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Lesser Trochanter Avulsion Fracture in an Adolescent after Seizure
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2016.06.007
Clinical Communications: Pediatrics LESSER TROCHANTER AVULSION FRACTURE IN AN ADOLESCENT AFTER SEIZURE Tristan McMillan, MBCHB, MRCS, Haroon Rehman, MBCHB, MRCS, and Martin Mitchell, MBCHB, FRCS (T&O) Aberdeen Royal Infirmary, Aberdeen, UK Reprint Address: Haroon Rehman, MBCHB, MRCS, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
, Abstract—Background: Injury secondary to epileptic seizure is widely documented in the literature. In particular, uncontrolled muscular contractions generated during a seizure can lead to a variety of musculoskeletal injuries. Case Report: We present the case of a 16-year-old male who presented on two separate occasions after a tonic clonic seizure with hip pain, an antalgic gait, and marked discomfort on hip flexion. Radiologic investigation revealed an acute isolated fracture of the lesser trochanters. Such fractures in adolescents are normally secondary to athletic injury and in adults are mainly associated with the presence of metastatic bone disease. Why Should an Emergency Physician Be Aware of This?: We present this case with its previously undocumented mechanism to highlight the injury to frontline emergency medical teams, create awareness of its presentation, and to discuss its potential mechanism and treatment. Ó 2016 Elsevier Inc. All rights reserved.
tions are also common, accounting for 17% of serious injuries secondary to seizure (2). Unilateral or bilateral posterior dislocations of the glenohumeral joints are commonly associated with epileptic seizure and are caused by a rapid, powerful, and unbalanced muscle contraction (3). We describe an unusual case of nonsimultaneous, bilateral, lesser trochanter avulsion fractures after separate epileptic seizures. We provide discussion on mechanism of injury and management. CASE REPORT The patient was an otherwise fit and active 16-year-old male with known epilepsy. He presented to the emergency department in February 2013 with right hip and groin pain after a tonic clonic seizure. He had a medical history of frontal lobe epilepsy, for which he was on a titrated dose of lamotrigine, with good control apart from occasional nocturnal events. He had normal childhood and skeletal development and no personal or family history of hip disease. On this particular occasion, his witnessed seizure occurred overnight. In the postictal period, he complained of severe right groin pain, unable to flex his hip or bear weight comfortably. He denied any prior symptoms or history of previous injury within the hip region. On examination, his gait was antalgic and there was tenderness over the medial aspect of his right hip. He was unable to flex or straight leg raise. The x-ray study
, Keywords—lesser trochanter; fracture; avulsion fracture; seizure injury
INTRODUCTION Patients who have epileptic seizures are at an increased risk of sustaining accidental injuries, including burns, contusions, and head injury (1). Fractures and disloca-
The patient gave informed consent for the publication of the case study.
RECEIVED: 20 February 2016; FINAL SUBMISSION RECEIVED: 28 May 2016; ACCEPTED: 2 June 2016 1
2
T. McMillan et al.
Figure 1. X-ray study on presentation demonstrating fracture of right lesser trochanter and intact left lesser trochanter.
showed a lesser trochanter avulsion fracture of the right hip (Figure 1). He was managed nonoperatively with rest, analgesia, followed by mobilization and weightbearing as able, and physiotherapy. In October 2013, the patient was attending the orthopedic clinic for follow-up of an unrelated injury and complained of new onset of left hip pain after another witnessed nocturnal seizure 1 month previously. X-ray studies confirmed a fracture of the left lesser trochanter with proximal migration of the fracture fragment (Figure 2). At 12 months post injury, the patient reported no functional deficit, was pain free, and had returned to his pre-injury functional level after conservative management.
DISCUSSION Lesser trochanter avulsion fracture is a rare injury in adolescents. The injury is well documented for the adult population and is considered highly suspicious for metastatic disease (4). There is a paucity of literature on lesser trochanter avulsion injuries in adolescents, with much of the literature existing is in the form of commentary. We present a successfully managed case of bilateral, lesser trochanter avulsion fractures in a 16-year-old male after an unusual mechanism of injury that has not been documented previously in the literature. No alternative cause for his injuries was identified during clinical assessment. Our patient was able to return to his pre-injury levels of activity with nonoperative management. To the extent
Figure 2. X-ray study on review, demonstrating fracture of the left lesser trochanter, with proximal migration of the fragment.
