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Isolated fractures of the greater trochanter are unusual injuries with a wide spectrum of presentation, investigations and management strategies.
Aims
The objective of this study was to evaluate the incidence and treatment protocols used in the management of Isolated Greater Trochanteric Fractures (IGTF).
Methods
A systematic literature review of the PubMed and Central Register of Controlled Trials (Cochrane) databases by using the search term ‘greater trochanter fracture and hip fracture’ was conducted for Randomised Controlled Trials (RCT's), including prospective and retrospective non-experimental studies.
Results
The search yielded 15 studies meeting our inclusion criteria encompassing 166 patients with Isolated Greater Trochanteric Fractures (IGTF). Most of the reports were observational studies due to paucity of coverage on this topic in literature. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) were the common modalities used to diagnose these injuries. Most of the patients were managed with non-operative methods.
Conclusion
This systematic review analyses the consensus of treatment of IGTF based on evidence-based practice. When the IGTF is identified, the majority of studies advocate conservative management to surgery for such cases. Furthermore, large cohort studies with clearly documented outcome follow up are required to establish objective treatment guidelines for IGTF.
Isolated greater trochanteric fractures (IGTF) are uncommon subtypes of hip fractures, with scarcity of orthopaedic reports in the literature and limited textbook coverage on their demographics and management protocols.
There is a widespread debate about the aetiology and exact patho-mechanism of IGTF with an epidemiological variance. Avulsion injuries are observed more commonly in children or younger adolescents, whereas traumatic injuries (following a direct blow or fall) are encountered more often in the elderly population.
The diagnoses of any proximal femoral fractures are based on the appropriate clinical history and physical examination and further confirmed by radiological imaging. However, the diagnoses of IGTF can be quite challenging, as they may clinically present similar to that of any other hip fracture, with an occult radiological presentation. The pain may be mild or even an asymptomatic incidental radiological finding.
When initial plain radiographs show an IGTF, the vast majority of studies strongly recommended further imaging analyses (with the use of Magnetic resonance imaging or Computed tomography). Often, many of these fractures extend beyond the intertrochanteric line, complicating the approach and management to such cases.
Several treatment options are recommended for managing IGTF. Due to the lack of an evidence-based classification of these injuries, and indications for surgical management, consensus on treatment selection has yet to be established. This systematic review focuses on managing IGTF, providing treatment recommendations with a pooled analysis of the most up-to-date available literature.
2. Methods & results
This systematic review was performed with adherence to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
Ethical approval for review of the literature was not required for this study.
2.1 Eligibility criteria
We identified studies that met the following criteria:
Inclusion Criteria: The inclusion criteria consisted of articles describing treatment protocols of IGTF, confirmed on Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), published in the English language, prospective and retrospective non-experimental studies, Randomised Control Trials (RCT's) and observational studies.
Exclusion Criteria: We excluded studies describing the management of IGTF in patients diagnosed using X-RAY imaging (plain radiographs) only, studies where no comment was made on the treatment of IGTF, not written in English, full-text unavailability, letters, and meeting proceedings.
Information sources, Literature search, study identification, and search strategy:
A systematic literature review of the PubMed, Central Register of Controlled Trials (Cochrane), EMBASE, and CINAHL databases by using the search term ‘greater trochanter fracture and hip fracture’ was undertaken and included all relevant studies from inception until January 2021. We also identified relevant studies by a backward and forward citation search within included studies. No grey literature was included in this study.
2.2 Data extraction
To ensure eligibility of the included studies, two of reviewers (AS and RB) independently performed title and abstract screening and assessed them. Duplicate studies were removed. Following this, the full text of the potentially eligible studies was independently evaluated. The search was further repeated in July 2021 to ensure the accuracy. Any disagreement was resolved by consultation with the senior author (RV).
2.3 Data and statistical analysis
Data extraction was performed independently by 2 authors (AS, RB). A predefined checklist was used to input data using the Microsoft Excel database. It included: year of publication, first author, study design, number of included patients, imaging modality used for diagnoses, mean age, method of management of IGTF, and average follow-up period. Articles that were included in the study were assessed using Sackett's Level of Evidence. Microsoft Excel version 2016 (Windows) was used for analysis. A meta-analysis could not be performed due to the heterogeneity of the reports.
The primary outcome measure included the type of treatment method utilised to manage IGTF categorized into two subgroups, surgical vs. conservative. Furthermore, each subset was classified according to the specific treatment applied. We analysed functional outcomes based on radiographic evidence and/or the resolution of symptoms and/or complication rates documented during the follow-up period.
2.4 Statistical methods
Microsoft Excel data sheet was used for data collection. SPSS 24.0 software (SPSS Inc. Chicago, Illinois, USA) was used for statistical analysis. Mean and standard deviation were used to summarize the data for continuous variables and frequency/proportion/percentage for categorical variables.
3. Results
3.1 Characteristics of the studies
In total, 15 studies suited the inclusion criteria in our search and were included in this systematic review (Fig. 1: PRISMA Flow Chart). Most of the reports were observational studies (n = 14), of which 12 are retrospective and 2 prospective studies. We also identified one systematic review. Finally, two case series were included in the study due to the limited evidence available in the literature on this subject.
The total number of patients identified with IGTF was 166. It was difficult to determine the mean age and gender predominance due to the absence of these variables in some of the studies. More detailed demographic data has been provided in Table 1.
Table 1Summary of studies reporting series on Isolated Greater Trochanteric Fractures with demographic data.
