Avulsion fracture of the ischial tuberosity in adolescents--an easily missed diagnosis

Imaging of Overuse Injuries of the Hip

Overuse injuries of the hip are common, and clinical diagnosis may be difficult because of overlapping and nonspecific clinical symptoms. Imaging can play an essential role in guiding diagnosis and management. Femoroacetabular joint structural abnormalities result in various conditions that can predispose patients to early development of osteoarthritis. Repetitive stress on the skeletally immature hip can result in apophyseal injuries. Notable nonosseous overuse hip pathologies include athletic pubalgia, trochanteric bursitis, and injuries involving the iliopsoas myotendinous unit. Timely diagnosis of overuse injuries of the hip can facilitate improved response to conservative measures and prevent irreversible damage.

Pelvic Avulsion Fractures in Adolescent Athletes: Analyzing the Effect of Delay in Diagnosis

OBJECTIVE

To evaluate whether delay in the diagnosis of pelvic avulsion fractures in young athletes leads to prolonged treatment and prolonged return toward sport activities, whether fractures at certain locations are associated with a greater risk of diagnostic delay, and what reasons may exist for delay in diagnosis.

DESIGN

Retrospective chart review of young patients who presented with pelvic region avulsion fracture to a community-based sports medicine clinic over a 19-year period.

SETTING

Private practice, primary care sports medicine clinic.

PATIENTS

Patients younger than 20 years diagnosed with pelvic region avulsion fracture.

INTERVENTIONS

None, this was a retrospective study.

MAIN OUTCOME MEASURES

Clearance for return toward sport activities.

RESULTS

Two hundred twenty-five cases were reviewed for reasons for delay in diagnosis; 208 cases met criteria for the duration of treatment and return to play activities portions of the study. The mean time from date of injury diagnosis was 19.59 days, and the mean duration from date of injury to clearance for return to play advancement was 67.20 days. Duration of treatment varied slightly depending on timing of diagnosis, whereas duration from date of injury to clearance for return to play advancement varied greatly depending on diagnostic delay. Those who did not sense a "pop" at the time of injury were more likely to experience diagnostic delay, as were athletes with ischial tuberosity fractures. The most common cause of diagnostic delay was patient/family decision on when to seek care; misdiagnosis as a muscle strain was also common.

CONCLUSIONS

Diagnostic delay of adolescent pelvic avulsion fractures may unnecessarily prevent athletes from returning to play within an optimal time frame. Our observations highlight a need for educating athletes and their families on when to seek initial or follow-up medical care as well as educating medical providers regarding the diagnosis of pelvic avulsion fractures.

Treatment of Acute Bony Avulsion of Ischial Tuberosity With Cortical Screw Fixation

Displaced bony avulsion of the hamstring origin is a rare condition that necessitates surgical treatment. This article describes the surgical treatment of acute apophyseal separation of the ischial tuberosity via open reduction and internal fixation with cortical screws.

Delayed proximal hamstring tendon repair after ischial tuberosity apophyseal fracture in a professional volleyball athlete: a case report

Background

Ischial tuberosity apophyseal fractures are avulsion fractures of the anatomic footprint of the proximal hamstring tendons. Generally, these injuries are rare and frequently occur in skeletally immature, active patients due to incomplete ossification. Depending on the fragment displacement, non-operative or operative treatment approaches are used.

Case presentation

We report a case of a 29-year-old professional volleyball athlete who has suffered from a nonunion avulsion fracture for 14 years. Isolated suture anchor fixation was performed after open excision of a large bony fragment followed by excellent clinical and functional outcome at 1 year postoperatively.

Conclusion

In conclusion, avulsion fractures of the ischial tuberosity with large fragments and restrictions to activities of daily living due to pain can, in individualized cases, be treated with an open excision of the fragment followed by repair of the proximal hamstring tendons using suture anchors.

Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment

BACKGROUND

We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis.

METHODS

We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed.

RESULTS

We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon.

CONCLUSIONS

We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.