Avulsion Fracture Secondary to Epileptic Seizure
of our knowledge, no such case report has been published previously. In adolescents, lesser trochanter fractures have been described in young athletes (5). The lesser trochanter serves as the site of attachment for the powerful iliopsoas complex. Iliopsoas strains are usually localized near its insertion on the lesser trochanter (6). It is recognized that avulsion injuries represent the extreme on a continuum of these injuries. The iliac crest, antero-superior iliac spine, antero-inferior iliac spine, ischial tuberosity, greater trochanter, and lesser trochanter are the sites most frequently implicated in apophyseal or avulsion injuries in young runners (7). Although uncommon, lesser trochanter avulsions have been described in sprinters or jumpers during vigorous hip flexion (8). Lesser trochanter avulsions have also been documented after chronic microtrauma or overuse during sporting activities, such as ballet (9,10). It is important to exclude alternative pathologies if there is any doubt about underlying diagnosis. Our case involved two separate acute injuries as a presumed consequence of seizures. The forces generated by the powerful iliopsoas complex have been sufficient to overcome the ultimate tensile strength of the apophysis and, ultimately, an avulsion fracture has occurred. Although lesser trochanter fracture through forceful psoas muscle contraction is a recognized injury mechanism, lesser trochanter fractures are not typically associated with epilepsy (11,12). Electrocution and electroconvulsive therapy can cause injury patterns similar to those observed with epileptic seizures. While no cases have so far been documented, it is possible that these insults could cause hip injury through the mechanism described. In this case, the diagnosis was made based with standard x-ray images in the absence of clinical features suggestive of malignancy. The clinical team did not think additional imaging would contribute any more information. The association of neoplasm with these injuries in adult patients warrants further evaluation with computed tomography (CT) or magnetic resonance imaging (MRI), especially in those patients presenting with a nontraumatic fracture. In young patients with a clear mechanism of injury and obvious diagnosis on plain xray images, we do not recommend further radiation exposure using CT. Where the diagnosis is equivocal, MRI could be considered. We chose to manage this patient nonoperatively and achieved full, pain-free recovery. Our management strategy is supported by the current literature on these injuries (13,14). Symptomatic treatment involved analgesic medication and crutches initially, followed by range of motion and strengthening exercises overseen by the physiotherapists. Function is likely to be maintained through the compensatory actions of the nonaffected
3
hip flexors. Currently, we are not aware of any indications for operative intervention for isolated and uncomplicated avulsion fractures of the lesser trochanter due to the good conservative outcomes and the risk of damage to nearby neurovascular structures, including anterior division of the obturator nerve and medially the femoral vessels and nerves. The only literature that currently supports operative intervention in the acute treatment is a 3-patient case series of arthroscopically assisted fixation of the lesser trochanter fracture by Khemka et al. (15). Chronic pain after lesser trochanter avulsion has been described in a single case report, with complete resolution after excision of a loose fragment (10). Additionally, a review by McKinney and colleagues recommends that small symptomatic nonunions and painful exostosis should be treated operatively with excision and muscle reattachment (16). The successful management of these patients requires a multidisciplinary approach. Input should be sought from neurology to advise on control of seizures. Preventing further seizures will prevent other injuries from occurring and reduce the risk of any resultant long-term morbidity. Consultation with orthopedics will be necessary to aid in the diagnosis and to plan the management and appropriate follow-up. Early consultation with physiotherapy should also be arranged to ensure that early range of motion exercises, followed by the introduction of strengthening and proprioceptive exercises. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case raises the importance of a thorough assessment for seizure-related injuries and that clinicians should consider the possibility of this rare injury when assessing young patients with hip or groin pain after an epileptic seizure or electrocution. It is important to consider the possibility of alternate diagnoses and, if any concern exists about the possibility of pathologic fractures, there should be an early consultation with orthopedics to discuss the potential need for additional cross-sectional imaging, such as CT or MRI. In our experience, nonoperative symptomatic treatment provides excellent outcomes in the acute setting, with a return to pre-injury activity levels seen in this patient. We recommend that patients be followed up to assess for chronic pain or a symptomatic nonunion that would potentially merit surgical intervention. REFERENCES 1. Wirrell EC. Epilepsy-related injuries. Epilepsia 2006;47(Suppl. 1): 79–86.
