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 Table of Contents  
CASE REPORTS
Year : 2022  |  Volume : 37  |  Issue : 2  |  Page : 100-102

Conservative management of a lesser trochanter avulsion fracture: A case report


Department of Orthopedics, Teerthanker Mahaveer Medical College & Research Centre (TMMC&RC), Moradabad, Uttar Pradesh, India

Date of Submission25-Jul-2022
Date of Acceptance14-Sep-2022
Date of Web Publication19-Oct-2022

Correspondence Address:
Hamza Habib
Accidental Care Hospital, Railway Station Road, Gorakhpur 273001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_13_22

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  Abstract 

A 12-year-old male patient came to our outpatient department with a complaint of pain in the left hip region after he slipped and fell on a wet floor while playing at school. The symptoms were pain left the hip region with functional impairment, difficulty in walking, tenderness on inguinal region palpation, and restricted hip movements. The X-ray and computed tomography scan showed an avulsion fracture of the left lesser trochanter. The treatment included rest, immobilization, analgesia, and non-weight bearing. After a 9-month follow-up, the patient had a completely normal range of motion and was fully able to do all his daily activities

Keywords: Apophysis, avulsion fracture, case report


How to cite this article:
Saraf A, Bishnoi S, Habib H, Aggarwal S. Conservative management of a lesser trochanter avulsion fracture: A case report. J Bone Joint Dis 2022;37:100-2

How to cite this URL:
Saraf A, Bishnoi S, Habib H, Aggarwal S. Conservative management of a lesser trochanter avulsion fracture: A case report. J Bone Joint Dis [serial online] 2022 [cited 2022 Nov 29];37:100-2. Available from: http://www.jbjd.in/text.asp?2022/37/2/100/358793




  Introduction Top


The lesser trochanter is a growing apophysis, which is the insertion point for the iliopsoas muscle. An avulsion fracture in this area is rare and is generally caused by a strain on the muscle attachment.[1] This type of injury is exceedingly rare and if present is common only in the adolescent age group with a peak incidence in the 13–14 age group.[2] The insertion of the tendon being stronger than the growth plate causes a disruption due to the sudden contraction of the muscle fibers.[3] The avulsion type of fracture is rare in incidence and can involve the calcaneum, tibial spine, malleoli of the tibia, the olecranon, etc. In the pelvis, these are seen in ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine; however, very rarely the lesser trochanter is involved due to the pull of the iliopsoas muscle.[4],[5] The clinical presentation is a pain in the groin region on palpation and difficulty in walking.[2],[3],[4],[5],[6] A definitive diagnosis can be made by a plain radiograph and can be augmented by the use of a computed tomography (CT) scan. The preferred treatment protocol includes analgesia, rest, and non-weight bearing. The prognosis remains favorable. Fractures secondary to metastasis should always be ruled out.


  Case Report Top


We report a 12-year-old male school-going patient who presented to our outpatient department with severe pain in his left hip and thigh region after he slipped and fell on a wet floor at the school while playing during recess. While falling, his left hip got hyperextended and abducted. He developed acute severe pain in his left hip which was aggravated on all movements of the left hip and walking. A swelling appeared on the left thigh. He was unable to do the straight leg raise test and had tenderness on palpation at the upper medial aspect of the left thigh near the groin.

The X-rays and CT scan [Figure 1] and [Figure 2] showed a fracture avulsion epiphysiolysis of the lesser trochanter. The patient was admitted and treatment was started with analgesics and rest was advised. The patient was also given a well-fitted de-rotation boot and bar cast to comfort the limb and limit any rotational movement at the hip joint.
Figure 1: Plain radiograph of pelvis with both hips in a neutral position and in abduction showing avulsion fracture of the left lesser trochanter

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Figure 2: Is a CT scan of the pelvis with both hips showing a 3D reconstruction of the injury

