Introduction and background
The lesser trochanter (LT), the insertion site of the iliopsoas tendon, is an unusual site for an isolated fracture in skeletally mature patients. In adolescents, LT avulsion is typically an apophyseal injury related to forceful hip flexion or sports activity. After skeletal maturity, the same radiographic finding carries a different implication. Adult isolated LT fractures are rare, and the evidence base consists mainly of case reports and small case series rather than prospective studies or standardized treatment pathways [ 1 ]. This case-based literature is highly susceptible to publication and selection bias and cannot establish the true frequency of malignancy or other etiologies among unselected adults.
In adults, the concern is that a small avulsed LT fragment may be the first finding that brings an occult lesion to attention, and the published adult literature spans malignant, infectious, benign traumatic, stress-related, osteoporotic, and metabolic diagnoses [ 2 - 29 ]. A radiology teaching-file review from a specialist orthopedic oncology center found LT avulsion in 15 of 295 aggressive proximal femoral tumors, underscoring how subtle the sign can be; metastatic disease was most common, but myeloma, Ewing sarcoma, chondrosarcoma, non-Hodgkin lymphoma, and giant cell tumor were also represented [ 29 ]. In the case literature, patients commonly present with hip or groin pain after no trauma or a low-energy event. The initial radiograph may show only an apparently isolated fragment, while CT, MRI, bone scan, PET/CT, or biopsy later reveals proximal femoral tumor infiltration. Reported malignant causes include metastatic carcinoma from lung, breast, colon, renal, nasopharyngeal, bronchogenic, and other primary sites, as well as primary malignant bone tumors, plasma-cell neoplasms, hematologic malignancy, and tumor-like disorders [ 2 , 3 , 6 - 9 , 11 - 17 , 20 - 23 , 25 - 27 , 29 ].
That pattern does not mean every adult LT fracture is malignant. Published cases also include tuberculosis, stress-related injury, low-energy osteoporotic fractures in elderly patients, nonpathologic traumatic injuries, and renal osteodystrophy associated with end-stage renal disease [ 4 , 5 , 10 , 18 , 19 , 24 , 28 ]. Papineni et al. reported a 31-year-old adult with a radiographically isolated left LT avulsion fracture after minor trauma in the setting of renal osteodystrophy and secondary hyperparathyroidism [ 28 ]. Although bilateral olecranon avulsion fractures occurred concurrently, the LT fracture itself had no reported intertrochanteric, subtrochanteric, femoral neck, or shaft extension and therefore met the anatomical inclusion definition. For orthopedic surgeons, radiologists, and oncologists, the differential includes metastatic disease, primary bone tumor, infection, metabolic bone disease, benign avulsion, occult intertrochanteric extension, and mechanical instability.
The workup is part of the treatment decision, not a separate issue. Plain radiographs can identify the LT fragment, but they may miss marrow replacement, cortical destruction, soft-tissue extension, or the true length of proximal femoral involvement. This limitation matters when hip or groin pain is evaluated with a single anteroposterior pelvis or hip radiograph; the fragment may be easier to see than the underlying lesion. For adult atraumatic LT avulsion, MRI of the hip, plasma electrophoresis, and staging studies have been recommended to evaluate for primary or metastatic bone disease [ 29 ]. In practice, advanced imaging can define the lesion, guide biopsy, evaluate systemic disease, and help determine whether prophylactic stabilization or reconstruction is needed. When imaging suggests tumor infiltration or infection, tissue diagnosis is often the step that separates observation or protected weight bearing from biopsy, oncologic therapy, radiation, intramedullary fixation, dynamic hip screw fixation, resection, arthroplasty, or endoprosthetic reconstruction [ 1 - 3 , 14 , 18 , 21 , 29 ].
To be clinically useful, a synthesis of this literature must do more than report how often malignancy appears in published cases. The primary review question was: among adults aged 18 years or older with a radiographically isolated LT fracture or avulsion fracture, what malignant, infectious, and benign etiologies, diagnostic pathways, treatments, and outcomes have been reported? The review therefore mapped the etiologic spectrum, described the diagnostic pathways reported in published cases, identified how often malignancy was recognized before or after the fracture, and connected diagnosis with treatment and structural risk.
Review
Methods
Search Strategy and Study Selection
This descriptive systematic review was reported in accordance with PRISMA 2020 guidance [ 30 ]. A structured search was performed in PubMed, Embase, and Scopus from May 1, 2026, through July 15, 2026, with the final search in each database completed on July 15, 2026. Searches used database-specific combinations of terms for the LT and fracture or avulsion, and raw record counts were documented before duplicate removal. The search was limited to English-language full-text reports because translation resources were unavailable; the potential for language bias was considered when interpreting the findings. The combined search yielded 204 records: PubMed (n = 127), Embase (n = 32), and Scopus (n = 45). Complete database-specific search strategies are provided in Table 1 . The review protocol was not prospectively registered. Eligibility criteria, extraction variables, etiologic categories, and the narrative synthesis plan were established before study screening and data extraction. The PRISMA flow diagram was generated using the PRISMA2020 R package and Shiny application (R Foundation for Statistical Computing, Vienna, Austria) [ 31 ].
Table 1
Database-specific search strategies and identified records The combined search identified 204 records before deduplication: PubMed (n = 127), Embase (n = 32), and Scopus (n = 45). LT: Lesser trochanter.
