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Apophyseal Avulsion Fractures of the Hip and Pelvis

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Apophyseal Avulsion Fractures of the Hip and Pelvis líeview Article Apophyseal Avulsion Fractures of the Hip and Pelvis BART I. MCKINNEY, MD; CORY NELSON, MD; WESLEY CARRION, MD educational objectives As a result of reading this article, physicians should be able to: is nonopemtive, controversies exist regard- 1. Describe the anatomy and mechanism of injury associated with apophy- ing operative treatment. What are the indi- seal avulsion fractures of the hip and pelvis. cations for surgery? U these injuries are to 2. List the different stages of nonoperative management in patients with he treated operatively, what type of fixa- apophyseal avulsion, tion should be used? This article will pro- vide the reader with a hetter understanding 3. Discuss the operative treatment options and surgical approaches for treat- of these controversies and what recom- ment of these injuries. mendations are in the literature. 4. Identify the controversies and common complications in the treatment of COMMON SITES OF AVULSION IN THE apophyseal avulsion fractures of the hip and pelvis. HIP AND PELVIS Metzmaker and Pappas^ reviewed 27 pophyseal avulsion fractures of This article reviews the most common cases of avulsion fractures and found the the hip and pelvis are injuries sites of avulsions, anatomy, findings on most common location to he the anterior A that usually occur in the ado- history and physical examination, imaging superior iliac spine. Other common loca- lescent athlete. However they may pres- commonly used in establishing the diag- tions that were found included the ischial ent in a patient as late as the mid-20s.' nosis, treatment, physical therapy proto- tuherosity. anterior inferior iliac spine, If not properly diagnosed and treated, col, and when these patients should return lesser trochanter and iliac crest.^ In the these injuries can he debilitating to to sports. While the mainstay of treatment largest study evaluating these injuries. an adolescent athlete. An increase of adolescent participation in competitive Drs McKinney, Nelson, uml Carrion are pom Stony Brook University Hospifal, Stony Brook. New York. sporting activities and hetter musculo- Drs McKinney, Nehoii. and Carrion have no relevan! financial relationships to disclose. Dr Mor- skeletal imaging techniques has led to gan, CME Editor, has disclosed the following relevant financial relationships: Sttyker. speakers bureau: Smith & Nephew, speakers bureau, research ¡itant recipient: AO International, speakers bureau, re- an increased awareness of these injuries search grant recipient: Synthes. institutional support. Dr D 'Ambrosia. Editor-in-Chief, has no relevant hy the medical community. Apophyseal financial relation.ships to disclose. The staff of ORTHOPEDICS have no relevant financial relationships avulsion fractures are usually the re- to disclose. sult of a sudden forceful concentric or The material presented at or in any Vindico Medical Education continuing education activity does not necessarily reflect the views ami opinions of Vindico Medical Education or ORTHOPEDICS. Nei- eccentric contraction of the muscle at- ther Vindico Medical Education or ORTHOPEDICS, nor the faculty endorse or recommend any tech- tached to the apophysis. Like other pe- niques, commercial products, or manufacturers. The faculty/authors may discuss the use of materials diatric fractures, apophyseal avulsion and/or products that have not yet been approved by the US Eood and Druf" Administration. All readers and continuing education participants should verify all information before treating patients or utilizing fractures fail through the physis.' The any product. primary age for these injuries to occur is Correspondence should be üddres.^ed to Bart I. McKinney, MD. 3176 Birdseye Circle, Gulf Breeze, between 14 and 25 years.'•'••* FL 32563. 42 ORTHOPEDICS APOPHYSEAL AVULSION FRACTURES OF THE HIP AND PELVIS I MCKlNNEY ET AL Cover illustration © Lisa Clark JANUARY 2009 Volume 32 • Numher 1 43 Review Article Rossi and Dragoni"* found the most com- extension may be present in someone with epiphyseal plate because the Sharpey's fi- mon locations were the ischiai tuberosity an anterior superior iliac spine avulsion bers attaching the muscle to the epiphysis (54%), anterior inferior iliac spine (22%), fraeture. There may even be some loss are stronger than the junction of cells be- anterior superior iliac spine (19%), supe- of hip abduction in anterior superior iliac tween the calcified and uncalcified epiph- rior comer of pubic symphysis (3%), and spine avulsion fractures as the sartorius is a ysis.' Salter and Harris- found this weak iliac crest (1%). Soccer (74 cases) and weak hip abductor. junction of cells where the separation usu- gymnastics (55 cases) had