GUEST RADIOLOGYREVIEW The Pop That Stopped the Soccer Game Michelle Kavin, PA-C, and Adam T. Chrusch, MD, practice at the Rothman Institute at Thomas Jefferson University in Philadelphia. 13-year-old girl presents with her been using ice and ibuprofen without relief. mother for evaluation of right hip pain Her medical history is unremarkable. A following a soccer game two days On physical exam, you note a well- ago. The patient says she felt a “pop” in her developed, well-nourished female in no right hip while running and kicking the ball. acute distress. No ecchymosis, erythema, She was escorted off the field, unable to fin- or abrasions can be seen on skin exam. The ish the game. patient has point tenderness over the right Since then, she has had pain over the iliac crest. She has mild pain and weakness right superior pelvic region. She rates the with hip flexion and significant pain with pain as a 1/10 at rest but 7/10 with ambu- abduction. The extremity is neurovascularly lation. She is unwilling to bear weight sec- intact. ondary to discomfort and has been using A pelvic radiograph is obtained. What is crutches provided by her trainer. She has your impression? mdedge.com/clinicianreviews JULY 2018 • Clinician Reviews e9 GUEST RADIOLOGYREVIEW ANSWER ment consists of conservative manage- The radiograph shows an avulsion fracture ment—rest, protected weight bearing, and of the right iliac crest. While the patient physical therapy. Surgery is typically re- does have a growth plate in this location, served for those with > 2 cm displacement there is asymmetry between the right and of the fracture fragment. left sides. In athletes, a gradual return to sports is Pelvic avulsion fractures can be easy to advised, with full participation at four to 12 overlook and are often misdiagnosed as weeks postinjury. Possible complications strains. Providers must remember that the include recurrent symptoms, prolonged pelvis serves as an insertion site for mul- healing time, nonunion, malunion, or hip tiple muscles; in both adolescent and adult weakness. patients, certain activities (eg, sprinting, This patient was placed on crutches jumping, kicking) can increase tension and with non-weight-bearing status for one result in a bone avulsion. Affected patients week. She used OTC pain medication as typically report a popping sensation, pain needed. The patient completed a four- with range of motion, and point tenderness week course of physical therapy and re- over the fracture. turned to full weight-bearing status. After Avulsion fractures can usually be iden- six weeks, the patient had returned to full tified on x-ray; CT and MRI are used only activity with pain-free range of motion when definitive diagnosis is unclear. Treat- and full strength. CR e10 Clinician Reviews • JULY 2018 mdedge.com/clinicianreviews.