Greater and/or Intertrochanteric Fractures

History: Assault, Pain.

First of all,  CLAHE all these pelvis trauma films - the soft tissue penetration can really inhibit cortical sharpness. I recommend setting an easy keyboard shortcut.  It will come in handy. 

Better!  Now lets talk about Greater Trochanter fractures.  

They are always tough because the trochanter is an irregular surface, they are at the edge of the film and superimposed soft tissue will cause problems. 

Universal MSK Rule: USE THE ASYMPTOMATIC SIDE FOR REFERENCE! 

You'll notice that the GT cortex makes a nice box shape on the normal left but we get offset of the tubercle portion of the right GT.   In my experience, following the cortex is a much more specific way to diagnose a fracture in this location.  You will find that if you are chasing lucencies over the GT, you'll see a lot of buttock, pannus, and inguinal folds that will play with your emotions. 

If your spidey sense is tingling, get the CT.  Trust me, the ED will not hesitate to comply. They've been waiting for the invitation. 

Something worth noting:

Many GT fractures are associated with Intertrochanteric fractures. 
 

Isolated GT vs Intertrochanteric is a critical distinction for our Ortho colleagues because an isolated GT fracture is a stable, non-operative fracture.  Intertrochanteric is a non-stable, operative fracture.  They may get an MR just to be sure they can or cannot get their knives out. 

Red arrow shows the base of the isolated GT fracture.  The blue circle shows the preserved T1 bright fatty marrow of the intertrochanteric segment of the proximal femur.  Escaped the surgeon this time.

Things to remember:

1. CLAHE for all pelvis films (right click on PACS -> Image Processing -> CLAHE ).  
2. Always, always, always use your asymptomatic contralateral structures.
3. Isolated GT vs intertrochanteric fractures are an important management point. R/o intertrochs.

https://radiopaedia.org/articles/isolated-greater-trochanteric-fracture-1?lang=us