Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases.

BACKGROUND: Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents. METHODS: A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms. RESULTS: Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019. CONCLUSIONS: Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries. LEVEL OF EVIDENCE: This is a level III retrospective study.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis.

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Pelvic Region Avulsion Fractures in Adolescent Athletes: A Series of 242 Cases.

OBJECTIVE: The objective of this descriptive study was to evaluate pelvic region avulsion fractures in adolescents, including age of injury, location of injury, activity and mechanism at time of injury, treatments used, duration of treatment, and outcomes. DESIGN: This was a retrospective chart review of patients who presented with pelvic region avulsion fracture over a 19-year period. SETTING: Private practice, primary care sports medicine clinic. PATIENTS: All patients younger than 20 years of age diagnosed with an acute pelvic region avulsion fracture. INTERVENTIONS: There was no set intervention protocol. A variety of interventions and combination of interventions were used and determined by the treating physician on a case-by-case basis. MAIN OUTCOME MEASURES: Clearance for return toward sport activities. RESULTS: Of the 242 cases, 162 were male. Soccer was the most common sport at the time of injury, and running/sprinting was the most common mechanism. Males were generally older at presentation and were more likely than females to have anterior inferior iliac spine injuries, whereas females were more likely to have iliac crest avulsions. Conservative treatment was effective in all cases. Males were treated for a shorter duration than females, but this difference was not statistically significant. CONCLUSIONS: Pelvic avulsion fractures are a rare injury in adolescent athletes. Males are twice as likely to experience these injuries and are older at presentation compared to females. Conservative management leads to successful outcomes in most cases.

A surgical reduction technique for posterior cruciate ligament avulsion fracture in total knee arthroplasty: a comparison study.

BACKGROUND: Posterior cruciate ligament (PCL) avulsion fracture of the tibia is an uncommon but serious complication during primary cruciate-retaining total knee arthroplasty (TKA). The first objective of this report was to conduct a retrospective cohort study to investigate the incidence and potential risk factors of PCL avulsion fracture in primary cruciate-retaining TKA. The second objective was to assess the functional outcomes of the knee after reduction of PCL avulsion fracture. METHODS: From January 2014 to January 2016, 56 patients who experienced PCL avulsion fracture of the tibia in primary cruciate-retaining TKA were included in the study group. Patients in this group underwent reduction of avulsion fracture. In this period, we selected 224 patients (control group) for comparison. Patients in this group also underwent the same TKA, but no PCL avulsion fracture occurred. The range of motion of the knee and Knee Society Scores were assessed. The Forgotten Joint Score was used to analyze the ability to forget the joint. Differences were considered statistically significant at p < 0.05. RESULTS: In our series, the incidence of PCL avulsion fracture was 4.6%. There were no significant differences (p > 0.05) with regard to the preoperative or postoperative range of motion of the knee, final 4-year mean clinical score in the study and control groups 92.4 ± 2.7 and 93.6 ± 1.9, respectively, and mean functional scores of 85.1 ± 1.8 and 87.1 ± 1.2, respectively. CONCLUSIONS: The incidence of PCL avulsion fracture of the tibia is relatively high. Older age and female gender were the two risk factors of fracture in primary cruciate-retaining TKA. Reduction of PCL avulsion fracture with a high-strength line can achieve good stability and function of the knee.

Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents.

Although rare, tibial tubercle avulsion fracture must be considered in the differential diagnosis for the pediatric patient presenting with acute knee pain. In the adolescent population, tibial tubercle avulsion fracture is a rare injury that is typically seen in boys who engage in sporting activities that involve jumping or sprinting. The proximal tibial physis closes distally in the posteromedial to anterolateral direction, creating an environment that predisposes the tubercle to a potential avulsion injury. Historically, the Ogden classification has guided nonoperative and operative management of this condition. Multiple fracture fixation methods have been described with the overall goal of restoring the extensor mechanism and the joint surface.

Anterior Iliac Spine Avulsion Fracture Treatment Options in Young Athletes.

Purpose: The aim of this research is to perform a literature review of the treatments available for the anterior iliac spines avulsion fracture on the young subjects. Material and Methods: We performed a systematic literature search for studies on spines avulsion fractures in young subjects from January 1, 2013, to February 2018; abstracts were screened by a single reviewer. For those studies meeting the eligibility criteria, full-text articles were obtained. Results: From 112 studies found only six articles were included in this systematic review. All the studies belonged to level IV of scientific evidence. 64 patients suffered an anterior inferior iliac spine fracture while patients 36% patients suffered an anterior superior iliac spine fracture. 93.2% underwent conservative treatment and 6.8% underwent surgery. Conclusions: The anterior iliac spine avulsions fractures are rare injuries that occur in young male athletes and the conservative option is the most selected treatment modality.

