Evans, J Bone Joint Surg Br 1949 - The Treatment of Trochanteric Fractures of the Femur

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The Treatment of Trochanteric Fractures of the Femur

Evans·J Bone Joint Surg Br·1949·378 citations·Retrospective cohort

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Evans tested whether trochanteric femoral fractures can be classified by stability and whether routine operative fixation is justified. Retrospective review of 148 patients in three treatment groups (conservative, operative with Capener-Neufeld nail-plate, sent home), plus a literature review of 1,648 cases, assessing coxa vara and mortality.

Key Findings

Classification by integrity of the medial cortical buttress:
- Type 1, Group 1: undisplaced, buttress intact, stable
- Type 1, Group 2: overlap present but reducible, stable after reduction
- Type 1, Group 3: overlap not reduced, unstable
- Type 1, Group 4: buttress comminuted, unstable
- Type 2: reversed obliquity, prone to medial shaft displacement
Coxa vara occurred in about 20% of cases with both operative and conservative treatment, only when the medial buttress was not restored. Group 1 made up 65% of fractures and Type 2 made up 8%.
Nail-plate fixation cut mean hospital stay from 15 to 7 weeks. There were no deaths in 22 consecutive unselected operative cases, including patients up to 90 years old.
Mortality in the literature review: conservative 33.7% (403/1,194) versus operative 18.3% (83/454). Patients sent home for lack of beds (mean age 77) had 44% mortality.
Significance: The paper defined trochanteric fracture stability by the integrity of the posteromedial buttress, now known as the Evans classification, and supported operative fixation in elderly patients.

Board PearlIn the Evans classification, a trochanteric fracture is stable when the posteromedial cortical buttress is intact or restored by reduction, and reversed obliquity (Type 2) is inherently unstable.

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The Treatment of Trochanteric Fractures of the Femur

Evans·J Bone Joint Surg Br·1949·378 citations·Retrospective cohort

|

Evans tested whether trochanteric femoral fractures can be classified by stability and whether routine operative fixation is justified. Retrospective review of 148 patients in three treatment groups (conservative, operative with Capener-Neufeld nail-plate, sent home), plus a literature review of 1,648 cases, assessing coxa vara and mortality.

Key Findings

Classification by integrity of the medial cortical buttress:
- Type 1, Group 1: undisplaced, buttress intact, stable
- Type 1, Group 2: overlap present but reducible, stable after reduction
- Type 1, Group 3: overlap not reduced, unstable
- Type 1, Group 4: buttress comminuted, unstable
- Type 2: reversed obliquity, prone to medial shaft displacement
Coxa vara occurred in about 20% of cases with both operative and conservative treatment, only when the medial buttress was not restored. Group 1 made up 65% of fractures and Type 2 made up 8%.
Nail-plate fixation cut mean hospital stay from 15 to 7 weeks. There were no deaths in 22 consecutive unselected operative cases, including patients up to 90 years old.
Mortality in the literature review: conservative 33.7% (403/1,194) versus operative 18.3% (83/454). Patients sent home for lack of beds (mean age 77) had 44% mortality.
Significance: The paper defined trochanteric fracture stability by the integrity of the posteromedial buttress, now known as the Evans classification, and supported operative fixation in elderly patients.

Board PearlIn the Evans classification, a trochanteric fracture is stable when the posteromedial cortical buttress is intact or restored by reduction, and reversed obliquity (Type 2) is inherently unstable.

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