The 'nightstick' ischial fracture: a unique oddity of the pelvic injury family

We present an unusual ischial fracture unreported in the literature. We discuss the mechanism and describe the appropriate investigations and surgical management of this fracture. A 36-year-old man sustained a direct blow to his right buttock following a fall from a dirt bike. Examination revealed a firm haematoma, with severe pain on any stretch involving the posterior compartment of the thigh. Radiographs revealed a displaced fracture of the ischial body. CT confirmed integrity of the pelvic ring. The patient underwent open reduction and internal fixation with a partially threaded cannulated screw via a 'modified longitudinal' posterior approach to the ischium. The patient was managed partially weight-bearing for 6 weeks; 6-month follow-up confirmed satisfactory clinical and radiographic outcomes. Clinicians should be aware of this novel pelvic fracture and its unusual presentation, currently not included in any pelvic fracture classification system. We report a novel operative technique for appropriate surgical management of such injuries.

Surgically Treated Nonunion following Ischial Tuberosity Avulsion Fracture of a 14-Year-Old Athlete

A 14-year-old girl experienced acute left buttock pain during a sprint. At the local hospital, she was diagnosed with an avulsion fracture of the left ischial tuberosity. She was kept for observation for about 10 months; however, the buttock pain persisted, and the bone fragments did not unite. She was referred to our hospital approximately 11 months after the injury. Plain radiography revealed an increased transposition of the bone fragment, from 12 mm immediately after the injury to 23 mm. Twelve months after the injury, she underwent osteosynthesis using two cannulated cancellous screws and three suture anchors. Following postoperative rehabilitation, the power in her left hamstring recovered, and she was able to run at full speed and returned to athletics 9 months after the surgery. The operative indications for avulsion fractures of the ischial tuberosity are unclear. Careful follow-up is required as the rate of nonunion after conservative treatment tends to be high. This needs to be identified in order to provide timely treatment that allows for early return to sport. Although she had significant chronic pain and muscle weakness, the surgery successfully treated the fracture, and her muscle power recovered, leading to her return to sports.

Surgical treatment of an ischial tuberosity avulsion fracture with delayed presentation

Avulsion fractures of the ischial tuberosity usually occur in skeletally immature athletes following eccentric contraction of the hamstrings. When displaced fractures are left untreated, subsequent non-union and proximal hamstring fibrosis may lead to chronic pain and reduced activity. However, the indications for and outcomes of operative fixation when presentation is delayed remain unclear. We report the case of a 14 year old male athlete who presented to our institution 6 weeks after sustaining a displaced ischial tuberosity avulsion fracture. He underwent open reduction and internal fixation using a cannulated screw system via a posterior approach, with excellent results at 18 months follow-up. We report our surgical findings in detail as well as a novel method for post-operatively assessing functional screw head prominence-the seated radiograph.

Pediatric Sports Injuries

With increasing pediatric participation in organized sport and the early specialization of children in single sports, the number of injuries seen in the pediatric and adolescent athletic population continues to increase. Children experience acute traumatic injuries during practice and competition as well as chronic overuse injuries secondary to the repetitive stress on their developing bodies. The unique nature of the pediatric patient often requires a different diagnostic, prognostic, and treatment approach to sports injuries compared with their adult counterparts.

Range of Motion and Injury Occurrence in Elite Spanish Soccer Academies. Not Only a Hamstring Shortening-Related Problem

Sanz, A, Pablos, C, Ballester, R, Sanchez-Alarcos, JV, and Huertas, F. Range of motion and injury occurrence in elite Spanish soccer academies. Not only a hamstring shortening-related problem. J Strength Cond Res 34(7): 1924-1932, 2020-Age-related development of range of motion (ROM) during an active hip flexion (active straight leg raise) and its relationship with hamstring injury occurrence were examined in 1657 young male soccer players (9-18 years of age). Age-related differences in ROM showed a significant decrease from U9 to U11 (p = 0.001), from U11 to U13 (p < 0.005), and from U9 to U13 (p < 0.001), whereas ROM increased from U13 to U15 and from U13 to U18 (both p's < 0.001). Interestingly, younger and older players reached similar ROM values (U9-U18, p = 0.87). Higher ROM was found in dominant than nondominant leg in all age groups (all ps < 0.001). No differences related to playing position were found on ROM (all ps > 0.478). During the follow-up period (11 months) 97 hamstring injuries were reported showing higher rates in the older age groups (p < 0.001) and outfield players (p < 0.001). Remarkably, no differences in ROM average were found between injured players and noninjured players (p = 0.152). Our results suggest that ROM during hip flexion does not only depend on the hamstrings shortening but also on the variables related to joint stability, motor control, and hip flexor muscle weakness. Sport scientists in youth sport soccer academies should develop age-specific screening and action plans to develop strength, motor control, and flexibility to optimize ROM and reduce injuries from the grassroots stages.

