[Traumatic avulsion of the tuberosity of the ischium]

The apophysis of the ischial tuberosity usually becomes united with the hipbone by 25 years of age. The highest incidence of avulsion in this region occurs between 15 and 17 years in young active persons. Apophysitis should be differentiated from apophyseolysis or an avulsion fracture of the ischial tuberosity. Apophysitis may be associated with chronic excessive sports activities in young men and women and is manifested by pain in the region involved. Its presence is confirmed by radiographic findings. The patient with an avulsion fracture of the ischial tuberosity reports an injurious event, usually a sudden movement during sports activities, associated with immediate pain. The diagnosis is again confirmed by radiology. Apophysitis is treated conservatively with no resulting problems. The poor healing of an avulsion fracture may result in chronic complaints, particularly painful sitting. This condition is treated by resection of the fractured apophysis. The authors describe the case of a 28-year-old man who complained of experiencing pain when sitting. At 20 years of age, he suffered an avulsion fracture of the ischial tuberosity that was treated conservatively. He was examined at our department and an unhealed fracture of the ischial tuberosity was diagnosed by radiology and computed tomography. The separated bony fragment was removed and the patient was followed up to 1 year. He remained free from any complaints. An avulsion fracture of the ischial tuberosity is an injury rarely reported in our as well as foreign literature. The available case reports are discussed.

Urinary incontinence after pelvic trauma: a case report

Stress and Urge urinary incontinence may develop after a pelvic trauma especially after pelvic bone fractures. Incontinence may persist even though any type of bladder neck suspension is performed if malunion occurs between fracture ends. In stress and urge urinary incontinence developed after pelvic trauma, patients should also be evaluated for malunion of fractures which may lead to bone spurs and during any type of bladder neck suspension these should also be removed.

Late sciatic nerve palsy following avulsion of the biceps femoris muscle from the ischial tuberosity

A case of late sciatic nerve palsy following avulsion of the biceps femoris muscle from the ischial tuberosity in a 27-year-old athlete is reported.

Clinical findings associated with chronic ischial fracture in a gelding

An 8-year-old show-jumper gelding was referred for examination as a result of a purchase dispute for reported back pain. Clinical examination identified back pain and atrophy of the left semimembranosus and semitendinosus muscles, but no lameness. Standing pelvic radiography demonstrated a chronic nonunion fracture of the left ischium, the clinical significance of which was uncertain. The apparent back pain was thought to be probably unrelated to the pelvic lesion. We conclude that chronic ischial fracture in the horse can lead to specific atrophy of the semimembranosus and semitendinosus muscles, which originate from this bone.

Pelvic fractures in pregnant multiple trauma patients

OBJECTIVE

To study the outcome of pelvic fractures and fetuses in pregnant patients involved in blunt multiple trauma.

DESIGN

Retrospective follow-up study.

SETTING

Level I trauma center.

PATIENTS

Pregnant multiple trauma patients with pelvic fractures between 1974 and 1998.

INTERVENTIONS

Conservative and operative treatment of pelvic fractures adapted to the clinical status of the mother.

MAIN OUTCOME MEASURES

Clinical, functional, and social outcomes were evaluated.

RESULTS

Out of 4,196 patients with blunt multiple trauma treated between 1974 and June 1998, seven demonstrated the combination of blunt multiple trauma, pregnancy, and pelvic fractures. These patients had a mean Injury Severity Score of 29.9 points. Five mothers and three fetuses survived their injuries. All dead fetuses died on the scene. One surviving fetus was found to have hydrocephalus unrelated to the injury; the remaining fetuses had an uneventful delivery and were healthy. In two of the three patients whose fetuses survived, the treatment of the pelvic fracture was modified for the sake of fetal well-being. In all of these patients, acceptable outcome was achieved.

CONCLUSION

Modification of the treatment of the pelvic fracture in pregnant women with multiple trauma may be necessary to minimize the risk of fetal injury. In our experience with these rare cases, this modified treatment did not severely alter the clinical outcome of the mother's pelvic fracture.

Just a pulled hamstring?

Images

Abnormal bone scan findings of the equine ischial tuberosity and third trochanter

Obtaining high-quality radiographs of the proximal aspect of equine limbs is difficult because of the large muscles in these regions. The use of scintigraphy may provide further information. Abnormal bone scan findings of the ischial tuberosity or the third trochanter were found in 29 adult horses with obscure hind limb lameness between 1986 and 1996 at the Large Animal Clinic of the University of Bern. Each had abnormal radiopharmaceutical uptake but not all had radiographic changes. Radiopharmaceutical uptake ratios between the ischial tuberosity and the greater trochanter were calculated. The uptake ratio in a control group of 11 clinically sound horses was lower than in 11 lame horses with subjectively enhanced radiopharmaceutical uptake.