Anterior inferior tibiofibular ligament avulsion fractures in operatively treated ankle fractures: a retrospective analysis.

BACKGROUND: There is no consensus about the optimal treatment of anterior inferior ligament avulsion fractures of the ankle. The aim of this study is to provide insights regarding the incidence of anterior inferior ligament avulsion fractures, the association with fracture type, and correlation with treatment. METHODS: This study is a retrospective analysis in a level-1 trauma center of adult patients with an ankle fracture operated between the dates 01-01-2009 and 01-09-2017 who had a pre- and postoperative CT-scan. Within the study population, the incidence of AITFL avulsion fracture was defined. Primary outcome was the type of avulsion fracture and related treatment. Secondary outcome was additional surgery in relation to the initial treatment. RESULTS: In total, 65 of 252 (25.8%) patients were diagnosed with an anterior inferior ligament avulsion fracture. Zero patients had a Wagstaffe type 1 fracture, 28 (43.1%) had a type 2, 32 (49.2%) had a type 3, and 5 (7.7%) had a type 4. There was a correlation between Wagstaffe type 2 and Weber B fractures, p < 0.0001, and Wagstaffe type 3 avulsions were correlated with a Weber C fracture, p < 0.0001. Thirty-five of the avulsed fragments (53.8%) were smaller than 5 mm. In 13 (20%) of patients with anterior inferior ligament avulsion fracture, the avulsed fragments were directly fixated during initial surgery. Size and direct fixation of the fragment were significantly correlated (p < 0.0001). Within the anterior inferior ligament avulsion fracture group, only a total of four patients (6.2%) underwent a revision. CONCLUSION: In the current study, an incidence of 25.8% of anterior inferior ligament avulsion fracture in surgically treated ankle fractures is reported. A correlation between the type of Wagstaffe injury and Weber classification was showed. Most fragments smaller than 5 mm were not fixated; however, not all injuries needed syndesmotic screws due to syndesmotic instability. LEVEL OF EVIDENCE: Level IV.

Lesiones en la lucha tradicional: el caso de la lucha leonesa (2005-2015) / Injuries in traditional wrestling: the leonese wrestling case study (2005-2015)

El objetivo de este estudio fue describir la localización anatómica, el tipo y la gravedad de las lesiones ocurridas en las competiciones oficiales de las ligas de verano masculinas (2005-2015) de Lucha Leonesa. Al objeto de realizar un análisis más profundo, se tuvo en cuenta, el perfil del luchador. Se produjeron un total de 401 lesiones, siendo los luchadores de mayor nivel los que menos número de lesiones sufrieron. Las contusiones fueron las lesiones más frecuentes (41,4%) pero entre las graves fueron los esguinces (42,3%). Los miembros inferiores fueron la localización más frecuente en el total de lesiones (38,2%) y entre las graves (45,4%). La rodilla, el tórax y el hombro acumulaban casi la mitad de las lesiones y el 68% de las lesiones graves. Los resultados obtenidos sugieren que las características de las lesiones que se pueden observar en la lucha leonesa son similares a las de otros deportes de combate

This study aimed at describing the anatomical location, type and severity of the sport injuries observed during the Leonese Wrestling "masculine summer leagues" official tournaments (2005-2015). The wrestler’s profile was taken into account as a way to achieve a deep analysis. A total of 401 injuries were registered. The best wrestlers were the ones that suffered the least number of injuries. Contusions were the type of injuries more frequently registered (41.4%), while sprains were the most common cause of severe injury (42.3%). The most frequent anatomical location affected and the one in which a great number of severe injuries occurred were the lower limbs (38.2% and 45.4%). The knee, thorax, and shoulder accounted for almost half of the total injuries and represented 68% of the severe injuries. The obtained results suggest that Leonese Wrestling show a similar injury pattern to the one observed in other combat sports

Epidemiology of injury in a non professional basketball club during a regular season: a prospective study / Epidemiología lesional en club de baloncesto no profesional durante una temporada regular: estudio prospectivo

