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Apophyseal Avulsion of the Rectus Femoris Tendon Origin in Adolescent Soccer Players. CHILDREN 2022; 9:children9071016. [PMID: 35884000 PMCID: PMC9320601 DOI: 10.3390/children9071016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/01/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Abstract
Apophyseal avulsions of the rectus femorus tendon (RFT) at the anterior inferior iliac spine (AIIS) can occur in adolescents, often while performing soccer. Patient-reported outcomes (PROMs) and time to return to sport of these patients are relatively unknown. Therefore, the aim of this study was to assess the PROMs and return to sports of patients with AIIS avulsions and compare the results with those reported in the literature. This is a case series of seven consecutive patients presenting at our hospital between 2018 and 2020 with an apophyseal avulsion of the RFT from the AIIS. The patients were assessed with use of the WOMAC and Tegner scores and return to sports was evaluated. All patients were male soccer players (median age 13 years; range, 12–17). They were all initially treated non-operatively. One of the patients subsequently needed excision surgery of a heterotopic ossification because of non-transient hip impingement. All other patients recovered after a period of relative rest. Median time to return to sports was 2.5 months (range, 2–3). At a median follow-up of 33 months (range, 18–45), the WOMAC (median, 100; range, 91–100) and Tegner scores (median, 9; range, 5–9) were high. In accordance with the existing literature, most patients with apophyseal avulsions of the AIIS recover well with non-operative treatment. However, the avulsion can lead to hip impingement due to heterotopic ossifications possibly needing surgical excision. Sport resumption is achievable after 2–3 months, and patient-reported outcomes are highly satisfactory in the long term.
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Should proximal ruptures of the anterior rectus femoris muscle be treated surgically? Chin J Traumatol 2022; 25:232-236. [PMID: 34903464 PMCID: PMC9252935 DOI: 10.1016/j.cjtee.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 09/29/2021] [Accepted: 10/27/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE No therapeutic consensus has been established about proximal ruptures of the rectus femoris muscle. The objective of this literature review is to determine a therapeutic course of action. METHODS We conducted a literature review on the PubMed database using the following keywords (in French and English, respectively): "quadriceps/quadriceps", "droit antérieur/rectus femoris", "proximal/proximal", "chirurgie/surgical", "avulsion/avulsion". We collected 266 articles, 36 of them were selected, which were related to our topic: proximal rupture of the anterior rectus femoris. Patients with a proximal rupture of the rectus femoris, minor or major patient of traumatic origin were included in this study. Patients injured at another lesion level, or non-traumatic lesions of the proximal rectus femoris (tendinitis without ruptures, tumor or others) were excluded. For each patient, the indications, the type of treatment and the functional result were analyzed, with the time to recovery and the level of recovery from sports and professional activities (same sport/profession or not, same level or not) as the main criterion of judgment. Fisher exact test was used for statistical comparison. RESULTS The aims of conservative treatment are to be pain free for the patient, to fight hematoma and to rehabilitate the injury as quickly as possible. The surgical techniques are varied, with most consisting of either a reinsertion of the musculo-tendon stump or a resection of the scar tissue with myo-tendino-aponeurotic suture in place. The functional results are good for the majority of the treatments proposed, but the conservative treatment has a shorter recovery time (3 months vs. 4 months for the best surgical results). Highly displaced bone avulsion is the only indication for first-line surgical treatment. CONSLUSION The main disadvantage of conservative treatment is the risk of residual pain beyond 3 months (10%), justifying an MRI to guide secondary surgical treatment. We propose a treatment plan for proximal rupture of the proximal rectus femoris rupture.
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Arthroscopic and Endoscopic Treatment of Proximal Rectus Femoris Avulsion. Orthopedics 2022; 45:e1-e6. [PMID: 34734771 DOI: 10.3928/01477447-20211101-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Proximal rectus femoris avulsion (PRFA) is an uncommon injury that is poorly reported in the literature. Historically, these injuries have been treated nonoperatively or with open techniques. This is the first study showing endoscopic treatment of this injury. We present a systematic review of PRFA treatment and a case report of a patient whose injury was treated endoscopically. Sixty-four injuries were reported across several sports. Patients underwent nonoperative management, suture repair, suture anchor repair, or excision of the tendon stump. Surgical complications included lateral femoral cutaneous nerve injury and wound complications. The patient who underwent arthroscopic treatment had a good outcome. [Orthopedics. 2022;45(1):e1-e6.].