Displaced avulsion of the ischial apophysis: a hamstring injury requiring internal fixation

A case is reported of an adolescent sprinter who was chronically disabled by pain after non-operative management for an acute hamstring injury. He had sustained an avulsion fracture of the ischial apophysis with displacement of 2.5 cm. Avulsion fractures of the ischial apophysis with displacement of 2 cm or more are unusual, but they frequently result in a symptomatic non-union, and early diagnosis, open reduction, and internal fixation is to be encouraged.

Avulsion fracture of the ischium following complex total hip arthroplasty: an unusual cause of hip pain

Total hip arthroplasty in the high riding dislocated hip is a technically difficult undertaking, with major reconstruction required on both the acetabular and femoral sides. With reconstruction at a near-anatomic hip center, reduction of the arthroplasty is difficult because of the long-standing limb shortening. The major block to reduction is tension of the soft tissues, particularly the hamstrings. We report a case of ischial tuberosity avulsion fracture following such a complex reconstruction despite femoral shortening subtrochanteric osteotomy. This illustrates the importance of the hamstring group in maintaining the dislocation and emphasizes the need to prevent overtension of the soft tissues in such complex reconstructive procedures.

[Osseous avulsion of the ischio-crural muscle group with concomitant sciatica]

Avulsion fractures of the ischial tuberosity are rare. They are often caused by a typical "splits"-like accident. In general the patients feel sudden severe pain in the buttock with localized tenderness in the region of the ischial tuberosity, rarely in combination with sciatic nerve irritation. According to the functional anatomy, flexion of the knee and extension of the hip may be impaired. Roentgenograms often reveal no abnormality and show no evidence of fracture. Therefore, inadequate therapy because of missed diagnosis can result in avoidable persistent pain. We report on a 42-year-old man with an avulsion fracture of the ischial tuberosity. The epidemiology, symptoms, including irritation of the sciatic nerve, differential diagnoses, diagnostic procedures and therapy are presented in detail.

[Fractures of the ischium after laminoarthrectomy. Retrospective study of a series of 31 patients]

PURPOSE OF THE STUDY

Pars interarticularis fracture is one possible source of pain after laminoarthrectomy. The purposes of this study were: to describe the pars defect, to determine its causes and to analyse its consequences on the functional final result.

MATERIAL AND METHOD

31 patients operated for disc herniation or degenerative lumbar stenosis were retrospectively studied. Clinical symptoms were evaluated before and 3 months after initial surgery, at the time of postlaminectomy radiological examination and at last follow-up according to Beaujon rating scale. Radiological evaluation included: description of the pars defect on plain radiographs and CT imaging, calculation of the amount of bone just above the inferior articular process that was resected, analysis of the postoperative stability of the spine both on static and dynamic radiographs. Any remaining disc herniation or stenosis were also noted.

RESULTS

39 pars interarticularis fractures were disclosed. These fractures were identified as a linear luency on plain radiographs or on reformed CT imaging view. Asymmetric widening of the facet joint space just below the pars defect was easier to observe and was present in 66 per cent of the cases on plain radiographs and in 79 per cent on CT imaging. After initial surgery 12 slipping appeared. In all of these cases pars fracture was bilateral at the same level or associated to a complete unilateral facetectomy at the same level. The amount of bone resected just above the inferior facet process was 66 per cent in average, range from 45 to 84 per cent. All the patients complained for low back pain and/or leg pain. In 62 per cent of cases symptoms occurred within one year after surgery, at an average onset of 7.6 months postlaminectomy. 27 patients were reported Revision surgery was in all cases a posterolateral fusion with or without instrumentation; new decompression was performed in 15 cases. At last follow-up, according to our classification, results were very good in 9 cases, good in 15 cases and fair in the remaining 3 cases. Improvement rate obtained after the initial surgery was 75 per cent in average, it was 59 per cent after revision surgery, difference was statistically significant.

CONCLUSION

Pars interarticularis fractures may be a source of postlaminectomy pain. They appear to be caused primarily by an excessive resection (more than one half) of the bone immediately superior to the inferior articular process at the level of the laminectomy. These results suggest that caution in resection of this bone or additional posterolateral fusion in case of large resection of pars interarticularis, can avoid the problem. Asymmetric widening of the joint space just below the defect seems to be the key to this diagnosis in the postoperative lumbar laminectomy patient with persistent or recurrent pain.

Overgrowth of the ischial tuberosity complicating femoral bone and muscle atrophy: implications for a delayed complication of malunited apophyseal avulsion fracture

Delayed complications occurring several years after the fused avulsion of ischial tuberosity have rarely been reported. We present a patient with overgrowth of the ischial tuberosity who complained of knee pain associated with significant bone and muscle atrophy in the thigh, which occurred 10 years after the ischial injury. Reinforcement exercise of the hamstrings relieved the knee pain. Here, we emphasize that avulsion fractures of the ischial tuberosity can cause persistent disability and that patients with avulsion fracture of the ischial apophysis in the adolescent period should actively maintain the strength of the hamstrings, even after more than 1 decade.

Ischiopubic insufficiency fractures: MRI appearances

OBJECTIVE

To evaluate the MRI appearances in insufficiency fractures.

