Authors: J. Bartoníček 1,2 ; R. Bartoška 3 ; J. Skála-Rosenbaum 3 ; J. Alt 1 ; O. Naňka 2 ; M. Tuček 1 Authors place of work: Department of Orthopedics, First Faculty of Medicine, Charles University and Military University Hospital Prague, Czech Republic 1; Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic 2; Department of Orthopedics and Traumatology, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic 3 Published in the journal: Rozhl. Chir., 2026, roč. 105, č. 3, s. 113-122. Category: Původní práce doi: https://doi.org/10.48095/ccrvch2026113
Three-part pertrochanteric fractures with a large posterior fragment have been reported both in historical and recent 3D CT studies, however, without a detailed description.
Material and methods: From the collection of the Institute of Anatomy, the authors obtained 6 specimens of hip joints of individuals who had sustained a three-part pertrochanteric fracture with a large posterior fragment, and 7 patients with the same type of fracture were identified in a cohort of 56 patients with a trochanteric fracture documented by 3D CT reconstructions. The study focused on the anatomy of the posterior fragment, the courses of the fracture lines, the integrity of the medial cortex and the lateral trochanteric wall.
Results: Two types of the posterior fragment were identified, the quadrangular and the triangular ones. Separation of either of them markedly weakened the lateral trochanteric wall, more specifically, one quarter to two-thirds of its lateral surface. The triangular fragment was associated with shear instability on the medial aspect of the proximal femur and was markedly displaced in 5 of 7 cases. Exact identification of the shape and size of the posterior fragment was impossible with the use of postinjury radiographs alone.
Conclusion: In agreement with historical and recent CT studies, the findings of this study confirm the existence of a three-part type of pertrochanteric fracture with a large posterior fragment, and provides its detailed description, including its relevance to clinical practice.
pathoanatomy – pertrochanteric fractures – posterior fragment – 3D CT reconstructions – instability of pertrochanteric fractures
Classification of trochanteric fractures is still an unresolved chapter of fractures of the proximal femur. Many recent studies [1–7] have questioned the validity of the AO/ASIF classification and not even its latest revision has removed the principal issues [8,9].
Both the Evans [10] and the AO/OTA [11] classifications divide pertrochanteric fractures (31A1 + 31A2) according to their stability and the number of fragments, with instability increasing with the number of fragments. One of the categories comprises three-part fractures, where the third fragment is formed by a separated part of the greater or lesser trochanter. Historical pathoanatomic studies [12–16] repeatedly described a three-part pertrochanteric fracture, when the third flat, large fragment, formed by the posterior part of the greater trochanter, the intertrochanteric crest, and the entire lesser trochanter, or its proximal part, involved the meta-diaphyseal cortex distally. Such a fragment has been briefly mentioned also in recent 3D CT and pathoanatomic studies [1,3–5]. However, nobody has so far dealt with this type of the posterior fragment in detail.
The study was divided into two parts, the pathoanatomic (PA) and radiological ones.
The PA part was based on our previous study [17]. In a series of 16 pathoanatomic specimens of pertrochanteric fractures from the collection of the Institute of Anatomy of First Faculty of Medicine, Charles University, Prague, we singled out 6 specimens with the proximal femur broken into three main fragments. A large, flat posterior fragment always carried parts of the greater and lesser trochanters, the intertrochanteric crest and the posterior meta-diaphyseal cortex. All these cases were documented by postinjury and postoperative radiographs.
In the series of 57 trochanteric fractures treated between 2013 and 2022 at the authors’ Department, and documented by 3D CT examination, we identified 7 three-part pertrochanteric fractures in which the posterior fragment complied with the above-mentioned description. Thereby, we obtained a total of 13 cases, 5 men and 8 women with the mean age of 79 years (range 61–95), the basic characteristics of which are included in Tab. 1.
The technique of dissection in postmortem specimens was described in detail in our previous study [17]. In 6 radiologically examined cases, radiograph of the pelvis and the injured hip joint was performed as the first step, followed by CT examination, including 3D CT reconstructions, minimally in the anterior, posterior, medial and lateral views. Postoperative radiographs were available in all 13 cases.
