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

Hip Sideline Emergencies and Hip Injuries in Elite Athletes

PURPOSE OF REVIEW

Hip injuries in elite athletes are an increasingly recognized problem and range from chronic overuse injuries, such as adductor strains and labral tears, to acute traumatic injuries such as hip dislocations. In this article, we review common hip pathology experienced by elite athletes and sideline management of emergent hip injuries.

RECENT FINDINGS

Elite athletes are subject to unique physical and mental stresses and therefore must be evaluated and treated in a unique manner. Hip and groin injuries account for approximately 6% of sport injuries overall and 3-15% of all injuries in professional sports. Hip sideline emergencies were rare but can include hip dislocations, subluxations, and avulsion fractures. Hip and groin injuries represent an important subset of injuries which can greatly impact an athlete's ability to perform. Understanding the physiology and types of hip/groin injuries, which athletes are prone to injuries, the impact on recovery time, recurrence risk, and the potential need for surgery aid sports medicine physicians in decision-making.

Outcomes following adolescent athlete proximal hamstring apophyseal avulsion bone fragment excision and direct tendon-ischial tuberosity reattachment

Apophyseal proximal hamstring bone avulsion is uncommon, occurring in adolescents following sudden forceful contraction of the musculotendinous unit. It can be severely disabling, preventing return to sport. This study assessed outcome following avulsed bone excision and direct hamstring tendon-ischial tuberosity reattachment using bone anchors. Validated hamstring-specific Sydney hamstring orthopaedic research evaluation PROMs were prospectively collected from consecutively treated athletes (7 elite and 11 recreational) by a single surgeon over 13 years. Outcomes at 1-year and final follow-up for primary acute surgery at less than 3 months after injury (group 1), primary chronic surgery at more than 3 months after established nonunion (group 2) and revision following failed screw fixation (group 3) were analyzed with sport participation and level at 1 year. Sixteen primary and two revision procedures were analyzed. Mean injury age was 14.6 years (SD, 1.8). Combined primary mean injury scores improved from 11.89 (SD, 7.32) to 33.31 (SD, 2.30) and showed mean 1 year and final follow-up scores within 0.3-6.1% of preinjury values. Pronounced improvement occurred from injured scores for groups 1 versus 2, respectively at 1 year by 247.7% versus 59.0% and at final follow-up by 251.0% versus 64.1%, for groups 1 versus 2, respectively. Final outcome scores of group 3 were high. All cases returned to preinjury sport level by 1 year and indicated satisfaction to repeat treatment. No significant complications occurred. As the largest series to assess outcomes following this surgical technique, success is highlighted by high score improvements close to preinjury values and return to preinjury sport level.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases

BACKGROUND

Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents.

METHODS

A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms.

RESULTS

Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019.

CONCLUSIONS

Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries.

LEVEL OF EVIDENCE

This is a level III retrospective study.

Avulsion fractures of the ischial tuberosity in the pediatric athlete: a systematic review and return to sport analysis

Apophyseal avulsion fractures of the ischial tuberosity (AFIT) in pediatric athletes are relatively uncommon injuries with treatment and return to sport (RTS) outcomes being largely unknown. The purpose of this review is to perform a systematic review analyzing RTS and predictors of successful RTS for pediatric athletes sustaining AFIT. Studies reporting on athletes strictly under the age of 18 years sustaining an AFIT with reported RTS status were included. RTS was analyzed based on injury acuity, mechanism, and management, whereas the incidence of any complications was recorded. A total of 33 studies comprising 90 cases of AFIT were identified. The mean age of athletes sustaining injuries was 14.7 + 1.4 years (range, 9-17 years), most commonly participating in soccer ( n = 25), sprinting ( n = 21), and gymnastics ( n = 7). Acute trauma during sporting activities was responsible for 74.4% ( n = 77/90) of injuries. A total of 82% ( n = 74/90) of athletes reported successful RTS at an average of 7.0 + 5.0 months. Athletes undergoing surgery had a significantly higher RTS rate ( n = 36/38, 94.7%) compared with athletes treated nonoperatively (n = 38/52, 73.08%; P = 0.008). When reported, a high rate of misdiagnosis was reported (39.4%, n = 28/71). Complications were reported in 15.8% ( n = 7/38) and 32.7% ( n = 17/52) of athletes managed surgically and conservatively, respectively. As such, the high rate of misdiagnosis and subsequent high rate of complications and poor rate of RTS highlight the importance of accurate diagnosis and treatment. Future prospective studies evaluating patient outcomes based on fracture displacement, sporting activity, and management strategies are warranted to better treat pediatric athletes. Study design: Level IV, systematic review.

Pelvic Avulsion Fractures in Adolescent Athletes: Analyzing the Effect of Delay in Diagnosis

OBJECTIVE

To evaluate whether delay in the diagnosis of pelvic avulsion fractures in young athletes leads to prolonged treatment and prolonged return toward sport activities, whether fractures at certain locations are associated with a greater risk of diagnostic delay, and what reasons may exist for delay in diagnosis.