Avulsion fracture of the ischial tuberosity treated with the suture bridge technique: a case report

Background

In cases of avulsion fracture of the ischial tuberosity in which the bone fragments are substantially displaced, nonunion may cause pain in the ischial area. Various surgical procedures have been reported, but achieving sufficient fixation strength is difficult.

Case presentation

We treated a 12-year-old male track-and-field athlete with avulsion fracture of the ischial tuberosity by suture anchor fixation using the suture bridge technique. The boy felt pain in the left gluteal area while running. Radiography showed a left avulsion fracture of the ischial tuberosity with approximately 20-mm displacement. Union was not achieved by conservative non-weight-bearing therapy, and muscle weakness persisted; therefore, surgery was performed. A subgluteal approach was taken via a longitudinal incision in the buttocks, and the avulsed fragment was fixed with five biodegradable suture anchors using the suture bridge technique.

Conclusions

Although the majority of avulsion fractures of the ischial tuberosity can be treated conservatively, patients with excessive displacement require surgical treatment. The suture bridge technique provided secure fixation and enabled an early return to sports activities.

Avulsion Fractures of the Ischial Tuberosity: Progress of Injury, Mechanism, Clinical Manifestations, Imaging Examination, Diagnosis and Differential Diagnosis and Treatment

Avulsion fracture of the ischial tuberosity (AFIT) is a rare adolescent sports injury. At present, there is no consensus on its therapeutic paradigm, but conservative treatment appears to be the predominate choice. Furthermore, the degree of fracture displacement (DFD) remains as an important factor in determining whether AFIT needs internal fixation. The aim of the present study was to review and update the injury mechanism, clinical manifestations, imaging examination, diagnosis and differential diagnosis, and treatment of AFIT.

A literature search was performed on a variety of databases using text words, and the results were limited to the English language.

This review provides an important reference for the diagnosis and treatment of AFIT.

AFIT can be easily misdiagnosed. Therefore, a detailed medical history and imaging examination are crucial for a correct diagnosis and differential diagnosis. For the choice of treatment of AFIT, it is necessary to consider not only the size of the fracture and DFD, but also the long-term functional needs of the patient.

Pediatric avulsion fractures of pelvis: current concepts

PURPOSE OF REVIEW

Provide the reader with an evidence-based update on the importance of accurate diagnosis of commonly missed avulsion fractures of pelvis apophyses, the necessary imaging studies, the feared complications and the recent treatment recommendations.

RECENT FINDINGS

Accurate diagnosis of avulsion fractures of pelvis apophyses is high yield as misdiagnosis leads to improper treatment. They should be differentiated from muscle strain and apophysitis. These fractures are usually associated with good outcomes; however, missed diagnosis can lead to further displacement, nonunion, functional limitation, femoroacetabular impingement and infection. A/P and frog lateral pelvis radiograph show the fracture and its displacement in the majority of cases. Conservative treatment, consisting of a short period of rest and immobilization followed by passive stretching then progressive resisted activity before return to sports, is recommended in minimally displaced avulsions. Surgical treatment is favored in displaced fractures (>15 mm), as it is associated with quicker return to sports.

SUMMARY

Treating physicians should keep a high index of suspicion in pediatric and adolescent patients presenting with typical clinical exam findings. Pelvic Anteroposterior and frog leg radiographs are often diagnostic. Missed diagnosis can aggravate the prognosis of a usually benign condition. Adequate medical or surgical treatment should then be administered.