Both groups of specimens were examined in terms of pathoanatomy of the posterior fragment, its shape and the course of the fracture line, which separated it from the proximal (head and neck) and distal (diaphyseal) fragments. The course of the fracture lines was analyzed on the medial aspect of the proximal femur and in the region of the lateral trochanteric wall (LTW). Finally, we compared the pathoanatomic and 3D CT findings with the postinjury radiographs.
Pathoanatomic analysis
The analyzed series comprised 6 (3 male and 3 female) specimens with a mean age of 81 years (range 61–95).
The shape of the posterior fragment: we identified two basic types of the posterior fragment, the quadrangular and the triangular ones (Fig. 1). In both types, the fracture line separating them from the other fragments passed from the greater trochanter mediodistally through the trochanteric fossa to the lesser trochanter. Posteriorly, the fracture line ran in all cases to the calcar femorale, which was part of the proximal (head and neck) fragment.
Fig. 1. / Obr. 1. Basic types of the large posterior fragment. A) Quadrangular type. B) Triangular type.Základní typy velkého zadního fragmentu. A) Quadrangulární typ. B) Triangulární typ.
In the quadrangular type (3 specimens), the fracture line passed transversally through the lesser trochanter, running transversally through the posterior meta-diaphyseal cortex, then it turned and continued proximolaterally to the posterolateral edge of the greater trochanter. Thus, the posterior fragment carried only the proximal half of the lesser trochanter.
In the triangular type (3 specimens), the fracture line separated completely the lesser trochanter; on the posterior surface of the proximal femur it passed distally and laterally as far as the linea aspera. From there it made a sharp turn proximolaterally towards the greater trochanter. The posterior fragment carried the entire lesser trochanter with the adjacent posterior cortex.
In all 6 pathoanatomic specimens, both types of the posterior fragment were formed by a thin cortex with a minimum of cancellous bone.
Medial aspect of the proximal femur: the shape of the fracture line in the medial cortex at the level of the lesser trochanter differed depending on the shape of the posterior fragment (Fig. 1). In the quadrangular type, the fracture line separating the proximal and the distal fragments had the shape of V with a hyphen (V-), as the posterior arm of the V-line gave off a secondary fracture line separating the lesser trochanter into two parts. In the triangular type, the fracture line was Y-shaped and separated the entire lesser trochanter with the adjacent posteromedial cortex. Neither of the two types, however, showed comminution of the medial cortex.
LTW: due to separation of the posterior fragment, the LTW was markedly weakened in all 6 cases. In the posterior view, the size of the weakened area corresponded to the distal propagation of the posterior fragment (Fig. 2). The lateral view revealed that in all 6 specimens, the posterior fragment carried the posterior third of the lateral cortex of the proximal femur.
Fig. 2. / Obr. 2. Weakening of the lateral trochanteric wall due to separation of the posterior fragment. A) Quadrangular type. B) Triangular type; yellow arrow – calcar femorale.Zeslabení laterální trochanterické stěny v důsledku odlomení zadního fragmentu. A) Kvadrangulární type. B) Triangulární typ; žlutá šipka – calcar femorale.
Comparison of pathoanatomic specimens and radiographs: all 3 fractures with the quadrangular type of the posterior fragment were non-, or minimally, displaced on the postinjury radiograph, with the fracture line always passing through the lesser trochanter. All 3 fractures with the triangular type of the posterior fragment showed separation of the lesser trochanter with the adjacent posteromedial cortex forming a typical spike. The continuity of the medial cortex (Adams’ arch) [18] was impaired in all cases. The proximal head and neck fragment was displaced into a varus, in 2 cases quite markedly (Fig. 3).
The width of the LTW slightly varied on AP radiographs, depending on the rotation of the distal (diaphyseal) fragment. In all 6 pathoanatomic specimens, the posterior fragment carried the posterior third of the lateral surface of the LTW. It was, however, impossible to determine an exact shape and size of the posterior fragment in any case.