DESIGN

Retrospective chart review of young patients who presented with pelvic region avulsion fracture to a community-based sports medicine clinic over a 19-year period.

SETTING

Private practice, primary care sports medicine clinic.

PATIENTS

Patients younger than 20 years diagnosed with pelvic region avulsion fracture.

INTERVENTIONS

None, this was a retrospective study.

MAIN OUTCOME MEASURES

Clearance for return toward sport activities.

RESULTS

Two hundred twenty-five cases were reviewed for reasons for delay in diagnosis; 208 cases met criteria for the duration of treatment and return to play activities portions of the study. The mean time from date of injury diagnosis was 19.59 days, and the mean duration from date of injury to clearance for return to play advancement was 67.20 days. Duration of treatment varied slightly depending on timing of diagnosis, whereas duration from date of injury to clearance for return to play advancement varied greatly depending on diagnostic delay. Those who did not sense a "pop" at the time of injury were more likely to experience diagnostic delay, as were athletes with ischial tuberosity fractures. The most common cause of diagnostic delay was patient/family decision on when to seek care; misdiagnosis as a muscle strain was also common.

CONCLUSIONS

Diagnostic delay of adolescent pelvic avulsion fractures may unnecessarily prevent athletes from returning to play within an optimal time frame. Our observations highlight a need for educating athletes and their families on when to seek initial or follow-up medical care as well as educating medical providers regarding the diagnosis of pelvic avulsion fractures.

Pelvic Region Avulsion Fractures in Adolescent Athletes: A Series of 242 Cases

OBJECTIVE

The objective of this descriptive study was to evaluate pelvic region avulsion fractures in adolescents, including age of injury, location of injury, activity and mechanism at time of injury, treatments used, duration of treatment, and outcomes.

DESIGN

This was a retrospective chart review of patients who presented with pelvic region avulsion fracture over a 19-year period.

SETTING

Private practice, primary care sports medicine clinic.

PATIENTS

All patients younger than 20 years of age diagnosed with an acute pelvic region avulsion fracture.

INTERVENTIONS

There was no set intervention protocol. A variety of interventions and combination of interventions were used and determined by the treating physician on a case-by-case basis.

MAIN OUTCOME MEASURES

Clearance for return toward sport activities.

RESULTS

Of the 242 cases, 162 were male. Soccer was the most common sport at the time of injury, and running/sprinting was the most common mechanism. Males were generally older at presentation and were more likely than females to have anterior inferior iliac spine injuries, whereas females were more likely to have iliac crest avulsions. Conservative treatment was effective in all cases. Males were treated for a shorter duration than females, but this difference was not statistically significant.

CONCLUSIONS

Pelvic avulsion fractures are a rare injury in adolescent athletes. Males are twice as likely to experience these injuries and are older at presentation compared to females. Conservative management leads to successful outcomes in most cases.

Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment

BACKGROUND

We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis.

METHODS

We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed.

RESULTS

We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon.

CONCLUSIONS

We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.

Conservative Treatment of Avulsion Injuries of the Lesser Trochanter in Adolescent Athletes

BACKGROUND

 Avulsion injuries of the lesser trochanter apophysis are relatively uncommon injuries and there have been no peer-reviewed case series dedicated to the evaluation and treatment of this injury. The purpose of this study is to characterize avulsion injuries of the lesser trochanter apophysis, review treatment protocols, and time to return to sport.  Methods: We reviewed 30 confirmed avulsion fractures of the lesser trochanter. Clinical data were reviewed to evaluate treatment protocols, duration, and time to return to sport. Radiographs were reviewed to confirm lesser trochanter avulsion and fracture displacement.

RESULTS

There were 26 males and 4 females, with the average age at the time of injury being 14.2 years. Treatment modalities consisted of protective weight-bearing, discontinuation of the patient's sport in all cases, and formal physical therapy in 18 cases. The average treatment duration was 30.7 days. The mean follow-up time was 102 days. The radiographic assessment demonstrated an average fracture displacement of 5.1 mm. The average return to sport was 11 weeks.

CONCLUSION

This is the first large case series studying avulsion injuries of the lesser trochanter. We have shown that these athletes can be managed non-surgically and can successfully return back to sport within three months.

[Apophyseal avulsion in the pelvic region in childhood and adolescence]

BACKGROUND

The importance of the apophyseal plates during growth is often underestimated. They act as a muscular insertion and influence the joint mechanics by the load-dependent change in shape.

PATHOMECHANISMS

An anatomically functional adaptation occurs as protection from overloading. In special kinds of sports with highly dynamic movements, sudden changes of direction and eccentric/concentric muscle activities the resulting stress may exceed the strength of the apophyseal plate. In adolescence this results in a total or partial tearing of the apophysis in the sense of an avulsion injury. In the pelvic region the ischial tuberosity, the anterior superior and inferior iliac spine are mainly affected.

