M.E.Müller: Atlas: Fracture 31-A2

Femur, Proximal, extra-articular fracture, trochanteric area, pertrochanteric multifragmentary 9,55% of the total
16,40% of the femur
23,44% of the segment

2011 fractures
37,4% group
25%M, 75%F

2468 fractures
45,9% group
24%M, 76%F

902 fractures
16,7% group
34%M, 66%F

With one intermediate fragment With several intermediate fragments Extending more than 1 cm below the lesser troch ante

These are pertrochanteric fractures with either partial or total detachment of the lesser trochanter. A hairline fracture of the lesser trochanter means a potential loss of stability of the proximal fragment support. The fragmentation and detachment of the lesser trochanter means a real loss of bone stock. Ref. Manual of Internal Fixation :
262 - 265. 272 - 275. 528 - 531.
Surgeon. MS, RO.

The DHS achieves a dynamic fixation through its load tutoring effect. In these fractures it also acts as a buttress implant since the postero-medial cortex does not participate in the stability of the assembly.

When the detachment and fragmentation of the lesser trochanter is significant it is better to look for a valgus reduction, easier to obtain with a 130º angled blade-plate with the tip of the blade placed below the hard core of the femoral head. With impaction of the fragments,

the tip of the blade penetrates into the head and the lag screw retropulses by the same amount.

It is useless to attempt the reduction and fixation of the lesser trochanter. It lengthens the surgical time unnecessarily and the fragment´s fragility, sometimes multifragmented, rarely permits a solid hold with a single screw. If the fracture is stable, the lesser trochanter will heal with a more or less massive callus.

preoperative + 4 months

preoperative + 6 months

preoperative 0 months

+ 4 months + 4 months

These are pertrochanteric fractures involving the lesser trochanter and the posterior intertrochanteric wall, which is either crushed or multifragmented. As a whole, there is significant postero-medial bone stock loss and, therefore, great instability. These fractures occur in very osteoporotic elderly patients. Ref. Manual of Internal Fixation:
262 - 265. 272 - 275. 528 - 531.
Surgeon. RO, JM, JM.

Reduction is very difficult in this subgroup of fractures and sometimes it can only be achieved with the foot in external rotation and pushing up the greater trochanter with Hohmann retractors.

The favoured implant is the DHS since it facilitates the impaction of the two main fragments while the remaining fragments randomly cluster together. Attempts to reduce the lesser trochanter are useless. Instead, it is useful to put together the greater trochanter fragments with a wire loop acting as a tension band.

A lateral cortex fracture can sometimes be encountered when inserting the sliding screw, while screwing the plate or immediately postoperatively when the assembly is dynamically loaded. This results in a diaphyseal medialization, affecting the anatomic reduction but usually not disturbing the stability since it is favoured by the impaction guided by the sliding screw. In any case, 31-A2.2 fractures should be considered to be very unstable and weight bearing must be postponed.

preoperative + 10 years

preoperative postoperative

preoperative postoperative

preoperative + 0 months + 0 months

+ 1 year + 1 year

preoperative preoperative

+ 5 months + 5 months

These are pertrochanteric fractures involving the lesser trochanter and the posterior intertrochanteric wall, which is either crushed or multifragmented. As a whole, there is significant postero-medial bone stock loss and, therefore, great instability. These fractures occur in very osteoporotic elderly patients. Ref. Manual of Internal Fixation:
262 - 265. 272 - 275. 530 - 531.
Surgeon. RO, RO.

For the reasons stated on the previous page, some of the fractures of the subgroups 31-A2.2 and 31-A2.3, occuring in very osteoporotic bone, are impossible to reduce even close to anatomically, so that the bone cannot participate in the stability of the assembly. This is the reason why we maintain in our armamentarium, as a salvage technique for extreme cases, the technique of humeralization either with the 130º blade plate or with the DHS.

The technique is not difficult to perform if it has been previously planned. It offers good postoperative stability, that is dependent on the interfragmentary lag screw placed into the calcar. This screw is essential in the technique, even when using a DHS. A wire loop reassembling the greater trochanter fragments is also imperative.

preoperative + 4 months

preoperative postoperative

These are pertrochanteric fractures extending more than 1 cm below the lesser trochanter into the diaphysis, meaning more postero-medial cortex bone loss than the fractures of the A2.2 subgroup. The fractures can be either linear or with major comminution of the posterior intertrochanteric region. Ref. Manual of Internal Fixation:
262 - 265. 272 - 275. 530 - 531.
Surgeon. CS, RO.

The main pertrochanteric fracture can be fixed either with a dynamic implant like the DHS or with a buttress effect implant like the 95º condylar plate. In this fracture subgroup, in order for the bone to participate in the stability, it is very important to reconstruct the large postero-medial fragment and fix it with one or several interfragmentary compression screws.