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Operative versus conservative treatment of proximal rectus femoris avulsions: A systematic review with meta-analysis of clinical outcomes, complications and return to sports. J Clin Orthop Trauma 2020; 15:83-92. [PMID: 33717921 PMCID: PMC7920143 DOI: 10.1016/j.jcot.2020.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/10/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022] Open
Abstract
PROSPERO REGISTRATION NUMBER CRD42020198333. OBJECTIVE To compare the surgical and conservative treatment of proximal rectus femoris avulsions regarding clinical outcomes, rate of return to sports and incidence of complications. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane, Medline, Scopus and SPORTDiscus. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies reporting on outcomes of PRFAs or return to sports were included. RESULTS Nine studies consisting of a total eighty-two patients met the inclusion criteria. The mean age was 22.2 years and 75.9% of patients were male. Mean follow-up was 28.9 months and 65% avulsions were managed surgically. The overall outcomes were similar in surgical and conservative treatment group (p = 0.72) with similar incidence of complications (14%). The rate of return to sports was 95% in surgical and 92.7% in the conservative management groups (p = 0.93). Overall, the quality of the methodology of included studies was low, with a mean CMS of 45.6. CONCLUSION Both conservative and operative treatment provide excellent outcomes in proximal rectus femoris avulsions, with similar rates of return to sports and incidence of complications. More prospective and good quality studies are needed to compare surgical techniques and time to return to sports. Avulsions with retraction of more than 20 mm and high demand patients may benefit from surgical treatment. Patients should be counselled accordingly.
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Sonography of the indirect tendon of the rectus femoris. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:298-303. [PMID: 30684271 DOI: 10.1002/jcu.22698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 07/05/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
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Narrative review of injuries in powerlifting with special reference to their association to the squat, bench press and deadlift. BMJ Open Sport Exerc Med 2018; 4:e000382. [PMID: 30057777 PMCID: PMC6059276 DOI: 10.1136/bmjsem-2018-000382] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/17/2022] Open
Abstract
Pain and injuries are considered a common problem among elite athletes and recreational lifters performing the squat, bench press and deadlift. Since all three lifts engage multiple joints and expose the lifters’ bodies to high physical demands often several times a week, it has been suggested that their injuries might be related to the excessively heavy loads, the large range of motion during the exercises, insufficient resting times between training sessions and/or faulty lifting technique. However, no previous article has summarised what is known about specific injuries and the injury aetiology associated with the three lifts. Thus, the aim of this narrative review was to summarise what is known about the relationships between the powerlifting exercises and the specific injuries or movement impairments that are common among lifters and recreationally active individuals.
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Sonographic Overview of Usual and Unusual Disorders of the Rectus Femoris Tendon Origins. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1543-1553. [PMID: 28857221 DOI: 10.1002/jum.14352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/22/2017] [Indexed: 06/07/2023]
Abstract
Rectus femoris muscle proximal injuries are not rare conditions. The proximal rectus femoris tendinous anatomy is complex and may be affected by traumatic, microtraumatic, or nontraumatic disorders. A good knowledge of the proximal rectus femoris anatomy allows a better understanding of injury and disorder patterns. A new sonographic lateral approach was recently described to assess the indirect head of the proximal rectus femoris, hence allowing for a complete sonographic assessment of the proximal rectus femoris tendons. This article will review sonographic features of direct, indirect, and conjoined rectus femoris tendon disorders.