DIAGNOSTICS

The medical history and clinical diagnostics are supplemented by conventional radiographic imaging. Sectional imaging diagnostics are usually unnecessary.

TREATMENT

Conservative management by reduced (partial) weight bearing and physiotherapy represents the gold standard in treatment. In cases with a fragment displacement >1.5-2.0 cm and in competitive athletes an open reduction should be considered.

Pelvic Avulsion Injuries in the Adolescent Athlete

Pelvic avulsion fractures are common in youth athletes; many of these injuries can be treated conservatively. This article reviews the etiology, presentation, and management of the more common pelvic avulsion fractures, including anterior superior iliac spine, anterior inferior iliac spine, ischial tuberosity, and iliac crest avulsions. Adolescent pelvic avulsion fractures rely on the amount of fracture displacement to guide treatment. Conservative management includes rest and avoiding use of the muscle(s) that attach to the avulsed fragment. Operative treatment is reserved for widely displaced fractures or symptomatic nonunions. With appropriate treatment, young athletes frequently return to their same level of sport.

Arthroscopic Reduction and Fixation of a Lesser Trochanter Avulsion Nonunion

Identifying and treating avulsion fractures of the pelvis and proximal femur in adolescent athletes has become increasingly more important as the rate of competitive sports participation has grown. The majority of these fractures can be treated conservatively, with most returning to full activity. Surgical treatment of these injuries has been traditionally indicated for >2 cm displacement, painful nonunion, symptomatic exostosis formation, or persistent pain and symptoms. Lesser trochanter avulsion injuries are extremely rare and literature outlining their surgical treatment lacking. We present our method of arthroscopic reduction and fixation of lesser trochanter avulsion nonunions.

The hominid ilium is shaped by a synapomorphic growth mechanism that is unique within primates

The human ilium is significantly shorter and broader than those of all other primates. In addition, it exhibits an anterior inferior iliac spine (AIIS) that emerges via a secondary center of ossification, which is unique to hominids (i.e., all taxa related to the human clade following their phyletic separation from the African apes). Here, we track the ontogeny of human and other primate ossa coxae. The human pattern is unique, from anlage to adulthood, and fusion of its AIIS is the capstone event in a repositioning of the anterior gluteals that maximizes control of pelvic drop during upright walking. It is therefore a hominid synapomorphy that can be used to assess the presence and age of bipedal locomotion in extinct taxa.

Avulsion Fractures of the Ischial Tuberosity: Progress of Injury, Mechanism, Clinical Manifestations, Imaging Examination, Diagnosis and Differential Diagnosis and Treatment

Avulsion fracture of the ischial tuberosity (AFIT) is a rare adolescent sports injury. At present, there is no consensus on its therapeutic paradigm, but conservative treatment appears to be the predominate choice. Furthermore, the degree of fracture displacement (DFD) remains as an important factor in determining whether AFIT needs internal fixation. The aim of the present study was to review and update the injury mechanism, clinical manifestations, imaging examination, diagnosis and differential diagnosis, and treatment of AFIT.

A literature search was performed on a variety of databases using text words, and the results were limited to the English language.

This review provides an important reference for the diagnosis and treatment of AFIT.

AFIT can be easily misdiagnosed. Therefore, a detailed medical history and imaging examination are crucial for a correct diagnosis and differential diagnosis. For the choice of treatment of AFIT, it is necessary to consider not only the size of the fracture and DFD, but also the long-term functional needs of the patient.

Iliac crest apophyseal insufficiency avulsion fractures

Iliac crest apophyseal avulsion fractures are rare injuries caused mainly through forceful contraction of attached muscles during high level sporting activities. We present the first case of a spontaneous iliac crest apophyseal avulsion insufficiency fracture in a patient with severe atopic eczema on oral steroids and review the relevant literature.

Osteonecrosis of the Femoral Head and Hip Arthritis in an Adolescent Following an Isolated Fracture of the Greater Trochanter: A Case Report and Review of the Literature

CASE

A healthy adolescent sustained an isolated fracture of the greater trochanter after falling from a height. He was treated nonoperatively. After 10 weeks of improvement, the pain recurred, and osteonecrosis of the femoral head was diagnosed. Core decompression and a bone-marrow injection were performed. Transient relief was achieved, followed by deterioration to end-stage hip arthritis.

CONCLUSION

To our knowledge, 19 other cases of isolated fractures of the greater trochanter in adolescents have been reported since 1905. All high-energy injuries (10 cases) progressed to osteonecrosis, independent of the intervention; none of the low-energy cases progressed to osteonecrosis. We advocate vigilance and early magnetic resonance imaging for these injuries to detect and treat osteonecrosis in its early stages.