Fig. 3. / Obr. 3. Comparison of postinjury radiographs and pathoanatomic specimens. A) Minimally displaced quadrangular type; yellow arrow – fracture line separating proximal part of lesser trochanter. B) Slightly (up to 10 degrees) displaced triangular type, proximal head and neck fragment is in a 10-degree varus, medial cortex is interrupted; black arrow – distal cortical spike. C) Severely (more than 20 degrees) displaced triangular type, proximal head and neck fragment is in a 30-degree varus, distal spike of medial cortex of proximal fragment displaced deeply into medullar channel (white arrow); red arrows – fracture line. Srovnání rtg poúrazových snímků a pathoanatomických preparátů. A) Minimálně dislokovaný kvadrangulární typ; žlutá šipka – lomná linie oddělující proximální část malého trochanteru. B) Mírně (do 10°) dislokovaný triangulární typ, proximálnífragment tvořený hlavicí a krčkem femuru je v 10° varozitě, mediální kortikalis je porušena; černá šipka – distální kortikální hrot. C) Více (nad 20°) dislokovaný triangulární typ, proximální fragment tvořený hlavicí a krčkem femuru je v 30° arozitě,distální hrot mediální kortikalis proximálního fragmentu je vražen hluboko do dřeňového kanálu (bílá šipka); červená šipka –lomná linie.
The study group comprised 7 patients (2 men, 5 women), with a mean age of 77 years (range, 66–87).
Shape of the posterior fragment: we identified 3 cases with a quadrangular posterior fragment and 4 cases with a triangular posterior fragment. In 2 quadrangular types, the fragment was banana-shaped (Fig. 4), while in 1 case the distal part of the fracture line formed a small spike (Fig. 5). The relationship between the posterior fragment and the calcar femorale was impossible to specify.
Fig. 4. / Obr. 4. ig. 4. Quadrangular (banana-shaped) posterior fragment. A) Postinjury radiograph, severe displacement of proximal fragment. B) 3D CT posterior view. C) 3D CT posterolateral view. D) 3D CT lateral view. E) 3D CT anterior view; yellow arrow – typical interfragment from apex of greater trochanter. Kvadrangulární (banánovitý) zadní fragment. A) Poúrazový rtg snímek s výraznou dislokací proximálního fragmentu. B) 3D CT rekonstrukce, zadní pohled. C) 3D CT rekonstrukce, posterolaterální pohled. D) 3D CT rekonstrukce, laterální pohled. E) 3D CT rekonstrukce, přední pohled; žlutá šipka – typický mezifragment z apexu velkého trochanteru.
Fig. 5. / Obr. 5. Quadrangular posterior fragment with a distal cortical spike. A) Postinjury radiograph, minimal displacement of proximal fragment. B) 3D CT posterior view. C) 3D CT lateral view. D) 3D CT medial view; red arrow – proximally displaced posterior fragment.Kvadrangulární zadní fragment s distálním kortikálním hrotem. A) Poúrazový rtg snímek, minimální posun proximálního fragmentu. B) 3D CT rekonstrukce, zadní pohled. C) 3D CT rekonstrukce, laterální pohled, červená šipka – proximálně dislkovaný zadní fragment. D) 3D CT rekonstrukce, mediální pohled, červená šipka – proximálně dislokovaný zadní fragment.
Medial aspect of the proximal femur: the course of the fracture line, with regard to the lesser trochanter, was the same in both the quadrangular and the triangular posterior fragments as in pathoanatomic specimens (Fig. 6, 7).
Fig. 6. / Obr. 6. Nondisplaced pertrochanteric fracture with a quadrangular (banana-shaped) minimally displaced posterior fragment. A) Postinjury radiograph. B) 3D CT posterior view. C) 3D CT lateral view. D) 3D CT medial view.Nedislokovaná pertrochanterická zlomenina s kvadrangulárním (banánovitým) minimálně posunutým zadním fragmentem. A) Poúrazový rtg snímek. B) 3D CT rekonstrukce, zadní pohled. C) 3D CT rekonstrukce, laterální pohled. D) 3D CT rekonstrukce,mediální pohled.
Fig. 7. / Obr. 7. Displaced triangular posterior fragment. A) Postinjury radiograph. B) 3D CT posterior view. C) 3D CT lateral view, posterior fragment carries posterior half of lateral trochanteric wall. D) 3D CT medial view.Obr. 7. Dislokovaný triangulární zadní fragment. A) Poúrazový rtg snímek. B) 3D CT rekonstrukce, dorzální pohled. C) 3D CT rekonstrukce, laterální pohled, zadní fragment nese dorzální polovinu laterální trochanterické stěny. D) 3D CT rekonstrukce, mediální pohled.
