Transiliac-Shortening Osteotomy to Treat Ischial Pressure Injury due to Fixed Pelvic Obliquity: A Case Report.

CASE: A 17-year-old adolescent boy with Gross Motor Function Classification System 5 cerebral palsy and neuromuscular scoliosis underwent posterior spinal fusion and segmental spinal instrumentation from T3 to the pelvis. He developed a right ischial pressure injury a few months postoperatively, which persisted despite nonoperative measures. He subsequently underwent an ipsilateral transiliac-shortening osteotomy 16 months after spinal surgery to treat his residual pelvic obliquity and the ischial pressure injury, which healed completely. At the 1-year follow-up visit, there were no further signs of pressure injury. CONCLUSION: This case report describes transiliac-shortening osteotomy as a viable treatment option for non-healing ischial pressure injuries secondary to fixed pelvic obliquity.

Outcomes following adolescent athlete proximal hamstring apophyseal avulsion bone fragment excision and direct tendon-ischial tuberosity reattachment.

Apophyseal proximal hamstring bone avulsion is uncommon, occurring in adolescents following sudden forceful contraction of the musculotendinous unit. It can be severely disabling, preventing return to sport. This study assessed outcome following avulsed bone excision and direct hamstring tendon-ischial tuberosity reattachment using bone anchors. Validated hamstring-specific Sydney hamstring orthopaedic research evaluation PROMs were prospectively collected from consecutively treated athletes (7 elite and 11 recreational) by a single surgeon over 13 years. Outcomes at 1-year and final follow-up for primary acute surgery at less than 3 months after injury (group 1), primary chronic surgery at more than 3 months after established nonunion (group 2) and revision following failed screw fixation (group 3) were analyzed with sport participation and level at 1 year. Sixteen primary and two revision procedures were analyzed. Mean injury age was 14.6 years (SD, 1.8). Combined primary mean injury scores improved from 11.89 (SD, 7.32) to 33.31 (SD, 2.30) and showed mean 1 year and final follow-up scores within 0.3-6.1% of preinjury values. Pronounced improvement occurred from injured scores for groups 1 versus 2, respectively at 1 year by 247.7% versus 59.0% and at final follow-up by 251.0% versus 64.1%, for groups 1 versus 2, respectively. Final outcome scores of group 3 were high. All cases returned to preinjury sport level by 1 year and indicated satisfaction to repeat treatment. No significant complications occurred. As the largest series to assess outcomes following this surgical technique, success is highlighted by high score improvements close to preinjury values and return to preinjury sport level.

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.

Avulsion fractures of the ischial tuberosity in the pediatric athlete: a systematic review and return to sport analysis.

Apophyseal avulsion fractures of the ischial tuberosity (AFIT) in pediatric athletes are relatively uncommon injuries with treatment and return to sport (RTS) outcomes being largely unknown. The purpose of this review is to perform a systematic review analyzing RTS and predictors of successful RTS for pediatric athletes sustaining AFIT. Studies reporting on athletes strictly under the age of 18 years sustaining an AFIT with reported RTS status were included. RTS was analyzed based on injury acuity, mechanism, and management, whereas the incidence of any complications was recorded. A total of 33 studies comprising 90 cases of AFIT were identified. The mean age of athletes sustaining injuries was 14.7 + 1.4 years (range, 9-17 years), most commonly participating in soccer ( n = 25), sprinting ( n = 21), and gymnastics ( n = 7). Acute trauma during sporting activities was responsible for 74.4% ( n = 77/90) of injuries. A total of 82% ( n = 74/90) of athletes reported successful RTS at an average of 7.0 + 5.0 months. Athletes undergoing surgery had a significantly higher RTS rate ( n = 36/38, 94.7%) compared with athletes treated nonoperatively (n = 38/52, 73.08%; P = 0.008). When reported, a high rate of misdiagnosis was reported (39.4%, n = 28/71). Complications were reported in 15.8% ( n = 7/38) and 32.7% ( n = 17/52) of athletes managed surgically and conservatively, respectively. As such, the high rate of misdiagnosis and subsequent high rate of complications and poor rate of RTS highlight the importance of accurate diagnosis and treatment. Future prospective studies evaluating patient outcomes based on fracture displacement, sporting activity, and management strategies are warranted to better treat pediatric athletes. Study design: Level IV, systematic review.

