Is cross sectional imaging of the hip necessary in isolated greater trochanter fracture?
Date First Published:
August 17, 2020
Last Updated:
February 10, 2021
Report by:
Henry Shirreff, Senior Clinical Fellow (University Hospitals Plymouth NHS Trust)
Search checked by:
Henry Shirreff, University Hospitals Plymouth NHS Trust
Three-Part Question:
In [patients with isolated fracture of the greater trochanter on plain film] does [three dimensional imaging] detect [clinically important intertrochanteric extension]?
Clinical Scenario:
In patients who have isolated fracture of the greater trochanter seen on plain film, does further cross sectional imaging (CT or MRI) help diagnose occult unstable extension of the fracture
Search Strategy:
Medline (1950 - 15.9.2020), EMBASE (1974 onwards - 15.9.2020) and Cochrane were searched with the following terms
Search Details:
(((Trochanter).ti OR (Trochanteric).ti) AND ((Fracture).ti OR (Fractures).ti)) AND ((Imaging).ti,ab OR (MRI).ti,ab OR (MR).ti,ab OR (Occult).ti,ab)
Outcome:
88 publications found
26 relevant publications, 12 of which duplicates, one a literature review, leaving 13 publications comprising one case report and 12 retrospective cohort studies
26 relevant publications, 12 of which duplicates, one a literature review, leaving 13 publications comprising one case report and 12 retrospective cohort studies
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures. Noh J, Lee KH, Jung S, Hwang S. Mar-19 South Korea | 100 patients with isolated greater trochanter fracture on plain film with subsequent further imaging |
Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanteric extension found in 90/100 patients. 62 patients (those with fracture extension across the medial cortex) were managed surgically. | Not directly stated whether study includes all patients with isolated GT fracture or only those requiring further imaging. The outcomes for those patients who had fracture extending across the medial cortex and were managed conservatively were not discussed. |
| Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs. Moon, N.H., Shin, W.C., Do, M.U. et al. 2018 South Korea | 30 consecutive patients that had plain film demonstrating isolated GT# who then went on to have further imaging | Retrospective cohort | Intertrochanteric extension on subsequent imaging. Management. | Intertrochanteric extension found in 21/30 patients. 20 patients were managed surgically. | Not stated whether study includes all patients with isolated GT fracture or only those requiring further imaging. |
| How can MRI change the treatment strategy in apparently isolated greater trochanteric fracture? Park JH, Shon HC, Chang JS, et al. 2018 South Korea | Patients undergoing MRI following isolated greater trochanter fracture seen on plain film | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanteric extension found in 14/37 patients. Only 4 patients required surgical management. | Not stated whether study includes all patients with isolated GT fracture or only those requiring further imaging. Abstract only published |
| The management of isolated greater trochanter fractures: Is crosssectional imaging necessary? Thurston D.; Marson B.; Ollivere B.; Westbrook T.; Moran C. et al. Sep-18 Uk | Consecutive patients with plain film demonstrating isolated GT#. | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanteric extension found in 15/85 patients. 4 were managed surgically. | Abstract only published. Unclear how patients were selected for surgery. |
| Occult intertrochanteric fracture mimicking the fracture of greater trochanter Chung PH, Kang S, Kim JP, et al 2016 South Korea | Patients that had plain film demonstrating isolated GT# that then went on to have CT/MRI | Retrospective cohort | Study aims to compare MRI and CT rather than determine the incidence of fracture extension. | ||
| Occult Intertrochanteric Extension in Isolated Greater Trochanteric Fracture on Plain Radiographs. Wong WY, Chu PY, Chan SWC, Yeung TW, Yuen MK 2016 Hong Kong | Consecutive patients with plain film demonstrating isolated GT#. | Retrospective cohort | Proportion of patients with intertrochanteric extension when imaged with CT and management and outcome | Intertrochanteric extension found in 10/58 patients. 5 were managed surgically. There were no complications in the surgical or conservative management group including 2 patients who met the criteria for surgical Mx but in who surgery was contraindicated. | Use of CT rather than MRI which is thought to be less sensitive. - different form |
| Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis Kim SJ, Ahn J, Kim HK, Kim JH 2015 South Korea | Patients with initial plain film showing isolated greater trochanter fracture | Systematic review | Review of previous literature on the subject. Includes several small studies with variable inclusion criteria and with low relevance to our question. | ||
| Greater trochanteric fracture with occult intertrochanteric extension Reiter M, O’Brien SD, Bui-Mansfield LT, Alderete J. 2013 United states | Single case of patient undergoing surgery following occult greater trochanter fracture | Case report | Case report involving a patient requiring surgical intervention. | ||
| Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures Suzuki K, Kawachi S, Nanke H 2011 South Korea | Patients undergoing surgery for intertrochanteric extension on MRI following isolated greater trochanter fracture on plain film | Retrospective cohort | Includes only patients requiring surgical intervention. Small sample. | ||
| Isolated fractures of the greater trochanter with occult intertrochanteric extension. Lee KH, Kim HM, Kim YS, et al. 2010 South Korea | Inclusion criteria - consecutive patients that had plain film demonstrating isolated GT# with suspected IT extension | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanteric extension found in 20/25. 15 were managed surgically. There were no complications amongst those treated conservatively including 4 patients who met the criteria for surgical Mx but in who surgery was contraindicated. | Not stated whether study includes all patients with isolated GT fracture or only those requiring further imaging. |