Operative treatment of pelvic apophyseal avulsions in adolescent and young adult athletes: a follow-up study

INTRODUCTION

Pelvic apophyseal avulsion can limit young athletes' performance for months and may result in permanent disability. Nonoperative treatment is most commonly preferred, while surgical management with reduction and fixation is reserved for selected cases. Our aim was to evaluate outcomes of operative management of pelvic apophyseal avulsions in a series of adolescents and young adult athletes.

MATERIALS AND METHODS

Operative room registries and medical records were reviewed to identify patients who received surgical treatment for pelvic apophyseal avulsions who were younger than 24 years and with a minimum of 12 month follow-up.

RESULTS

Thirty-two patients (16.8 years ± 2.6) were identified. The most common avulsion sites were anterior inferior iliac spine (34.4%, N = 11) and ischial tuberosity (34.4%, N = 11). Other avulsions were five cases (15.6%) of the pubic apophysis, four cases (12.5%) of the anterior superior iliac spine apophysis and one case of the iliac crest apophysis. Seventeen cases (53.1%) underwent surgery early, i.e., during the first 3 months after the acute injury. Twenty-two cases (68.8%) involved reduction with internal fixation, and six cases (18.8%) involved resection of the fragment. Twenty-six athletes (81.3%, N = 26) reported good outcomes and were able to return to preinjury sports level. Six patients (18.8%) had moderate outcome and reported activity limitations during high-level sports. Large displacement (> 20 mm) or delayed (> 3 months) surgery was not associated with inferior outcomes (P = 0.690 and P = 0.392, respectively). Injury side (P = 0.61) or gender (P = 0.345) did not affect outcomes.

CONCLUSIONS

Operative management of pelvic apophyseal avulsion results in return to the preinjury sports level in more than 80% of the cases. However, while both acute surgery for large displacement and delayed intervention for failed nonoperative treatment are generally successful in improving sports function in these cases, comparative studies are required to refine criteria for surgery.

LEVEL OF EVIDENCE

Case series, IV.

Sports Injuries about the Hip: What the Radiologist Should Know

Injuries of the hip and surrounding structures represent a complex and commonly encountered scenario in athletes, with improper diagnosis serving as a cause of delayed return to play or progression to a more serious injury. As such, radiologists play an essential role in guiding management of athletic injuries. Familiarity with hip anatomy and the advantages and limitations of various imaging modalities is of paramount importance for accurate and timely diagnosis. Magnetic resonance (MR) imaging is often the modality of choice for evaluating many of the injuries discussed, although preliminary evaluation with conventional radiography and use of other imaging modalities such as ultrasonography (US), computed tomography, and bone scintigraphy may be supplementary or preferred in certain situations. Stress fractures, thigh splints, and posterior hip dislocations are important structural injuries to consider in the athlete, initially imaged with radiographs and often best diagnosed with MR imaging. Apophyseal injuries are particularly important to consider in young athletes and may be acute or related to chronic repetitive microtrauma. Femoroacetabular impingement has been implicated in development of labral tears and cartilage abnormalities. Tear of the ligamentum teres is now recognized as a potential cause of hip pain and instability, best evaluated with MR arthrography. Greater trochanteric pain syndrome encompasses a group of conditions leading to lateral hip pain, with US playing an increasingly important role for both evaluation and image-guided treatment. Muscle injuries and athletic pubalgia are common in athletes. Lastly, snapping hip syndrome and Morel-Lavallée lesions are two less common but nonetheless important considerations. ^©RSNA, 2016.

Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete

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.

Multimodal Care in the Management of a Patient With Chronic Tendinopathy of the Biceps Femoris: A Case Report

OBJECTIVE

The purpose of this case report was to describe the use of dry needling in conjunction with auricular acupuncture, core exercises, and light aerobic activity for treating chronic tendinopathy of the biceps femoris.