| Database | Search strategy | Limits/screening rule | Records identified |
| PubMed | ("lesser trochanter"[Title/Abstract] OR "lesser trochanteric"[Title/Abstract] OR "trochanter minor"[Title/Abstract]) AND (fracture*[Title/Abstract] OR avulsion*[Title/Abstract] OR "pathologic fracture"[Title/Abstract] OR "pathological fracture"[Title/Abstract] OR "Femoral Fractures"[Mesh] OR "Avulsion Fractures"[Mesh]) | English; humans; adult eligibility applied during screening | 127 |
| Embase | ('lesser trochanter':ti,ab,kw OR 'lesser trochanteric':ti,ab,kw OR 'trochanter minor':ti,ab,kw) AND (fracture*:ti,ab,kw OR avulsion*:ti,ab,kw OR 'pathologic fracture':ti,ab,kw OR 'pathological fracture':ti,ab,kw OR 'femur fracture'/exp OR 'avulsion fracture'/exp OR 'pathologic fracture'/exp) | Humans; English; adult eligibility applied during screening | 32 |
| Scopus | TITLE-ABS-KEY(("lesser trochanter" OR "lesser trochanteric" OR "trochanter minor") AND (fracture* OR avulsion* OR "pathologic fracture" OR "pathological fracture")) | English; adult eligibility applied during screening | 45 |
| Total | PubMed + Embase + Scopus | Total records before deduplication | 204 |
All retrieved citations were imported into Zotero (Corporation for Digital Scholarship, Vienna, VA) for citation management and deduplication. Potential duplicates were identified electronically and then manually verified by comparing titles, authors, publication years, and available DOI or PMID information. After removal of 151 duplicate records, 53 unique records remained. Titles and abstracts were screened independently by two reviewers, followed by independent full-text review of potentially eligible reports. Disagreements regarding eligibility were resolved through discussion and consensus. As every unique record contained potentially relevant LT fracture terminology, no record was excluded at the title/abstract stage, and all 53 reports advanced to full-text assessment; this accounts for the zero title/abstract exclusions shown in Figure 1 .
Both reviewers also examined the reference lists of all included studies and relevant review-style publications and performed forward citation searching. Supplementary citation searching was completed on July 15, 2026, and identified no additional eligible original cases. During peer review, one potentially eligible report was identified through other methods, assessed against the same prespecified eligibility criteria, and included in the final review.
Studies were eligible if they reported adults aged 18 years or older with an isolated LT fracture or avulsion fracture and included extractable patient-level data. An isolated fracture was operationally defined as a discrete fracture fragment arising from the LT without reported intertrochanteric, subtrochanteric, femoral neck, femoral shaft, periprosthetic, or multifragmentary proximal femoral extension on the available radiographs or cross-sectional imaging. Concomitant fractures outside the proximal femur did not preclude inclusion when the LT fracture itself met this anatomical definition. CT or MRI findings were used to exclude occult extension when those studies were reported; later progression to a larger proximal femoral fracture did not negate eligibility if the initial presentation was isolated. Each included case had sufficient information to establish adult status, the isolated fracture pattern, and a final etiology, together with at least one extractable variable related to presentation, diagnostic evaluation, management, or outcome. Missing fields were recorded as not reported. Review articles, teaching-file reviews, and aggregate imaging summaries were used for reference-list checking and contextual discussion only unless they contributed original or clearly new cases. To identify overlapping cases and prevent double-counting, reports were compared by author group, institution, publication period, patient age and sex, tumor type, and clinical chronology; the most complete primary report was retained, and previously published cases repeated in review-style articles were not re-extracted. Inclusion and exclusion criteria are summarized in Table 2 .
Table 2
Inclusion and exclusion criteria LT: Lesser trochanter.
| Criterion type | Criterion |
| Inclusion | Patient aged 18 years or older |
| Radiographically isolated lesser trochanter fracture or avulsion fracture | |
| Concomitant fractures outside the proximal femur permitted when the lesser trochanter fracture itself met the radiographic isolation definition | |
| Case report, case series, or observational report | |
| Extractable patient-level data establishing final etiology plus at least one variable on presentation, diagnostic evaluation, management, or outcome | |
| English-language full-text report | |
| Exclusion | Patient younger than 18 years |
| Adolescent athletic apophyseal avulsion injury | |
| Intertrochanteric fracture with lesser trochanter involvement | |
| Subtrochanteric fracture with lesser trochanter involvement | |
| Femoral neck fracture with lesser trochanter involvement | |
| Femoral shaft fracture with lesser trochanter involvement | |
| Periprosthetic fracture | |
| Multifragmentary proximal femur fracture in which the lesser trochanter was not the primary isolated fracture finding | |
| Biomechanical study without patient-level clinical data | |
| Abstract-only report | |
| Report without adequate patient-level details | |
| Non-English report | |
| Review article, teaching-file review, or aggregate imaging summary without original extractable cases |
Data Extraction and Quality Appraisal
Extracted variables included author/year, patient age and sex, mechanism or trigger, presenting symptoms, fracture site/laterality, etiology group, final diagnosis or primary tumor, whether malignancy was known before the LT fracture, imaging/workup, LT/proximal femoral lesion tissue diagnosis or pathology confirmation, treatment, and outcome/follow-up. Two reviewers independently performed patient-level data extraction and quality appraisal, with disagreements resolved through discussion and consensus. The 22 case reports were appraised with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports, while the six case series were evaluated with the dedicated JBI Critical Appraisal Checklist for Case Series, as described in the JBI Manual for Evidence Synthesis [ 32 ]. Appraisal findings were used to judge completeness, selection bias, and confidence in interpretation; studies were not excluded solely based on appraisal results (Table 3 ).
Table 3
JBI critical appraisal summary by study design Case-report domains: Q1 demographics; Q2 history/timeline; Q3 clinical condition; Q4 diagnostic methods/results; Q5 intervention; Q6 post-intervention condition; Q7 adverse events/harms; Q8 takeaway lessons. Case-series domains: Q1 clear inclusion criteria; Q2 condition measured in a standard/reliable way; Q3 valid identification methods; Q4 consecutive inclusion; Q5 complete inclusion; Q6 demographics; Q7 clinical information; Q8 outcomes/follow-up; Q9 reporting of site/demographic characteristics; Q10 appropriate statistical analysis. CR: Case report; CS: Case series; Y: Yes; N: No; U: Unclear; NA: Not applicable; JBI: Joanna Briggs Institute.