Of the 166 patients, 106 were diagnosed using MRI, whereas the remaining 60 were identified on CT Imaging.
3.4 Management strategies
99.4% of patients (n = 165) were managed conservatively, with only one patient undergoing surgical treatment in the form of tension band wiring. A summary of the different types of conservative treatment methods applied is included in Table 3.
3.5 Follow-up period
It was difficult to determine the overall follow-up period, as this information was not recorded in all the studies. A summary of the average follow-up period in other studies can be found in Table 2. Of these, all patients treated conservatively and surgically had no complications and were discharged.
Table 2Summary of the diagnostic modalities and types of treatment methods applied in the evaluated studies.
Author
Isolated Greater Trochanteric Fractures (IGTF).
Mode of Diagnosis
Conservative
Surgery
Mean Follow-up in Weeks
Omura et al.
1
MRI
1
0
NA
Craig et al.
3
MRI
3
0
12
Feldman et al.
2
MRI
2
0
12
Frihagen F
6
MRI
6
0
N/A
Wong et al.
41
CT
41
0
73
Lee et al.
5
MRI
5
0
NA
LaLonde et al.
10
MRI
10
0
60
Kambali et al.
2
MRI
1
1
24
Kim SJ
11
MRI
11
0
N/A
Chung PH
1
MRI
1
0
N/A
Arshad R
35
CT (n = 19) MRI (n = 16)
35
0
N/A
Park JH
23
MRI
23
0
N/A
Ren et al.
7
MRI
7
0
52
Moon et al.
9
MRI
9
0
140
Noh J
10
MRI
10
0
N/A
Abbreviations: MRI = Magnetic Resonance Imaging; CT= Computerised Tomography; NA= Not available.
IGTF is a rare subtype of extracapsular femoral neck fractures that pose a challenge to Orthopaedic Surgeons, as no consensus has been developed to guide management. Thus, treatment is usually based on clinical expertise and the surgeon's preference. The literature is currently scarce of any systematic reviews that highlight the essential factors that influence the basis of a valid, evidence-based treatment selection. The primary aim of this review is to identify management protocols of IGTF based on the literature; report the efficiency of outcomes centered on those treatment plans and establish appropriate treatment recommendations.
The first line investigation of patients presenting with hip pain following trauma is often a plain radiograph of the hip and pelvis.
When an IGTF is identified, most research studies signify this as an indicator of an occult ITF. A missed diagnosis of an occult ITF extension carries a risk of fracture displacement, which may be associated with increased patient morbidity and mortality due to delayed treatment, prolonged hospital length of stay, and deferred rehabilitation.
Therefore, the most recent published literature advocates early MRI (sensitivity of 99%) or CT (sensitivity of 53%) imaging to further delineate the fracture pattern and establish whether an intertrochanteric extension exists.
Fractures that do not cross the midline of the intertrochanteric region are usually biomechanically stable. These carry a low risk of causing limb shortening or an external rotation deformity.
Traditionally, the favoured treatment for presumed IGTF confirmed on plain radiographs was non-operative management, as the weight-bearing portion of the femoral neck was assumed to be intact. Treatment strategies involved bed rest with the application of skin traction for an average of three to six weeks, followed by full weight bear mobilisation.
99.4% of reports within our review employed a conservative approach in treating IGTF. Subtle differences between the methods of treatment were found, with no consensus regarding treatment protocols. Some surgeons advocated a trial of bed rest between one to three weeks followed by full weight bear mobilisation with good outcome measures recorded on follow-up.
Lablonde and Moon et al. were more aggressive with their treatment, allowing their patients to immediately mobilise full weight bear with the aid of analgesia and support. These results reported adequate patient outcomes on routine follow-up.
Wong et al. had the largest sample of patients diagnosed with IGTF on CT imaging and managed conservatively. Although this study failed to explain the method of treatment applied, on average follow-up of up to 73 weeks, all patients were discharged with no hip pain or radiographic evidence of fracture extension.
Therefore, the decision to manage these injuries conservatively should be taken into careful consideration. Only one study within our report opted for surgical fixation.
It was in the form of an open reduction and internal fixation of the greater trochanter using the tension band wiring technique. This decision was based solely on older studies
which advocated surgical treatment in cases where there is a marked separation of the GT or soft tissue interposition.
4.1 Limitations
The main limitation in this study is that the number of studies included is fairly small. This was mainly due to the strict inclusion and exclusion criteria as well as paucity of this topic in the literature. Furthermore, large cohort studies with clearly documented outcome and follow up are required to establish objective treatment guidelines for IGTF.
5. Conclusion
This systematic review analyses the consensus of treatment of IGTF based on evidence-based practice. Initially, it is recommended that an MRI is done to rule out occult IT fractures. When IGTF are identified, the majority of studies advocate conservative management to surgery for such cases. The difference in outcomes of the different conservative methods applied remains unclear, however, these factors are critical to take into consideration as an Orthopaedic surgeon, to plan appropriate management for such cases.
Author's contributions
AS and RB involved in Conceptualization, literature search, manuscript writing and editing. AS and KPI Literature search, manuscript writing, references, data analysis and editing. RV supervised overall submission and approved final draft. All authors read and agreed the final draft submitted.
Funding statement
The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclosure statement and conflict of interest statement
Nothing to disclose. “The authors declare no conflict of interest”.
Statement of ethics
The current submitted article is not a clinical study and does not involve any patients.
Financial disclosures
No financial disclosures.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
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