CLINICAL FEATURES

A 30-year-old white female presented with chronic biceps femoris tendinopathy. The injury had occurred 18 months prior while training for a triathlon. Active stretching of her right biceps femoris while standing with her feet 6 inches apart aggravated the pain at the origin in the right tendon of the biceps femoris at 0 degrees of movement.

INTERVENTION/OUTCOME

The combination of dry needling and auricular acupuncture with core rehabilitation exercises and light activity was employed. Alleviation of pain with full range of motion was achieved during hip extension, knee flexion, and standing biceps femoris stretch at the 11th, 16th, and 18th treatments. In addition, the patient also reported improvement in her symptoms, including night sweats, insomnia, anxiety, tension, and constipation.

CONCLUSIONS

This patient's symptoms and function improved after 18 treatments of multimodal care. Dry needling employed simultaneously with auricular acupuncture, core exercises, and light activity could be considered a possible strategy for treating chronic tendinopathy.

Ischiofemoral impingement and hamstring dysfunction as a potential pain generator after ischial tuberosity apophyseal fracture non-union/malunion

PURPOSE

The purpose of this study was to describe the occurrence of ischiofemoral impingement (IFI) and hamstring dysfunction following malunion or non-union of ischial tuberosity apophyseal avulsion fractures and report the short-term outcomes of surgical treatment with regard to alleviating symptomatic extra-articular impingement.

METHODS

All patients who underwent surgery for recalcitrant hip and buttock pain in the setting of prior ischial tuberosity avulsion fracture at three tertiary-level hip preservation centres were included for this review. A total of ten patients met our inclusion criteria and underwent sciatic neurolysis, resection of the ischial tuberosity fragment and hamstring reattachment. Clinical outcomes scores were collected post-operatively including the Modified Harris Hip Score (mHHS) and the Hip Outcomes Score (HOS).

RESULTS

Ten patients with a mean age of 18 years (range 14-28) underwent surgery for symptomatic ischiofemoral impingement after ischial tuberosity avulsion fracture. At a mean of 2.2-year follow-up (range 1.7-3.5), the median post-operative mHHS was 89.7 (65.7-96.8) and HOS ADL and Sport subscales were 90 % or greater in all cases. Five patients (50 %) rated their hip as normal, and five patients (50 %) rated their hip as near normal.

CONCLUSION

Malunion or non-union following ischial tuberosity apophyseal fracture can lead to IFI and hamstring dysfunction. Clinically, the resultant pain and dysfunction is often chronic, and can be debilitating. In select cases, a reliable surgical technique is presented to improve hamstring function and correct ischiofemoral impingement in this setting with good-to-excellent outcomes in the majority of cases at short-term follow-up.

LEVEL OF EVIDENCE

IV.

Ischial Tuberosity Avulsion Stress Fracture after Short Period of Repetitive Training

Fatigue fracture of the pelvis is the form of fracture due to repetitive micro-stress accumulation, can be affected by a number of factors such as patient's nutritional status, biomechanics, social status and so on. Still there is no study about precise standard degree of external force that lead to stress fracture, but it may caused by compression force, traction force or complex force and others. Avulsion stress to ischial tuberosity or anterior superior iliac spine by attached muscle is known as the main factor for the avulsion fracture. This report will deal with 19 years old conscripted policeman who occurred ischial tuberosity avulsion fracture after training of 6-hour running for 5 days accompanying hip hyper-flexion motion. This reports aims to provide case study of stress fracture occurred after 5 days of exercise which is relatively short period who had no specific trauma history or pain.

[Apophyseal Avulsions of the Hip Region in Adolescents]

BACKGROUND

In daily practice apophyseal avulsions of sportive adolescents are frequently being diagnosed with a time delay and treated heterogeneously.

GOAL

Using the most actual literature and the own experience the current diagnostic and therapeutic strategies are put into perspective with regards of the needs of the adolescent athlete.

MATERIAL AND METHODS

The apophyseal lesions of the hip area in adolescence are separated in those at the pelvis and those at the proximal femur. They are reviewed according to its frequency and relevance using the most updated literature. The treatment methods reported focus on the degree of dislocation and level of sports activity.

