Athletic Injuries Involving the Hip 35 Justin Roth and Jefrey J. Nepple Introduction Pelvic Apophysitis Hip pain in the adolescent patient can be due to a Pelvic apophysitis can cause pain secondary to variety of factors, including acute injury or repetitive stress at various apophyses throughout chronic overuse. The current chapter will cover the pelvis and proximal femur with apophysitis four common causes of pain in this population. of the iliac crest occurring most commonly. Pelvic apophysitis commonly occurs as a chronic Symptoms from apophysitis can also originate overuse injury resulting from overload of these from the anterior inferior iliac spine (AIIS, from pelvic growth centers. Pelvic avulsion fractures overpull of the direct head of rectus femoris) and are among the most common acute injuries in this from the ischial tuberosity (at the hamstrings ori- population and generally are treated with conser- gin). Similar to its presentation in the knee, vative methods. Athletic pubalgia, or sports her- apophysitis is generally a clinical diagnosis that nia, occurs less commonly in the adolescent can be supported by radiographic fndings. compared to adults, and is a chronic overuse con- Radiographs in the setting of apophysitis may dition of the abdominal wall. Acetabular labral demonstrate fragmentation of the apophysis. tears are the most common surgically treated Antero-posterior (AP) pelvis radiographs are use- injury in the adolescent patient and generally ful as they allow a comparison to the contralateral occur as the result of underlying bony deformity hip. Although MRI is generally not necessary for including femoroacetabular impingement (FAI) diagnosis, MRI may demonstrate edema within or acetabular dysplasia. The current chapter will the apophysis in clinically equivocal cases. cover these injuries and their arthroscopic treat- “Pelvic apophysitis has clinical presenta- ment, while FAI and acetabular dysplasia are tion, radiographic appearance, and treat- covered in separate chapters. ment similar to other common sites of apophysitis”. The treatment of pelvic apophysitis is similar to those occurring in other joints. Rest is impor- tant as many individuals have associated overuse from excessive or repetitive training. Ice and non- J. Roth · J. J. Nepple (*) steroidal anti-infammatories (NSAIDs) can be Department of Orthopaedic Surgery, Washington AU1 University School of Medicine, St. Louis, MO, USA helpful in symptom management after activities. e-mail: [email protected] Many cases of pelvic apophysitis will beneft © Springer Nature Switzerland AG 2019 S. Alshryda et al. (eds.), The Pediatric and Adolescent Hip, https://doi.org/10.1007/978-3-030-12003-0_35 J. Roth and J. J. Nepple from physical therapy to correct any underlying patients while iliac crest avulsions occur mainly muscular imbalances playing a role in the devel- in Risser 4 patients [3]. opment of pain. This commonly includes Avulsion fractures generally occur as the strengthening of weak core and hip musculature, result of an acute injury, although some may as well as stretching of tight muscle groups report prodromal symptoms prior to the fracture including the hamstrings. Most cases of pelvic consistent with apophysitis. Acute symptoms apophysitis improve with these conservative include sudden shooting pain, loss of muscular measures and are able to return to sports within 6 function, swelling and tenderness with local pal- to 12 weeks. However, some patients have recur- pation and passive movement of the involved rent episodes of pain until reaching skeletal extremity. Diagnosis is confrmed radiographi- maturity. Ongoing maintenance strengthening cally using the AP pelvis flm, although other and stretching programs remain important to views including the false profle may provide bet- avoid recurrent pain. ter visualization of certain avulsion fractures (ASIS, AIIS). Frog lateral radiographs are gener- ally useful in this population to rule out slipped AU2 Pelvic Avulsion Fractures capital femoral epiphysis (SCFE). Rarely, advanced imaging (CT/MRI) is required unless Avulsion fractures of the pelvis or hip are the operative intervention is being considered for result of a sudden large forceful concentric con- displacement or residual symptoms due to sub- traction through the musculotendinous unit or spine impingement or symptomatic non-union. from sudden passive lengthening with an eccen- A meta-analysis investigating adolescent pel- tric contraction. Avulsion fractures in the imma- vic avulsion injures by Eberlach et al. included ture patient occur through the cartilaginous 596 patients from 14 studies and found a mean apophysis as the weak link between the muscu- patient age of 14.3 years with 75.5% being male lotendinous unit