4 2. Neufeld M, Vishne T, Chistik V, Korczyn A. Life-long history of injuries related to seizures. Epilepsy Res 1999;34:123–7. 3. Lasanianos N, Mouzopoulos G. An undiagnosed bilateral anterior shoulder dislocation after a seizure: a case report. Cases J 2008;1:342. 4. Phillips CD, Pope TL Jr, Jones JE, Keats TE, MacMillan RH III. Nontraumatic avulsion of the lesser trochanter: a pathognomonic sign of metastatic disease? Skeletal Radiol 1988;17:106–10. 5. Papacostas NC, Bowe CT, Shaffer Strout TD. Lesser trochanter avulsion fracture. J Emerg Med 2013;45:256–7. 6. Renstrom PA. Tendon and muscle injuries in the groin area. Clin Sports Med 1992;11:815–31. 7. Kneeland JB. MR imaging of sports injuries of the hip. Magn Reson Imaging Clin N Am 1999;7:105–15. viii. 8. Paluska SA. An overview of hip injuries in running. Sports Med 2005;35:991–1014. 9. Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, Chow S. Imaging features of avulsion injuries 1. Radiographics 1999;19: 655–72.
T. McMillan et al. 10. Quarrier NF, Wightman AB. A ballet dancer with chronic hip pain due to a lesser trochanter bony avulsion: the challenge of a differential diagnosis. J Orthop Sports Phys Ther 1998;28: 168–73. 11. Theologis T, Epps H, Latz K, Cole W. Isolated fractures of the lesser trochanter in children. Injury 1997;28:363–4. 12. Poston H. Traction fracture of the lesser trochanter of the femur. Br J Surg 1921;9:256–8. 13. Rockwood CA, Green DP, Bucholz RW, Heckman JD. Rockwood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. 14. Zuckerman JD. Comprehensive Care of Orthopaedic Injuries in the Elderly. Vienna: Urban & Schwarzenberg; 1990. 15. Khemka A, Raz G, Bosley B, Ludger G, Al Muderis M. Arthroscopically assisted fixation of the lesser trochanter fracture: a case series. J Hip Preserv Surg 2014;1:27–32. 16. McKinney BI, Nelson C, Carrion W. Apophyseal avulsion fractures of the hip and pelvis. Orthopedics 2009;32:42.
http://dx.doi.org/10.1016/j.jemermed.2016.06.007
Clinical Communications: Pediatrics LESSER TROCHANTER AVULSION FRACTURE IN AN ADOLESCENT AFTER SEIZURE Tristan McMillan, MBCHB, MRCS, Haroon Rehman, MBCHB, MRCS, and Martin Mitchell, MBCHB, FRCS (T&O) Aberdeen Royal Infirmary, Aberdeen, UK Reprint Address: Haroon Rehman, MBCHB, MRCS, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
, Abstract—Background: Injury secondary to epileptic seizure is widely documented in the literature. In particular, uncontrolled muscular contractions generated during a seizure can lead to a variety of musculoskeletal injuries. Case Report: We present the case of a 16-year-old male who presented on two separate occasions after a tonic clonic seizure with hip pain, an antalgic gait, and marked discomfort on hip flexion. Radiologic investigation revealed an acute isolated fracture of the lesser trochanters. Such fractures in adolescents are normally secondary to athletic injury and in adults are mainly associated with the presence of metastatic bone disease. Why Should an Emergency Physician Be Aware of This?: We present this case with its previously undocumented mechanism to highlight the injury to frontline emergency medical teams, create awareness of its presentation, and to discuss its potential mechanism and treatment. Ó 2016 Elsevier Inc. All rights reserved.
tions are also common, accounting for 17% of serious injuries secondary to seizure (2). Unilateral or bilateral posterior dislocations of the glenohumeral joints are commonly associated with epileptic seizure and are caused by a rapid, powerful, and unbalanced muscle contraction (3). We describe an unusual case of nonsimultaneous, bilateral, lesser trochanter avulsion fractures after separate epileptic seizures. We provide discussion on mechanism of injury and management. CASE REPORT The patient was an otherwise fit and active 16-year-old male with known epilepsy. He presented to the emergency department in February 2013 with right hip and groin pain after a tonic clonic seizure. He had a medical history of frontal lobe epilepsy, for which he was on a titrated dose of lamotrigine, with good control apart from occasional nocturnal events. He had normal childhood and skeletal development and no personal or family history of hip disease. On this particular occasion, his witnessed seizure occurred overnight. In the postictal period, he complained of severe right groin pain, unable to flex his hip or bear weight comfortably. He denied any prior symptoms or history of previous injury within the hip region. On examination, his gait was antalgic and there was tenderness over the medial aspect of his right hip. He was unable to flex or straight leg raise. The x-ray study
, Keywords—lesser trochanter; fracture; avulsion fracture; seizure injury
INTRODUCTION Patients who have epileptic seizures are at an increased risk of sustaining accidental injuries, including burns, contusions, and head injury (1). Fractures and disloca-
The patient gave informed consent for the publication of the case study.
