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.

Missed Sleeve Fracture of the Superior Pole of Patella

Patellar sleeve fracture is a form of injury in which small osseous fragments avulsed with periosteum and cartilage. 15-year-old male patient, playing in school football team, apllied to our clinic with a history of previously missed patellar superior pole sleeve avulsion fracture. Care must be taken in order not to miss the patellar superior pole sleeve fractures, which are very rare in children. Extra care must be taken in patients, whose X-ray imaging is clean but there is a problem in the extensor mechanism of the knee. INTRODUCTION Since the patella has high mobility and large cartilage surfaces, it's fracture is very rare in children (9). Growing patella is more prone to osteochondral or avulsion fractures (8). Patellar sleeve fracture is a form of injury in which small osseous fragments fractured with periosteum and cartilage (5). Avulsion or sleeve fractures of patella can be seen in inferior and superior patellar poles. Fractures in superior pole is very rare and only a few cases have been described in the literature (2).

Complete Avulsion of Quadriceps Tendon in a Child with Juvenile Idiopathic Arthritis: A Case Report

CASE

We report a rare case of complete avulsion of the quadriceps tendon in an 8-year-old child with juvenile idiopathic arthritis (JIA). Our patient presented with acute onset of pain and effusion with a history of feeling a "pop" in the knee after a fall while playing kickball. Although knee radiographs showed a cortical irregularity involving the superior patellar pole, it was assumed that the symptoms were a result of a JIA flare rather than an acute injury. Complete quadriceps disruption was later diagnosed by magnetic resonance imaging, and surgical repair was performed.

CONCLUSIONS

Complete rupture of the quadriceps tendon is an unusual, disabling injury in children that necessitates prompt diagnosis and early surgical repair. High index of suspicion and thorough physical evaluation are essential for the diagnosis of such injuries, especially in children with complex medical conditions.

Intra-articular dislocation of the patella: a rare variant to an uncommon injury

Horizontal intra-articular dislocation of the patella is a very rare traumatic entity. We present an unusual case of horizontal intra-articular dislocation in which the patellar articular surface was facing upwards besides having an avulsion of the quadriceps tendon from the superior pole. There was associated posterolateral knee subluxation, which has not been described with intra-articular dislocation of the patella. A 20-year-old man presented with open patellar dislocation and locked knee after a roadside accident. The patient was managed successfully by open reduction and repair of the quadriceps tendon. There was buttonholing of the medial femoral condyle through the medial retinaculum leading to irreducible dislocation. A special reduction manoeuvre was employed to bring the knee to its normal alignment. Knowledge of this injury pattern is of utmost importance for proper recognition and appropriate allocation of the surgical technique.

Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in adolescents: a case report

Simultaneous occurrence of tibial tubercle fracture and patellar tendon avulsion is an extremely rare condition. However, they have become more frequent due to increased participation in sports at a younger age. Diagnosis is not always straightforward, and treatment consists of open reduction and internal fixation. Only a few case reports of such injuries were reported in the literature with limited information according to diagnoses, treatment, and outcome in adolescents.

Arthroscopic Treatment of a Displaced Nonunion of the Anterior Inferior Iliac Spine Causing Extra-articular Impingement

This report describes a case of nonunion of an anterior inferior iliac spine (AIIS) apophyseal avulsion fracture with resultant subspine impingement combined with symptomatic femoroacetabular impingement (FAI). A 16-year-old male soccer player presented with a 6-month history of right groin pain exacerbated by kicking and running. The patient was diagnosed with a displaced nonunion of the AIIS apophysis avulsion fracture causing secondary extra-articular impingement beyond cam-type FAI by physical examination and radiological findings. The authors performed arthroscopic AIIS decompression, with concurrent FAI correction and labral repair and capsular closure. At 4 months after surgery, a radiograph and a computed tomography scan showed complete bony union of the AIIS apophyseal nonunion. Modified Harris Hip Sore and Nonarthritic Hip Score improved from 74.8 and 61, respectively, to 100 for both at final follow-up. The effectiveness of arthroscopic decompression of the AIIS as part of a comprehensive minimally invasive surgery including FAI correction and labral repair resulted in complete union of the AIIS and pain-free return to sport and bony union. [Orthopedics. 2017; 40(4):e725-e728.].

Severe cartilage damage from a broken absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the posterior cruciate ligament: A case report

INTRODUCTION

The use of bioabsorbable interference screws has become popular for treatment of avulsion fractures of the posterior cruciate ligament (PCL). Complications are uncommon. We report a case of severe chondral damage caused by the early breakage of an absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the PCL. The patient felt a sudden locking of the knee when getting off a car at 4 months after the PCL surgery. MRI revealed intraarticular migration of the head of the interference screw. During revision surgery, the broken part was removed without incident, and severe cartilage damage was observed. The patient experienced a complete resolution of symptoms at the 6-month follow-up.

CONCLUSION

MRI examination is recommended in case of sudden locking of the knee for patients undergoing PCL fixation with bioabsorbable interference screws. Surgical treatment should be performed immediately when screw breakage was confirmed.

[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.