| Studies (design) | Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | Q9 | Q10 |
| Cho et al., 2020 [ 1 ] (CS) | Y | Y | Y | U | U | Y | Y | N | Y | Y |
| Herren et al., 2015 [ 2 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Afra et al., 1999 [ 3 ] (CS) | Y | Y | Y | U | U | Y | Y | Y | Y | NA |
| Miyake et al., 2022 [ 4 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Agrawal et al., 2023 [ 5 ] (CR) | Y | Y | Y | Y | Y | Y | Y | Y | NA | NA |
| Yu et al., 2024 [ 6 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Creissen et al., 2020 [ 7 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Kumar et al., 2017 [ 8 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Pang et al., 2025 [ 9 ] (CR) | Y | Y | Y | Y | Y | Y | Y | Y | NA | NA |
| Sharma et al., 2022 [ 10 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Vanhoenacker et al., 2021 [ 11 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Uddin et al., 2016 [ 12 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Rouvillain et al., 2011 [ 13 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Khoury et al., 1998 [ 14 ] (CS) | U | Y | Y | U | U | Y | Y | N | Y | NA |
| Fox et al., 2014 [ 15 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| McCambridge et al., 2023 [ 16 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Edmonds et al., 2003 [ 17 ] (CR) | Y | Y | Y | Y | N | N | N | Y | NA | NA |
| Bonshahi et al., 2004 [ 18 ] (CS) | Y | Y | Y | U | U | Y | Y | Y | Y | NA |
| Singh et al., 2015 [ 19 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Bertin et al., 1984 [ 20 ] (CS) | Y | Y | Y | U | U | Y | Y | Y | Y | NA |
| Heiney and Leeson, 2009 [ 21 ] (CR) | Y | Y | Y | Y | Y | Y | Y | Y | NA | NA |
| Reategui-Villegas et al., 2013 [ 22 ] (CR) | Y | Y | Y | Y | Y | Y | Y | Y | NA | NA |
| Phan and Vu, 2018 [ 23 ] (CR) | Y | Y | Y | Y | Y | N | N | Y | NA | NA |
| Uzun et al., 2016 [ 24 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Koçer et al., 2021 [ 25 ] (CR) | Y | Y | Y | Y | Y | Y | N | Y | NA | NA |
| Phillips et al., 1988 [ 26 ] (CS) | Y | Y | Y | U | U | Y | Y | N | Y | NA |
| Gradwohl and Mailliard, 1987 [ 27 ] (CR) | Y | Y | Y | Y | N | N | N | Y | NA | NA |
| Papineni et al., 2025 [ 28 ] (CR) | Y | Y | Y | Y | Y | N | N | Y | NA | NA |
The etiologic groups (metastatic solid malignancy, primary malignant bone or plasma-cell tumor, hematologic malignancy, infectious disease, other neoplastic/tumor-like disease, and benign/nonpathologic cause) and the narrative synthesis methods were defined before data extraction. Meta-analysis was not performed because the evidence base consisted predominantly of case reports and small case series with heterogeneous clinical reporting. Results are presented descriptively using patient-level counts and clearly stated denominators. Details not explicitly reported were coded as not reported and were not assumed to be absent. Percentages represent reporting frequencies in selected published cases and were not interpreted as prevalence, diagnostic accuracy, comparative effectiveness, or recommended test utilization.
Results
Study Selection and Patient Characteristics
Twenty-eight English-language studies met inclusion criteria and contributed 46 original patient cases. The evidence base comprised 22 case reports and six case series; no comparative or prospective observational studies met inclusion criteria. Twenty-seven studies were identified from the database and citation-search workflow, and one additional eligible case report was identified during peer review and assessed using the same prespecified criteria. All included cases provided extractable adult and isolated-fracture status, a final etiology, and at least one patient-level variable related to presentation, diagnostic evaluation, management, or outcome. Table 4 summarizes the patient-level characteristics and outcomes, and Figure 1 shows the study selection process.
Table 4
Patient-level characteristics and outcomes of adult isolated lesser trochanter fractures Each row represents one extracted patient/case. Review-style articles contributed only original/new cases; prior literature-review cases were not re-extracted. The Papineni et al. [ 28 ] case was added during peer review and met the anatomical definition because the LT fracture itself was isolated within the proximal femur despite concomitant olecranon fractures. LT: Lesser trochanter; NR: Not reported; MUTARS: Modular Universal Tumor and Revision System; US: Ultrasound; IM: Intramedullary; ORIF: Open reduction and internal fixation; SFA: Superficial femoral artery; ABI: Ankle-brachial index; MRA; Magnetic resonance angiography; CTA: Computed tomography angiography; NSCLC: Non-small cell lung cancer; CECT: Contrast-enhanced computed tomography; ATT: Anti-tuberculosis treatment; PSA: Prostate-specific antigen; LCH: Langerhans cell histiocytosis; FDG: Fluorodeoxyglucose; DHS: Dynamic hip screw; SLR: Straight leg raise; NWB: Non-weight-bearing; GI: Gastrointestinal; TFN-A: Trochanteric fixation nail-advanced; PTH: Parathyroid hormone.