DESIGN

A retrospective analysis of spin echo MR images with gadolinium-enhancement was undertaken with the emphasis on the signal change and the shape of the fracture gap and the adjacent bone marrow.

PATIENTS

Five elderly women who had ischiopubic insufficiency fractures (pubis, 4; ischium 1) underwent MRI to exclude the possibility of pathologic fractures.

RESULTS AND CONCLUSIONS

In no case was contrast enhancement noted at the fracture gap or the adjacent bone marrow, but a cleft-life, elongated bright signal area suggesting "fluid collection" was noted within the fracture gap. Absence of contrast enhancement and "fluid collection" at the fracture gap might suggest non-union of a fracture, which is additional information provided only by MRI.

Ischial tuberosity apophysitis and avulsion among athletes

Ischial tuberosity pain in athletes may be caused by several clinical entities, which include acute and old bony or periosteal avulsions and apophysitis. We studied the natural course of these injuries based on our clinical case series of fourteen patients with apophysitis and twenty-one with avulsion of the ischial tuberosity. Only patients with the diagnosis confirmed by X-ray finding were included. The clinical diagnostic criteria by ischial apophysitis consisted of gradually increasing functional and palpatory pain at the ischial tuberosity without any major trauma at the beginning of the symptoms. Typically there was asymmetry on plain radiographs of the ischial tuberosities in apophysitis; the involved apophyseal area became sclerotic, wider than the non-symptomatic apophysis, osteoporotic patches developed and the lower margin of the ischial tuberosity became irregular. The patients with avulsion reported an acute trauma at the beginning of the symptoms and an avulsion fragment was immediately after injury or later seen in plain radiographs. The mean age of the patients with apophysitis (14.1 yrs) was lower than that of the subjects with avulsions (18.9 yrs). Apophysitis of the ischial tuberosity usually healed well without complications. Avulsions often caused more prolonged pain with referral pain to the posterior parts of the thigh which often required operative interventions. A small bony or periosteal avulsion sometimes grew to a pseudotumor calcification. We recommend conservative treatment as the primary treatment modality for both ischial tuberosity apophysitis and avulsion fractures.

Avulsion of the ischial apophysis

Avulsion of the ischial apophysis is a rare injury. We report the successful treatment of an avulsion of the ischial apophysis by open reduction and internal fixation.

The evaluation of pelvic injury in the female athlete

The differential diagnosis of pelvic pain and possible injury in the female athlete is quite broad and must include gastrointestinal and genitourinary aetiologies, as well as musculoskeletal injuries. These considerations reflect the anatomical complexity of the female pelvis. The pelvic bones house the lower gastrointestinal and genitourinary viscera and transmit stress from the lower extremities to the upper body. The innervation of the pelvic structures also complicates evaluation and diagnosis when somatic and visceral afferent information affects the athlete's interpretation of pain. An algorithmic approach can facilitate evaluation and rehabilitation of pelvic injuries in the female athlete in the contest of previously described mechanisms of musculoskeletal injury.

Rupture of the ischial origin of the hamstring muscles

We treated eight patients who had complete rupture of the ischial origin of the hamstring muscles. This uncommon injury results from a sudden forceful flexion of the hip joint when the knee is extended and the hamstring muscles powerfully contracted. The injuries occurred during athletic exercise in six men and two women who had a mean age of 40 years (range, 22 to 53). With prompt diagnosis and surgery the final functional results in these patients were good. If the diagnosis is delayed, it is not possible to accomplish a primary suture of the hamstring muscles to the ischial bone. Consequently, another surgical procedure will need to be performed to restore function. Unlike cases of bony avulsion of the ischial apophysis in growing children, acute complete rupture of the proximal hamstring muscles origin in adults should be treated with prompt surgery.

[Avulsion fracture of the ischial tuberosity. A rare lesion whose early diagnosis and correct treatment may prevent late sequelae]

Avulsion fractures of the ischial tuberosity are often mistaken for sprains or a muscle tears. We present two cases of displaced fractures with a diagnostic delay of eighteen months and two years, respectively. Both cases were treated conservatively and resulted in discomfort on sitting and in one case persistent functional disability. Since early diagnosis is important for a successful treatment, an anteroposterior radiograph of the pelvis is recommended in patients presenting a history and symptoms indicating a lesion in the posterior aspect of the upper thigh. Accumulated experience indicates, that acute displaced fractures should be treated by open reduction and internal fixation.

Swollen ischiopubic synchondrosis: a dilemma for the radiologist

Differences in size and shape of ischiopubic synchondrosis in childhood may present problems in diagnosis and differential diagnosis. Whereas asymptomatic swollen ischiopubic synchondrosis represents a normal ossification process, painful swelling is a symptom of underlying pathology. Five children are described with symptomatic ischiopubic synchondrosis swelling, four representing stress reaction and one with osteomyelitis. Radiologists should be careful when reporting on swollen ischiopubic synchondrosis in symptomatic children.