Musculo-skeletal   [back to the Category]

Apophyseal avulsions   [read the french version]

Author :   Docteur Anne Thiescé

The centers of ossification which interest us here include : the anterior superior iliac spine which provides the insertion for the tensor fasciae latae and the sartorius ; the anterior inferior iliac spine which provides the insertion for the rectus femoris ; the ischium which provides the insertion for the hamstrings ; the lesser trochenter which provides the insertion for the iliopsoas and the iliac crest which provides the insertion for the postero-latero muscles of the abdomen.

Apohyseal avulsion of the pelvis concerns ballet dancers between the ages of 14 and 25 who, 9 times out of 10, are male.

Avulsion of the anterior iliac spine

Avulsion, as far as the anterior iliac spines are concerned, is caused by a sudden hyper-extension of the hip particularly during a jump, or even during a sudden half-turn. The initial pain is sharp with localisaed cracking at the root of the thigh. The immediate disability is acute, the patient is able to stand but completely unable to walk.
Clinical examination in the initial hours reveals that the young injured person is producing an antalgic flessum and must be concentrated above all to absolve the hip so that further disorders, especially of an articular nature, acnnot be missed.
Coxofemoral mobility is painful in extension, knee flexed increases the pain. Active movement is generally painful, but it is, above all, impossible for the patient to lift his heel off the bed.
Palpation reveals an inconspicuous local bloating at the top of the inguinal fold.
Walking becomes possible after several days, however, the posterior step causes pain that results in a limp. There is no bruising, as a general rule. The limp quickly improves and passive mobility becomes painless, except in the last degrees of bending and extension.

Isometric tests confirm the dignosis : AIIS, if resisted contraction of the rectus femoris is painful ( bending at the hip, knee extended),ASIS, if the isometric contraction of the sartorius is painful( bending at the hip, external rotation and abduction, knee flexed ) , to test the tensor fasciae latae, resistance must be set against the abduction-flexion-internal rotation.

The sensivity of the thigh must be checked because a major avulsion of the ASIS is able , on rare occasions, to stretch the musculo-cutaneous nerve and provoke painful paresthesia of the antero-internal part of the thigh.

The AIS is identified with front view, pelvic X-rays and oblique, sometimes the avulsion is obvious, sometimes it is not so obvious, displacement always occurs forwards, downwards, and sidewards, it is rarely larger than 10mms : Fig 1.

The diagnosis differential occurs mainly with the rupture of the rectus femoris which rarely happens under the age of 18, the diagnosis is confirmed using X-rays.

Avulsion of the ischium

This occurs between the ages of 13 and 20, more often to young boys(80%).
It is easy to differentiate between the sudden accident that is a genuine avulsion an d the chronic pain bordering on a straightforward growing apophysitis.
A genuine case of avulsion is the result of an excessive extension of the hamstrings or an abrupt contraction. The accident happens during a forward loss of balance or even whilst involuntarily doing the splits or during a battement tendu en quatrième. The excruciating pain is felt under the buttock, the disability is acute and dictates the sporting acitvity.
The diagnosis is easily made from the curl up attitude and the impossibility to get up from a sitting position which is, in itself, painful. It is possible to note a bulging under the buttock and even the disappearance of the horizontal buttock fold. Passive flexion of the hip, knee extended is impossible as is the attempt at an isometric contraction of the hamstring. There is an increase in amplitude in flexion of the affected hip. Palpation of the ischium is very painful. The clinical picture is resolvent in 10 to 15 days.
In the case of an apophysose, then the accident is, usually, banal and the speed of resolution of the symptoms means that the diagnosis is often ignored.

The diagnosis is confirmed by an X-ray of the pelvis, the avulsion can be serious and situated at the postero-lateral angle of the apophysis, sometimes it is only a slight chip. The X-ray can also show any irregularity of the ischium, an asymmetrical lowering of an ischio-pubic branch which appears ti have gained in volume or an osseous formation under the ischium. A delayed X-ray picture is impressive with an aspect of genuine fracture of the ischium.



Avulsion of the iliac crest:
This is very rare as it only occurs before the fusion of the apophysis and after puberty. Traction is provided by the transverse and oblique muscles. Pain occurs during a jump, a half turn, in actual fact, it usually comes from a rotation of the torso, pelvis steady. The pain is a lateral pain of the adolescent torso, palpation reveals pain at the junction of the middle third with the external third of the iliac wing, abdominal contraction is painful. X-rays are often negative, migration generally does not exist, thus, calling for centred photographs, even, a scintigraphy. Fig 2, Fig3.

Avulsion of the lesser trochanter. Fig 4.
The psoas muscle can wrench the lesser trochanter between the ages of 12 and 16.

Treatment

Treatment consists of rest in a pain-free position, very often in bed, for anything from several days up to three weeks. It depends on the location of the avulsion. It is sometimes possible to start walking again after the first 5 to 8 days, work outs can be resumed progressively after 1 to 3 months. Localised massage and premature re-education must be avoided.
It is rare that symptoms dictate surgery.
Consolidation X-rays are taken after the clinical diagnosis has been made.

Complications:

The cicatricial callus can sometimes be hypertrophic and can be painful for some time whilst resuming sporting activities; though a local injection is seldom necessary. Vicinity compressions are rare and can sometimes affect the sciatic nerve under the ischium, or even, the cutaneous femoris nerve under the anterior superior iliac spine.

The secondary osteoma is the rare appearance of a calcification of the soft parts that form the post-traumatic bruise. This is brought on by ill-timed, localised massage and energetic re-education. It appears only in young adults. It can sometimes be linked to intermittent pain and a definite limitation in certain precise movements. Examination reveals pain when stretching. It is crucial that all sport is stopped whilst the osteoma cools down, between 10 and 18 months. A scintigraphy provides the necessary confirmation. Treatment can then be considered. Surgical exeresis can only be justified by a functional disability.

Hypertrophic pseudarthrosis mainly exists at the ischium level, causing a neoformation which can be very large, serious functional discomfort can exclude the undertaking of any sport. The sitting position, in severe cases, is painful and a source of postural lumbago. The only solution then, is surgical treatment but there is no guarantee that a satisfactory sporting ability will be restored.


Bibliography:

Courroy J.B. Les arrachements du bassin
Journal de traumatologie du sport Vol.1N°2 p60-65 1984

Courroy J.B. Les arrachements apophysaires du bassin
6° séminaire de traumatologie du sport 23/5/87 Da balaia- Portugal p20-23

Courroy J.B. Les arrachements du bassin
Microtraumatologie du sport sous la direction de Rodineau J. Simon L.
Ed Masson, 1990

Lambert M. J., MD, Flinger D. J.: Avulsion of the iliac crest apophysis: A rare fracture in adolescent athletes
Ann. Emerg. Med. July 1993; 22: 1218-1220

Lascombes P., Tanguy A., Ramseyer P., Les ostéochondrites de croissance
EMC App. Loco. 14028 A 20 1994 8 p.

Raguet M.: Les ostéochondroses de la crête iliaque
6° séminaire de traumatologie du sport 23/5/87 Da balaia - portugal p112-115