Greater trochanter fracture and fixation in a teenage athlete: A case report

Introduction: Greater trochanter fractures are rare subtypes of hip fractures¹, with limited reports in the literature, resulting in disparities in demographics and management protocols.² Isolated greater trochanter fractures can occur due to avulsion injuries in younger patients caused by strong hip abduction, as well as pathological processes or traumatic injuries in the elderly. Fractures displaced by more than one centimeter typically require open reduction internal fixation (ORIF), while others can often be managed nonoperatively.³ These displaced fractures more pressing concerns due to the risk of avascular necrosis (AVN) of the femoral head, which may occur if the medial circumflex femoral artery is disrupted as it traverses the greater trochanter.⁴ Pediatric patients are particularly at risk for traumatic AVN in the setting of displaced fractures. Unlike skeletally mature patients, whose vascular supply to the femoral head may include contributions from the metaphysis, pediatric patients rely heavily on the medial femoral circumflex artery for femoral head blood supply. This reliance increases their risk of AVN with greater displacement and delayed reduction. Although displaced fractures necessitate surgical intervention, ORIF carries inherent risks, including potential iatrogenic injury to the medial circumflex femoral artery, which could also result in femoral head AVN.

Case Description: A 14-year-old male presented to the emergency department with complaints of right hip pain following a “dog-pile” manner while playing football. Radiographs of the right hip revealed an isolated, displaced right greater trochanter fracture. Subsequent MRI confirmed the fracture as isolated, without intertrochanteric or intraarticular extension. Upon orthopedic consultation, ORIF was determined as the most appropriate management. During surgery, the fracture was visualized and reduced by forcefully internally rotating the greater trochanteric apophysis. Reduction was confirmed intraoperatively using fluoroscopic imaging. A semitubular Smith and Nephew plate was applied to the femur, and screws were inserted to secure the plate. Following fixation, the surgical team mobilized the patient’s hip to confirm stability and absence of fracture movement. Postoperatively, the patient was discharged with instructions for touch-down weight bearing using crutches and a plan to gradually increase weight-bearing activities over two to four weeks. At a two-week follow-up, the patient exhibited a well-healed incision, intact motor and sensory function, and no complications. Weight bearing was gradually increased over the following weeks. At the eight-week follow-up, the patient reported no new issues and showed satisfactory progress.

Discussion/Conclusion: Isolated greater trochanter fractures are a rare subset of hip fractures, with minimal literature detailing their etiology, management, and prognosis, particularly in young athletes. Prompt and definitive treatment, such as ORIF, is crucial for minimizing complications like AVN and facilitating return to play. However, the surgical approach itself poses risks, including iatrogenic injury to the medial circumflex femoral artery, which could jeopardize femoral head viability. Given these dual risks, comprehensive preoperative planning is essential to optimize outcomes. The rarity of this injury underscores the importance of recognizing unusual pathologies and generating sufficient literature to guide management for all age groups and injury mechanisms.