[Apophyseal avulsion in the pelvic region in childhood and adolescence]. / Apophysenausrisse in der Beckenregion im Kindes- und Adoleszentenalter.

BACKGROUND: The importance of the apophyseal plates during growth is often underestimated. They act as a muscular insertion and influence the joint mechanics by the load-dependent change in shape. PATHOMECHANISMS: An anatomically functional adaptation occurs as protection from overloading. In special kinds of sports with highly dynamic movements, sudden changes of direction and eccentric/concentric muscle activities the resulting stress may exceed the strength of the apophyseal plate. In adolescence this results in a total or partial tearing of the apophysis in the sense of an avulsion injury. In the pelvic region the ischial tuberosity, the anterior superior and inferior iliac spine are mainly affected. DIAGNOSTICS: The medical history and clinical diagnostics are supplemented by conventional radiographic imaging. Sectional imaging diagnostics are usually unnecessary. TREATMENT: Conservative management by reduced (partial) weight bearing and physiotherapy represents the gold standard in treatment. In cases with a fragment displacement >1.5-2.0 cm and in competitive athletes an open reduction should be considered.

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.

Pelvic Avulsion Injuries in the Adolescent Athlete.

Pelvic avulsion fractures are common in youth athletes; many of these injuries can be treated conservatively. This article reviews the etiology, presentation, and management of the more common pelvic avulsion fractures, including anterior superior iliac spine, anterior inferior iliac spine, ischial tuberosity, and iliac crest avulsions. Adolescent pelvic avulsion fractures rely on the amount of fracture displacement to guide treatment. Conservative management includes rest and avoiding use of the muscle(s) that attach to the avulsed fragment. Operative treatment is reserved for widely displaced fractures or symptomatic nonunions. With appropriate treatment, young athletes frequently return to their same level of sport.

Traumatic Obturator Internus and Quadratus Femoris Injury in a Pediatric Patient: A Case Report.

We present the case of a 11-year-old White female patient with a traumatic quadratus femoris and obturator internus tear after a sprint while at school. She felt immediate pain, swelling, and point tenderness in her posterosuperior thigh with a severely antalgic gait. Magnetic resonance imaging demonstrated a quadratus femoris tear, obturator internus tear, and ischial spine avulsion fracture. Although a less common etiology for acute hip pain in the pediatric population, traumatic injury to the short external rotators should not be excluded. The prognosis is favorable with a full return to previous activities expected using an appropriate rehabilitation program.

Management and retrospective analysis of pelvic ramus tumors and tumor-like lesions: Evaluation with 31 cases.

OBJECTIVES: This study aims to investigate the characterization, treatment approaches, and follow-up results of tumors and tumor-like lesions located in the pelvic ramus. PATIENTS AND METHODS: Thirty-one patients (9 males, 22 females; mean age 48.9 years; range, 7 to 79 years) with benign and malignant tumors or tumor-like lesions in the pelvic ramus region treated and followed-up in our clinic between January 2005 and January 2019 were evaluated retrospectively. Surgical procedures were performed with anterior approach or inner-thigh approach. Twelve patients were diagnosed with malignant tumors, 12 patients with benign tumors, and seven patients with tumor-like lesions. RESULTS: Seventeen patients who underwent surgical treatment were followed-up for a mean period of 61.7 months. The diameters of benign and malignant tumors were similar (p=0.425). Of all lesions, 64.5% were located in the pubis. Ischium location was significantly higher in patients with malignant lesions than tumor-like lesions. The most common complication was diffuse subcutaneous edema in the inguinal region and thigh (8.3%). CONCLUSION: There are many different tumoral lesions in the pelvic ramus. Pelvic ramus tumors tend to settle more frequently in pubic ramus, whereas ramus ischium tumors are more likely to be malignant. In addition, the diagnosis of insufficiency fracture should be considered primarily in pathologic fractures of pubic ramus in females over 50 years of age. In the postoperative follow-up of pelvic ramus tumors, diffuse edema may occur even if there is no intraoperative vascular damage.