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Operative Fixation of an Anterior Inferior Iliac Spine Apophyseal Avulsion Fracture Nonunion in an Adolescent Soccer Player: A Case Report. JBJS Case Connect 2017; 7:e29. [PMID: 29244669 DOI: 10.2106/jbjs.cc.16.00167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 14-year-old male competitive soccer player presented with a history of recurrent right hip pain for 18 months. He was diagnosed with an anterior inferior iliac spine (AIIS) apophyseal avulsion fracture nonunion with subspinal impingement, which was confirmed by radiographs, computed tomography, and magnetic resonance imaging. The patient underwent surgical fixation and subspinal decompression. He returned to competitive soccer 5 months postoperatively. CONCLUSION AIIS apophyseal avulsion fractures occur in adolescent athletes and generally respond to nonoperative treatment. When such management is unsuccessful, surgical fixation can lead to resolution of pain with return of full function.
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Anterior Inferior Iliac Spine Deformity as a Cause for Extra-articular Hip Impingement in Young Athletes After an Avulsion Fracture: A Case Report. Sports Health 2017; 10:272-276. [PMID: 29211625 PMCID: PMC5958449 DOI: 10.1177/1941738117744547] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Extra-articular hip impingement from prior traumatic injury to the anterior inferior iliac spine (AIIS) is an uncommon cause of groin pain in young athletes. Currently, the most common treatment for this injury is arthroscopic decompression. However, hip arthroscopy is not universally available and requires advanced skills. We report 2 cases of the development of extra-articular hip impingement from unusual bony exostoses off the AIIS after traumatic injury in 2 young athletes who underwent open surgical resection. The multidisciplinary sports medicine team should be aware of the development of extra-articular impingement from traumatic injury to the AIIS and that open surgical resection is a viable alternative to arthroscopic decompression.
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Tenosuspension of the Reflected Head of the Rectus Femoris in Hip Arthroscopy: Description of a Portal and a Surgical Maneuver. Arthrosc Tech 2017; 6:e1015-e1019. [PMID: 28970986 PMCID: PMC5621485 DOI: 10.1016/j.eats.2017.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/09/2017] [Indexed: 02/03/2023] Open
Abstract
Arthroscopy is a surgical technique useful in the treatment of intra- and extra-articular hip pathologies, including femoroacetabular impingement (FAI). In the arthroscopic treatment of pincer-type FAI, tendon interposition of the reflected head of the rectus femoris frequently hinders acetabular edge resection in the anterior-superior region (acetabuloplasty) and labrum repositioning, even causing tendon injury during the surgical procedure. Many surgeons do not give importance to the reflected head of the rectus femoris, and during the procedure they try to avoid it, giving 30° of flexion to the hip. However, this does not always prevent tendon injury caused by the instruments. Some surgeons even resect part of the tendon to improve visualization or to use it as a labral graft. The objective of this work is to describe a reproducible surgical maneuver that allows to perform the anterior-superior acetabular edge resection and chondrolabral union repair with less damage to the reflected head of the rectus femoris.
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Abstract
Lower extremity avulsion fractures are uncommon in the pediatric population and can be misdiagnosed without proper imaging and/or clinical suspicion for these injuries. The most common locations of avulsion injuries are the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine. Less often, avulsion fractures occur in the tibial tubercle, calcaneus, and greater and lesser trochanters. When treated properly with rest and altered weight bearing, most of these injuries heal without complication. Although surgical intervention is rarely necessary, it has a high degree of success when it is used. However, avulsion injuries are often misdiagnosed as muscle strains or apophysitis and are mistakenly treated with early range of motion. An error in diagnosis and/or management can cause nonunion or further displacement, which may require surgery. Improper identification of these injuries can also lead to nerve irritation, chronic pain, and gait dysfunction. Awareness of these injuries and their natural history is important because healed avulsion fractures may resemble neoplastic bone on radiographs.