Introduction: The knowledge about patterns of injury in non professional and adolescent basketball players is the base for prevention programs. While large series about injuries in professional basketball players have been published previously, little is known in non professional and young-in-training athletes. This study aims to describe the epidemiology of injuries, relate it with gender and type of activity in a non-professional basketball club over one season. Material and method: Two hundred and thirty players (Mean age: 17.3, SD 5.7 years, 73.9% males) were enrolled in a one season prospective study. An injury report form was used to systematically collect all data and was filled weekly by each player. Characteristics of injuries were described and its distribution by gender and type of activity. Incidence of injury is shown as number of injuries /1000 hours exposure. Results: Overall incidence was 3.86 injuries /1000h. The ankle (32.3%) was the most common location of injury and sprain (35.5%) the most frequent diagnosis, which was also seen in subgroups analysis. Mean time loss was 7.52 sessions (SD 11.28) Wrist injuries meant largest time loss (14.5 sessions, SD 13.43). Males showed higher incidence than females (4.16/1000h vs 3.04/1000h), who were more prone to fractures and upper extremity injuries. During competition, incidence of injury was 11.7 times higher than practices, and patterns of injury differed in each setting. Conclusion: Ankle sprain was the most common injury in our study. Wrist injuries meant the longest time loss. Males got injured more often than females. Injuries during competition were notably more frequent than during practice with different patterns of injuries

Introducción: Conocer los patrones de lesión en baloncesto es la base para desarrollar programas preventivos. Aunque se han publicado grandes series en jugadores profesionales, poco se conoce sobre jugadores en formación y no profesionales. El objetivo de este estudio es describir la epidemiología de las lesiones en un club de baloncesto no profesional durante una temporada, y relacionarla con el género y el tipo de actividad competitiva. Material y método: Doscientos treinta jugadores (edad media: 17,3, DS 5,7 años, 73,9% varones) se incluyeron en un estudio prospectivo a lo largo de una temporada. Un cuestionario sobre aparición de lesiones se utilizó para registrar los datos y se rellenó semanalmente por cada jugador. Se describieron las características de las lesiones y su distribución por género y tipo de actividad. La incidencia lesional se muestra como número de lesiones/1000 horas de exposición. Resultados: La incidencia global fue de 3,86 lesiones /1.000 h. El tobillo (32,3%) fue la localización más común y el esguince (35,5%) el diagnóstico más frecuente. Esto también se observó en los análisis de subgrupos. El tiempo medio de baja fue de 7,52 sesiones (DS 11,28). Las lesiones de la muñeca conllevaron tiempos de baja más prolongados (14,5 sesiones, DS 13,43). Los varones presentaron una incidencia mayor que las mujeres (4,16/1000h vs 3,04/1000h), las cuales mostraron mayor tendencia a sufrir fracturas y lesiones del miembro superior. La incidencia de lesión durante la competición fue 11,7 veces mayor que durante el entrenamiento, y los patrones de lesión diferían. Conclusión: El esguince de tobillo fue la lesión más frecuente en nuestro estudio. Las lesiones de muñeca supusieron mayores tiempos de baja. Los varones se lesionaron con más frecuencia que las mujeres. Las lesiones durante la competición fueron notablemente más frecuentes que durante el entrenamiento y presentaron diferente espectro

Apophyseal avulsion fractures of the pelvis. A review.

BACKGROUND AND AIM OF THE WORK: Fractures of the pelvis classically occur in adolescent during sports activities with forceful and repetitive contractions or passive lengthening acting on not yet ossified growth plates. Their misdiagnosis lead to disability, chronic pain and decrease of performances. Evidence based treatment guidelines do not exist; aim of this paper is to point out clinical outcomes, return to sport rates and complications of surgical and conservative approach. METHODS: A systematic search based on MEDLINE database was performed in August 2017 to identify all published articles from 2010 to 2017 reporting outcomes, return to sport and complications rates after surgical and non-operative treatment of avulsion fractures of the pelvis. RESULTS: Mean age was 14,5 years with anterior inferior iliac spine avulsion representing the most common injury (46%), followed by anterior superior iliac spine avulsion (32%), ischial tuberosity avulsion (12%) and iliac crest avulsion (11%). Rates of excellent outcome and return to sports at pre-injury levels were higher after surgical treatment; surgery has a higher risk of heterotopic ossification (9%) compared to conservative treatment (1,8%), whereas the risk of non-unions is lower (0% versus 2,5%). CONCLUSIONS: Surgery is preferred for major dislocations and fragment sizes, providing a faster return to pre-injury level of activity, decreasing the risk of pseudoarthrosis. Conservative treatment is advisable for minimally displaced fractures when a rapid recovery is not required; patient and his family should be informed on the risk of non-unions and the eventuality of a delayed surgical approach.

Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus.

