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Results of operative treatment of avulsion fractures of the iliac crest apophysis in adolescents
Injury, Int. J. Care Injured 45 (2014) 721–724
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Results of operative treatment of avulsion fractures of the iliac crest apophysis in adolescents Xigong Li, Sanzhong Xu *, Xiangjin Lin, Quan Wang, Jun Pan Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhejiang University, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 6 October 2013
Background: Avulsion fracture of the iliac crest apophysis is a rare condition that commonly occurs in adolescent athletes. Conservative treatment for this injury can produce excellent functional outcomes. However, the rehabilitation process requires a rather long immobilisation period. This study aimed to evaluate the use of cannulated screws for fixation of avulsion fractures of iliac crest apophysis. Methods: Ten patients with avulsion fractures of iliac crest apophysis were treated by open reduction and internal fixation using cannulated screws. Results: The mean age of patients was 14.6 years (range, 13–15 years). The mean intraoperative blood loss was 14.9 ml (range, 10–25 ml). The mean operative time was 40.3 min (range, 33–52 min). The mean follow-up period was 11.2 months (range, 6–20 months). At the 4-week follow-up, all patients returned to previously normal activity without pain and had no evidence of lower extremity muscle weakness. At the final follow-up, all patients resumed their athletic activity without any complications. Conclusion: Open reduction and internal fixation for the treatment of avulsion fracture of iliac crest apophysis can be recommended for patients requiring rapid rehabilitation. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Iliac crest apophysis Avulsion fracture Adolescents Operative treatment Rapid rehabilitation
Introduction Avulsion fracture of the iliac crest apophysis is a rare condition that commonly occurs in adolescent athletes [1]. As the cartilaginous growth plate of iliac crest apophysis during adolescence remains weaker than the attached musculotendinous unit, a sudden forceful contraction or repetitive actions of the sartorius and the tensor fasciae latae may result in avulsion fractures of the iliac crest apophysis [2]. The characteristic presentation of avulsion fractures of the iliac crest apophysis is a suddenly sharp pain localised to the anterior pelvic area, and the injured area is usually swollen and tender to pressure. Despite patients are able to walk, any active extension of the hip, especially against resistance causes severe pain [3]. Currently, the mainstay of treatment for this injury remains conservative, including analgesics, bed rest, immobilisation of the lower extremity in a Bohler Braun splint, and physical rehabilitation [4–6]. However, this process of clinical recovery is time-consuming, generally lasting for a period of 6–10 weeks or even 12 weeks [7], which do not meet some active cases’ rehabilitation requirements.
* Corresponding author at: Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhejiang University, Qingchun Road 79, Hangzhou, Zhejiang Province 310003, China. Tel.: +86 571 87236848. E-mail address: [email protected] (S. Xu). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.005
In this study, we present a series of 10 patients surgically treated at our institution for avulsion fractures of the iliac crest apophysis. The rehabilitation period is considerably shortened, patients can begin active exercise of the hip 2 days after surgery, and return to their full athletic activities 4 weeks after the injury.
Patients and methods From January 2009 to February 2011, the authors’ institution had 10 patients with avulsion fractures of iliac crest apophysis who had been treated with internal fixation using cannulated screws only. All of the 10 fractures, involving nine men and one woman, were unilateral. The mean age of these patients at surgery was 14.6 years (range, 13–15 years). All patients were injured while taking part in running sports. Preoperatively, patients were evaluated with one anteroposterior pelvic radiograph and computed tomography with threedimensional reconstruction (Fig. 1a–c). Surgery was performed 2– 5 days after injury. Patients were positioned supine with the affected hip in flexion (Fig. 2). A 6-cm incision was made at the region of the broken iliac crest apophysis, and the fractured fragment was exposed. During the operation, an avulsed bony fracture of iliac crest coexisting with part of the apophysis was commonly noted (Fig. 3). The size of the entire mass was larger than that of the fractured fragment initially measured on
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X. Li et al. / Injury, Int. J. Care Injured 45 (2014) 721–724
Fig. 2. Positioning of patient in the operation theatre.
Fig. 3. Intraoperative findings showed an avulsed bony fracture coexisting with part of the apophysis (arrow head).
Fig. 4. The patient underwent the operation by open reduction and internal fixation using cannulated screws.
Fig. 1. A 15-year-old girl injured while sprinting. Preoperative anteroposterior radiograph (a) and CT scan with three-dimension reconstruction (b) and (c) showed an avulsion fracture of right avulsion.
computed tomography. Then the avulsed fragments were reduced with minimal stripping of the soft tissue and temporarily fixed with Kirschner wires. Two to four 4.0 mm cannulated screws with washers (Stryker Trauma AG, Selzach, Switzerland) were ultimately inserted to fix a fracture according to the size of the fragment (Fig. 4). Intraoperative fluoroscopy was used to check the screw length and position. Drains were inserted, and the surgical wound was closed in layers. On the second day after surgery, the drains were removed, and patients began to get up and walk with partial weight bearing after
X. Li et al. / Injury, Int. J. Care Injured 45 (2014) 721–724
Fig. 5. At the 20-month follow-up, the patient resumed her athletic activity and surgical removal of the screws was performed.