Operative Fixation of an Anterior Inferior Iliac Spine Apophyseal Avulsion Fracture Nonunion in an Adolescent Soccer Player: A Case Report

CASE

A 14-year-old male competitive soccer player presented with a history of recurrent right hip pain for 18 months. He was diagnosed with an anterior inferior iliac spine (AIIS) apophyseal avulsion fracture nonunion with subspinal impingement, which was confirmed by radiographs, computed tomography, and magnetic resonance imaging. The patient underwent surgical fixation and subspinal decompression. He returned to competitive soccer 5 months postoperatively.

CONCLUSION

AIIS apophyseal avulsion fractures occur in adolescent athletes and generally respond to nonoperative treatment. When such management is unsuccessful, surgical fixation can lead to resolution of pain with return of full function.

Operative treatment of pelvic apophyseal avulsions in adolescent and young adult athletes: a follow-up study

INTRODUCTION

Pelvic apophyseal avulsion can limit young athletes' performance for months and may result in permanent disability. Nonoperative treatment is most commonly preferred, while surgical management with reduction and fixation is reserved for selected cases. Our aim was to evaluate outcomes of operative management of pelvic apophyseal avulsions in a series of adolescents and young adult athletes.

MATERIALS AND METHODS

Operative room registries and medical records were reviewed to identify patients who received surgical treatment for pelvic apophyseal avulsions who were younger than 24 years and with a minimum of 12 month follow-up.

RESULTS

Thirty-two patients (16.8 years ± 2.6) were identified. The most common avulsion sites were anterior inferior iliac spine (34.4%, N = 11) and ischial tuberosity (34.4%, N = 11). Other avulsions were five cases (15.6%) of the pubic apophysis, four cases (12.5%) of the anterior superior iliac spine apophysis and one case of the iliac crest apophysis. Seventeen cases (53.1%) underwent surgery early, i.e., during the first 3 months after the acute injury. Twenty-two cases (68.8%) involved reduction with internal fixation, and six cases (18.8%) involved resection of the fragment. Twenty-six athletes (81.3%, N = 26) reported good outcomes and were able to return to preinjury sports level. Six patients (18.8%) had moderate outcome and reported activity limitations during high-level sports. Large displacement (> 20 mm) or delayed (> 3 months) surgery was not associated with inferior outcomes (P = 0.690 and P = 0.392, respectively). Injury side (P = 0.61) or gender (P = 0.345) did not affect outcomes.

CONCLUSIONS

Operative management of pelvic apophyseal avulsion results in return to the preinjury sports level in more than 80% of the cases. However, while both acute surgery for large displacement and delayed intervention for failed nonoperative treatment are generally successful in improving sports function in these cases, comparative studies are required to refine criteria for surgery.

LEVEL OF EVIDENCE

Case series, IV.

Avulsion of the Anterior Inferior Iliac Spine Rehabilitation in a Rural Private Practice

An unusual case is presented of an 11-year-old girl presenting for treatment to a semirural private physical therapy practice, not specializing in pediatric care, following an avulsion fracture of the anterior inferior iliac spine. The patient presented initially non-weight-bearing, with little hip movement due to pain. Following treatment, the patient returned to preinjury status including return to full participation in netball. A review of the literature regarding healing and rehabilitation is described. Concepts of neuromuscular retraining were integrated in the rehabilitation program. Recent evidence demonstrates deficiencies in hip and knee control for girls between 11 and 15 years of age. Evidence suggests that these deficiencies may be a precursor to injury and poor outcomes in lower extremity injuries in this patient group.

Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports

BACKGROUND

Avulsion fractures of the pelvic apophyses typically occur in adolescent athletes due to a sudden strong muscle contraction while growth plates are still open. The main goals of this systematic review with meta-analysis were to summarize the evidence on clinical outcome and determine the rate of return to sports after conservative versus operative treatment of avulsion fractures of the pelvis.

METHODS

A systematic search of the Ovid database was performed in December 2016 to identify all published articles reporting outcome and return to preinjury sport-level after conservative or operative treatment of avulsion fractures of the pelvis in adolescent patients. Included studies were abstracted regarding study characteristics, patient demographics and outcome measures. The methodological quality of the studies was assessed with the Coleman Methodology Score (CMS).

RESULTS

Fourteen studies with a total of 596 patients met the inclusion criteria. The mean patient age was 14.3 ± 0.6 years and 75.5% of patients were male. Affected were the anterior inferior iliac spine (33.2%), ischial tuberosity (29.7%), anterior superior iliac spine (27.9%), iliac crest (6.7%) lesser trochanter (1.8%) and superior corner of the pubic symphysis (1.2%). Mean follow-up was 12.4 ± 11.7 months and most of the patients underwent a conservative treatment (89.6%). The overall success rate was higher in the patients receiving surgery (88%) compared to the patients receiving conservative treatment (79%) (p = 0,09). The rate of return to sports was 80% in conservative and 92% in operative treated patients (p = 0,03). Overall, the methodological quality of the included studies was low, with a mean CMS of 41.2.