BACKGROUND: Calcaneal insufficiency avulsion (CIA) fractures often present with neuropathic etiology, such as Charcot neuroarthropathy (CN). Under the same surgical procedures, the outcomes of CIA fractures are less desirable, compared to the outcomes of the traumatic calcaneal avulsion fractures. Here, the study suggests Achilles tenodesis technique using suture anchor after resection of the CIA fracture fragments could provide satisfactory clinical results in the cases of surgically indicated CIA fractures. MATERIALS AND METHODS: This retrospective study included seven patients of calcaneal avulsion fracture who had underlying diabetes mellitus (DM) and no specific traumatic event. The patients were treated with Achilles tenodesis techniques for their CIA fractures. Achilles tenodesis was performed using suture anchor with removal of the fracture fragments. The patients were evaluated with the Foot and Ankle Outcome Score (FAOS), visual analogue scale (VAS), single-heel rise test, and X-ray images on their final follow-ups. RESULTS: Initially, three of the CIA fracture cases treated with traditional open reduction and internal fixation reported pullout failure. Consequently, all patients received Achilles tenodesis using suture anchor after bone fragment resection and had good clinical outcomes. Only one subject with low compliance reported poor outcome. The FAOS of each patient were obtained at a mean of 16.3 months after surgery. The results are as follows: pain 80.6 (SD = 6.2), symptom 83.8 (SD = 4.9), activities of daily living 80.5 (SD = 8.0), sport and recreation function 75.6 (SD = 11.93), and foot- and ankle-related quality of life 77.9 (SD = 6.7). On their final follow-ups, the average VAS was 2.6 (range, 1 to 4). CONCLUSION: Achilles tenodesis using suture anchor after bone fragment resection achieved competent clinical results in the patients with CIA fractures. The study proposes that this surgical procedure could be an appropriate treatment option for patients with CIA fractures. TRIAL REGISTRATION: The study was approved by the institutional review board (IRB) of our medical center (IRB File No. 2016-07-043), retrospectively registered.

High prevalence of all complex Segond avulsion using ultrasound imaging.

PURPOSE: The aim of this study was to determine the prevalence of a Segond avulsion fractures in acute ACL tears with ultrasound and to investigate whether other injuries can predict the avulsion. MATERIALS AND METHODS: One hundred thirty-eight ultrasound analyses of acute knee trauma were collected and scored for diagnosed injuries. The reports of patients with an ACL tear (N = 87) were evaluated to determine possible increased prevalence of Segond avulsion fracture with ultrasound. The associations between the diagnosed injuries and presence of a Segond avulsion were scored. The sports carried out at the time of injury were evaluated as possible prognostic factor. RESULTS: In 25/87 (29%) of the patients with an ACL tear, a Segond avulsion was observed in ultrasound. Lateral femoral condyle (LFC) impaction showed the strongest individual association with a Segond avulsion and was the best predicting variable. LFC impaction, sustained during low-risk pivoting sport, shows a stronger association with a Segond avulsion, as compared to LFC impaction sustained during high-risk pivoting sports. CONCLUSION: Ultrasound shows a higher prevalence of Segond avulsions as literature shows with MRI or radiography. LFC impaction is the best variable in predicting this type of avulsion. Ultrasound examination should be considered, if this fracture was not diagnosed with MRI or radiographic analysis. LEVEL OF EVIDENCE: IV.

[Acute tibial tubercle avulsion fractures]. / Avulsionsverletzungen der proximalen Tibia.

BACKGROUND: The tear-off of the apophysis of the proximal tibia is a rare injury (< 1 % of all apophysal lesions). It mainly affects male adolescents (14,6 years). Main causes are concentric and eccentric stress during sport activity. Morbus Osgood-Schlater seems to be a predisposing factor. AIM: Up-to-date survey of pathogenesis, diagnostics and treatment strategies. MATERIAL AND METHODS: Literature research (level III and IV studies) as well as own results. RESULTS: The affected patients are mostly male (97 %), type III fractures are most frequently seen (48 %). Accompanying injuries are not to be missed (10 %). The treatment usually consists of surgery by means of an open reposition and internal refixation, recently also minimal invasi. The results are mainly very good to good, approximately 95 % reach their old level of activity again. Almost one third of the patients develop a mostly slight complication. CONCLUSION: The acute tear-off of the apophysis of the proximal tibia is an infrequent disease. In dislocated injuries the standard procedure is the open reposition and the internal fixation. Lesions within the knee are particularly to be expected in intraarticular fractures und must not be missed. A very good to good result is to be expected with correct treatment, momentous complications are all together rare.

[Apophyseal Avulsions of the Hip Region in Adolescents]. / Avulsionsverletzungen der Hüftregion des Jugendlichen.

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.