RESULTS

The most frequent apophyseal avulsion of the pelvis is the avulsion of the tuber ischiadicum, followed by the inferior anterior iliac spine the superior anterior iliac spine and the apophysis of the ilium. The most affected structure at the proximal femur is the lesser trochanter, lesions of the greater trochanter are rare. The cause of injury is a specific acute contracture of the muscle inserting at the affected apophysis during different sporting activities. The treatment of pelvic apophyseal injuries is surgical only in cases with considerable fragment dislocation and in high level athletes. At the femoral side the patients are treated almost always conservatively.

DISCUSSION

Despite of modern and efficient osteosynthetic techniques the treatment of avulsion lesions of the hip region is mainly conservative, even in athletes. By applying consequent diagnostic and therapeutic principles the development of pseudarthroses and heteropic ossifications can be minimised.

Orthopedic emergencies: a practical emergency department classification (US-VAGON) in pelvic fractures

Trauma is one of the leading causes of death before the age of 40 years and approximately 5% of patients with trauma who require hospital admission have pelvic fractures. This article updates the emergency department classification of pelvic fractures first described in 2000. This information is of practical value to emergency physicians in identifying the potential vascular, genitourinary, gastrointestinal, orthopedic, and neurologic complications and further assists them in the initial evaluation and treatment of patients with pelvic fractures.

A novel approach to treatment for chronic avulsion fracture of the ischial tuberosity in three adolescent athletes: a case series

BACKGROUND AND INCIDENCE

Ischial tuberosity fracture and its associated complications are an under recognized diagnosis in the adolescent athlete. Apophyseal injuries of the pelvis in the skeletally immature athlete can occur in multiple locations but are most common at the ischial tuberosity, affecting males more commonly than females.

DESCRIPTION OF INJURY AND CURRENT MANAGEMENT

The most common cause of ischial tuberosity avulsion fracture is a quick eccentric load to the proximal hamstrings, occurring with kicking as in soccer, football, or dance. Signs and symptoms are similar to a proximal hamstring injury but avulsion injuries often go undiagnosed, as radiographs are not frequently obtained. In acute cases, rest and relative immobilization are the recommended course of care. In chronic cases, including those with delayed diagnosis, or those that remain symptomatic after initial care due to non-union or associated sciatic nerve adhesions, surgery is often performed in order to restore normal anatomy, alleviate symptoms, and help return the athlete to full activity.

PURPOSE

The authors' share a novel treatment approach consisting of ultrasound guided percutaneous needle fenestration for the treatment of three adolescent athletes with symptomatic delayed diagnoses of ischial tuberosity fractures. Needle fenestration was followed by a physical therapy progression which was developed based on tissue healing rates, symptom presentation, and the available literature related to proximal hamstring injuries.

OUTCOMES

Two athletes reported elimination of pain, full functional recovery and return to sport without limitations as measured by use of the Numeric Pain Rating Scale, the Global Rating of Change Scale, and the Lower Extremity Functional Scale. One athlete reported elimination of pain and full functional recovery and chose to return to a new sport. Symptoms of possible concurrent hamstring syndrome are discussed as well the management of this condition.

DISCUSSION/CONCLUSIONS

This case series introduced a novel approach for treatment of symptomatic delayed union ischial tuberosity fractures in three adolescents prior to consideration of surgical intervention. Percutanous needle fenestration and the described subsequent rehabilitation provided positive treatment outcomes in the presented cases, including full return to athletic and recreational endeavors.

LEVEL OF EVIDENCE

Level 5.

Open reduction and percutaneous fixation of a rare hamstring avulsion fracture

Surgical treatment has been advocated for ischial tuberosity avulsion fractures in athletes. This article presents the case of an elite rower with a large avulsion fracture involving the entire inferior obturator ring with a novel technique for open reduction using a limited Kocher-Langenbeck approach and percutaneous fixation using posterior column lag screws. The fracture healed anatomically, and at 1 year follow-up the patient had full range of motion, normal gait and had returned to high-level sporting activities.