Lateral trochanteric wall: the lateral view demonstrated that the posterior fragment in the quadrangular (banana-shaped) type carried the posterior quarter to the posterior third of the lateral cortex of the proximal femur (Fig. 6). In the triangular type, the fragment carried in one case the posterior third, in the other case one half and in the third case two thirds of the lateral cortex (Fig. 2, 7, 8).
Comparison of pathoanatomic specimens and radiographs: comparison of postinjury radiographs and CT scans was of interest (Tab. 1). In 2 cases the fracture line could hardly be seen on radiographs, but CT showed in both cases (quadrangular and triangular types) a minimally displaced posterior fragment (Fig. 6, 9). Radiographs revealed a nondisplaced head and neck fragment, but a slightly, proximally, displaced posterior quadrangular fragment in 1 case (Fig. 5), and a 10-degree varus displacement of the proximal (head and neck) fragment with interruption of the medial cortex, but a nondisplaced posterior quadrangular fragment in 1 case, too (Fig. 4). In 3 cases the neck and head fragment showed marked varus displacement and the triangular posterior fragment mediodistal displacement (Fig. 3C, 7). In summary, the displacement of the quadrangular posterior fragment could not be seen on radiographs in 2 cases, and it was minimal in 1 case. The displacement of the triangular posterior fragment was not shown radiographically in 1 case and was well-seen in 3 cases.
Fig. 8. / Obr. 8. Displaced triangular posterior fragment. A) Postinjury radiograph. B) 3D CT posterior view. C) 3D CT lateral view, posterior fragment carries posterior two thirds of lateral trochanteric wall. D) 3D CT medial view.Dislokovaný triangulární zadní fragment. A) Poúrazový rtg snímek. B) 3D CT rekonstrukce, zadní pohled. C) 3D CT rekonstrukce, laterální pohled, zadní fragment nese dorzální dvě třetiny lateralní trochanterické stěny. D) 3D CT rekonstrukce, mediální pohled.
Fig. 9. / Obr. 9. Nondisplaced pertrochanteric fractures with a minimally displaced triangular posterior fragment. A) Postinjury radiograph. B) 3D CT posterior view. C) 3D CT lateral view, posterior fragment carries posterior two thirds of lateral trochanteric wall, red arrow – fracture line in base of greater trochanter.Nedislokovaná pertrochanterická zlomenina s minimálně posunutým triangulárním zadním fragmentem. A) Poúrazový RTG snímek. B) 3D CT rekonstrukce, zadní pohled. C) 3D CT rekonstrukce, laterální pohled, zadní fragment nese dorzální dvě třetiny lateralní trochanterické stěny; červená šipka – linie lomu baze velkého trochanteru.
Results of the analysis of both study groups demonstrated that the posterior large fragment occurred in two forms, the quadrangular and the triangular ones, that differed from each other by the shape, involvement of the lesser trochanter and the course of the fracture line on the medial surface of the proximal femur. The fracture line passing through the lesser trochanter was typical of the quadrangular type, while the triangular type was characterized by separation of the entire lesser trochanter with the adjacent inferomedial cortex. The V-fracture line in the quadrangular type provided support to the posterior fragment. The Y-fracture line in the triangular type showed shear instability, resulting in mediodistal displacement of the posterior fragment (Fig. 7, 8).
In pertrochanteric fractures with a quadrangular fragment, the proximal (head and neck) fragment was nondisplaced in 2 cases, displaced up to 10 degrees of varus in 3 cases and more than 20 degrees of varus only in 1 case. The posterior fragment was nondisplaced in 4 cases and minimally displaced (up to 5 mm) in 2 cases.
Pertrochanteric fractures with a triangular fragment were displaced more frequently. Severe varus displacement (of more than 20 degrees) of the proximal (head and neck) fragment was revealed in 5 cases, slight varus displacement (10 degrees) in 1 case and in 1 case the fracture was nondisplaced. Correspondingly, the posterior fragment was displaced in 2 cases only minimally (up to 2 mm) and in 5 cases markedly (more than 10 mm).
The LTW was less involved in cases of a quadrangular fragment (one quarter to one third posteriorly) as compared to the triangular type with posterior one - to two - thirds of LTW involvement.
Our study provided details about the large posterior fragment described as early as in 19th centuries on the basis of PA studies [12–14] and rediscovered by recent 3D CT studies [1,3,4,6].