CONCLUSION

On the basis of the present meta-analysis, the overall success and return to sports rate was higher in the patients receiving surgery. Especially in patients with fragment displacement greater 15 mm and high functional demands, surgical treatment should be considered.

Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete

Lower extremity avulsion fractures are uncommon in the pediatric population and can be misdiagnosed without proper imaging and/or clinical suspicion for these injuries. The most common locations of avulsion injuries are the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine. Less often, avulsion fractures occur in the tibial tubercle, calcaneus, and greater and lesser trochanters. When treated properly with rest and altered weight bearing, most of these injuries heal without complication. Although surgical intervention is rarely necessary, it has a high degree of success when it is used. However, avulsion injuries are often misdiagnosed as muscle strains or apophysitis and are mistakenly treated with early range of motion. An error in diagnosis and/or management can cause nonunion or further displacement, which may require surgery. Improper identification of these injuries can also lead to nerve irritation, chronic pain, and gait dysfunction. Awareness of these injuries and their natural history is important because healed avulsion fractures may resemble neoplastic bone on radiographs.

Avulsion of the Lesser Trochanter Following a Shot Put Sport Session

Avulsion of the lesser trochanter is an uncommon injury. In children and adolescents it usually occurs as a sports injury via traumatic avulsion of the psoas major tendon. In adults, isolated fractures of the lesser trochanter are most commonly pathological due to metastatic tumor invasion of the proximal femur. This case report documents how a 14-year-old boy, who presented with an avulsion of the lesser trochanter of the proximal femur following a seemingly atraumatic shot put session at a track and field event, was diagnosed and successfully treated with a conservative approach.

Surgical treatment of two adolescent athletes with dislocated avulsion fracture of the anterior superior iliac spine (ASIS)

INTRODUCTION

Avulsion fractures of the anterior superior iliac spine are rare. Therefore, evidence-based treatment guidelines do not exist. The therapeutic options are either conservative treatment or surgical intervention. The decision depends on grade of dislocation, age of the patient, and his sportive demands and competitive requirements.

MATERIALS AND METHODS

We present the cases of two young athletes suffering from traumatic avulsion fractures of the anterior superior iliac spine. In both cases, the musculotendinous unit (sartorius muscle and tensor of the fascia lata) remained attached to the loose dislocated fragment. Both patients were treated by means of open reduction with a new surgical technique using suture anchors.

RESULTS

Both patients were pain-free 4 weeks after surgery and had full range of motion. They were able to return to their preoperative sportive activity levels 10 weeks after surgery. No complications were reported at final follow-up 18 months postoperatively.

CONCLUSION

Operative treatment of avulsion fracture of the ASIS using suture anchors shows excellent clinical outcome and a short convalescence period. The patients achieve their preinjury sportive levels within 3 months.

Ischiofemoral impingement and hamstring dysfunction as a potential pain generator after ischial tuberosity apophyseal fracture non-union/malunion

PURPOSE

The purpose of this study was to describe the occurrence of ischiofemoral impingement (IFI) and hamstring dysfunction following malunion or non-union of ischial tuberosity apophyseal avulsion fractures and report the short-term outcomes of surgical treatment with regard to alleviating symptomatic extra-articular impingement.

METHODS

All patients who underwent surgery for recalcitrant hip and buttock pain in the setting of prior ischial tuberosity avulsion fracture at three tertiary-level hip preservation centres were included for this review. A total of ten patients met our inclusion criteria and underwent sciatic neurolysis, resection of the ischial tuberosity fragment and hamstring reattachment. Clinical outcomes scores were collected post-operatively including the Modified Harris Hip Score (mHHS) and the Hip Outcomes Score (HOS).

RESULTS

Ten patients with a mean age of 18 years (range 14-28) underwent surgery for symptomatic ischiofemoral impingement after ischial tuberosity avulsion fracture. At a mean of 2.2-year follow-up (range 1.7-3.5), the median post-operative mHHS was 89.7 (65.7-96.8) and HOS ADL and Sport subscales were 90 % or greater in all cases. Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal.

CONCLUSION

Malunion or non-union following ischial tuberosity apophyseal fracture can lead to IFI and hamstring dysfunction. Clinically, the resultant pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up.

LEVEL OF EVIDENCE

IV.

Apophyseal injuries in children's and youth sports

INTRODUCTION

The authors reviewed the current English literature regarding apophyseal injuries affecting young athletes, to highlight the frequency and characteristics of these injuries, to clarify risk factors and specific prevention measures, and to identify future research objectives.

SOURCES OF DATA

The authors performed a comprehensive search of the medical literature, using the Medline database, including all English articles. Various combinations of the Keywords 'injury', 'sports', 'athletic injuries', 'avulsion fractures', 'physeal', 'physis', 'apophysis', 'apophysitis', 'growth plate' were used.

