Classification Garden

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sis for surgical indications in various countries, particularly in German-speaking areas. Today it has lost almost completely its importance (Kazar et al, 1960; Dynan and Parker, 1998). On the one hand, it became evident that fracture surfaces are not smooth, they are almost always jagged and fragmented modifying considerably the interaction between the fragments. On the other hand, the stability of internal fixation has been considerably improved over the years. Therefore, it is nowadays considered obsolete to base the choice of a surgical

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b
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d

Fig. 65. Classification of femoral neck fractures after Garden.

a. Garden-I, valgus position, incomplete fracture; b. Garden-II fracture without displacement; c. Garden-III tilted in varus, the main compression trabeculae are broken but the fracture surfaces are partly in contact; d. In the Garden-IV the compression trabeculae of the femoral head remain parallel to those of the neck but are shifted. The fracture surfaces are not in contact anymore (Manninger and Fekete, 1982)

Garden Classification Neck Femur
Fig. 66. Original radiographs of the four types of Garden classification (1961b). a. Garden-I; b. Garden-II; c. Garden-III; d. Garden-IV

method on the angle of inclination, i.e., for a Pauwels-II fracture an internal fixation and for a Pauwels-III fracture an arthroplasty. It is an error to make a decision based on radiographs taken with the limb in external rotation. The distal fragment on these films usually shows a vertical angle, a fact that does not correspond to reality (Gosset, 1950; Hulth, 1961).

The Pauwels angle is today of importance in two situations:

(1) Some authors recommend a valgus osteotomy according to Pauwels for vertical pseudarthro-sis of the neck; in changing the shear moments into compressive forces a consolidation can be achieved (Marti et al, 1989; Anglen, 1997). We do not perform this operation anymore because the incidence of pseudarthrosis has been considerably lowered thanks to modern, dynamic implants and the introduction of angle-stable plates increasing the stability and thus eliminating the considerable surgical trauma of an osteotomy. In addition, as described in section 1.5 a valgisation of the hip is always accompanied by an increased stress on the femoral head, a fact, that influences unfavorably the blood supply.

(2) The medially running Pauwels-III fracture is problematic on the account that the entire Adam's arch remains either attached to the proximal fragment or is avulsed. In these instances, the second buttressing point is lost and the two-armed lever action of the implant is transformed in a single lever arm because of its insufficient but

Garden Classification

Fig. 67. The importance of lateral radiographs when using the Garden classification, schematic representation (Manninger et al, 1992).

Based on a.-p. films all three fractures (a, b, c) belong to the group of undisplaced fractures. However, lateral films taken in example c show such a degree of antecurvature and lateral translation that the fracture must be considered to be displaced (Garden-III?)

Fig. 67. The importance of lateral radiographs when using the Garden classification, schematic representation (Manninger et al, 1992).

Based on a.-p. films all three fractures (a, b, c) belong to the group of undisplaced fractures. However, lateral films taken in example c show such a degree of antecurvature and lateral translation that the fracture must be considered to be displaced (Garden-III?)

tressing (see Fig. 211c-g). In this instance a more stable fixation must be chosen to maintain the neck/shaft angle to prevent a loss of reduction resulting in a varus deformity with a posterior displacement. The use of a caudal cannulated screw with longer threads (34 or 44 mm) is advisable as it has a better purchase in the long head fragment.

Garden (1961b and 1964) based his classification on the displacement of fractures as seen on the a.-p. film. He distinguishes between fractures in valgus (Garden-I), without displacement (Garden-II), with slight displacement in va-rus (the fracture surfaces are partly in contact) (Garden-III) and with complete displacement (Garden-IV) (Fig. 65 and 66).

Garden assumed that type-I fractures (valgus type) are not complete. This happens, however, very rarely as in fatigue fractures. Many authors use the term undisplaced fractures for Garden-I and -II fractures. This terminology is also used by the Multicenter Hip Fracture Study and by the SAHFE project (Editorial, Acta Orthop. Scand., 1988; Thorn-gren et al, 1990; Thorngren, 1998). The justification for combining Garden-I and -II fractures is said to be their identically favorable prognosis in respect to stability and development of a late avascular necrosis. Similarly, the term displaced fractures is used for Garden-III and -IV

fractures, in spite of the fact, that some authors separate strictly both groups and recommend for typeIII fractures an internal fixation and for type IV an arthroplasty (Hulth, 1961; Galla and Lobenhoffer, 2004). Publications in the pertinent literature fail to show a significant difference in the incidence of necrosis. This depends also on the fact that the degree of displacement as seen on the original radiographs may deteriorate subsequently while waiting for surgery; during this waiting period the patients care and positioning may cause displacement. The assessment can also considerably be influenced by the quality of films. If the radiograph has been taken in the recommended internal rotation, a severely displaced fracture can appear only as a Garden-III fracture. Once the limb has fallen back into external rotation, a much greater displacement becomes evident. Given these uncertainties the choice of the surgical method should not be based on films taken in one plane only.

