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

Ischiofemoral Impingement Due to an Undiagnosed Pelvic Avulsion Fracture

ABSTRACT

Ischial tuberosity (IT) avulsion fractures are an uncommon cause of injuries in athletes. In this case, a 26-year-old female suffering from posterior right hip pain for over a decade presented with debility and a decrease in athletic function. Notable history included a hamstring strain while sprinting in elementary school. Clinical examination suggested hamstring tendinopathy and ischiofemoral impingement (IFI). Magnetic resonance imaging (MRI) revealed a chronic, fragmented, IT apophyseal avulsion fracture with ischial bursitis and edema within the fragmented bone, suggesting the development of heterotopic ossification (HO). Diagnostic ultrasound revealed signs of IFI, not evident on MRI. Ultrasound-guided corticosteroid injection in her ischial bursa and ischiofemoral space provided complete relief. The patient was able to resume her activities of daily living and sports-related activities without pain. Although interventional treatments may provide temporary pain relief, a multimodal approach is required for the treatment of HO.

Bilateral Ischial Tuberosity Stress Fractures in an Adolescent Football Player: A Case Report

ABSTRACT

Pelvic stress fractures are rare, making up an estimated 1% to 7% of all stress fractures with the primary locations being the pubic rami, pubic symphysis, and sacrum. Two cases of stress fractures of the ischium have been previously described in the literature, with both occurring in the ischial body. In this case, a 17-year-old high school American football player presented with nonspecific pelvic pain and bilateral point tenderness on deep palpation of the ischial tuberosities. Advanced imaging identified bilateral ischial tuberosity stress fractures. This report outlines the diagnosis and management of the first reported case of bilateral ischial tuberosity stress fractures. We report how ischial tuberosity stress fractures present clinically, potential management strategies, and highlight the use of computed tomography imaging for pelvic stress fractures. Knowledge of unusual stress fracture locations may improve early diagnosis, limit complications, reduce healthcare costs, and promote an accelerated recovery time.

Chronic Ischial Avulsion Fracture Excision With Primary Proximal Hamstring Repair: A Technique

Ischial avulsion fractures classically occur in the pediatric population and are relatively uncommon. These injuries are treated conservatively; however, in cases where there is greater than 2 cm of displacement, surgical intervention is recommended. In some cases, displaced fractures are either misdiagnosed or proper treatment is neglected, and patients who transition into adulthood are left with chronic nonunions that can become a source of pain and disability. Here we present a surgical technique for a chronic ischial avulsion fracture nonunion that is excised, and the hamstring tendons are then primarily repaired to the ischium using suture anchors.

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.

Uncommon Bone Injuries in Soccer Players

Soccer is the most common team sport in the world. A significant number of players are associated with a large number of injuries. Injuries occur in a variety of contexts regardless of the age or performance level of players. The vast majority of injuries involve soft tissues. Bone injuries are less common, but usually result in long-term exclusion from the game. Three different types of fractures related to soccer are classified as acute types, stress fractures and avulsion. This manuscript outlines the diagnostic procedures and treatments for stress fractures, avulsion fractures and bone cyst. The common feature of the described injuries includes frequent difficulties associated with the correct diagnosis and treatment direction. In therapeutic treatment, the doctor and the patient often have to choose between conservative treatment and surgical treatment, which in many cases is not simple. We suggest that in the event of injuries to soccer players, surgical treatment should be used, shortening the time to return to full sports activity. A very important element of the therapeutic process is proper rehabilitation, which should be individually tailored to the patient in order to optimize the treatment process. Some of the rehabilitation protocols should be permanently incorporated into the warm-up protocols for training. Such a procedure has a preventive effect.

Avulsion fracture of the ischial tuberosity: A surgical dilemma

The clinician should make the treatment choice considering the patient's requirements. Thus, surgical treatment can successfully achieve long-lasting satisfactory results and provide the best chance for a rapid return to sports.

Chemoprotection with botulinum toxin following proximal hamstring-Ischial tuberosity avulsion fracture repair: Running title: Chemoprotection for hamstring avulsion fractures

INTRODUCTION

Surgical treatment for avulsion injuries of the proximal hamstrings has gained increasing popularity over the past decade. Despite good outcomes, early failures have been noted and have been attributed to slipping and falling, postoperative muscle spasm, or early mobilization. In a recent review of hamstring repair rehabilitation protocols, it was shown that there is marked variability in post-operative management. Post-operative bracing with limiting knee extension and hip flexion is the standard of care in most early rehabilitation protocols. Braces with limitation of hip flexion and knee locked in 90⁰ flexion can be awkward, cumbersome and create fall risk.Chemoprotection has more recently been proposed to be an alternative approach to prevent tendon repair failure and controlled mobilization which has been shown to be superior to complete immobilization. We present the first case series of the use of botulinum toxin for chemo-protection of the proximal hamstring ischial avulsion repair, demonstrating its safety and efficacy.

METHODS

Retrospective case series at a tertiary children's hospital which included patients <18 years of age who underwent interventional treatment for proximal hamstring avulsion injuries of the ischium utilizing botulinum toxin as a chemoprotective agent. Data collected included demographic data, injury and treatment details, imaging, post-operative rehabilitation and return to activity. Descriptive statistical analysis was conducted.

RESULTS

Five male patients with mean age 14 years (12-17) were included in the study. All were sports related non-contact injuries. Radiographs showed displaced avulsion fractures in all 5 patients. All patients had failed conservative management initially; mean time to surgery from initial injury was 34.4 weeks. 4 patients underwent open reduction and internal fixation (ORIF), 1 patient with less displacement had bone marrow aspirate (BMA) injection; all had chemoprotection using botulinum toxin injected in the hamstrings. No patient required hip immobilization or knee immobilization locked to 90°. We elected to use a brace locked at 20° knee flexion in 2/5 patients. All patients underwent supervised physical therapy and achieved symmetric knee range of motion (ROM). Post-operative radiographs confirmed healing of the avulsion fracture in all 5 patients and they all returned to previous level of activity at mean 32 weeks (21-43) from surgery. None of the patients had a hamstring re-injury at mean follow up of 27 months (11-42).

CONCLUSION

Our case series is the first in literature that shows the safety and efficacy of chemoprotection with botulinum toxin for the post-operative management of avulsion injuries of proximal hamstrings, by minimizing the need for cumbersome bracing and allowing controlled motion during physical therapy.