AREAS OF AGREEMENT

Growth benefits from a moderate physical activity.

AREAS OF CONTROVERSY

Growth deficit may occur in young athletes involved in intensive practice of sport following apophysitis.

GROWING POINTS

Apophyseal injuries occurring during sport are less common than overall rate of injuries affecting the adolescent population. Growth disturbance occurs only rarely after an apophyseal injury.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies should consider analytical as well as descriptive components of apophyseal injuries, to allow the identification of new possible risk factors and preventive measures and to help early detection and proper treatment as well.

[Apophyseal Avulsions of the Hip Region in Adolescents]

BACKGROUND

In daily practice apophyseal avulsions of sportive adolescents are frequently being diagnosed with a time delay and treated heterogeneously.

GOAL

Using the most actual literature and the own experience the current diagnostic and therapeutic strategies are put into perspective with regards of the needs of the adolescent athlete.

MATERIAL AND METHODS

The apophyseal lesions of the hip area in adolescence are separated in those at the pelvis and those at the proximal femur. They are reviewed according to its frequency and relevance using the most updated literature. The treatment methods reported focus on the degree of dislocation and level of sports activity.

RESULTS

The most frequent apophyseal avulsion of the pelvis is the avulsion of the tuber ischiadicum, followed by the inferior anterior iliac spine the superior anterior iliac spine and the apophysis of the ilium. The most affected structure at the proximal femur is the lesser trochanter, lesions of the greater trochanter are rare. The cause of injury is a specific acute contracture of the muscle inserting at the affected apophysis during different sporting activities. The treatment of pelvic apophyseal injuries is surgical only in cases with considerable fragment dislocation and in high level athletes. At the femoral side the patients are treated almost always conservatively.

DISCUSSION

Despite of modern and efficient osteosynthetic techniques the treatment of avulsion lesions of the hip region is mainly conservative, even in athletes. By applying consequent diagnostic and therapeutic principles the development of pseudarthroses and heteropic ossifications can be minimised.

Pelvic Apophyseal Avulsion Fractures: A Retrospective Review of 228 Cases

BACKGROUND

The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of pelvic apophyseal avulsion fractures.

METHODS

A retrospective records review of imaging and clinical documentation was performed for patients diagnosed with pelvic apophyseal avulsion fractures at our institution from 2007 to 2013. Patient's Risser score, triradiate status, fracture location, size, and displacement were recorded based on initial injury radiographs. Further clinical and radiographic chart review was utilized to determine mechanism of injury, presence of multiple/bilateral injuries, nonunion, chronic pain, as well as any surgical interventions performed.

RESULTS

We identified 225 patients diagnosed with 228 apophyseal avulsion fractures with mean age of 14.4 years. Males represented 76% of the patients. Anterior inferior iliac spine (AIIS) avulsions were the most common, representing 49% of all avulsion fractures, followed by anterior superior iliac spine (30%), ischial tuberosity (11%), and iliac crest (10%). The most common mechanism of injury was sprinting/running (39%) followed by kicking (29%), but the mechanism varied by fracture type with 50% of AIIS avulsions caused by kicking. Multiple pelvic fractures were identified in 6% of patients. Pain >3 months out from initial injury was present in 14% of all patients and AIIS avulsion fractures were 4.47 times more likely to have chronic pain. Five nonunions were identified, 4 of which were ischial tuberosity avulsions. Initial fracture displacement >20 mm increased the risk of nonunion by 26 times. Surgical treatment was indicated in 3% of cases.

CONCLUSIONS

In this series, nearly all pelvic avulsion fractures (97%) were managed successfully with a conservative approach. Contrary to prior studies, AIIS avulsions represented half of the avulsion fractures. AIIS and ischial tuberosity fractures are at increased risk of developing future pain and nonunions, respectively. Patients and families need to be counseled about this possibility because future intervention may be necessary.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Avulsion fracture of the lesser trochanter: an unusual cause of hip pain in an adolescent

Sports injuries involving the hip and groin are common. Special consideration must be given to musculoskeletal injuries in children and adolescents as their immature skeletons have growth plates that are relatively weaker than the tendons and ossified bone to which they connect. We present a case of an adolescent athlete with acute-onset groin pain who was found to have an avulsion fracture of the lesser trochanter.

[Tearing of the anterior superior and lower anterior iliac spines in teenage athletes: report of two cases]

Les arrachements des épines iliaques antéro-supérieures et antéro-inférieures sont des entités rares qui touchent surtout l'enfant et l'adolescent. Elles se voient généralement lors d'une activité sportive. Le tableau clinique est dominé par une douleur brutale et importante de la hanche de type mécanique. Alors que le diagnostic est confirmé par les examens radiologiques. Nous rapportons deux cas de fractures arrachement des épines iliaques l'une antéro-supérieure et l'autre antéro-inférieure.

