Management of Lesser Trochanter Fracture After Intertrochanteric Medullary Rod Insertion
A lesser trochanter fracture occurring after intertrochanteric medullary rod insertion generally requires surgical repair, particularly in the context of metastatic disease or when it indicates instability, as fracture of the lesser trochanter is recognized as a specific indication for prophylactic surgical intervention. 1
Clinical Context and Decision Framework
When Surgical Repair is Indicated
The presence of a lesser trochanter fracture carries specific biomechanical and prognostic implications that guide management:
In metastatic disease: Lesser trochanter avulsion is explicitly listed as an indication for prophylactic surgery when the proximal femur is involved, as it signifies structural compromise and impending complete fracture risk 1
Biomechanical instability: A lesser trochanter fracture with extension compromises both axial compression strength (reduced by 50%) and torsional strength (reduced to one-sixth of normal), creating high risk for secondary complete fracture 2
Post-operative occurrence: When a lesser trochanter fracture occurs after intramedullary nailing, it represents either inadequate initial fixation or progression of instability that was not adequately addressed 3
Surgical Approach
The recommended technique involves modified candy-package wiring of the lesser trochanter fragment combined with the existing intramedullary nail fixation 3:
This minimally invasive wiring technique increases fixation force at the fracture site and achieves stable bony union in unstable intertrochanteric fractures with lesser trochanter comminution 3
Union rates of 100% have been achieved with this approach, with mean fracture union time of 16.6 weeks 3
The technique maintains ambulatory capacity in 81.8% of patients compared to pre-trauma status 3
Important Caveats and Contraindications
Absolute contraindications to surgical intervention include 1:
- Life expectancy less than 4 weeks
- Poor general condition precluding safe anesthesia and surgery
- Severe medical comorbidities that outweigh surgical benefits
Post-Operative Management
Following surgical repair, specific protocols should be implemented 1, 4:
Post-operative radiotherapy should be administered 2-4 weeks after the orthopedic procedure if the fracture is pathologic (30 Gy in 10 fractions or 20 Gy in 5 fractions) 1
Immediate weight-bearing as tolerated is appropriate with adequate fixation 4
DVT prophylaxis with fondaparinux or low molecular weight heparin should be continued 4
Regular paracetamol for pain management, with cautious opioid use especially in renal dysfunction 4
Alternative Consideration
In rare cases of isolated greater trochanter fracture with occult lesser trochanter involvement detected only on MRI, conservative management may be considered if the patient is not a surgical candidate, as these can heal without displacement regardless of extension into the intertrochanteric area 5. However, this scenario differs from a frank lesser trochanter fracture occurring after intramedullary rod insertion, which represents established mechanical failure requiring intervention.