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Adolescent Avulsion Injuries of the Pelvis a Case Study and Review of the Literature

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Adolescent Avulsion Injuries of the Pelvis a Case Study and Review of the Literature 1.5 ANCC Contact Hours Adolescent Avulsion Injuries of the Pelvis A Case Study and Review of the Literature Erden Ali ▼ Vikas Khanduja Avulsion fractures of the pelvic apophyses are a result of adductors brevis, longus, and magnus; extension of the repetitive strain injuries or sudden, forceful eccentric or hip is governed posteriorly by the gluteus maximus and concentric contractions of corresponding muscle groups in the hamstring muscles—biceps femoris, semitendino- the leg. Using a case study approach, we present the clinical sus, and semimembranosus; abduction is produced by and radiological features, and management of a 14-year- gluteus medius and minimus and lateral rotation by ob- old boy who presented to our hospital with an avulsion turator internus and externus, piriformis, and the supe- rior and inferior gemelli. fracture of the anterior inferior iliac spine. The literature on the subject, along with the management of the condition, is reviewed and presented. A condition often treated nonop- Mechanism of Injury eratively, the focus of treatment is based on effective nurs- The etiology of injury has been ascribed to chronic re- ing and rehabilitation of the patient on an outpatient basis. petitive traction on a developing apophysis or as a re- Without this vital role, patients are at risk of unnecessary sult of sudden, forceful, or unbalanced contraction of hospitalization that also has adverse socioeconomic effects. an attached musculotendinous unit while engaged in a sporting event (El-Khoury, Brandser, Kathol, Tearse, & Callaghan, 1995; Kujala & Orava, 1993; Tehranzadeh, 1987; Salvan & Weiker, 1977 ). These fractures are often Introduction associated with the time of ossifi cation of the apophyses Avulsion fractures of the pelvis (Ischial Tuberosity) were and their subsequent fusion to the corresponding pelvic fi rst described by Berry in 1912 ( Berry, 1912 ) with the tuberosities. Two distinct patterns exist for develop- fi rst report of an anterior inferior iliac spine (AIIS) avul- ment of the hip and pelvis; this in turn with the degree sion injury being reported in 1929 ( Kohler, 1929 ). They of skeletal maturity has a direct effect on the incidence are seen in adults and more commonly in the athletic of injury ( Houghton, 2009 ). Growth of the acetabulum male adolescents, with some arguing that they are most is from its cartilaginous periphery and the triradiate common in those athletes competing in sporting activi- cartilage. Developmental disruption of this cartilage ties such as football and gymnastics (Rossi & Dragoni, can predispose patients to acetabular dysplasia and 2001). As the sports industry grows at such a rapid rate, degenerative joint disease in later life (Trousdale & with female competitors becoming more common, the Ganz, 1994). incidence of avulsion fractures in adolescents is contin- There are three ossifi cation centers in the proximal uing to increase (McKinney, Nelson, & Carrion, 2009). femur—the capital femoral epiphysis and the greater and This is confounded by high expectations of coaches and lesser trochanters. The pelvis and hip are allowed circum- trainers and the inclusion of younger year groups into ferential growth through several apophyses or secondary competitive sport (Sundar & Carty, 1994). ossifi cation centers. These sites of ossifi cation also have muscle attachments and, because of the increased tensile strength of surrounding soft tissues, avulsion injuries are Anatomy The pelvis is composed of three bones, the ilium, the is- chium, and the pubis, which meet in the acetabulum to form the “Mercedes” symbol (see Figure 1 ). The pelvis is Erden Ali, BSc, MBBS, Doctorate Student, Magdalene College, made up of three important joints: the acetabulofemo- University of Cambridge, United Kingdom. ral joint or hip joint, the sacroliliac joint, and the pubic Vikas Khanduja, MB, BS, MRCS (G), MSc, FRCS, FRCS (Tr & Orth), symphysis. The muscles of the hip and pelvis are ar- Consultant Orthopaedic Surgeon, Department of Trauma and ranged so that their anatomical position dictates their Orthopaedic Surgery, Addenbrooke’s Hospital, Cambridge University action on the hip joint. The anterior group is responsi- NHS Foundation Trust, Cambridge, United Kingdom. ble for hip fl exion and is composed of the iliopsoas, sar- The authors and planners have disclosed no potential confl icts of torius, and rectus femoris muscles; adduction of the hip interest, fi nancial or otherwise. is produced by the action of gracilis, pectineus and the DOI: 10.1097/NOR.0000000000000115 © 2015 by National Association of Orthopaedic Nurses