[A boy with acute pain in his right buttock]. / Een jongen met acute pijn in de bil.

A 14-year-old boy presented to the emergency department with pain in his right buttock after a breakdance move. He got injured while simultaneously hyperflexing his hip and extending his knee. Upon physical examination he had tenderness over his right ischial tuberosity and an inability to perform combined hip extension and knee flexion. Radiography and CT-imaging showed an avulsion fracture of the ischial tuberosity.

Delayed-Union of Acetabular Stress Fracture in Female Gymnast: Use of Teriparatide to Augment Healing.

Pelvic stress fractures are rare and present unique challenges for medical personnel. Delayed healing can lead to increased physical, psychological, and social stress for athletes. Recent literature suggests effective use of a synthetic derivative of parathyroid hormone, teriparatide, to augment healing of delayed-union stress fractures. We present a case of a female National Collegiate Athletic Association Division I gymnast successfully returned to play after a 12-week course of teriparatide injections for an ischioacetabular stress fracture.

Chronic ischial tuberosity avulsion nonunion fracture treated with a platelet-rich plasma injection as a bone graft.

We present a case of an 18-year-old with a 2-year history of buttock pain who failed extensive treatment for a perceived hamstring strain. Upon evaluation, he was diagnosed with an ischial tuberosity nonunion avulsion fracture. The patient underwent bone grafting via an ultrasound guided leukocyte rich platelet-rich plasma injection followed by the use of a bone stimulator to enhance the bone healing. At 3 months, he was asymptomatic and had radiographic evidence of excellent bone healing. He remained asymptomatic at 1 year and had resumed full activities. This case report is the first in the literature to describe the treatment of a chronic ischial tuberosity nonunion avulsion fracture with the use of platelet-rich plasma as a bone graft.

Surgical treatment for acute ischial tuberosity avulsion fracture: A case report.

RATIONALE: Ischial tuberosity avulsion fracture (ITAF) is a very rare sports injury, and there is currently no consensus on its diagnosis and treatment. Although conservative treatment is adequate for most patients, those with large displacement of the fracture need surgical management. PATIENT CONCERNS: A 13-year-old male athlete experienced tearing pain in the right hip during a sprint. Radiographic examination showed an avulsion fracture of the right ischial tuberosity. DIAGNOSIS: Right ITAF. INTERVENTIONS: On the 3rd day of injury, the patient was treated with open reduction and internal fixation of ITAF under general anesthesia. OUTCOMES: The patient received a systematic postoperative exercise in 2 weeks, and the fracture healed 4 weeks later. After 8 months, the patient returned to the field to participate in the competition. LESSONS: Early surgical treatment can bring about good results in the treatment of ITAF with large displacement. The longitudinal incision and subgluteal approach is an ideal choice for the operative procedure.

Ischial tuberosity avulsion fracture nonunions in the adolescent population treated with a posterior column screw: A case series of two patients.

Various surgical techniques exist to approach an ischial tuberosity avulsion fracture, including open reduction and internal fixation with screws and suture anchors, augmentation with allograft tendon, and excision of the fragment. However, the majority of these techniques approached acute fractures, and nonunions were not addressed nor studied. This case series describes two adolescent patients treated for ischial tuberosity nonunions with a posterior column screw through a subgluteal approach. Both patients demonstrated radiographic healing of their nonunion sites at 6 months' follow-up. Each patient reported no pain during activity, had symmetric hamstring strength, and were able to return to pre-injury level of activity by final follow-up. In conclusion, the authors utilized a muscle-sparing approach to the ischial tuberosity nonunion site through a cosmetically appealing incision and introduced a novel approach to nonunion fixation without the use of bone graft, resulting in excellent clinical outcomes.

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.

Ischial Tuberosity Avulsion Fracture in a Young Female Ballet Dancer.