Treatment for ischial tuberosity avulsion fractures in adolescent athletes

PURPOSE

Avulsion fractures of the ischial tuberosity are rare sports injuries typically occurring in young athletes. Their misdiagnosis may lead to chronic pain or disability. The aim of this study is to report a retrospective series of patients sustaining a fracture of the ischial tuberosity and to propose decision guidelines.

METHODS

The mechanism of accident, the diagnostic management, the mode of treatment and outcome after avulsion fractures of the ischial tuberosity in adolescents were analysed.

RESULTS

Thirteen patients (1 female and 12 males) with a median age of 15 years (range 13-16 years) with an avulsion fracture of the ischial tuberosity were included. Twelve of these patients suffered from sports injuries leading to the avulsion fracture. Five of our patients with a displacement of >15 mm were treated operatively. The outcome was excellent in cases of acute presentation and osteosynthesis. Eight patients were treated conservatively: four of them showed a displacement of <15 mm and had an excellent outcome; and the other four patients had a displacement of >15 mm. Two of those patients had excellent outcome with regular bone healing, the remaining two patients developed pseudarthrosis associated with a good outcome.

CONCLUSION

The present paper shows that in patients with displacement of <15 mm, conservative treatment yields excellent results and early operative intervention should be considered in physically active patients with displacement of >15 mm.

Ischial apophyseal avulsions: proximal hamstring repair with bony fragment excision

BACKGROUND

Avulsion injury of the hamstring muscles from their origin on the ischium is an uncommon injury. In persons aged 14 to 25 years, such an avulsion may include detachment of an epiphyseal fragment at the growth plate of the ischial apophysis. The literature suggests that surgery is not necessary unless there is a large displacement of the fragment. The objective of this report is to present evidence that treatment planning should be based on symptoms, regardless of displacement.

METHODS

Between July 1998 and July 2002, 3 consecutive patients with avulsion of the immature ischial apophysis were evaluated by the senior author. In each case the bony fragment was excised and the hamstrings were reattached to the ischium with suture anchors. All patients were assessed postoperatively by biodex strength testing.

RESULTS

The average age of the patients was 15 years and the average time to repair was 7 months from the time of injury. The average retraction was 3.7 cm. The average follow-up period was 78 months. The average strength was 86% and the average power was 100% compared with the contralateral side at the final follow-up. In all 3 cases pain was relieved, and with adequate rehabilitation normal strength was regained and the subjects returned to sport. There was one complication involving an activity-related peroneal nerve palsy. This was treated by neurolysis with good functional return.

CONCLUSIONS

The 3 cases presented here suggest that treatment should be planned on the basis of pain and disability rather than pathology, and that surgical treatment can effectively address a chronic condition. Each case requires an individualized treatment plan and should include a consideration of the patient's functional goals.

A case of hypertrophic ischial tuberosity non-union treated by closed wedge osteotomy and plate and screws fixation

We report a case of a 21-year-old male with massive hypertrophic ischial tuberosity non-union. Among multiple other lesions, the patient suffered an open avulsion of the ischial tuberosity in a severe traffic accident in adolescence. A conservative treatment was decided for the avulsion. Because of sciatic pain and difficulties while sitting since the age of 19, X-rays were realised and showed a massive hypertrophic non-union of the ischial tuberosity. To preserve hamstring origin with bone attachment, the non-union was mobilised, reduced by osteotomy and fixed by plate and screws. At the follow up of one year, the patient sits without pain and can work without interruption. Avulsion of the ischial tuberosity is infrequent and the diagnosis is often missed (Gidwani et al., BMJ 329:99-100, 2004; Hamada, Clin Orthop 31:117-130, 1963). This lesion is more often seen in adolescence as the consequence of a sport injury (Gidwani et al., BMJ 329:99-100, 2004). Treatment is generally conservative and outcome good. Surgical therapy is only needed in cases with severe displacement. Long-term problems are seldom and surgical therapy to solve these problems is the exception.

MRI of radiographically occult ischial apophyseal avulsions

BACKGROUND

Acute avulsions of unossified ischial apophyses in children may go undetected on radiography. Therapy includes rest and rehabilitation; however, substantial displacement may require surgery.