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The patient seemed to be symptomatically relieved after about 5 days of inpatient management and was discharged with the de-rotation boot and bar cast in place for 6 weeks with some ambulation allowed using a walker. At the 6-week follow-up, the patient had no symptoms, and an almost complete range of motion at the hip joint, the boot, and bar cast were removed. Partial weight bearing was allowed at the 3-month follow-up. At the 9-month follow-up, the patient was completely asymptomatic and was able to walk and play as before without any residual disability or loss in the range of motion [Figure 3] and [Figure 4].
Figure 3: Showing the excellent range of motion at the 9-month follow-up

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Figure 4: Showing a completely healed fracture at the 9-month follow-up

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  Literature Review Top


The apparent paucity of literature on this topic is a result of the low incidence of such injuries. The limited review papers and studies that we found after an extensive search have found the nonsurgical treatment to give good results even in avulsions with significantly higher displacement. In these papers, the etiology was related to sports with the mechanism of trauma being, hyperextension with hip abduction.[7] Gamble James and John[8] described a patient similar to the one reported in this report and followed him up for 3 years; at the end of which they described a patient return without any residual disability and a full return to his pre-trauma activities.

Bed rest and treatment with a cast were cited in historical articles, published before 1960. McKinney and collaborators have made a review of publications in English on the subject and, in none of them, surgical treatment was indicated.[8] We also found two authors who suggested surgical treatment in cases where results after conservative management were not satisfactory.[9],[10]

Fasting[9] described the case of a 13-year-old boy who had a lesser trochanteric avulsion fracture whom he managed surgically by fixing it with a wire and giving a hip spica for 6 weeks. He reported the patient to be symptom-free and normal at the 2-year follow-up.

Khemka et al.[10] reported a case series of four cases where they did arthroscopic guided fixation with cannulated cancellous screws in three cases and anchor in one case. The reported unaided ambulation at 4 weeks, return to sports at 3 months, and no complications were reported intra- and postoperatively.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



 
  References Top

1.
Dimon JH 3rd. Isolated fractures of the lesser trochanter of the femur. Clin Orthop Relat Res 1972;82:144-8.  Back to cited text no. 1
    
2.
Singh P, Kumar A, Shekhawat V, Singh P Nonpathological lesser trochanter fracture in adult: Case report and brief review of literature. J Clin Diagn Res 2015;9:RD04-5.  Back to cited text no. 2
    
3.
Suarez JC, Ely EE, Mutnal AB, Figueroa NM, Klika AK, Patel PD, et al. Comprehensive approach to the evaluation of groin pain. J Am Acad Orthop Surg 2013;21:558-70.  Back to cited text no. 3
    
4.
Vazquez E, Kim TY, Young TP Avulsion fracture of the lesser trochanter: An unusual cause of hip pain in an adolescent. CJEM 2013;15:123-5.  Back to cited text no. 4
    
5.
Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, et al. Imaging Features of Avulsion Injuries JA: Hip and pelvis avulsion fractures in adolescents. Physician Sports Med 1994;22:41-9.  Back to cited text no. 5
    
6.
Byrne AM, Reidy D Acute groin pain in an adolescent sprinter: A case report. Int J Clin Pediatr 2012;1:46-8.  Back to cited text no. 6
    
7.
Green J, Gay F Avulsion of the lesser trochanter epiphysis. Southern Med J 1956;49:1308.  Back to cited text no. 7
    
8.
Gamble JG, Kao J Avulsion fracture of the lesser trochanter in a preadolescent athlete. J Pediatr Orthopaed B1993;2:188-90.  Back to cited text no. 8
    
9.
Fasting OJ Avulsion of the lesser trochanter. Arch Orthop Trauma Surg 1978;91:81-3.  Back to cited text no. 9
    
10.
Khemka RG, Bosley B, Ludger G, Al Muderis M Arthroscopically assisted fixation of the lesser trochanter fracture: A case series. J Hip Preserv Surg 2014;1:27-32.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Literature Review
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