Orthopaedic Nursing • January/February 2015 • Volume 34 • Number 1 21 Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. OONJ681.inddNJ681.indd 2211 009/01/159/01/15 99:19:19 PPMM Tehranzadeh, 1987), leading to a sudden muscle con- traction. The individual then complains of instant pain in the distribution of the fracture site with subsequent loss of function (Söyüncü & Gür, 2004). Examination reveals swelling and tenderness with pain on passive motion. A lump may be palpated, which represents the avulsed fragment (Atalar, Kayaog˘ lu, Yavuz, Selek, & Uras¸, 2007). Investigations and Imaging Acute injuries are often associated with avulsed bony fragments (Stevens, El-Khoury, Kathol, Brandser, & Chow, 1999) (see Figure 2 ). Both subacute injuries and healing avulsions can have radiological appearances that are classically seen in malignant or infective etiolo- gies. These can be seen as mixed areas of lysis, sclerosis, or destruction that are appearances associated with os- teomyelitis or Ewing’s sarcoma (Brandser, El-Khoury, & Kathol, 1995; Combs, 1994 ). In these cases, if fi ne needle biopsy was undertaken, it is likely to reveal the reactive nature of the process (Resnick et al., 1996). Chronic or old inactive injuries are frequently associated with a mass of new bone formation seen at radiography that, like subacute injuries, can be mistaken for infection or malignancy. With these injuries, diagnosis becomes dif- fi cult when an unclear history of trauma is elicited. In these instances, further imaging is undertaken instead of more invasive procedures such as fi ne needle aspira- tion. Computed tomography can be implemented to clarify the diagnosis (Brandser, El-Khoury, Kathol, F IGURE 1. Medical illustration demonstrating anatomy of the Callaghan, & Tearse, 1995). Computed tomography has hip and pelvis and sites of muscular attachments. 1—Pubic also been used to plan management in cases where im- symphysis, gracilis, and adductor attachments; 2—Ischial tu- pingement on the sciatic nerve is suspected (Miller, berosity, hamstring attachments; 3—Lesser trochanter, iliop- Stedman, Beisaw, & Gross, 1987). Magnetic resonance soas attachment; 4—Greater trochanter, gluteal attachment, imaging is also being used to detect injury site and ex- and lateral rotator attachments; 5—Anterior inferior iliac spine, tent, with some centers using it to predict the amount of rectus femoris attachment; 6—Anterior superior iliac spine, time an athlete will be disabled for and therefore help sartorius attachment; 7—Iliac crest, abdominal, pelvic, and defi ne the best treatment plan (De Paulis, Cacchio, back muscle attachments. Michelini, Damiani, & Saggini, 1998). Magnetic reso- nance imaging appears to be most useful when assessing more common than musculotendinous injuries in skele- tally immature individuals ( Houghton, 2009 ). Patterns of Injury Specifi c patterns of injury exist. Fractures of the iliac crest, anterior superior iliac spine (ASIS), AIIS, greater trochanter, lesser trochanter, and ischial tuberosity have been recorded with the muscle groups responsible being the rectus abdominis, sartorius, rectus femoris, gluteus medius, iliopsoas, and the hamstrings, respectively. The sites of these muscular attachments are demonstrated in Figure 1 . Fusion of the apophyses dictates the time at which avulsion injuries are seen. The ischial tuberosity fuses at the age of 20–25 years, the AIIS at the age of 16–18 years, the ASIS at the age of 21–25 years with the lesser trochanter at the age of 15–17 years (Moeller, 2003 ). Clinical Features F IGURE 2. Anteroposterior pelvic radiograph. The avulsed frag- The history is classically of an acute event, for example, ment of the lateral aspect of the right acetabulum is identifi ed jumping or kicking a ball (Kujala & Orava, 1993; by the arrow. 22 Orthopaedic Nursing • January/February 2015 • Volume 34 • Number 1 © 2015 by National Association of Orthopaedic Nurses Copyright © 2015 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. OONJ681.inddNJ681.indd 2222 009/01/159/01/15 99:19:19 PPMM if injury has occurred to muscles, tendons, or ligaments. abnormalities in the right lower limb and examination Some published data have demonstrated that radiogra- of the left hip was unremarkable. phy has poor sensitivity in evaluating hip and pelvic pain An anteroposterior radiograph of the pelvis demon- in patients who present acutely (Kirby & Spritzer, 2010). strated an avulsion fracture of the lateral aspect of the Despite this, diagnosis of pelvic avulsion fractures is best right acetabulum (see Figure 2 ). Magnetic resonance established with anteroposterior pelvic radiographs in imaging showed an avulsion of a 2-cm-long fragment of most cases, whereas AIIS fractures may be seen only bone from the right AIIS attached to the direct head of with
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