| MRI of seemingly isolated greater trochanteric fractures. Feldman F, Staron RB 2004 United states | Consecutive patients that had plain film demonstrating isolated GT# and also had MRI | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanter extension found in 35/37. 30 were managed surgically. There were no complications amongst those treated conservatively including 5 patients who met the criteria for surgical Mx but in who surgery was contraindicated. | Not stated whether study includes all patients with isolated GT fracture or only those requiring further imaging. |
| Greater trochanter fractures: MR assessment and its influence on patient management. Learch, T., Pathria, M. 2000 United States | Consecutive patients that had plain film demonstrating isolated GT# or GT# with suspected IT ext | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanter extension found in 8/8. 6 were managed surgically and 2 conservatively without complication in either group. | Only includes patients with suspected occult injury. Small sample size. |
| Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging. Craig JG, Moed BR, Eyler WR, van Holsbeeck M. 2000 United States | Consecutive patients that had plain film demonstrating isolated GT# and also had MRI | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanter extension found in 10/13. 6 were managed surgically and 7 (including 4 with limited extension of the fracture) were treated conservatively with no complications in either group. | Small sample size. Not stated whether study includes all patients with isolated GT fracture or only those requiring further imaging. Extent of fracture extension not quantified. |
| Evaluation of isolated fractures of the greater trochanter with magnetic resonance imaging Omura T, Takahashi M, Koide Y, et al 2000 Japan | Consecutive patients that had plain film demonstrating isolated GT# and seemed to have severer injury and had MRI | Retrospective cohort | Proportion of patients with intertrochanteric extension and management | Intertrochanter extension found in 7/8. All patients were managed conservatively without complication. | Small sample size. Patients with isolated GT fracture on plain film but did not require MRI were not included. |
Author Commentary:
Five more recent larger studies directly attempted to answer a similar question to our BET. The results are heavily polarised. The two most recent (Noh, Moon) showed that a large majority of patients (111/130 (85%)) were found to have intertrochanteric extension on MRI and 82/130 (63%) were surgically managed. In contrast three other recent papers (Park, Thurston, Wong) state that a minority (14/37, 15/85, 10/58 (22%)) patients showed intertrochanteric extension, and surgery performed in only 12/180 (7%) patients. Several earlier smaller studies attempt to answer the question but these are smaller with unclear selection criteria and there is a wide diversity of outcomes.
Across all studies to a significant but varied proportion of patients are managed surgically for intertrochanteric extension without complication, but without strong evidence to guide the decision making.
Of particular note to our BET, in those studies that recorded outcomes for all patients managed conservatively (272 of 434 patients) there was only one report of an adverse outcome (fracture displacement in a patient who declined surgery) (Park 2018).
Across all studies to a significant but varied proportion of patients are managed surgically for intertrochanteric extension without complication, but without strong evidence to guide the decision making.
Of particular note to our BET, in those studies that recorded outcomes for all patients managed conservatively (272 of 434 patients) there was only one report of an adverse outcome (fracture displacement in a patient who declined surgery) (Park 2018).
Bottom Line:
The evidence is weak and strongly polarised. UK research to date shows successful conservative management in 95% of isolated intertrochanteric fracture. Although MRI gives the greatest sensitivity in identifying occult fracture, little is known about the predictors of fracture completion and displacement in conservative management; the risk of which appears to be low but as yet unquantified.
References:
- Noh J, Lee KH, Jung S, Hwang S. . The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures.
- Moon, N.H., Shin, W.C., Do, M.U. et al.. Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs.
- Park JH, Shon HC, Chang JS, et al.. How can MRI change the treatment strategy in apparently isolated greater trochanteric fracture?
- Thurston D.; Marson B.; Ollivere B.; Westbrook T.; Moran C. et al.. The management of isolated greater trochanter fractures: Is crosssectional imaging necessary?
- Chung PH, Kang S, Kim JP, et al. Occult intertrochanteric fracture mimicking the fracture of greater trochanter
- Wong WY, Chu PY, Chan SWC, Yeung TW, Yuen MK. Occult Intertrochanteric Extension in Isolated Greater Trochanteric Fracture on Plain Radiographs.
- Kim SJ, Ahn J, Kim HK, Kim JH. Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis
- Reiter M, O’Brien SD, Bui-Mansfield LT, Alderete J.. Greater trochanteric fracture with occult intertrochanteric extension
- Suzuki K, Kawachi S, Nanke H. Insufficiency femoral intertrochanteric fractures associated with greater trochanteric avulsion fractures
- Lee KH, Kim HM, Kim YS, et al.. Isolated fractures of the greater trochanter with occult intertrochanteric extension.
- Feldman F, Staron RB. MRI of seemingly isolated greater trochanteric fractures.
- Learch, T., Pathria, M.. Greater trochanter fractures: MR assessment and its influence on patient management.
- Craig JG, Moed BR, Eyler WR, van Holsbeeck M. . Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging.
- Omura T, Takahashi M, Koide Y, et al. Evaluation of isolated fractures of the greater trochanter with magnetic resonance imaging