Surgical management of traumatic avulsion of the ischial tuberosity in young athletes

OBJECTIVE

Complete traumatic avulsion of the ischial tuberosity in young athletes is rare, and the optimal treatment is unclear. The purpose of this article is to present our experience and the efficacy of surgical repair of avulsions of the ischial tuberosity with bony dislocation of more than 2 cm and to discuss the complex postoperative rehabilitation.

METHODS

Three young athletes sustained complete avulsion of the ischial tuberosity with bony dislocation during different sport activities (long jump, soccer, sprinting). The age at the time of injury ranged from 13.8 to 15 years. All underwent surgical repair with reattachment of the hamstring muscle complex to the origin on the ischium. The time from injury to repair varied from 2 to 22 weeks. All patients underwent a specific postoperative rehabilitation program. Follow-up ranged from 12 to 24 months.

RESULTS

All athletes had improved with surgery and had good subjective and objective functional results. One patient needed operative revision 1 day after primary repair because of suture loosening because of excessive muscle contractions during wake up after general anesthesia. Finally, all returned to their preinjury sport at the same level.

CONCLUSIONS

Young athletes with traumatic avulsion of the ischial tuberosity and dislocation of more than 2 cm benefit from operative repair. Good results were achieved in all cases on the basis of functional recovery and patient satisfaction. Chronic complaints could be avoided, and also return to sport was possible. Surgery under spinal anesthesia is recommended.

Arthroscopically assisted fixation of the lesser trochanter fracture: a case series

Avulsion fractures of the lesser trochanter in adolescents are uncommon. This injury is a result of a sudden forceful contraction of the iliopsoas tendon. It usually occurs during vigorous sport activity. Historically, these injuries were treated non-operatively, with guarded results, including weak hip flexor strength and non-union, hindering return to competitive sport. We report a series of three arthroscopically assisted fracture fixations performed by the senior author, using cannulated screw fixation in two cases and an anchor in one case. Mobilization was commenced immediately following surgery, allowing weight bearing as tolerated using crutches for 4 weeks, thereafter unaided walking was allowed. Patients were assessed at 2 weeks, 6 weeks, 3 months and 1-year post-operatively. Radiographs were utilized to confirm full union. All three patients were able to mobilize unaided by 4 weeks post-operatively and two of the three patients returned to competitive sport at 3 months. Near—anatomical union was achieved in all cases. No complications were noted during surgery and the peri-operative period in our series. The utilization of arthroscopic reduction and fixation of avulsion of the lesser trochanter results in good fixation and allows a faster recovery with a return to sports activity, and therefore, we suggest it as a viable treatment option for such injuries.

Avulsion fracture of the iliac crest in a child

Avulsion fractures of the apophysis of the iliac crest have rare incidence and are little known. In this article, we report the case of an 11-year-old female patient who presented this injury after indirect trauma. From careful radiographic analysis, an avulsion fracture of the iliac crest was identified. It was decided to use nonsurgical treatment comprising analgesia and load restriction. This case report emphasizes the importance of suspecting avulsion fractures in cases of low-energy trauma, and also guides the treatment, so as to prevent functional deficit and deformities.

[Acetabulum injuries in infancy and childhood]

In this article, the anatomical and morphological features of the acetabulum in infancy and childhood are presented. The pathology and treatment of older children and adolescents is deliberately not covered, because the fracture morphology and treatment of patients aged 13 to 15 years is based on the criteria of adult medicine. Especially in the younger child, the anatomical differences are of particular importance. The younger the child is, the more difficult the diagnosis. Therefore today, MRI examinations should be generous used, even if anesthesia is necessary. If the injured child is hemodynamic stable, anesthesia can be electively used for a more complex diagnosis. Acetabular fractures are particularly problematic in infancy because even with optimal treatment and perfect reduction growth disturbances can occur. These manifest as so-called secondary dysplasia. During treatment, care should be taken to ensure that a surgical team having experience with the infant and juvenile skeleton is available and that appropriate implants are available.

Bilateral acetabular fractures in an adolescent after low-energy trauma

BACKGROUND

Pediatric pelvic fractures are rare, accounting for approximately 2.4% to 5.5% of annual admissions at large level I trauma centers. An acetabular fracture is involved in only about 1% to 15% of these cases and is almost exclusively caused by a high-energy trauma.

METHODS

This is a report of an otherwise healthy 15-year-old male adolescent who sustained a nondisplaced bilateral anterior column and wall acetabular fracture after a low-energy mechanism during a hockey game. The patient was managed nonoperatively with non-weight-bearing restrictions and had complete resolution of his symptoms by 10 weeks.

RESULTS

This case shows that a low-energy mechanism can create significant bilateral acetabular fractures in the immature skeleton.

CONCLUSIONS

The presented case may represent an underdiagnosed cause of hip and groin pain in the adolescent patient/athlete when initial radiographs appear normal.