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Imaging of rectus femoris proximal tendinopathies. Skeletal Radiol 2016; 45:889-97. [PMID: 26956398 DOI: 10.1007/s00256-016-2345-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/27/2016] [Accepted: 02/01/2016] [Indexed: 02/02/2023]
Abstract
The rectus femoris is the most commonly injured muscle of the anterior thigh among athletes, especially soccer players. Although the injury pattern of the muscle belly is well documented, less is known about the anatomy and specific lesions of the proximal tendons. For each head, three distinctive patterns may be encountered according to the location of the injury, which can be at the enthesis, within the tendon, or at the musculotendinous junction. In children, injuries correspond most commonly to avulsion of the anteroinferior iliac spine from the direct head and can lead to subspine impingement. Calcific tendinitis and traumatic tears may be encountered in adults. Recent studies have shown that traumatic injuries of the indirect head may be underdiagnosed and that injuries of both heads may have a surgical issue. Finally, in the case of tears, functional outcome and treatment may vary if the rupture involves one or both tendons and if the tear is partial or complete. Thus, it is mandatory for the radiologist to know the different ultrasound and magnetic resonance imaging (MRI) patterns of these lesions in order to provide accurate diagnosis and treatment. The purpose of this article is to recall the anatomy of the two heads of rectus femoris, describe a reliable method of assessment with ultrasound and MRI and know the main injury patterns, through our own experience and literature review.
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Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment. Br J Sports Med 2016; 50:1181-6. [DOI: 10.1136/bjsports-2015-095137] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2016] [Indexed: 01/29/2023]
Abstract
IntroductionAthletic groin pain requiring surgery remains a diagnostic and therapeutic challenge. This systematic review aims to identify the most common causes of groin pain in athletes requiring surgery. Additionally, it aims to further characterise their susceptible athlete profiles, common physical examination and imaging techniques, and surgical procedures performed. This will enable the orthopaedic sports medicine clinician/surgeon to best treat these patients.Materials and methodsThe electronic databases MEDLINE, PubMed and EMBASE were searched from database inception to 13 August 2014 for studies in the English language that addressed athletic groin pain necessitating surgery. The search was updated on 4 August 2015 to find any articles published after the original search. The studies were systematically screened and data were abstracted in duplicate, with descriptive data presented.ResultsA total of 73 articles were included within our study, with data from 4655 patients abstracted. Overall, intra-articular and extra-articular causes of groin pain in athletes requiring surgery were equal. The top five causes for pain were: femoroacetabular impingement (FAI) (32%), athletic pubalgia (24%), adductor-related pathology (12%), inguinal pathology (10%) and labral pathology (5%), with 35% of this labral pathology specifically attributed to FAI.ConclusionsGiven the complex anatomy, equal intra-articular and extra-articular contribution, and potential for overlap of clinical entities causing groin pain leading to surgery in athletes, further studies are required to ascertain the finer details regarding specific exam manoeuvres, imaging views and surgical outcomes to best treat this patient population.
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Abstract
BACKGROUND The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of pelvic apophyseal avulsion fractures. METHODS A retrospective records review of imaging and clinical documentation was performed for patients diagnosed with pelvic apophyseal avulsion fractures at our institution from 2007 to 2013. Patient's Risser score, triradiate status, fracture location, size, and displacement were recorded based on initial injury radiographs. Further clinical and radiographic chart review was utilized to determine mechanism of injury, presence of multiple/bilateral injuries, nonunion, chronic pain, as well as any surgical interventions performed. RESULTS We identified 225 patients diagnosed with 228 apophyseal avulsion fractures with mean age of 14.4 years. Males represented 76% of the patients. Anterior inferior iliac spine (AIIS) avulsions were the most common, representing 49% of all avulsion fractures, followed by anterior superior iliac spine (30%), ischial tuberosity (11%), and iliac crest (10%). The most common mechanism of injury was sprinting/running (39%) followed by kicking (29%), but the mechanism varied by fracture type with 50% of AIIS avulsions caused by kicking. Multiple pelvic fractures were identified in 6% of patients. Pain >3 months out from initial injury was present in 14% of all patients and AIIS avulsion fractures were 4.47 times more likely to have chronic pain. Five nonunions were identified, 4 of which were ischial tuberosity avulsions. Initial fracture displacement >20 mm increased the risk of nonunion by 26 times. Surgical treatment was indicated in 3% of cases. CONCLUSIONS In this series, nearly all pelvic avulsion fractures (97%) were managed successfully with a conservative approach. Contrary to prior studies, AIIS avulsions represented half of the avulsion fractures. AIIS and ischial tuberosity fractures are at increased risk of developing future pain and nonunions, respectively. Patients and families need to be counseled about this possibility because future intervention may be necessary. LEVEL OF EVIDENCE Level IV-therapeutic.