Both types of the large posterior fragment were described for the first time by Smith in 1840 [12] and 1850 [13]. His drawings correspond exactly to our findings. He was followed by Kocher [14] in 1896, Fragenheim [15] in 1903 and Tanton [16] in 1916. All these descriptions were based on autopsy findings. However, the introduction of radiography gradually replaced postmortem examination. As a result, the subsequently developed classifications of trochanteric fractures were based solely on radiographs. This often led to misinterpretations and mentions of the large posterior fragment disappeared from the literature. Only later, have 3D CT reconstructions shown that the reality considerably differs in many cases from the interpretations of radiographs and the existence of a large posterior fragment has again come to the forefront.
Futurma et al. [1] in 2016, i.e., 100 years after the last pathoanatomic description [16], were the first to use 3D CT reconstructions to describe a quadrangular type of a large posterior fragment, which they termed a banana-shaped fragment.
In 2017, Cho et al. [3] published detailed 3D CT reconstructions of the triangular type of the posterior fragment, which they termed a single large coronal fracture fragment. They also described the quadrangular type, which they called a greater and lesser trochanter fragment.
Sharma et al. [4] in 2017, published a 3D CT reconstruction of a triangular fragment, which they called a single posteromedial fragment. The same descriptions were recorded by Xiong et al. [6] in 2019.
The large posterior fragment, however, was not presented in any of the existing classifications of trochanteric fractures [19–22], including the Evans [10] and the AO/OTA schemes [11]. This supports the requirement for a revision of the AO/OTA classification that would be based on 3D CT reconstructions [1–6,17].
Both (quadrangular and triangular) types may, during the trauma process, break in two parts (greater and lesser trochanteric fragments), resulting in four-part pertrochanteric fractures. A sign of this tertiary fracture line was found in our one pathoanatomic specimen and one 3D CT reconstruction. As shown by previous studies [1,3,4,6,17], the number of posterior fragments is not so important as their overall size which has a direct impact on weakening of the LTW.
In the literature, we may sometimes find the term “posteromedial fragment” [4]. It is based on radiographic studies and is not quite exact. CT [1,3,5,6] and PA [17] studies have demonstrated that the posterior fragment involves much more the lateral than the medial aspect of the proximal femur.
Our analysis has shown that it is almost impossible to determine the size and shape of the posterior fragment on a postinjury radiograph. In fractures with a nondisplaced posterior fragment it was difficult even to identify it. In fractures with a markedly displaced posterior triangular fragment, its shape could be well seen on the radiograph (Fig. 7).
Weakening of the LTW could not be detected on the radiograph in any case. LTW width in the AP view depended on rotation of the distal diaphyseal fragment. Therefore, suggestions to use the width of the LTW in the coronal plane as a criterion of fracture instability are, in our view, illusory [23]. Besides, Li et al. [24] have recently pointed out that of much greater importance is weakening of the LTW in the anterior-posterior direction.
The weakness of our study is the relatively small number of cases. Nevertheless, the acquired results are almost identical in a number of aspects. This study has not dealt with the incidence of this type of the posterior fragment in pertrochanteric fractures. As this type has not been included in any classification currently in use, most authors completely ignored its existence. Recently the situation has changed when this type has been noticed on 3D CT reconstructions as one of possible variants of the posterior fragment [1,3,5,6,17]. Determining its incidence is a task for future studies.
This study provides a detailed description of a large posterior fragment in pertrochanteric fractures. This fragment, which has not been included in any classification of trochanteric fractures, is, in most cases, difficult to diagnose on radiographs alone. Nevertheless, its existence has to be taken into account because its separation creates shear instability on the medial surface of the proximal femur. Laterally it markedly weakens the LTW, with all potential consequences. Therefore, the existence of this type of pertrochanteric fractures should be reflected in future revisions of their classifications.
Acknowledgements
The authors wish to thank Chris Colton, Prof, MD, FRCS, and Ludmila Bébarová, PhD, for their assistance in the preparation of the manuscript.
Dedication
Open access publishing supported by the National Technical
Library in Prague. This study is supported by IP DZRVO MO1012.
Conflict of interests
The authors declare that they have no conflict of interest related to the creation of this article, and that this article has not been published in any other journal with access to congress abstracts.
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