| Study/report | Age/sex | Mechanism/presentation | Etiology group | Final diagnosis | Diagnostic workup | Management/outcome |
| Cho et al., 2020 [ 1 ] | Original case 1: 57/M | Individual mechanism NR; overall current series 5 no trauma/1 slip. Presentation: Groin pain/antalgic gait | Metastatic solid malignancy | Hepatocellular carcinoma | Radiographs; MRI; CT-guided core needle biopsy | Management: Tumor prosthesis/MUTARS. Outcome: NR |
| Cho et al., 2020 [ 1 ] | Original case 2: 68/M | Individual mechanism NR; overall current series 5 no trauma/1 slip. Presentation: Groin pain/antalgic gait | Metastatic solid malignancy | Thyroid cancer | Radiographs; MRI | Management: Tumor prosthesis/MUTARS. Outcome: NR |
| Cho et al., 2020 [ 1 ] | Original case 3: 56/M | Individual mechanism NR; overall current series 5 no trauma/1 slip. Presentation: Groin pain/antalgic gait | Metastatic solid malignancy | Renal cell carcinoma | Radiographs; MRI; CT-guided core needle biopsy | Management: Tumor prosthesis/MUTARS. Outcome: NR |
| Cho et al., 2020 [ 1 ] | Original case 4: 72/M | Individual mechanism NR; overall current series 5 no trauma/1 slip Presentation: Groin pain/antalgic gait | Metastatic solid malignancy | Prostate cancer | Radiographs; MRI | Management: Radiation therapy. Outcome: NR |
| Cho et al., 2020 [ 1 ] | Original case 5: 62/M | Individual mechanism NR; overall current series 5 no trauma/1 slip. Presentation: Groin pain/antalgic gait | Metastatic solid malignancy | Renal cell carcinoma | Radiographs; MRI | Management: Tumor prosthesis/MUTARS. Outcome: NR |
| Cho et al., 2020 [ 1 ] | Original case 6: 62/M | Individual mechanism NR; overall current series 5 no trauma/1 slip. Presentation: Groin pain/antalgic gait | Primary malignant bone/plasma-cell tumor | Osteosarcoma | Radiographs; MRI | Management: Bipolar hemiarthroplasty. Outcome: NR |
| Herren et al., 2015 [ 2 ] | 61/F | Chiropractor treatment/minor manipulation. Presentation: Right groin pain, low back pain, weight loss, night sweats | Metastatic solid malignancy | Poorly differentiated breast carcinoma with liver/skeletal metastases | X-ray; CT pelvis; breast US/mammography; CT staging | Management: Conservative ortho care; palliative paclitaxel/bevacizumab; refused IM nail. Outcome: No complaints/no mobility limitation at 5 months |
| Afra et al., 1999 [ 3 ] | Case 1: 44/M | No antecedent trauma; acute worsening while sailing. Presentation: Left hip/groin pain; hip flexion weakness | Primary malignant bone/plasma-cell tumor | Solitary plasmacytoma | Radiographs; CT; technetium bone scan; skeletal survey | Management: Zickel nail + methylmethacrylate; postoperative irradiation. Outcome: Asymptomatic; reconstruction intact; no recurrence or progression to multiple myeloma at latest follow-up |
| Afra et al., 1999 [ 3 ] | Case 2: 69/M | No trauma; avulsion while exiting automobile. Presentation: Left groin pain, increasing pain/difficulty lifting limb | Primary malignant bone/plasma-cell tumor | Chondrosarcoma | Radiographs; MRI; bone scan; CT chest | Management: ORIF initially; wide en bloc proximal femur resection and custom proximal femoral endoprosthesis. Outcome: Local recurrence and pulmonary metastasis; died May 1991 after massive stroke with pulmonary metastases at death |
| Afra et al., 1999 [ 3 ] | Case 3: 19/M | No specific trauma; crack stepping onto curb. Presentation: Right groin pain; massive swelling of thigh/buttock | Primary malignant bone/plasma-cell tumor | Ewing sarcoma | Radiographs; CT | Management: Neoadjuvant chemotherapy/radiation; wide resection and custom proximal femoral component. Outcome: Widespread osseous/pulmonary metastases within 2 months; died 6 months later |
| Afra et al., 1999 [ 3 ] | Case 4: 36/M | No trauma stated; chronic back/radicular history with new groin pain. Presentation: Left groin pain and weak hip flexion | Primary malignant bone/plasma-cell tumor | High-grade chondrosarcoma | Radiographs; MRI | Management: Wide resection and allograft-prosthesis composite; later resection of metastatic nodules. Outcome: No additional local recurrence or metastatic disease for 2 years at latest follow-up |
| Miyake et al., 2022 [ 4 ] | 40/M | Baseball pitching stress; stumble getting into car. Presentation: Gradual left hip pain with acute worsening | Benign/nonpathologic | Stress avulsion fracture | Radiographs; MRI; CT; gadolinium MRI; technetium scintigraphy | Management: Conservative. Outcome: Returned to sports 12 weeks; asymptomatic/full ROM at 1 year despite nonunion |
| Agrawal et al., 2023 [ 5 ] | 19/M | Hockey injury with nondisplaced LT avulsion. Presentation: Intermittent claudication, calf cramping, medial knee numbness | Benign/nonpathologic | Adductor canal syndrome/SFA occlusion after LT avulsion | X-ray; duplex; ABI; MRA; angiogram; CTA | Management: SFA interposition bypass; later thrombolysis/angioplasty; aspirin/rivaroxaban. Outcome: Pain-free/without claudication at 4 months; not yet returned to hockey |
| Yu et al., 2024 [ 6 ] | 71/M | No reported trauma. Presentation: Progressive left hip/thigh pain, difficulty weight bearing, weight loss | Metastatic solid malignancy | Metastatic paraganglioma | X-ray; MRI; labs; CT-guided biopsy; DOTATATE PET/CT | Management: Doxazosin; external beam radiation 3000 cGy/10 fractions. Outcome: Intermittent weight-bearing pain after RT; normetanephrine decreased at 3 months |
| Creissen et al., 2020 [ 7 ] | 66/F | Atraumatic/popping sensation while sitting. Presentation: Right medial thigh/groin pain, bruising, antalgic gait | Metastatic solid malignancy | NSCLC lung carcinoma | X-ray; MRI; CT neck/chest/abdomen/pelvis | Management: Analgesia/non-weight bearing; afatinib palliative chemotherapy. Outcome: Good response with reduced tumor bulk at publication |
