Avulsion fractures of the pelvis in children: a report of 32 fractures and their outcome

Avulsion injuries of the apophyses of the pelvis are mainly athletic injuries and are usually seen in adolescents. In a series of 80 pelvic fractures in children seen and managed in The Royal Liverpool Children's Hospital, Alder Hey, in the last 10 years, 32 avulsion fractures in 25 patients were diagnosed and treated. Twenty-two of these patients were followed for an average of 44 months (range 4-120 months). Eight (33%) were girls, a higher proportion than in other published series. The average age of the children was 13.8 years. These fractures, though generally regarded as trivial injuries, have left disability persisting into adult life, with limitation of sporting ability in 10 of the 22 patients and persistent symptoms in 6, mostly in those with ischial avulsion injuries. Fourteen patients with acute injuries needed hospitalisation, with an average stay of 5 days. The other 11 were suffering from chronic traction injuries sustained in sport. This distinction between acute and chronic injuries has not been emphasized in the other reviews. The radiological appearances, diagnostic problems and morbidity are discussed in order to increase awareness of these injuries.

Ischial apophysis injuries in athletes

The diagnosis and treatment of ischial tuberosity pain in athletes include several clinical entities. These injuries include apophysitis, adult tug lesion, painful unfused apophysis, and acute and old avulsions. In some avulsion injuries a bony fragment can be seen, but they can also be x-ray-negative, especially in children. An insertional tendon rupture is also possible. Conservative treatment of apophysitis includes modification of activities and anti-inflammatory medication. Avulsions, if diagnosed early, usually heal with conservative therapy, especially if the displacement is not marked. Urgent surgical treatment is recommended in cases with total or nearly total soft-tissue hamstring muscle insertion rupture. Surgery has to be considered also in cases with dislocation of the apophysis or bony avulsion of more than 2cm. Excision of the excessive mass or poorly united fragment provides relief of pain in some cases of old avulsions.

Irregularity of the apophysis of the ischial tuberosity

We report five cases of irregularity of the apophysis of the ischial tuberosity (Kremser's disease). In four, plain radiographs showed that the density of the radiolucent area increased within several months of a minor injury. Serial computerised tomography demonstrated new bone formation across the widened apophyseal plate, although there was no change in the shape or density of the apophysis itself. The separation repaired and remodelled spontaneously within a year. In one case, CT showed that the apophyseal ossification centre was smaller than that on the opposite side. Our findings showed that in four cases the irregularity of the apophysis of the ischial tuberosity may have been caused by an avulsion fracture, but the appearance in the fifth case was a normal variant of the ossification centre.

Retro runner with ischial tuberosity enthesopathy

In reviewing the literature, no studies were found reporting the use of retro running on flat and hilly terrain, which elicited enthesopathy (stress reaction) at the ischial tuberosity. Therefore, this case study of an atypical enthesopathy condition warrants careful scrutiny in order to generate future research. This case study describes the clinical management of a female runner with bilateral patellofemoral pain who self-initiated a program of backward running and stationary bicycling after reading an article about retro running in a runners' magazine. She subsequently developed ischial tuberosity enthesopathy verified by scintigraphy (bone scan). Her symptoms gradually resolved with physical therapy intervention. Eventually, she was able to forward jog 2 miles on flat surfaces without complaint of pain but did not resume retro running. This case not only suggests the need for further research in retro running kinetics and kinematics but highlights the proactive role health professionals must assume in injury prevention.

[Traumatic apophyseolysis of the ischiadic tuber]

Traumatic apophyseolysis of the os ischii is a rare injury occurring during sports activities. It mostly affects young men between 14 and 25 years of age. Conservative treatment is often sufficient unless there is a mechanical obstruction or an irritation of the conditioned rupture of the os ischii with subsequent load-dependent complaints.

Stabilization of bilateral sacroiliac fracture-luxations in small animals with a single transsacral screw

Bilateral sacroiliac fracture-luxations in four dogs and four cats weighing 3.5 kg to 30.9 kg were reduced and stabilized with a single 3.5 mm, 4.5 mm, or 6.5 mm transsacral screw. Alignment of the drill bit was visual in six cases and assisted by the use of an aiming device in two cases. Seven animals were reevaluated at months 3 to 6. No significant screw loosening or loss of reduction had occurred. Although no intraoperative complications were encountered with visual drill bit alignment, use of an aiming device for transsacral drilling is strongly recommended.