The problem with the Garden classification is the fact that it is solely based on a.-p. films. We have seen repeatedly that Garden-I fractures, diagnosed on a.-p. films, show such a major angle of displacement in lateral films that these fractures must be considered Garden-III fractures on account of their displacement. The same problem is encountered when differentiating between Garden-III and Gar

Fig. 68. The importance of lateral radiographs.

69-year-old woman. a. The a.-p. shows a valgus position corresponding to a Garden-I fracture; b. The lateral film shows an obvious antecurvature of 45° (Garden-I-III?).

Note that the femoral head appearing on the a.-p. film as a sphere should be suspicious of a major displacement confirmed by the lateral radiograph

Fig. 68. The importance of lateral radiographs.

69-year-old woman. a. The a.-p. shows a valgus position corresponding to a Garden-I fracture; b. The lateral film shows an obvious antecurvature of 45° (Garden-I-III?).

Note that the femoral head appearing on the a.-p. film as a sphere should be suspicious of a major displacement confirmed by the lateral radiograph den-IV fractures. A fracture that appears as Garden-III on the a.-p. film (as in slight varus malposition) may show a major displacement on the lateral film. The femoral head may lie not infrequently posterior to the neck (Manninger et al, 1992) (Figs. 67 and 68).

For this reason the Alignment-Index, also described by Garden, is of great clinical value since it takes the a.-p. and lateral view into account. The midline of the compression trabeculae as seen on the a.-p. film forms normally an angle of 160° with the medial border of the diaphysis. On lateral films the compression trabeculae form an angle of 180° with the diaphyseal axis. Both values combined result in the anatomic Garden Alignment-Index of 160/180 (Fig. 69).

The Alignment-Index does not only allow describing better borderline fractures, it also is of use postoperatively to assess exactly the reduction. The Alignment-Index of Garden-II fractures, undisplaced in both planes, or anatomically reduced fractures amounts to 160/180. If a smaller or greater angle is present, a reduction is necessary in Garden-I and -II fractures and a correction of reduction in Garden-III and -IV fractures.

Another internationally well known grouping, particularly in German speaking countries is the AO/ASIF classification (Müller et al, 1990) (Fig. 70).

Their classification of great use in other body parts can only be adapted to the hip with difficulties. For this reason we do not use it. At the proximal end of the femur (segment code 31) trochanteric fractures are labeled A, neck fractures B and intraarticular fractures C (Fig. 71).

Raaymakers (1993) attempted to combine the Garden classification used in the Anglo-American countries with the AO/ASIF classification (Marti and Jacobs, 1993). According to this attempt the medial fractures of Garden type -I and -II correspond to 31-B11, B12 resp. B13 fractures. The Garden types -III and -IV correspond to 31-B22 and B23 as well as to 31-B31, B32, B33 fractures. The 31-B21 (latero-basal) fractures are extracapsular.

Basal Neck Femur FractureInternal Fixator ImageGarden Alignment IndexGarden Alignment Index

Fig. 69. Garden Alignment-Index (1964), schematic representation.

a. Midline of the compression trabeculae and longitudinal diaphyseal axis (along the medial cortex) form in the a.-p. film an angle of 160°; b. In the lateral film going through the midline of the femur this angle is 180°. The anatomical Garden Alignment-Index amounts to 160/180; c, d. The index also serves for the intra- and postoperative assessment of reduction: an a.-p. angle varying between 160 to 180° (indicating a slight valgus position) (c) and an angle seen in the lateral film of 180 to 160° (d) represent an acceptable position

Classification Pauwels

Fig. 70. Basic principles of the AO/ASIF classification (Muller, 1990).

The identification starts with the bone (femur = 3). It is followed by the segment in question (proximal end of femur = 31). Following this the type of fracture is taken into consideration (at the diaphysis the fragmentation and at the epiphysis the involvement of the joint are decisive: extraarticular fracture = A, simple intraarticular fracture = B, intraarticular comminuted fracture = C). Finally, a grouping or subgrouping is added depending on the severity of the fracture

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