| Kumar et al., 2017 [ 8 ] | 60/F | Atraumatic; getting out of bed. Presentation: Left hip pain with weight-bearing | Metastatic solid malignancy | Primary lung carcinoma with widespread metastasis | X-ray; MRI; CECT chest/abdomen; PET; proximal femur core needle biopsy | Management: Proximal femoral nail; chemoradiation/supportive care. Outcome: At home under supportive care at publication |
| Pang et al., 2025 [ 9 ] | 79/M | Minor trauma/hip loading while bicycling. Presentation: Left hip pain and limited mobility; persistent pain after bed rest | Metastatic solid malignancy | Poorly differentiated squamous cell carcinoma of lung | X-ray; CT; MRI; contrast MRI; CT chest/abdomen; bone scan | Management: Initial bed rest; palliative radiotherapy; carboplatin/paclitaxel/tislelizumab. Outcome: Died of severe pulmonary infection |
| Sharma et al., 2022 [ 10 ] | 40/M | Atraumatic; while climbing stairs. Presentation: Right groin pain, inability to bear weight | Infectious | Mycobacterium tuberculosis | X-ray; MRI; CT-guided biopsy; GeneXpert/cultures | Management: 4-drug ATT; staged weight-bearing/activity modification. Outcome: No pain/limitations at 2 years; displaced fragment persisted |
| Vanhoenacker et al., 2021 [ 11 ] | 18/NR | No clear trauma; cyclist. Presentation: Months of left groin pain; night pain | Primary malignant bone/plasma-cell tumor | Ewing sarcoma | CT; MRI; follow-up radiograph; repeat MRI | Management: Neoadjuvant chemotherapy; resection; femoral prosthesis. Outcome: Uneventful follow-up |
| Uddin et al., 2016 [ 12 ] | 48/F | Atraumatic/trivial movement getting into car. Presentation: Acute right hip pain; painful hip flexion | Metastatic solid malignancy | Undifferentiated bronchial adenocarcinoma | Radiographs; chest x-ray; CT chest/abdomen; MRI hip; MRI brain; bone scan; bronchoscopic biopsy; intraoperative femur biopsy | Management: Prophylactic cephalomedullary nailing; chemotherapy. Outcome: Transferred to oncology; longer outcome NR |
| Rouvillain et al., 2011 [ 13 ] | 63/M | Atraumatic. Presentation: Thigh-root pain, limp, worsening function | Metastatic solid malignancy | Mucosecreting metastatic pulmonary adenocarcinoma | X-ray; MRI; CT; PET | Management: En-bloc resection/reconstruction with megaprosthesis; cisplatin/pemetrexed chemotherapy; T3 vertebral cementoplasty/radiation. Outcome: At 9 months, walking without cane/limp; normal pain-free hip mobility; PMA 18/18 |
| Khoury et al., 1998 [ 14 ] | Case 1: 65/F | Non-traumatic. Presentation: LT avulsion due to neoplasm | Metastatic solid malignancy | Breast cancer metastasis | Details not extractable from available PDF | Management: Palliative radiation. Outcome: NR |
| Khoury et al., 1998 [ 14 ] | Case 2: 37/M | Non-traumatic. Presentation: LT avulsion due to neoplasm | Metastatic solid malignancy | Synovial sarcoma | Details not extractable from available PDF | Management: Prophylactic fixation. Outcome: NR |
| Khoury et al., 1998 [ 14 ] | Case 3: 49/M | Non-traumatic. Presentation: LT avulsion due to neoplasm | Primary malignant bone/plasma-cell tumor | Osteosarcoma | Details not extractable from available PDF | Management: Prophylactic fixation. Outcome: NR |
| Fox et al., 2014 [ 15 ] | 75/M | Very low-impact fall while sitting. Presentation: Left groin pain and difficulty in weight-bearing | Metastatic solid malignancy | Renal cell carcinoma suspected/large renal mass with bony metastasis | Radiographs; CT hip/pelvis; CT abdomen/pelvis; chest x-ray; PSA | Management: Prophylactic IM nail; palliative chemotherapy/treatment. Outcome: Stable disease; discharged with palliative care |
| McCambridge et al., 2023 [ 16 ] | 18/M | Pain after kicking punching bag; recurrence after baseball swing. Presentation: Right hip pain, night pain, lytic LT lesion | Other neoplastic/tumor-like | Multifocal single-system LCH of bone | Radiographs; MRI; bone scan; CT chest; FDG-PET/CT; brain imaging | Management: Prophylactic IM nail; curettage/cryoablation; vinblastine/prednisone. Outcome: Lesions improved after 3 months; chemotherapy stopped; continued oncology follow-up planned every 6-12 months for 5 years |
| Edmonds et al., 2003 [ 17 ] | 63/F | No trauma. Presentation: Progressive right upper thigh pain | Metastatic solid malignancy | Metastatic colon adenocarcinoma | Radiograph; CT; MRI; chest CT | Management: NR. Outcome: NR |
| Bonshahi et al., 2004 [ 18 ] | Case 1: 90/F | Fall backward twisting left leg. Presentation: Unable to mobilize due to pain | Benign/nonpathologic | Osteoporotic traumatic LT fracture; no tumor on postmortem | X-ray | Management: Initial nonoperative; later DHS after intertrochanteric fracture. Outcome: Died postoperatively of bronchopneumonia/chest complications |
| Bonshahi et al., 2004 [ 18 ] | Case 2: 79/F | Fall backward from stool. Presentation: Unable to bear weight due to pain | Benign/nonpathologic | Osteoporotic traumatic LT fracture | X-ray | Management: Initially full weight-bearing with Zimmer frame; later DHS after intertrochanteric fracture. Outcome: Uneventful postoperative recovery |
| Bonshahi et al., 2004 [ 18 ] | Case 3: 84/F | Slipped on kitchen floor and fell backward. Presentation: Failed mobility assessment; displaced isolated LT fracture | Benign/nonpathologic | Osteoporotic traumatic LT fracture | X-ray | Management: Prophylactic DHS before mobilization. Outcome: Bearing weight with assistance at discharge to rehab day 6 |
| Singh et al., 2015 [ 19 ] | 40/F | Road traffic accident/dashboard-like injury. Presentation: Severe right groin pain, thigh swelling, unable to perform SLR | Benign/nonpathologic | Nonpathologic displaced LT avulsion | X-ray; skeletal survey; labs; serial x-rays | Management: Derotation boot/bar brace/cast; partial weight-bearing. Outcome: Symptom-free by 6 weeks; no pathology on serial radiographs |