RECEIVED: 20 February 2016; FINAL SUBMISSION RECEIVED: 28 May 2016; ACCEPTED: 2 June 2016 1
2
T. McMillan et al.
Figure 1. X-ray study on presentation demonstrating fracture of right lesser trochanter and intact left lesser trochanter.
showed a lesser trochanter avulsion fracture of the right hip (Figure 1). He was managed nonoperatively with rest, analgesia, followed by mobilization and weightbearing as able, and physiotherapy. In October 2013, the patient was attending the orthopedic clinic for follow-up of an unrelated injury and complained of new onset of left hip pain after another witnessed nocturnal seizure 1 month previously. X-ray studies confirmed a fracture of the left lesser trochanter with proximal migration of the fracture fragment (Figure 2). At 12 months post injury, the patient reported no functional deficit, was pain free, and had returned to his pre-injury functional level after conservative management.
DISCUSSION Lesser trochanter avulsion fracture is a rare injury in adolescents. The injury is well documented for the adult population and is considered highly suspicious for metastatic disease (4). There is a paucity of literature on lesser trochanter avulsion injuries in adolescents, with much of the literature existing is in the form of commentary. We present a successfully managed case of bilateral, lesser trochanter avulsion fractures in a 16-year-old male after an unusual mechanism of injury that has not been documented previously in the literature. No alternative cause for his injuries was identified during clinical assessment. Our patient was able to return to his pre-injury levels of activity with nonoperative management. To the extent
Figure 2. X-ray study on review, demonstrating fracture of the left lesser trochanter, with proximal migration of the fragment.
Avulsion Fracture Secondary to Epileptic Seizure
of our knowledge, no such case report has been published previously. In adolescents, lesser trochanter fractures have been described in young athletes (5). The lesser trochanter serves as the site of attachment for the powerful iliopsoas complex. Iliopsoas strains are usually localized near its insertion on the lesser trochanter (6). It is recognized that avulsion injuries represent the extreme on a continuum of these injuries. The iliac crest, antero-superior iliac spine, antero-inferior iliac spine, ischial tuberosity, greater trochanter, and lesser trochanter are the sites most frequently implicated in apophyseal or avulsion injuries in young runners (7). Although uncommon, lesser trochanter avulsions have been described in sprinters or jumpers during vigorous hip flexion (8). Lesser trochanter avulsions have also been documented after chronic microtrauma or overuse during sporting activities, such as ballet (9,10). It is important to exclude alternative pathologies if there is any doubt about underlying diagnosis. Our case involved two separate acute injuries as a presumed consequence of seizures. The forces generated by the powerful iliopsoas complex have been sufficient to overcome the ultimate tensile strength of the apophysis and, ultimately, an avulsion fracture has occurred. Although lesser trochanter fracture through forceful psoas muscle contraction is a recognized injury mechanism, lesser trochanter fractures are not typically associated with epilepsy (11,12). Electrocution and electroconvulsive therapy can cause injury patterns similar to those observed with epileptic seizures. While no cases have so far been documented, it is possible that these insults could cause hip injury through the mechanism described. In this case, the diagnosis was made based with standard x-ray images in the absence of clinical features suggestive of malignancy. The clinical team did not think additional imaging would contribute any more information. The association of neoplasm with these injuries in adult patients warrants further evaluation with computed tomography (CT) or magnetic resonance imaging (MRI), especially in those patients presenting with a nontraumatic fracture. In young patients with a clear mechanism of injury and obvious diagnosis on plain xray images, we do not recommend further radiation exposure using CT. Where the diagnosis is equivocal, MRI could be considered. We chose to manage this patient nonoperatively and achieved full, pain-free recovery. Our management strategy is supported by the current literature on these injuries (13,14). Symptomatic treatment involved analgesic medication and crutches initially, followed by range of motion and strengthening exercises overseen by the physiotherapists. Function is likely to be maintained through the compensatory actions of the nonaffected