[Avulsion fracture of the lesser trochanter]

An avulsion fracture of the lesser trochanter is a very rare injury often misdiagnosed as a muscle lesion or hip distortion. This report concerns the avulsion fracture of the lesser trochanter of a 13-year-old boy, suffered on a runway preparing for a long jump. Conservative treatment without weight-bearing was indicated for 6 weeks. Twelve weeks after the injury the patient resumed his normal sport activities.

Anterior superior iliac spine avulsion in a young soccer player

Avulsion fractures of the anterior superior iliac spine are rare. They usually occur in teenagers during sport activities. Cases concerning adults are very uncommon. We report here the case of a 23-year-old man who was admitted for recent pain of the left hip that worsened while kicking a ball in a soccer match eight days earlier. The examination found pain when moving the left hip in extension. Radiographs showed an avulsion fracture of the left anterior superior iliac spine, which was confirmed by computer tomography. The treatment was conservative consisting in rest and non-weight bearing with releasing of pain a few weeks later.

Orthopaedic magnetic resonance imaging challenge: apophyseal avulsions at the pelvis

Apophyseal avulsion injuries of the hip and pelvis are frequent athletic injuries in children and adolescents, most commonly associated with explosive movement or sprinting. This article details typically encountered apophyseal injuries and their appearance on magnetic resonance imaging.

Simultaneous ipsilateral avulsion of the anterior superior and anterior inferior iliac spines in an adolescent

BACKGROUND

Only one case of simultaneous avulsion fractures of the anterior superior and anterior inferior iliac spines has been previously reported. This was associated with a hip dislocation.

METHODS

A 16-year-old male adolescent sustained ipsilateral avulsion fractures of his superior and inferior iliac spines from a hyperextension injury of his right hip in a skiing accident. He healed satisfactorily after nonoperative treatment with protected weight bearing and limited active hip range of motion.

RESULTS

The patient healed in 12 weeks and returned to full activities, including sports, without complications.

CONCLUSIONS

Conservative treatment of simultaneous ipsilateral avulsion fractures of the anterior superior and anterior inferior iliac spines can lead to a good outcome.

Apophyseal avulsion fractures of the hip and pelvis

Apophyseal avulsion fractures of the hip and pelvis are infrequent pediatric fractures. However an increase of adolescent participation in competitive sporting activities and better musculoskeletal imaging techniques has led to an increased awareness of these injuries by the medical community. These fractures can be easily missed. When these fractures are diagnosed and treated appropriately, nonsurgical protocol has bee proposed in the literature. Surgical treatment is usually reserved for certain indications. Complications of these injuries include painful nonunion, exostosis, osteonecrosis, and mechanism of injury and treatment options, these fractures can be successfully diagnosed and treated.

Acetabular avulsion fracture in a 13-year-old patient after a minor trauma

The pelvis fracture in children is extremely rare, and only in about 10% of these cases the acetabulum is involved. According to the literature, such acetabulum fractures have been exclusively reported after a major trauma. We report the case of a 13-year-old previously healthy patient, who sustained a posterior wall fracture of the right acetabulum after a minor trauma while playing football. The patient was managed with an open reduction and internal fixation of the fracture through 3 single lag screws. In the 2-year follow-up, the patient did not have any functional impairment and has returned to all usual activities. This case shows that a seemingly inadequate trauma can result in an acetabular fracture in children. Therefore, a correct workup leading to the diagnosis should be carried out. The treatment of those fractures follows the known principles of the traumatology in adults. Because the injury mechanism and the age of our patient are typical for avulsion fractures of the pelvis, a similar mechanism is discussed for this reported posterior wall fracture of the acetabulum.

Sports-related acute and chronic avulsion injuries in children and adolescents with special emphasis on tennis

Acute and chronic sports-related muscle and tendon injuries are not infrequent in youngsters. In particular, the physis is prone to trauma as it constitutes the weakest part of the immature skeleton. The type of sports activity determines the location of the lesion. Most commonly, apophyses of the hip and pelvis are subject to avulsion. The purpose of this paper is to give a short overview of the pathogenesis, location, prevalence and imaging characteristics of acute and chronic avulsion injuries in the immature skeleton, with special emphasis on tennis-related injuries. Tennis-related injuries particularly involve apophyses of the ischial tuberosity, the anterior inferior or superior iliac spine and the iliac crest.

Imaging of sports injuries in children and adolescents

Sports injuries may be unique in childhood and adolescence due to the inherent weakness of the growing skeleton at specific sites, mainly the cartilaginous parts. Many injuries are predictable based on the known mechanism of injury encountered in certain sports. There are two distinct patterns of injury in sports; acute, and chronic or overuse. Imaging plays an important role in the diagnosis and management of these entities. Radiologists should be familiar with the advantages and limitations of the various imaging modalities when evaluating the injured young athlete. The present review focuses on the radiological findings and appropriate imaging approach in injuries that are typically or most commonly encountered in the skeletally immature athletes.

Broken Bones

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.