Anterior inferior iliac spine avulsion fracture: a case report in soccer playing adolescent twins

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.

Reevaluation of the surgical indications for anterior inferior iliac spine avulsion fractures in an acute setting - A narrative review of the current literature

Purpose

The anterior inferior iliac spine (AIIS) is a frequent site of avulsion fracture in the pelvis, and these lesions could be observed mainly in teenage athletes. The present study aimed to re-evaluate the appropriate acute surgical treatment of AIIS avulsion fractures considering the three-dimensional anatomy of the supracetabular region.

Methods

This study evaluated current evidence of AIIS avulsion fracture treatments and outcomes. A literature search was done in the following databases: PubMed, SCOPUS, Embase, and Cochrane Library. All relevant information was used in this review.

Results

Several studies have shown how conservative treatment of these injuries lead to excellent outcomes, even when there is radiological evidence of displacement. However, only some surgeons describe clinical and radiological follow-up beyond six months. On the other side, recent studies have demonstrated the efficacy of arthroscopic or open procedures to solve a frequent cause of extra-articular femur-acetabular impingement (FAI) syndrome associated with previous AIIS avulsion fractures, the so-called sub-spine impingement. The acute surgical indication in AIIS avulsion fractures should be considered according to the three-dimensional anatomy of the supracetabular region, especially in young patients with high functional demands.

Conclusions

Three-dimensional assessment allows accurate evaluation of the position and dislocation of the fragment, predicting the risk of complications related to conservative treatment and guiding toward surgical indication only when appropriate.

Lack of Abdominal Stability and Control as a Possible Contributor to Rectus Femoris Avulsion Fracture in the Adolescent Soccer Player: A Case Report

PURPOSE

To describe evaluation and physical therapy treatment for an athlete who is male and 13 years old with healing bilateral rectus femoris avulsion fractures.

SUMMARY OF KEY POINTS

Fractures of the anterior inferior iliac spine may be linked to poor abdominal stability in soccer athletes who are male and an adolescent. The development and use of an abdominal stability screening tool could be an efficient and effective way to determine fracture risk and guide prevention programs.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Following 8 weeks of conservative physical therapy treatment, the athlete met all goals and returned to pain-free soccer activities without residual impairments. Four months following discharge, he reported full participation in soccer competition without complications. This case illustrates that abdominal weakness is a potential risk factor for anterior inferior iliac spine avulsion fracture. Screening for abdominal weakness and incorporating preventative programs into training regimens is recommended to prevent anterior inferior iliac spine injuries in this population.

Anterior Inferior Iliac Spine (AIIS) and Subspine Hip Impingement

BACKGROUND

Abnormal morphology of the anterior inferior iliac spine (AIIS) and the subspine region of the acetabular rim are increasingly being recognised as a source of symptomatic extra-articular hip impingement. This review article aims to highlight important differences in the pathogenesis, clinical presentation and management of extra-articular hip impingement from both the AIIS and subspine bony regions, and the outcome following surgical intervention.

METHODS

A literature review was undertaken to examine the supporting evidence for AIIS and subspine hip impingement. A narrative account of the Author's professional experience in this area, including operative technique for arthroscopic correction, is also presented.

RESULTS

Abnormal morphology of the AIIS and subspine region has been classified using cadaveric, radiological and arthroscopic means; the clinical presentation and operative treatment has been documented in several case series studies. Dual pathology is often present - recognition and treatment of both intra- and extra-articular components are necessary for good postoperative outcome.

CONCLUSIONS

AIIS and sub-spine hip impingement should be considered as distinct pathological entities, which may also co-exist. Symptom relief can be expected following arthroscopic deformity correction with the treatment of concomitant intra-articular pathology. Failure to recognise and treat the extra-articular component may affect postoperative outcome.

LEVEL OF EVIDENCE

V.

Anterior inferior iliac spine avulsion fracture: a series of 5 cases

Avulsion fractures of the pelvic apophyses rarely occur in adolescent athletes in the course of sudden strong contraction of muscle attached to growth cartilage. This injury may usually be misdiagnosed for tendon or muscle strain. Patient's history, physical examination, and radiologic studies are important for diagnosis. The literature includes only a few case reports but no case series as yet. The aim of this study was to present the results of 5 cases of anterior inferior iliac spine (AIIS) avulsion fractures treated conservatively. The study included 5 patients (4 male, 1 female, mean age 13.6 years) who underwent conservative treatment for AIIS avulsion fractures and had an adequate follow-up. All patients were admitted to the emergency department and misdiagnosed as muscle strain. Three of them were football player, 1 skier, and 1 fighter. Each patient was treated with immobilization and nonsteroidal anti-inflammatory drugs. At follow-up, all patients showed relief from their pain and mechanical symptoms and regained full range of motion and returned to their previous levels of activity. Diagnosis requires careful attention to the physical examination and imaging. In this series, all pelvic avulsion fractures (100%) were managed successfully with a conservative approach. Good results and return to previous levels of activity can be achieved with conservative treatment.

Anterior inferior iliac spine deformity as an extra-articular source for hip impingement: a series of 10 patients treated with arthroscopic decompression

PURPOSE

To describe an arthroscopic technique for decompression of a prominent anterior inferior iliac spine (AIIS) leading to extra-articular hip impingement and to provide short-term outcome after this procedure.

METHODS

We retrospectively reviewed office charts, imaging studies, operative reports, arthroscopic images, preoperative and postoperative hip flexion range of motion, and preoperative and postoperative modified Harris Hip Scores in a consecutive series of 10 male patients who had arthroscopic decompression of symptomatic AIIS deformities leading to extra-articular hip impingement. The procedure was performed through standard anterolateral and mid-anterior hip arthroscopy portals that were also used to explore the joint and address concomitant intra-articular pathologies.

RESULTS

The mean age was 24.9 years, with 8 of 10 patients aged younger than 30 years. In 9 patients, an anterior cam lesion was identified and decompressed before the AIIS decompression. The mean follow-up time was 14.7 months (range, 6 to 26 months). Hip flexion range of motion improved from 99° ± 7° before surgery to 117° ± 8° after surgery (P < .001). The modified Harris Hip Score improved from 64 ± 18 before surgery to 98 ± 2 at latest follow-up after surgery (P < .001).

CONCLUSIONS

Arthroscopic decompression of a symptomatic AIIS deformity is a reproducible procedure that can provide excellent outcomes at short-term follow-up. As opposed to using an open approach for decompressing a prominent AIIS, an arthroscopic approach may be of particular value in patients with mixed intra- and extra-articular sources of hip dysfunction, because it enables the surgeon to address all pathologies with a single arthroscopic procedure.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.