A 14-year-old female ballet dancer sustained an injury during a routine ballet movement that was diagnosed as an ischial tuberosity avulsion fracture. This diagnosis was complicated by extensive soft tissue injury to the hamstrings, adductors, and external rotator musculature. Although uncommon, the potential for this injury should be uniformly considered in adolescent dancers due to the unique stresses in ballet training and the added risk of growth spurts during this stage of development. Prevention targeting individual deficiencies in flexibility and strength is essential to avoid similar devastating injuries. In most cases that are diagnosed early, avulsions heal with conservative treatment. Early imaging and correct diagnosis can serve to guide clinical management and prevent unnecessary surgery in the young dancer.

Evaluation of Pain in the Cognitively Impaired Patient in the Emergency Department.

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and the emergency nurse, and to assist with the translation of research into practice. For each column, a topic and a research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. In the current column, we examine the findings of A. from their article titled "An Iceberg Phenomenon in Dementia: Pain."

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.

Comportamiento de la fuerza isométrica máxima durante la aplicación de vendaje neuromuscular en acortamiento de isquiotibiales: un ensayo clínico aleatorizado / Maximum isometric strength during kinesiotape in shortening hamstrings: a randomized clinical trial

Objetivo: Analizar la fuerza isométrica máxima de los isquiotibiales durante 3 días de aplicación de vendaje neuromuscular o kinesiotape en adultos jóvenes con acortamiento, utilizando una técnica muscular inhibitoria comparado con un grupo control. Material y métodos: Fueron reclutados 54 jóvenes con acortamiento de isquiotibiales evaluados con el test de extensión activa de rodilla, 4 fueron perdidos en el seguimiento. Los sujetos fueron divididos a través de aleatorización simple, en grupo experimental (GE: 29; 20,8 [±1,53] años) y grupo control (GC: 21; 20,0 [±1,70] años). Al GE se le aplicó una técnica en «X» inhibitoria de vendaje neuromuscular en isquiotibiales. Se midió la fuerza isométrica máxima (FIM) de flexores de rodilla: basal, 24 h, 48 h y 72 h. Para el GE se consideró la evaluación 30 min. Se utilizó ANOVA de medidas repetidas. Resultados: GE mostró una disminución inmediata de la FIM del 12,5% a los 30 min (p<0,05), con un posterior aumento del 12,1%, entre los 30 min y las 24 h, de la aplicación (p<0,05). Entre las 24-48 h se produjo una disminución de la FIM del 8,4% (p<0,05). A las 72 h no se presentan cambios. El GC no presentó cambios. Al comparar la FIM entre ambos grupos, el GC presentó mayores valores de FIM (p<0,05) en todos los tiempos de evaluación. Conclusión: La aplicación de vendaje neuromuscular por 72 h en sujetos con acortamiento de isquiotibiales, genera una variación en el comportamiento de la FIM con diferencias estadísticamente significativas a los 30 min (disminuye), 24 h (aumenta) y 48 h (disminuye)

Objective: To analyze the hamstrings maximal isometric strength (MIS) during 3 days of kinesiotape application in young adults with shortening of these muscles, using a muscular inhibitory technique compared to a control group. Material and methods: 54 young people with hamstring shortening were recruited and evaluated with the active knee extension test. Subjects were divided by simple randomization in a experimental group (EG: 29;20.8 [±1,53] years) and a control group (CG: 21;20[±1.73] years). In EG was applied a ‘X’ kinesiotape inhibitory technique in hamstrings. Measures of the hamstrings MIS were taken in basal conditions (Pi), at 30 minutes of kinesiotape application (P30), at 24 hours (P24), at 48 hours (P48) and at 72 hours (P72). Repeated measures ANOVA was used to analyze data. Results: GE showed an immediate 12.5% decreased in Pi MIS (p<0.05), following with a 12.1% increased between P30 and P24 measures (p<0.05) and a 8.4% decreased between P24 and P48 (p<0.05). Not significant changes were observed between P48 and P72. CG did not present any changes in MIS values. Intergroup comparisons showed higher values of MIS (p<0.05) for the CG at any time of the evaluation. Conclusion: A 72 hours application of kinesiotape in subjects with hamstring shortening generates changes in the MIS behaviour with statically significant differences at 30 minutes (decreases), 24 hours (increases) and 48 hours (decreases)