OBJECTIVE

Our purpose is to illustrate the utility of MRI in the detection of these radiographically occult injuries in skeletally immature children.

MATERIALS AND METHODS

This retrospective study of more than 5 years included children with ischial avulsions who were evaluated with both radiography and MRI within 3 weeks of acute injury. Initially, radiographs were reviewed to identify those children with unossified ischial apophyses. Subsequently, their MRI examinations were assessed for physeal disruption, bone/soft tissue edema, periosteal/perichondrial elevation and disruption. Initial and follow-up radiographs (if available) were reviewed. Patient age, symptoms and offending activity were determined from clinical records.

RESULTS

Five children met inclusion criteria. All initial radiographs were normal. MRI showed: edema (n = 5), periosteal elevation (n = 4), periosteal/perichondrial disruption (n = 4), >5.5 mm displacement (n = 0). Follow-up radiographs in two children (2 and 2.5 months from MRI) showed osseous ischial irregularity. The apophyses remained unossified.

CONCLUSIONS

Acute unossified ischial apophyseal avulsions in children may be radiographically undetected. In the setting of correlative clinical symptoms, MRI can be used to identify these injuries and to help direct appropriate therapy.

Chronic complete proximal hamstring injury: The double-window approach for bony avulsions

Proximal hamstring injury represents a spectrum of trauma to either the bone or the soft tissues. Injuries can be complete or incomplete. Complete injuries usually require surgical treatment.We discuss the operative management of eight consecutive cases of chronic complete proximal hamstring injuries (injury to surgery >2.5 months). Of the eight patients, three patients had soft tissue avulsions, which were reattached with anchors via a longitudinal buttock crease incision. Five patients had bony avulsions requiring open reduction and internal fixation. In three of these, the retraction of the fragment into the thigh was so great that it was not easily retrievable and fixable through a conventional approach. On the basis of a cadaveric study, a double-window surgical approach was developed to enable us to treat these avulsions with extreme retraction. This approach can be used for other less severe injuries.

Avulsion injuries of the hamstring origin - a series of 12 patients and management algorithm

INTRODUCTION

Injuries to the origin of the hamstring muscles usually occur in athletes and can result in an avulsion fracture of the ischium, an avulsion of the ischial apophysis, or a pure avulsion of the hamstring tendons themselves, depending on the patient's age. These are rare injuries in the general population and are often initially misdiagnosed as a simple 'hamstring pull', leading to the development of chronic pain and disability.

PATIENTS AND METHODS

We present a retrospective case series of the 12 patients with such injuries who presented or were referred consecutively to the senior author between 1997 and 2006.

RESULTS

There was a significant delay (5 months to 12 years) in the diagnosis of the injury in 8 of the 12 patients. Five of these 8 patients required more extensive surgery than would otherwise have been required as a result of this delay, but all recovered well. The sporting career of one of the remaining three patients had already been brought to an end by her injury and the subsequent disability, and she elected not to have surgery. Of the four patients who were diagnosed acutely, three required surgery, and all four had an excellent result.

CONCLUSIONS

Injuries to the hamstring origin are rare and are often initially misdiagnosed as a simple 'hamstring pull', leading to the development of chronic pain and disability. Displaced injuries of the ischial apophysis and pure tendon avulsions are probably best treated surgically in the acute setting. As a result of our experience with these patients, we have produced a management algorithm.

A surgical approach for an avulsion fracture of the ischial tuberosity: a case report

We report a case of an avulsion fracture of the ischial tuberosity treated with a new surgical approach early after injury. Although surgical treatment of this fracture is usually avoided because of the difficulty of the procedure and the risk of sciatic nerve complication, we believe our subgluteal approach is simple and safe. We therefore recommend it for treating avulsion fractures of the ischial tuberosity, especially when the fragment is displaced by >2 cm and the sciatic nerve is not involved. If there is clinical evidence of sciatic nerve disturbance, it is likewise an indication for surgery. However, the incision needs to be deepened to approach the nerve, along the lines of the incisions advocated by both Miller and Spinner.