| Bertin et al., 1984 [ 20 ] | Case 1: 28/M | Putting on trousers. Presentation: Left groin pain | Metastatic solid malignancy | Pancreatic islet-cell carcinoma metastasis | Radiograph; bone scan; arteriogram; rib biopsy; GI series; pancreas biopsy | Management: Initial crutches/NWB; radiation/chemotherapy for metastases; later sliding nail after subtrochanteric fracture. Outcome: Subtrochanteric fracture nearly healed after fixation; died Jan 1978 after prolonged hospital course and multiple abdominal surgeries |
| Bertin et al., 1984 [ 20 ] | Case 2: 52/F | No trauma; starting up stairs. Presentation: Right groin pain | Metastatic solid malignancy | Metastatic follicular thyroid carcinoma | Radiograph; bone scan; tomograms | Management: Thyroidectomy + prophylactic sliding nail; radioactive iodine; later radiation; local resection/prosthetic replacement. Outcome: No subtrochanteric fracture before replacement; increasing pain/enlarging lesion at 2 years |
| Bertin et al., 1984 [ 20 ] | Case 3: NR/NR | Slight/no trauma. Presentation: Hip/groin pain | Metastatic solid malignancy | Prostate cancer metastasis | NR | Management: Initial conservative care; later ORIF after subtrochanteric fracture. Outcome: NR |
| Bertin et al., 1984 [ 20 ] | Case 4: NR/NR | Slight/no trauma. Presentation: Hip/groin pain | Metastatic solid malignancy | Adenocarcinoma of unknown origin metastasis | NR | Management: Initial conservative care; later ORIF after subtrochanteric fracture. Outcome: NR |
| Heiney and Leeson, 2009 [ 21 ] | Late 40s/F | Twisting/slight slip in kitchen; no fall. Presentation: Right hip/groin pain, inability to ambulate | Hematologic malignancy | Recurrent acute myeloid leukemia | Radiograph; CT; bone scan; MRI | Management: Prophylactic IM reconstruction nail; oncology care; palliative radiation. Outcome: Pain-free ambulation 4 months; hospice; died 4 months after surgery |
| Reategui-Villegas et al., 2013 [ 22 ] | 69/M | No trauma. Presentation: Right hip pain, worse at night, 2 months | Metastatic solid malignancy | Non-small cell lung carcinoma | Hip x-ray; chest x-ray; bronchoscopy; tumor markers; bone scintigraphy; CT | Management: Prophylactic IM nail and chemo planned but not performed. Outcome: Died of respiratory failure 19 days after hospitalization |
| Phan and Vu, 2018 [ 23 ] | 58/M | Fall onto buttocks. Presentation: Acute right hip pain and low back pain | Metastatic solid malignancy | Nasopharyngeal carcinoma metastasis; nondifferentiated carcinoma | Pelvic x-ray; CT; MRI | Management: Refused further treatment; discharged. Outcome: NR |
| Uzun et al., 2016 [ 24 ] | 86/M | Leg stuck at door; staggered, no fall. Presentation: Right hip pain and difficulty walking | Benign/nonpathologic | Displaced LT fracture without malignancy | Radiograph; CT; labs | Management: Cable and plate fixation. Outcome: Painless hip mobility/no walking difficulty at 3 months |
| Koçer et al., 2021 [ 25 ] | 55/M | Atraumatic; standing from bus seat. Presentation: Right hip pain/limp; later dyspnea/chest pain | Metastatic solid malignancy | Metastatic left perihilar bronchial carcinoma | X-ray; CT pelvis; chest CT; bronchoscopy; PET | Management: Initial conservative care; later TFN-A osteosynthesis/cementoplasty followed by radiotherapy. Outcome: No pain and walking without assistance; PET showed no recurrence by Oct 2020 |
| Phillips et al., 1988 [ 26 ] | Case 1: 55/M | No significant trauma. Presentation: Right hip pain | Metastatic solid malignancy | Colon adenocarcinoma | Radiograph; specimen radiograph/autopsy confirmation noted in figures | Management: NR. Outcome: NR |
| Phillips et al., 1988 [ 26 ] | Case 2: 38/M | No significant trauma. Presentation: Right hip and groin pain; chest x-ray - large mass | Metastatic solid malignancy | Large-cell carcinoma | Radiograph; CT; radionuclide bone scan; chest X-ray | Management: NR. Outcome: NR |
| Phillips et al., 1988 [ 26 ] | Case 3: 64/M | No significant trauma. Presentation: Left hip pain | Metastatic solid malignancy | Prostate adenocarcinoma | Radiograph | Management: NR. Outcome: NR |
| Phillips et al., 1988 [ 26 ] | Case 4: 51/M | No significant trauma. Presentation: Right hip and upper leg pain | Hematologic malignancy | Non-Hodgkin lymphoma | Radiograph; MRI | Management: NR. Outcome: NR |
| Gradwohl and Mailliard, 1987 [ 27 ] | 61/M | Severe cough after aspiration while drinking wine. Presentation: Sudden knife-like right groin pain | Metastatic solid malignancy | History of esophageal squamous cell carcinoma; bone scan suspicious for right rib and right mid-femur metastases | X-ray; bone scan; prior CT/bone scan surveillance | Management: Orthopedic management NR. Outcome: NR after LT fracture |
| Papineni et al., 2025 [ 28 ] | 31/M | Minor motorcycle accident (~10 km/h fall onto left side). Presentation: Left hip pain/tenderness with flexion and rotation; concurrent bilateral olecranon avulsion fractures | Benign/nonpathologic | Renal osteodystrophy with secondary hyperparathyroidism in end-stage renal disease; left iliopsoas/LT avulsion | Pelvis radiographs; CT pelvis; MRI hip; laboratory assessment including calcium, phosphate, PTH, alkaline phosphatase, creatinine/eGFR | Management: LT fracture treated conservatively; left olecranon surgically repaired. Outcome: LT-specific follow-up NR |
Etiologic Distribution
Table 5 and Figure 2 show the etiologic distribution. Metastatic solid malignancy made up the largest group, accounting for 27 of 46 cases (58.7%). Primary malignant bone or plasma-cell tumors accounted for seven cases (15.2%), and benign/nonpathologic etiologies, including renal osteodystrophy, accounted for eight cases (17.4%). Hematologic malignancy was reported in two cases (4.3%), while infectious disease and other neoplastic/tumor-like disease each accounted for one case (2.2%).