From the practical standpoint, the larger the postero-medial fragment prolonging from the lesser trochanter is, the easier is the reduction and stable fixation. The possibility to obtain anatomic reconstruction is often greater than with the 31-A2.2 fractures. If the lesser trochanter cannot be fixed, the fracture must be considered unstable and treated as such postoperatively.

preoperative + 1 year

preoperative + 4 months




						Femur, Proximal, extra-articular fracture, trochanteric area, pertrochanteric multifragmentary	9,55% of the total 16,40% of the femur 23,44% of the segment






These are pertrochanteric fractures with either partial or total detachment of the lesser trochanter. A hairline fracture of the lesser trochanter means a potential loss of stability of the proximal fragment support. The fragmentation and detachment of the lesser trochanter means a real loss of bone stock.		Ref. Manual of Internal Fixation : 262 - 265. 272 - 275. 528 - 531. Surgeon. MS, RO.

The DHS achieves a dynamic fixation through its load tutoring effect. In these fractures it also acts as a buttress implant since the postero-medial cortex does not participate in the stability of the assembly. When the detachment and fragmentation of the lesser trochanter is significant it is better to look for a valgus reduction, easier to obtain with a 130º angled blade-plate with the tip of the blade placed below the hard core of the femoral head. With impaction of the fragments,	the tip of the blade penetrates into the head and the lag screw retropulses by the same amount. It is useless to attempt the reduction and fixation of the lesser trochanter. It lengthens the surgical time unnecessarily and the fragment´s fragility, sometimes multifragmented, rarely permits a solid hold with a single screw. If the fracture is stable, the lesser trochanter will heal with a more or less massive callus.






These are pertrochanteric fractures involving the lesser trochanter and the posterior intertrochanteric wall, which is either crushed or multifragmented. As a whole, there is significant postero-medial bone stock loss and, therefore, great instability. These fractures occur in very osteoporotic elderly patients.		Ref. Manual of Internal Fixation: 262 - 265. 272 - 275. 528 - 531. Surgeon. RO, JM, JM.

Reduction is very difficult in this subgroup of fractures and sometimes it can only be achieved with the foot in external rotation and pushing up the greater trochanter with Hohmann retractors. The favoured implant is the DHS since it facilitates the impaction of the two main fragments while the remaining fragments randomly cluster together. Attempts to reduce the lesser trochanter are useless. Instead, it is useful to put together the greater trochanter fragments with a wire loop acting as a tension band.	A lateral cortex fracture can sometimes be encountered when inserting the sliding screw, while screwing the plate or immediately postoperatively when the assembly is dynamically loaded. This results in a diaphyseal medialization, affecting the anatomic reduction but usually not disturbing the stability since it is favoured by the impaction guided by the sliding screw. In any case, 31-A2.2 fractures should be considered to be very unstable and weight bearing must be postponed.






These are pertrochanteric fractures involving the lesser trochanter and the posterior intertrochanteric wall, which is either crushed or multifragmented. As a whole, there is significant postero-medial bone stock loss and, therefore, great instability. These fractures occur in very osteoporotic elderly patients.		Ref. Manual of Internal Fixation: 262 - 265. 272 - 275. 530 - 531. Surgeon. RO, RO.

For the reasons stated on the previous page, some of the fractures of the subgroups 31-A2.2 and 31-A2.3, occuring in very osteoporotic bone, are impossible to reduce even close to anatomically, so that the bone cannot participate in the stability of the assembly. This is the reason why we maintain in our armamentarium, as a salvage technique for extreme cases, the technique of humeralization either with the 130º blade plate or with the DHS.	The technique is not difficult to perform if it has been previously planned. It offers good postoperative stability, that is dependent on the interfragmentary lag screw placed into the calcar. This screw is essential in the technique, even when using a DHS. A wire loop reassembling the greater trochanter fragments is also imperative.






These are pertrochanteric fractures extending more than 1 cm below the lesser trochanter into the diaphysis, meaning more postero-medial cortex bone loss than the fractures of the A2.2 subgroup. The fractures can be either linear or with major comminution of the posterior intertrochanteric region.		Ref. Manual of Internal Fixation: 262 - 265. 272 - 275. 530 - 531. Surgeon. CS, RO.

The main pertrochanteric fracture can be fixed either with a dynamic implant like the DHS or with a buttress effect implant like the 95º condylar plate. In this fracture subgroup, in order for the bone to participate in the stability, it is very important to reconstruct the large postero-medial fragment and fix it with one or several interfragmentary compression screws.	From the practical standpoint, the larger the postero-medial fragment prolonging from the lesser trochanter is, the easier is the reduction and stable fixation. The possibility to obtain anatomic reconstruction is often greater than with the 31-A2.2 fractures. If the lesser trochanter cannot be fixed, the fracture must be considered unstable and treated as such postoperatively.