Avulsion of the ischial apophysis. The case for open reduction and internal fixation

We report three cases of avulsion of the ischial tuberosity with marked chronic disability after delay in diagnosis and non-union of the fracture. All were treated by open reduction and internal fixation with return to full function, allowing in one case, athletic performances of Olympic standard. We also report one patient with an acute apophyseal avulsion treated by early reduction and internal fixation with restoration of full function.

Traumatised ischial apophysis (report of six cases)

Six boys with traumatic ischial apophysis are reported. Two cases were diagnosed as stress apophysis and four as apophyseolysis. Two of our patients were referred to the hospital as malignant bone tumours--Ewing sarcoma and osteosarcoma.

Apophyseolysis and osteochondrosis of the ischial tuberosity. Criteria of differential diagnosis

The authors describe three pathological entities affecting the apophysis of the ischial tuberosity observed in young athletes. Acute and chronic apophyseolysis and osteochondrosis are studied separately in terms of their clinical characteristics, radiographic aspects, and treatment. A rare case of bilateral apophyseolysis is also reported. Unless correctly diagnosed and treated, these lesions may in the long term affect the sporting activity of the patient. Six cases are presented illustrating each of these syndromes.

[Apophyseal avulsion fractures in adolescents--a typical sports injury]

Pelvic apophyseal avulsion fractures in 22 adolescents were followed up for a longer period. Etiology, main localisation, diagnosis and differential diagnostic aspects in the pelvic and hip region, the usual treatment and complications of these stable pelvic fractures are discussed. Characteristic radiographs are demonstrated.

[Detection of occult fractures of the pelvic bones by roentgen computed tomography]

The informational value of C.T. concerning pelvic fractures is presented. Not all injuries to the hip joint and to the os sacrum can be seen on standard a.p.-projections, oblique views, special projections or conventional tomography. 17 typical examples have been selected from young patients with multiple injuries. C.T.-findings concerning fractures of the hip joint, of the os sacrum and of hidden pelvic fractures are described. Emphasis is placed on careful radiological analysis of fractures with special regard to the planning of conservative or operative treatment and also on the later functional results following fractures of the hip joint.

[Pelvic bone fractures in children]

An analysis of the treatment of fractures of pelvic bones in 158 children has shown that the conservative method of treatment is quite justified. Good and satisfactory results were achieved in 116 patients followed-up.

[Combined injuries of the pelvic bones and bladder in children]

On the basis of observations of 15 children with associated injuries of the pelvic bones and urinary bladder the author describes the clinical picture, diagnosis and treatment depending on the kind of injuries of the urinary bladder.

[Roentgen morphology of sport injuries to the pelvic apophyses]

Pelvic apophyses are places of insertion of strong muscles and tendons and are therefore places of least resistance at the end of skeletal growth. Avulsions and disruptions of pelvic apophyses can be caused by overstrain during different kinds of sport activity. Typical radiological findings in 8 different cases of ruptures of apophyses, osteochondropathies, and resulting conditions of sport injuries are demonstrated. The difficulties of correct diagnosis and differential diagnosis are pointed out. The significance of hormonal impairment of ossification for development and stress factor of pelvic apophyses is exposed. Questions of treatment and follow-up studies are discussed.

Pathologic fracture after radiation therapy for primary non-Hodgkin's malignant lymphoma of bone

Between 1963 and 1981, 32 patients with biopsy proven non-Hodgkin's lymphoma involving bone were treated at the Mallinckrodt Institute of Radiology either with radiation alone or in conjunction with chemotherapy. An unexpectedly high rate of fracture at the site of the tumor was observed. Six patients were excluded because they survived less than six months after the completion of radiotherapy or were lost to follow-up within six months. There were 15 appendicular and 17 axial sites treated. Local control was achieved in 30 of 32. There were 10 patients with appendicular lesions of which seven suffered a fracture. Of the seven patients with lesions in a weight bearing bone, six suffered fractures. Twenty-six sites of involvement received less than 5000 rad. Five sites of involvement with diffuse histiocytic lymphoma (DHL) involving the appendicular skeleton received 5000 to 6000 rad. One site with DHL involving the axial skeleton received 5000 rad. Of the six patients receiving high dose, two presented with pathologic fractures of the femur requiring surgical stabilization and the remaining four patients suffered subsequent fractures 7 to 30 months after completion of therapy. Two of these six had local recurrence of disease. It appears that involvement of the appendicular skeleton by lymphoma frequently results in fracture. Doses of 5000 rad or greater do not increase the probability of local control but may contribute to the risk of fracture following radiotherapy.

Ischial stress fracture

A single report of a very unusual stress fracture in the ischium of a fourteen year old athlete. The mechanism and the more usual lesion of ischial apophysiolysis is discussed.