Table 5
Etiologic distribution of adult isolated lesser trochanter fracture cases Studies and patient counts are based on extracted original/new cases only. Individual studies may contribute cases to more than one etiologic group; therefore, study counts across categories are not mutually exclusive and do not sum to 28.
| Etiology group | Studies with cases (n) | Patient cases (n) | % of patient cases | Representative diagnoses |
| Metastatic solid malignancy | 17 | 27 | 58.7% | Lung, renal cell, breast, colon, thyroid, prostate, paraganglioma, esophageal, pancreatic/islet cells |
| Primary malignant bone/plasma-cell tumor | 4 | 7 | 15.2% | Osteosarcoma, Ewing sarcoma, chondrosarcoma, solitary plasmacytoma |
| Benign/nonpathologic | 6 | 8 | 17.4% | Stress/repetitive-use, traumatic/athletic, osteoporotic/elderly, renal osteodystrophy/secondary hyperparathyroidism |
| Hematologic malignancy | 2 | 2 | 4.3% | Acute myeloid leukemia, non-Hodgkin lymphoma |
| Infectious | 1 | 1 | 2.2% | Mycobacterium tuberculosis |
| Other neoplastic/tumor-like | 1 | 1 | 2.2% | Langerhans cell histiocytosis |
Diagnostic Workup and Management
Table 6 summarizes diagnostic workup and treatment. Atraumatic, nontraumatic, or no significant trauma was explicitly documented in 27 of 46 cases (58.7%). Among the 36 malignant cases, malignancy was first recognized after the LT fracture in 25 cases (25/36, 69.4%; also 25/46, 54.3% of all included cases), was known before the fracture in eight cases (8/36, 22.2%; 8/46, 17.4% overall), and was unclear or not reported in three cases (3/36, 8.3%; 3/46, 6.5% overall). Radiographs were documented in 41 of 46 cases (89.1%), CT in 30 cases (65.2%), MRI in 23 cases (50.0%), bone scan/scintigraphy in 12 cases (26.1%), and PET or PET-CT in 5 cases (10.9%). LT/proximal femoral lesion tissue diagnosis or pathology confirmation was documented in 18 cases (39.1%); this category required biopsy, operative pathology, or pathologic confirmation of the fracture-associated LT/proximal femoral lesion and did not include prior malignancy history alone. These percentages describe what was reported in the published cases and do not measure diagnostic accuracy, comparative effectiveness, or recommended utilization.
Table 6
Diagnostic workup, management, and reporting summary Counts reflect patient-level documentation in the extracted data fields. NR or unavailable details were not assumed to be negative. The tissue diagnosis/pathology variable refers to biopsy, operative specimen pathology, or other pathologic confirmation of the fracture-associated LT/proximal femoral lesion; it does not count a prior cancer diagnosis or remote biopsy of a primary tumor alone. The three malignancy-timing categories are mutually exclusive and account for all 36 malignant cases. Imaging, treatment, and follow-up percentages are reporting frequencies in published cases and should not be interpreted as measures of sensitivity, diagnostic accuracy, comparative effectiveness, or recommended use. LT: Lesser trochanter; NR: Not reported.
| Variables | Patient cases with documented feature (n) | % of patient cases | Denominator |
| Atraumatic/nontraumatic or no significant trauma documented | 27 | 58.7% | 46 |
| Known malignancy before LT fracture documented | 8 | 22.2% (17.4% overall) | 36 malignant cases (46 overall) |
| Malignancy first recognized after LT fracture | 25 | 69.4% (54.3% overall) | 36 malignant cases (46 overall) |
| Timing of malignancy unclear or not reported | 3 | 8.3% (6.5% overall) | 36 malignant cases (46 overall) |
| Radiographs/X-ray documented | 41 | 89.1% | 46 |
| CT documented | 30 | 65.2% | 46 |
| MRI documented | 23 | 50.0% | 46 |
| Bone scan/scintigraphy documented | 12 | 26.1% | 46 |
| PET/PET-CT documented | 5 | 10.9% | 46 |
| Fracture-associated LT/proximal femoral tissue diagnosis/pathology documented | 18 | 39.1% | 46 |
| Orthopedic surgery/fixation/reconstruction documented | 27 | 58.7% | 46 |
| Radiation therapy documented | 12 | 26.1% | 46 |
| Systemic disease therapy documented | 14 | 30.4% | 46 |
| Outcome/follow-up reported | 27 | 58.7% | 46 |
Orthopedic surgery, fixation, or reconstruction of the LT/proximal femoral condition was documented in 27 cases (58.7%). Reported surgical strategies included prophylactic intramedullary nailing, sliding hip screw or dynamic hip screw fixation, tumor prosthesis, bipolar hemiarthroplasty, custom proximal femoral endoprosthesis, en bloc resection, and allograft-prosthesis reconstruction [ 1 , 3 , 10 , 13 , 18 , 20 , 21 , 24 , 25 ]. The Papineni LT fracture was treated conservatively; surgery addressed the concomitant olecranon injury rather than the proximal femur [ 28 ]. Radiation therapy was documented in 12 cases (26.1%), systemic disease therapy in 14 cases (30.4%), and outcome or follow-up in 27 cases (58.7%).
Discussion
Malignancy dominated the reported adult LT fracture literature. In the extracted dataset, malignant etiologies accounted for 36 of 46 published cases (78.3%), including 27 metastatic solid tumors. This value is a reporting frequency within a selected case-report and case-series evidence base, not an estimate of the prevalence of malignancy among unselected adults with LT fracture. Publication and selection bias likely favor unusual, severe, and malignant presentations, while uncomplicated benign cases may be underreported. The pattern is nevertheless consistent with earlier radiology reports describing atraumatic LT avulsion as a potential sign of proximal femoral tumor infiltration and supports a low threshold for further evaluation when the mechanism is atraumatic, low energy, unclear, or the radiographic appearance is suspicious [ 14 , 20 , 26 , 29 ].
The design-specific JBI appraisal directly informed interpretation of the synthesis. Case reports generally described the presenting condition and diagnostic workup, but adverse events and longitudinal outcomes were frequently absent. In the case series, consecutive and complete inclusion of eligible cases was often unclear, and outcome reporting was inconsistent. These limitations increase selection and reporting bias and reduce representativeness; therefore, the findings are descriptive and hypothesis-generating rather than estimates of prevalence, diagnostic performance, or treatment superiority.
The differential should not stop at malignancy. Benign, infectious, and metabolic diagnoses were also found. Bonshahi et al. described elderly patients with isolated LT fractures in whom occult intertrochanteric instability or osteoporotic injury was clinically relevant [ 18 ]. Singh et al. reported a nonpathologic adult LT fracture after trauma [ 19 ], and Miyake et al. described an adult stress avulsion related to repetitive baseball pitching [ 4 ]. Sharma et al. reported tuberculosis as an infectious mimic, while McCambridge et al. reported Langerhans cell histiocytosis in an 18-year-old [ 10 , 16 ]. Papineni et al. added renal osteodystrophy with secondary hyperparathyroidism in a young adult with end-stage renal disease, expanding the benign/nonpathologic spectrum beyond trauma and osteoporosis [ 28 ]. The concurrent olecranon fractures in that report did not alter the anatomical classification of the radiographically isolated LT fracture.
