Atypical "opened-bottle" proximal tibial fractures in young male patients with growth hormone and aromatase inhibitor treatment: case series.

Abstract

Atypical proximal tibial fractures in adolescents are rare, particularly when linked to hormonal therapy for short stature. This case series reports the clinical and imaging features of atypical proximal tibial and distal femoral physeal fractures in male adolescents undergoing combined growth hormone (GH) and aromatase inhibitor (AI) therapy for idiopathic short stature. We report three cases of skeletally immature male adolescents (ages 12-16) treated with GH and anastrozole who presented with acute leg pain following low-energy trauma during soccer. Computed tomography (CT) imaging identified fractures through the physis and metaphysis with characteristic anterior displacement-resembling an "opened-bottle" configuration. Fractures occurred during periods of rapid growth with delayed physeal closure and reduced bone mineral density. Two cases were managed surgically, and one conservatively. Salter-Harris and Ogden classification systems were used. These cases highlight the potential impact of growth-modulating therapies on bone integrity, particularly their influence on the growth plate and overall bone strength, which may increase fracture risk. Imaging and clinical findings emphasize the role of hormone-related delayed physeal closure and altered biomechanics in fracture development. This report aims to raise awareness of this complication and explores possible mechanisms connecting therapy to these atypical injuries.