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Abstract
BACKGROUND Acute groin injuries are common in high-intensity sports, but there are insufficient data on injury characteristics such as injury mechanisms and clinical and radiological findings. PURPOSE To describe these characteristics in a cohort of athletes. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS A total of 110 male athletes (mean age, 25.6 ± 4.7 years) with sports-related acute groin pain were prospectively included within 7 days of injury from August 2012 to April 2014. Standardized history taking, a clinical examination, magnetic resonance imaging (MRI), and/or ultrasound (US) were performed. RESULTS The most frequent injury mechanism in soccer was kicking (40%), and change of direction was most frequent in other sports (31%). Clinically, adductor injuries accounted for 66% of all injuries and primarily involved the adductor longus on imaging (91% US, 93% MRI). The iliopsoas and proximal rectus femoris were also frequently injured according to all examination modalities (15%-25%). Acute injury findings were negative in 22% of the MRI and 25% of the US examinations. Of the clinically diagnosed adductor injuries, 3% (US) and 6% (MRI) showed a radiological injury in a different location compared with 35% to 46% for clinically diagnosed iliopsoas and proximal rectus femoris injuries. CONCLUSION Adductor injuries account for the majority of acute groin injuries. Iliopsoas and proximal rectus femoris injuries are also common. More than 1 in 5 injuries showed no imaging signs of an acute injury. Clinically diagnosed adductor injuries were often confirmed on imaging, whereas iliopsoas and rectus femoris injuries showed a different radiological injury location in more than one-third of the cases. The discrepancy between clinical and radiological findings should be considered when diagnosing acute groin injuries.
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An anatomical study of the indirect tendon of the rectus femoris using ultrasonography. Eur Radiol 2015; 25:3614-9. [PMID: 25981219 DOI: 10.1007/s00330-015-3769-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/15/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED The aim of this study was to demonstrate that ultrasound can allow a precise assessment of the indirect tendon of the rectus femoris using a new lateral approach. METHODS AND MATERIALS Four hips were dissected for the anatomical study of the proximal rectus femoris insertions. Under ultrasonographic guidance, spinal needles piercing the direct tendon were placed in the indirect tendon, following by dissection. Then, high-resolution ultrasound was performed in 20 volunteers with assessment of the indirect tendon of the rectus femoris. RESULTS At dissection, the spinal needles were located in or immediately adjacent to the indirect tendon, thus confirming that it was correctly depicted by ultrasound. The indirect tendon could be identified in each cadaver and each volunteer with ultrasound. The optimal position of the probe to allow assessment of the indirect tendon could be defined. No significant changes in the appearance or thickness of the tendon could be observed. CONCLUSION The results of our study showed that the indirect tendon of the rectus femoris muscle can be clearly depicted by sonography in healthy adult subjects. The potential applications of this new use of sonography must now be confirmed by clinical studies. KEY POINTS • The anatomy of the proximal rectus femoris is reviewed • Until now, sonography was limited for assessing direct and conjoined tendons • The indirect tendon can be clearly depicted by sonography • A new lateral approach for studying the indirect tendon is described.
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Avulsion fractures involving the straight and reflected heads of the rectus femoris. Hip Int 2014; 24:206-9. [PMID: 24500831 DOI: 10.5301/hipint.5000110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2013] [Indexed: 02/04/2023]
Abstract
Tumours and sport injuries can both affect active, young patients, and the symptoms of the two often overlap. Neglected avulsion injuries sometimes cause a mass to develop which can mimic a tumour. We discuss the diagnosis, treatment, and results following nine anterior inferior iliac spine (AISS) avulsion fractures.
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