and attachment. Avulsion frac- [4]. Affected sites were the anterior inferior iliac tures in the pelvis typically involve the anterior spine (33.2%), ischial tuberosity (29.0%), ante- superior iliac spine (ASIS), AIIS, ischial tuber- rior superior iliac spine (27.9%), iliac crest osity, iliac crest, and superior pubic symphysis (6.7%), lesser trochanter (1.8%) and superior cor- as well as in the lesser trochanter of the proximal ner of the pubic symphysis (1.2%) (Figs. 35.1 and femur. These injuries usually occur in adoles- 35.2) [4]. Different relative distributions of these cents during sporting activities such as kicking a fractures have been reported but this variation can ball, running or jumping with the injury pattern be attributed to the demographics of their respec- correlating with the motion [1]. The cartilagi- tive cohorts that are likely infuenced by a number nous growth plates at the apophyses are weaker of factors including the predominant sport. than the musculotendinous unit and therefore “The three most common sites of pelvic fail frst in tension, resulting in a bony cartilagi- avulsion fractures are AIIS, ischial tuber- nous fragment attached to the musculotendinous osity, and ASIS, occurring at relatively unit. Accordingly, these injuries occur in adoles- similar rates”. cents between the times of radiographic appear- ance of the apophyseal secondary ossifcation The treatment of pelvic avulsion fractures is center and its fusion to the bony pelvis, becom- generally non-operative, with the vast majority ing its respective tuberosity. The AIIS secondary healing well without residual symptoms. Recent ossifcation center appears (11.1–15.3 years) and studies have suggested a role of surgical treat- closes (13.9–17.5 years) frst while the iliac ment in certain severely displaced fractures. apophyses appear (12.6–15.3 years) and close Although most patients heal uneventfully, even last (16.0–23.9 years) [2]. As one would expect, without surgical treatment, residual symptoms AIIS avulsions occur more frequently in Risser 0 have been most commonly reported for fractures 35 Athletic Injuries Involving the Hip ab cd Fig. 35.1 Common locations of pelvic and hip avulsion fractures (a) anterior superior iliac spine, ASIS, (b) anterior inferior iliac spine, AIIS, (c) ischial tuberosity, and (d) lesser trochanter. (Copyright © Jonathan Schoenecker) involving the ischial tuberosity (sitting pain or analysis, the complication rate was comparable residual weakness) and AIIS (pain with deep hip between the conservative and operative groups fexion due to subspine impingement). While (17% vs. 19%) including heterotopic ossifca- Eberlach et al. found that most patients were tion, re-injury, future fracture, recurrent pain and treated non-operatively (89.6%), the overall suc- symptomatic hardware. Future prospective cess rate was not different in those having sur- research studies are needed to better defne the gery versus those receiving conservative incidence of residual symptoms after pelvic treatment (88% vs. 79%, p = 0.09) [1]. Operative avulsion fractures. fxation has been recommended by some authors for displacement greater than or equal to 1.5 to “Most pelvic avulsion fractures result in 2 cm with fxation described using screws and excellent outcome after conservative suture anchors depending on surgeon preference treatment. Surgical treatment may have a and size of avulsed fragment [3–7]. In this meta- role in severely displaced fractures”. J. Roth and J. J. Nepple acd be Fig. 35.2 Pelvic and Hip Avulsion Fractures. AIIS avul- avulsion fracture, and (e) lesser trochanter avulsion. AIIS sion fracture seen on (a) AP pelvis and (b) false profle anterior inferior iliac spine, ASIS anterior superior iliac views. (c) ASIS avulsion fracture, (d) Ischial tuberosity spine Anterior Inferior Iliac Spine (AIIS) The proportion of all pelvic avulsion fractures that include the AIIS ranges from 22% to 49% The most common mechanism for AIIS avul- with one study reporting 85% of Risser 0 injuries sions is kicking activities including soccer and to be AIIS despite soccer being a year round sport track reported in 50 to 62% of injuries with bilat- in the geographic region investigated. [3, 4, 8] eral involvement in 5% [3, 8]. Other causes The upper portion of the AIIS gives origin to include tennis (22%), gymnastics (7%), wresting the direct head of the rectus femoris muscle (4%) and fencing (4%) [8]. The most common which is active during hip fexion. A teardrop- age is a patient of Risser 0 skeletal maturity with shaped lower portion of the AIIS gives origin to a closing or closed triradiate cartilage but this the iliofemoral ligament and iliocapsularis mus- injury occurs throughout all 5 Risser stages [3]. cle and borders