Pelvic Avulsion Fractures in the Adolescent Athlete

John M. Buchanan, D.O. Disclosures

I have no financial interests, relationships, or potential conflicts of interest relative to this presentation Apophysis: Definition

• Normal outgrowth of bone arising from secondary Center of Ossifications, with Age dependent fusion to mother bone • Site of muscle-tendon unit insertion

• Provide contour and shape to growing bones without adding length Apophysis Definition

▪ Weak link in the musculoskeletal chain at given age ranges ▪ Apophysis is less resistant to tensile forces (tearing forces) than the surrounding soft tissues ▪ Chronic (overuse) injuries = Apophysitis ▪ Acute injuries = Avulsion Fractures Apophysitis • Inflammation or stress injury at the apophysis • Chronic overuse injury resulting from: o Traction of a tendon at its insertion o Micro-avulsions at the bone-cartilage junction • Common during periods of rapid growth Apophysitis • Too much activity

• Inadequate healing time

• Incomplete tissue repair

• Pain Avulsion Fractures

• Tendon or ligament pulls off a piece of bone from the hip • Most commonly involve the apophysis-weak link • Acute mechanism of injury • Pop, swelling, bruising, severe disability • Musculoskeletal chain is broken • Often preceded by apophysitis

ASIS AVULSION FRACTURE

• SARTORIUS INSERTION

• STARTS TO OSSIFY AT 13-15 YO AND FUSES TO THE ILIUM AT 21-25 YO

• 27% OF PELVIC APOPHYSEAL FRACTURES

• COMMONLY A SOCCER INJURY AIIS AVULSION FRACTURES

• RECTUS FEMORIS INSERTION

• OSSIFIES AT 13-14 YO AND FUSES AT 16-18 YO

• 29% OF AVULSION FRACTURES

• COMMONLY RELATED TO SOCCER, TRACK, GYMNASTICS, AND CHEER ISCHIAL TUBEROSITY AVULSION FRACTURES

• HAMSTRINGS INSERTION SITE

• STARTS TO OSSIFY BETWEEN 14-16 YO AND USUALLY FUSES WITH ISCHIUM AT 18-21 YO

• 17% OF PELVIC AVULSION FRACTURES

• ASSOCIATED WITH SPRINTING ILIAC CREST AVULSION FRACTURES

• ABDOMINAL OBLIQUE MUSCLES, TENSOR FASCIA LATAE INSERTION SITES

• STARTS TO OSSIFY AT 13-15 YO AND FUSES AT 15-25 YO

• 11% OF PELVIC AVULSION FRACTURES

• ASSOCIATED WITH BASEBALL LESSER TROCHANTER AVULSION FRACTURES

• ILIOPSOAS INSERTION SITE

• 15% OF PELVIC AVULSION FRACTURES GREATER TROCHANTER AVULSION FRACTURES

• GLUTEUS MEDIUS/MINIMUS INSERTION SITE

• RARE INJURY

• POOR OUTCOMES- OSTEONECROSIS SYMPHYSIS PUBIS AVULSION FRACTURE

• GRACILIS AND ADDUCTOR INSERTION SITE

• SUPERIOR CORNER OF THE PUBIC SYMPHYSIS

• X-RAYS USUALLY NORMAL

• VERY RARE HISTORY

• Running, kicking, twisting • Concentric or eccentric muscle contraction • Passive stretch • Rapid directional change • Patients may perceive a “popping” sensation • Immediate pain • Swelling • Muscle weakness • Unable to continue play Physical examination • Limping

• Point tenderness

• Muscle testing weakness and pain

• Always compare to the unaffected side X-Rays • AP, lateral, oblique, outlet views of the pelvis

• May be normal

• Compare to uninjured side

• Follow up films with changes Secondary imaging • MRI

• CT scan

• Ultrasound Treatment

Conservative vs. Surgical

Non-Operative TX Operative Treatment Winner is?

Many Few Boston Children’s –Lyle Micheli ➢ Non op vs operative management

➢ 437 apophyseal avulsion fractures of the pelvis-1981-2012

➢ 413 non-operative treatment

➢ 72% male

➢ Mean age 14.5 Years

➢ ASIS-29%, AIIS 27%, IT 17%, LT 15%, Iliac Crest 11% Boston Children’s study – Orthopedic Journal of Sports Medicine -2014 ➢ 94 % were successfully treated nonoperatively- Time to healing and RTP < 3 months

➢ 25 patients underwent surgery- 72 % were initially treated non-operatively

➢ Ischial tuberosity most common site

➢ 48% fragment excision

➢ 11 had fixation-4.8 months time to union Non-operative treatment

• Crutches- Full vs Partial weight bearing

• Ice

• Pain control

• Parent/Patient education

• Follow up- 2,3,6, 12 weeks ? X-rays

• Physical Therapy

• Vitamin D supplementation Non-operative complications • Non union-pseudoarthrosis

• Heterotopic ossification: presence of bone in soft tissue where bone normally does not exist

• Hamstring syndrome: hard fibrotic bands irritate sciatic nerve at the insertion site of the hamstring muscles to ischial tuberosity.

• Chronic pain

• Inability to return to sports Non-Operative Complication images

HETERTOPIC OSSIFICATION →

•  HAMSTRING SYNDROME OPERATIVE TREATMENT • Fragment displacement > 2 cm or > 1.5 cm

• Fragment excision

• Fragment fixation o Screws/K-wire/Plates Operative treatment: Complications • Risk of nonunion lower

• More heterotopic ossifications

• Prolonged wound healing

• Keloid scarring

• Neurologic injury Operative vs Conservative treatment • LITERATURE REVIEW IS MOSTLY RETROSPECTIVE STUDIES- POOR QUALITY

• NOT MUCH DIFFERENCE IN OUTCOMES- SUCCESSFUL RETURN TO PLAY Take home points Prevention and education

➢ Early and correct diagnosis ➢ X-rays ➢ Secondary Imaging ➢ Slow/gradual return to play ➢ Conservative vs surgical management Thank you!