the highest External and abdominal obliques origi- ally occurs in the /one of hypertrophy. number of avulsion fractures documented. nate from the iliac crest. Apophyseal avul- We feel the difference in the two studies sion fractures of the iliac crest are usually HISTORY AND PHYSICAL EXAMINATION is most likely due to sample size. Metz- the result of a trunk twisting injury. The These patients usually present with a maker and Pappas^ reviewed a case series proximal attachment site of the hamstrings history of sudden pain during an activity of 27 patienis. while Rossi and Dragoni"* is the ischiai tuberosity. Weakness of knee such as a sporting event. The pain is most reviewed >1000 radiographs and found flexion and liip extension is a characteris- severe during activity and improves with 203 avulsion fractures. Apophyseal avul- tic of isehlal tuberosity avulsion fracture. rest. Swelling and local tenderness may sion fractures of the greater trochanter The hip adductors originate from the pu- be appreciated by palpation. The patient have also been documented in the litera- bic symphysis and insert onto the lemur. may actively guard against contraction of ture.^ '^ Although rare, bilateral avulsion An adolescent athlete with pubic symphy- the musculature attached to the injured fractures ean occur.'' sis avulsion fracture will have pain and apophysis. Passive stretch of these mus- weakness with hip adduction. The lesser cles will reproduce the pain. A limp may ANATOMY troehanter can also be a site ol'apophyseal be present. There is a noticeable weak- 111 order to properly diagnosis and treat avulsion fracture. The iliopsoas muscle in- ness in the muscle group attached to the these injuries, it is vital to understand the serts onto the lesser trochanter and flexes avutsed apophysis compared to the con- aniitoniy associated with the apophyseal the hip. The insertion of the hip abductors tralateral side. avulsion fracture (Figure 1). The direct on the greater trochanter is another site for The examination of these patients may head of the rectus femoris muscle origi- an apophyseal avulsion fracture. mimic an acute episode of apophysitis. It nates from the anterior inferior iliac spine In their classic article describing is important to know tbe signs of apophy- and inserts through the common quadri- growth plate injuries, Salter and Harris- sitis and how it can be differentiated from ceps tendon onto the patella. Because it describe 2 types of epiphysis: a traction an acute avulsion fracture. Apophysitis is crosses two Joints, patients with anterior epiphysis and a pressure epiphysis. A trac- an inflammation of the apophysis that is inferior iliac spine avulsion fractures may tion epiphysis is the site of the insertion or usually caused by overuse or repetitive have weakness in both hip flexion and knee origin of a major muscle or muscle group. traction to the physis. Both patients with extension. The anterior superior iliac spine A pressure epiphysis is situated at the end apophysitis and avulsions fractures may is the origin of the sartorius and tensor fas- of a long bone and is subjected to pres- have tenderness and swelling at the site of cia lata. Like an anterior inferior iliac spine sure across the joint. They state that the injury. However patients with apophysitis avulsion, weakness of hip flexion and knee weakest point of a traction epiphysis is the usually do not have significant bruising or ecchymosis. which may be present with an acute fracture. Patients with an apoph- yseal avulsion fracture should be able to recall a specific event that triggered the |iain compared to apophysitis. which has a more insidious onset of pain. IMAGING A plain anteroposterior (AP) radio- graph of the pelvis may demonstrate an avulsed fragment (Figure 2). If the frac- Figure 1 : Radiograph demonstrating the possible sites of apophyseal avulsion fractures about the hip and ture is not evident on the AP radiograph, pelvis, iliac crest (white arrow). ASiS (orange arrow), AiiS (red arrow), pubic symphysis (green arrow), additional oblique or axial projections ischiai tuberosity (yellow arrow), greater trochanter (purple arrow), lesser trochanter (blue arrow). Figure may help delineate the fracture. How- 2: Radiograph of a 15-year-old boy, who sustained an injury whiie playing hockey, demonstrates an avul- sion fracture of the anterior inferior iliac spine (arrow). ever, these injuries are frequently missed 44 ORTHOPEDICS APOPHYSEAL AVULSION FRACTURES OF THE Hlf AND PELVIS I MCKlNNEY ET AL on initial radiographs. A computed to- mography (CT) scan is excellent for de- tailing bony anatomy and demonstrating Liny displaced fracture fragments (Figure 3). Magnetic resonance imaging iTiay be useful in evaluating apophysitis and avul- sions in children who ossification center has yet lo ossify (Figure 4). Recently,
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