Radiographs are an appropriate starting point, but they are not enough when the presentation is atraumatic, low energy, or clinically discordant. An X-ray may show the fracture while missing marrow replacement, soft-tissue extension, skip lesions, or systemic disease burden. James and Davies highlighted this problem in the setting of initial anteroposterior hip imaging, where tumor infiltration may be subtle and additional projections or MRI can reveal destructive disease [ 29 ]. In the present review, CT and MRI were frequently used, and tissue diagnosis/pathology of the fracture-associated LT/proximal femoral lesion was documented in 18 cases (39.1%). MRI helps define local marrow and soft-tissue involvement, while CT, bone scan, and PET/CT can support staging or primary-tumor search. When neoplasm or infection remains in the differential, tissue diagnosis is especially important before definitive oncologic reconstruction.
Management often moves beyond routine fracture care. An isolated LT fragment may be the visible part of a larger proximal femoral lesion that can progress to subtrochanteric or intertrochanteric fracture. Several reports used prophylactic fixation or reconstruction to prevent catastrophic fracture and permit mobilization [ 1 , 3 , 13 , 18 , 20 , 21 , 25 ]. Treatment still has to be individualized based on lesion size, expected survival, systemic disease status, tumor histology, functional goals, and patient preference. Benign stress, traumatic, or metabolic cases may recover with conservative treatment and management of the underlying disorder, whereas malignant cases often require orthopedic stabilization, radiation, systemic therapy, or a combination of these approaches.
Suggested Diagnostic Approach
The following is an expert-informed approach based on the included reports and musculoskeletal-oncology guidance; it has not been formally validated by the included studies as a diagnostic pathway. In adults with an atraumatic, low-energy, unclear-mechanism, or radiographically suspicious isolated LT fracture, MRI of the pelvis/proximal femur may be considered after initial radiographs to define marrow and soft-tissue involvement. CT can further characterize cortical destruction and assist procedural planning. When imaging raises concern for destructive disease, infection, or systemic malignancy, staging studies and selected laboratory testing should be individualized rather than applied as a fixed panel [ 29 , 33 ]. Referral to orthopedic oncology should occur before biopsy, prophylactic fixation, or definitive tumor surgery whenever a primary bone tumor or indeterminate destructive lesion remains possible. Biopsy should be coordinated with the orthopedic oncologist, musculoskeletal radiologist, and pathologist so that the tract can be incorporated into any subsequent resection and that contamination of uninvolved compartments is minimized [ 34 ]. Clearly traumatic or metabolic cases with reassuring imaging may be managed according to fracture stability, the underlying bone disorder, and patient factors, while malignancy and infection remain in the differential until reasonably excluded.
Limitations
The limitations mainly reflect the source literature. Most reports were case reports or small case series, making the evidence highly susceptible to publication and selection bias; the data cannot establish the true incidence of LT fracture or the prevalence of malignancy in an unselected adult population. Diagnostic workup, follow-up duration, and outcome reporting varied across reports, and the JBI appraisal identified recurrent limitations in longitudinal outcome reporting and in the consecutive or complete inclusion of case-series patients. Several older articles contained limited patient-level detail, and some newer articles included literature-review summaries without uniform data fields. Counts therefore represent explicit documentation in published reports rather than population-level rates, diagnostic accuracy, or comparative effectiveness. The English-language restriction, adopted because reliable translation resources were unavailable, may have introduced language bias and led to missed cases. The review protocol was not prospectively registered, which is an additional limitation, although the eligibility criteria, extraction fields, etiologic categories, and synthesis plan were defined before extraction. Full-text availability and indexing limitations may also have led to missed reports. One additional report was identified during peer review and included, which improved completeness but also illustrates the possibility of residual missed literature. Finally, only original or clearly new cases were extracted from review-style publications to reduce double-counting, so the patient count may differ from prior narrative summaries.
Conclusions
An isolated LT fracture in an adult should raise concern for underlying pathology, particularly when the mechanism is atraumatic, low energy, unclear, or discordant with the imaging findings. In this systematic review of 28 studies and 46 published patient cases, 36 cases had malignant etiologies. Among those malignant cases, malignancy was first recognized after the fracture in 25 cases (25/36, 69.4%), was known beforehand in eight cases (8/36, 22.2%), and was unclear or not reported in three cases (3/36, 8.3%). These frequencies reflect a selected case-report and case-series literature and do not estimate the prevalence of malignancy among unselected adults. Primary malignant bone tumors, hematologic malignancy, infection, and benign/nonpathologic causes, including renal osteodystrophy, were also identified. Atraumatic, low-energy, or radiographically suspicious cases warrant advanced imaging and coordinated orthopedic-oncology evaluation, with carefully planned biopsy when indicated; clearly metabolic or traumatic cases should be managed according to the underlying disorder and fracture stability. Early recognition may prevent delayed cancer diagnosis, avoid poorly planned biopsy or fixation, guide stabilization decisions, and improve multidisciplinary coordination.
The authors thank the Kansas City University College of Osteopathic Medicine Library for assistance in accessing essential articles for this systematic review. Artificial intelligence tools (e.g., ChatGPT) were used for language editing, formatting, and organizational support. The authors independently verified all extracted data, citations, analyses, interpretations, and conclusions.
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Author Contributions
Concept and design: Ethan J. Sack, Max Deneroff
Acquisition, analysis, or interpretation of data: Ethan J. Sack, Zubair Mohammed, Austin Khau, Chadi Ellaham, Jared W. Nichols, Max Deneroff
Drafting of the manuscript: Ethan J. Sack, Max Deneroff
Critical review of the manuscript for important intellectual content: Ethan J. Sack, Zubair Mohammed, Austin Khau, Chadi Ellaham, Jared W. Nichols, Max Deneroff
Supervision: Jared W. Nichols
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