3
hip flexors. Currently, we are not aware of any indications for operative intervention for isolated and uncomplicated avulsion fractures of the lesser trochanter due to the good conservative outcomes and the risk of damage to nearby neurovascular structures, including anterior division of the obturator nerve and medially the femoral vessels and nerves. The only literature that currently supports operative intervention in the acute treatment is a 3-patient case series of arthroscopically assisted fixation of the lesser trochanter fracture by Khemka et al. (15). Chronic pain after lesser trochanter avulsion has been described in a single case report, with complete resolution after excision of a loose fragment (10). Additionally, a review by McKinney and colleagues recommends that small symptomatic nonunions and painful exostosis should be treated operatively with excision and muscle reattachment (16). The successful management of these patients requires a multidisciplinary approach. Input should be sought from neurology to advise on control of seizures. Preventing further seizures will prevent other injuries from occurring and reduce the risk of any resultant long-term morbidity. Consultation with orthopedics will be necessary to aid in the diagnosis and to plan the management and appropriate follow-up. Early consultation with physiotherapy should also be arranged to ensure that early range of motion exercises, followed by the introduction of strengthening and proprioceptive exercises. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case raises the importance of a thorough assessment for seizure-related injuries and that clinicians should consider the possibility of this rare injury when assessing young patients with hip or groin pain after an epileptic seizure or electrocution. It is important to consider the possibility of alternate diagnoses and, if any concern exists about the possibility of pathologic fractures, there should be an early consultation with orthopedics to discuss the potential need for additional cross-sectional imaging, such as CT or MRI. In our experience, nonoperative symptomatic treatment provides excellent outcomes in the acute setting, with a return to pre-injury activity levels seen in this patient. We recommend that patients be followed up to assess for chronic pain or a symptomatic nonunion that would potentially merit surgical intervention. REFERENCES 1. Wirrell EC. Epilepsy-related injuries. Epilepsia 2006;47(Suppl. 1): 79–86.
4 2. Neufeld M, Vishne T, Chistik V, Korczyn A. Life-long history of injuries related to seizures. Epilepsy Res 1999;34:123–7. 3. Lasanianos N, Mouzopoulos G. An undiagnosed bilateral anterior shoulder dislocation after a seizure: a case report. Cases J 2008;1:342. 4. Phillips CD, Pope TL Jr, Jones JE, Keats TE, MacMillan RH III. Nontraumatic avulsion of the lesser trochanter: a pathognomonic sign of metastatic disease? Skeletal Radiol 1988;17:106–10. 5. Papacostas NC, Bowe CT, Shaffer Strout TD. Lesser trochanter avulsion fracture. J Emerg Med 2013;45:256–7. 6. Renstrom PA. Tendon and muscle injuries in the groin area. Clin Sports Med 1992;11:815–31. 7. Kneeland JB. MR imaging of sports injuries of the hip. Magn Reson Imaging Clin N Am 1999;7:105–15. viii. 8. Paluska SA. An overview of hip injuries in running. Sports Med 2005;35:991–1014. 9. Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, Chow S. Imaging features of avulsion injuries 1. Radiographics 1999;19: 655–72.
T. McMillan et al. 10. Quarrier NF, Wightman AB. A ballet dancer with chronic hip pain due to a lesser trochanter bony avulsion: the challenge of a differential diagnosis. J Orthop Sports Phys Ther 1998;28: 168–73. 11. Theologis T, Epps H, Latz K, Cole W. Isolated fractures of the lesser trochanter in children. Injury 1997;28:363–4. 12. Poston H. Traction fracture of the lesser trochanter of the femur. Br J Surg 1921;9:256–8. 13. Rockwood CA, Green DP, Bucholz RW, Heckman JD. Rockwood and Green’s Fractures in Adults. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. 14. Zuckerman JD. Comprehensive Care of Orthopaedic Injuries in the Elderly. Vienna: Urban & Schwarzenberg; 1990. 15. Khemka A, Raz G, Bosley B, Ludger G, Al Muderis M. Arthroscopically assisted fixation of the lesser trochanter fracture: a case series. J Hip Preserv Surg 2014;1:27–32. 16. McKinney BI, Nelson C, Carrion W. Apophyseal avulsion fractures of the hip and pelvis. Orthopedics 2009;32:42.