H, Yadav SK, Mittal S. Classification of fracture neck of femur. J Orthop Dis Traumatol [serial online] 2018 [cited 2019 Jun 25];1:5-7. Available from: http://www.jodt.org/text.asp?2018/1/1/5/248901


  Introduction Top


Numerous classification systems were proposed for fracture neck of femur in adults in the past but none of them were without any limitations. A fracture classification is proposed either for taxonomical purpose, characterization, guiding intervention, or predicting outcomes of intervention.[1] Any useful system should consider the severity of the injury, be a guide to treatment, and facilitate the comparison of results.[2] It must also have good intra- and interobserver reliability. Fractures of femoral neck in adults were first classified as intracapsular or extracapsular and later distinguished as subcapital, mid-cervical, basal, intertrochanteric, or pertrochanteric types.[3] The subcapital was further divided into abduction, or impacted and adduction, or varus.


  Anatomical Classification Top


Anatomical classification is based on the anatomical location of fracture line shown in plain radiographs as subcapital, transcervical, or basicervical. It is difficult to locate fracture line in plain radiographs,[4],[5],[6] and location of intracapsular fracture (subcapital or transcervical) has not been shown to effect the result.[7] As the bone in transcervical region is stronger, it is doubtful if many fractures occur at this site. It is the degree of displacement rather than the location that is more important.


  Pauwels Classification Top


Described in 1935,[8] Pauwels classification system based on the obliquity of fracture line after reduction was proposed to predict fixation failure or nonunion with an increase in the angle of fracture [Figure 1] [Table 1]. According to this, fracture angle is directly proportional to instability and complications of fracture healing and fixation. Drawbacks of this classification are rarity of vertical plane fracture and non-reliability in predicting outcomes.[9],[10],[11],[12] Interobserver level of agreement was found to be poor.[12]
Figure 1: Pauwels classification

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Table 1: Pauwels classification

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  Garden Classification Top


Garden classification is a long-standing fracture classification system based on the degree of displacement,[3] which is determined by the relationship of trabecular lines present in femoral head with that present in acetabulum in radiographs before reduction [Figure 2] [Table 2]. This is the most frequently and most widely used classification system. The fracture types are classified, however, to indicate increasing fracture severity, greater fracture instability, and higher risk of complications with attempts at reduction and stabilization of the fracture. This feature of ordering fracture types by severity takes the classification system from a nominal system to an ordinal system. Pitfalls of this system[13] are as follows: (1) interobserver and intraobserver variability, (2) rarity of Grade II fractures, (3) outcome of undisplaced fracture (Grade I and II) is independent of grade, and (4) treatment of the most displaced fracture (Grade III and IV) is arthroplasty and outcome is independent of grade.
Figure 2: Garden’s classification

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Table 2: Garden’s classification

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  Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association Classification Top


Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification is the only universal classification system[14] that is in wide use. It is a modern classification system based on the description of location, displacement, and number of fracture lines on plain radiographs. As per AO/OTA classification, femoral neck is designated as 31B [Figure 3] [Table 3]. Its complexity limits its usefulness in routine clinical practices. Poor levels of agreement were found within the subdivisions of classification.[2] It was also not found to be useful in selecting treatment or predicting outcomes.
Figure 3: (A) and (B) Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification

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Table 3: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification

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Other classifications[13],[15] based on judging the stability of the fracture have been proposed but have not been widely accepted. Whether the fracture location is intracapsular or extracapsular (basal cervical) and whether the fracture is displaced or undisplaced are the key points in determining treatment and are predictive of the likely complications.[1] No newer classifications have been proven to be superior to these simple groupings. Older classifications are either of limited applicability in most patients (Pauwels)[8] or in the case of Garden, still widely used but of limited reliability. Most clinical studies are concerned with undisplaced or displaced femoral neck fractures, and the subdivision of these two groups based on various classification systems is not a reliable guide to treatment or prognosis.[1]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
John F, Keating. Femoral neck fractures, Rockwood and Green fracture in adults 8th Edition 2014, Wolters Kluwers.  Back to cited text no. 1
    
2.
Blundell CM, Parker MJ, Pryor GA, Hopkinson-Woolley J, Bhonsle SS. Assessment of the AO classification of intracapsular fractures of the proximal femur. J Bone Joint Surg Br 1998;1:679-83.  Back to cited text no. 2
    
3.
Garden RS. Low angle fixation in fractures of the femoral neck. J Bone Joint Surg 1961;1:647-63.  Back to cited text no. 3
    
4.
Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop 1976;1:259-64.  Back to cited text no. 4
    
5.
Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg Br 1964;1:630-47.  Back to cited text no. 5
    
6.
Klenerman L, Marcuson RW. Intracapsular fractures of the neck of the femur. J Bone Joint Surg Br 1970;1:514-7.  Back to cited text no. 6
    
7.
Rajan DT, Parker MJ. Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients. Injury 2001;1:53-6.  Back to cited text no. 7
    
8.
Pauwels F. Der Schenkelhalsbruch: Ein Mechanisches Problem. Stuttgart, Germany: Ferdinand Enke Verlag; 1935.  Back to cited text no. 8
    
9.
Cassebaum WH, Nugent G. Predictability of bony union in displaced intracapsular fractures of the hip. J Trauma 1963;1:421-4.  Back to cited text no. 9
    
10.
Ohman U, Björkegren NA, Fahlström G. Fracture of the femoral neck. A five-year follow up. Acta Chir Scand 1969;1:27-42.  Back to cited text no. 10
    
11.
Parker MJ, Dynan Y. Is Pauwels classification still valid? Injury 1998;1:521-3.  Back to cited text no. 11
    
12.
van Embden D, Roukema GR, Rhemrev SJ, Genelin F, Meylaerts SA. The Pauwels classification for intracapsular hip fractures: Is it reliable? Injury 2011;1:1238-40.  Back to cited text no. 12
    
13.
Beimers L, Kreder HJ, Berry GK, Stephen DJ, Schemitsch EH, McKee MD, et al. Subcapital hip fractures: The Garden Classification should be replaced, not collapsed. Can J Surg 2002;1:411-4.  Back to cited text no. 13
    
14.
James F. Kellam, eric G. meinberg, julic agel MA, Matthew D. Karan, Craig S. Roberts. Fracture and dislocation classification compendium. Journal of Orthopedic Trauma 2018;1.  Back to cited text no. 14
    
15.
Caviglia HA, Osorio PQ, Comando D. Classification and diagnosis of intracapsular fractures of the proximal femur. Clin Orthop Relat Res 2002;1:17-27.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Anatomical Class...
Pauwels Classifi...
Garden Classific...
Arbeitsgemeinsch...
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