postoperative anteroposterior pelvic radiograph confirming fracture reduction and fixation. The sutures were removed 10 days postoperatively, and patients were discharged from our hospital. Results All the operations were done by the same surgeon (SZX). The mean intraoperative blood loss was 14.9 ml (range, 10–25 ml). The mean operative time was 40.3 min (range, 33–52 min). The mean follow-up period was 11.2 months (range, 6–20 months). Generally, patients were allowed full weight bearing activity 2 weeks later. Four weeks after surgery, all patients returned to their previously athletic activity without pain and had no evidence of lower extremity muscle weakness. At the final follow-up, all patients resumed their athletic activity, and there were no complications recorded with these patients. Routine anteroposterior pelvic radiographs showed the avulsed fragments in the same position as immediately taken after the surgery but with signs of fracture healing. Three patients returned to our department for surgical removal of fixation screws and their avulsed iliac crest apophyses were fully fused (Fig. 5). Discussion The anterior superior iliac spine which develops from an anterior apophysis of the iliac crest, is the site of origin of the sartorius muscle and part of the tensor fasciae latae. Larger tension forces produced by these muscles, are translated to their apophyseal plate insertion at the iliac crest and result in avulsion fractures. Mostly, such injuries occurred in adolescent competitive athletes who often perform excessive range of movements and sudden changes in direction. The prognosis of iliac crest apophysis avulsion fractures treated conservatively is usually satisfactory. The protocol of conservative treatment is composed of a 3-week bed rest, and immobilisation of the lower extremity in a Bohler Braun splint with the hip being flexed at 608, followed by walking with crutches for an average of 5 weeks. The whole treatment progress lasts for a period of 6–10 weeks or even 12 weeks [7]. It is a relatively long convalescence that adversely disrupts the
723
regular training for the competitive athletes and leads to a missing in sports season. Additionally, several complications from conservative treatment of iliac crest apophysis avulsion fractures have been reported, including cosmetically unappealing exostoses or symptomatic malunion [7,8]. Therefore, some authors advocate surgical treatment depending on the individual’s rehabilitation requirements or the degree of fracture displacement [3,5]. In our series, ten adolescent athletes with iliac crest apophysis avulsion fractures were treated by open reduction and internal fixation. Fracture fixation using cannulated screws do not require additional protection and enable immediate active exercise 2 days after surgery. The convalescence is considerably shortened, patients can resume their full athletic activities 4 weeks after injury, with normal hip function and without any complications. However, the present study was not a randomised trial comparing operative and conservative treatment of the iliac crest apophysis avulsion fractures with respect to rapid rehabilitation. One previous study demonstrated that specific physiotherapy of a collegiate distance runner with iliac crest apophysis avulsion fracture allowed early functional restoration even at 3 weeks after injury [10]. This treatment strategy consisted of rest followed by nonweight-bearing graded exercise performed in the pool and on a Schwinn Airdyne, which is so complicated and needed to be individually supervised by therapists. The benefits of this therapy compared to operative treatment also need to be further evaluated. Cimerman et al. had compared the functional results of treatment of identical injuries to the anterior superior iliac spine in two adolescent sisters, one treated operatively and the other conservatively. The final functional results of both treatments were good, but the rehabilitation period of operative treatment was shorter, allowing an earlier return to athletic activity [11]. Their initial surgical experience showed that young athletes with iliac crest apophysis avulsion fractures treated by open reduction and internal fixation could resume sports at three to four weeks after the fracture [5], which was consistent with clinical outcomes in the present study. In our opinion, compared to the conservative treatment, operative treatment of the iliac crest apophysis avulsion fractures enabled athletic patients to earlier return to exercise, which contributed to restoration of the thigh muscle strength and maintenance of cardiorespiratory endurance. Despite there is no evidence of the superiority of surgery in terms of final function, treatment by open reduction and internal fixation can be recommended for patients requiring rapid rehabilitation. Conflict of interest No funds were received in support of this work, and no benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. References [1] Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skelet Radiol 2001;30:127–31. [2] White KK, Williams SK, Mubarak SJ. Definition of two types of anterior superioriliac spine avulsion fractures. J Pediatr Orthop 2002;22:578–82. [3] Kosanovic M, Brilej D, Komadina R, Buhanec B, Phili IA, Vlaevic M. Operative treatment of avulsion fractures of the anterior superior iliac spine according to the tension band principle. Arch Orthop Trauma Surg 2002;122:421–3. [4] Rosenberg N, Noiman M, Edelson G. Avulsion fractures of the anterior superior iliac spine in adolescents. J Orthop Trauma 1996;10:440–3. [5] Veselko M, Smrkolj V. Avulsion fractures of the anterior–superior iliac spine in athletes: case reports. J Trauma 1994;36:444–6.
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[6] Metzmaker JN, Pappas AM. Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349–58. [7] Schwoebel MG. Apophysenfrakturen bei Jugendlichen. Chirurg 1985;56:699– 704. [8] Irving MH. Exostosis formation after traumatic avulsion of the anterior inferior iliac spine. J Bone Joint Surg Br 1964;46:720–2.
[10] