[Avulsion fracture of the lesser trochanter]

[Clinical aspects of imaging the hip in infants, children and adolescents]

When a child with a hip problem is clinically evaluated, it is usually possible to make a presumptive diagnosis which is subsequently confirmed. The most important tool for confirmation in pediatric hip disorders is radiological imaging. Vice versa changes on sonogram, native X‑ray or magnetic resonance images (MRI) can often only be interpreted when the history and current clinical findings are known. In this constellation, it is desirable that all colleagues who are confronted with a child's hip problem know the most common and important pediatric hip disorders and use the same terminology. The aim of this article is to present a short outline of the pathogenesis and clinical aspects of congenital and neurogenic hip dysplasia, coxitis fugax, septic coxitis, Perthes' disease, infantile and adolescent femoroacetabular impingement, apophysiolyses, and slipped capital femoral epiphysis.

Isolated Avulsion Fracture of the Lesser Trochanter in an Adolescent: A Case Report and Review of the Literature

Avulsion fractures of the lesser or greater trochanter or the iliac crest are uncommon injuries in adolescents. The anterior superior iliac spine, ischium, and anterior inferior iliac spine are the most frequently affected sites. We report a rare case of a 14-year-old boy who sustained an avulsion fracture of the lesser trochanter while playing soccer. No malignancy or associated metabolic bone disease was detected. Conservative treatment was suggested, consisting of a non-weight-bearing period and analgesics. Routine follow-up was performed at one, three, and six months after the injury. Radiographs were utilized to confirm fracture healing. Full recovery and return to a pre-injury functional level were observed at six months. Within this timeframe, a thorough literature review is performed.

Retrograde fixation of the lesser trochanter in the adolescent: new surgical technique and clinical results of two cases

INTRODUCTION

Avulsions of the lesser femoral trochanter are rare injuries in the adolescent population. An acute avulsion causes severe functional impairment with compromised hip flexion. Recent literature reports the superiority of surgical treatment for apophyseal avulsion fractures of the pelvis in adolescents. Unfortunately, there are no guidelines for an evidence-based treatment of lesser trochanter avulsions established. We present the cases of two adolescent athletes treated operatively.

MATERIALS AND METHODS

Two adolescent males, 12 and 16 years old, suffered an avulsion of the lesser trochanter during soccer. They reported immobilizing groin pain with subjective impairment in daily activities and inability to perform sports. Surgical treatment with a new retrograde technique by applying an adapted mini-open anterior approach was performed. Intraoperatively, both cases showed an intact musculo-tendinous unit attached to the avulsed fragment.

RESULTS

Both patients showed excellent postoperative results and were satisfied with the clinical outcome. In the postoperative follow-up an adequate consolidation of the lesser trochanter was visible. No complications were postoperatively reported at final follow-up.

CONCLUSIONS

The retrograde fixation technique has led to an excellent outcome without complications in two adolescents with acute lesser trochanter apophyseal avulsions. Further clinical use may support the value of this new surgical technique.

[Isolated fracture of the lesser trochanter-What age-related differences are important?]

Isolated fractures of the lesser trochanter are very rare injuries. This case report describes the age-related differences based on two cases. A 13-year-old girl suffered an avulsion fracture of the lesser trochanter while sprinting. The patient received conservative treatment with pain-adapted partial weight bearing as tolerated using crutches with the goal of full weight bearing after 6 weeks. After 3 months she could return to the preinjury functional level without impairments. A 55-year-old woman also suffered an isolated fracture of the lesser trochanter, which was a pathological fracture due to a breast cancer metastasis. The cause of an isolated fracture of the lesser trochanter in adults is assumed to be the sign of an underlying malignant disease, until this has been disproven.

Avulsion fracture of the lesser trochanter in adolescents

INTRODUCTION

Avulsion fractures of the lesser trochanter in adolescents are rare. They are a result of a sudden and forceful contraction of the iliopsoas muscle. Functional results in the medium term after non-operative treatment are unknown. Therefore we aimed to report these in the present study.

MATERIALS AND METHODS

A retrospective two-center study was performed in a case series treated between 2011 and 2017. All adolescents with an acute avulsion fracture of the lesser trochanter were included. Age, gender, mechanism of injury, fracture side, amount of displacement, and therapy were analyzed. In the follow-up, the Harris Hip Score (HHS), the sports level, the power of flexion in the hip, and signs of an ischio-femoral impingement (IFI) were investigated.

RESULTS

An avulsion fracture of the lesser trochanter was diagnosed in 4 boys and 1 girl. The mean age of the patients was 13.8 years (range: 13-15 years). We observed 2 type II and 3 type III fractures. The patients received similar non-operative treatment. Follow-up was performed at a mean of 4.9 years (range: 3.5-6.2 years) after injury. All patients returned to competitive sports. The Harris Hip Score (HHS) was 100 out of 100 points. History and provocation test concerning an IFI were negative in all patients.

CONCLUSION

Our study shows excellent results with non-operative treatment in acute avulsion fractures of the lesser trochanter in a case series of five adolescents. All patients returned to competitive sports. In our opinion, acute avulsion fractures of the lesser trochanter should be treated non-operatively.

[Apophyseal Avulsions of the Hip Region in Adolescents]

BACKGROUND

In daily practice apophyseal avulsions of sportive adolescents are frequently being diagnosed with a time delay and treated heterogeneously.

GOAL

Using the most actual literature and the own experience the current diagnostic and therapeutic strategies are put into perspective with regards of the needs of the adolescent athlete.

MATERIAL AND METHODS

The apophyseal lesions of the hip area in adolescence are separated in those at the pelvis and those at the proximal femur. They are reviewed according to its frequency and relevance using the most updated literature. The treatment methods reported focus on the degree of dislocation and level of sports activity.

RESULTS

The most frequent apophyseal avulsion of the pelvis is the avulsion of the tuber ischiadicum, followed by the inferior anterior iliac spine the superior anterior iliac spine and the apophysis of the ilium. The most affected structure at the proximal femur is the lesser trochanter, lesions of the greater trochanter are rare. The cause of injury is a specific acute contracture of the muscle inserting at the affected apophysis during different sporting activities. The treatment of pelvic apophyseal injuries is surgical only in cases with considerable fragment dislocation and in high level athletes. At the femoral side the patients are treated almost always conservatively.

DISCUSSION

Despite of modern and efficient osteosynthetic techniques the treatment of avulsion lesions of the hip region is mainly conservative, even in athletes. By applying consequent diagnostic and therapeutic principles the development of pseudarthroses and heteropic ossifications can be minimised.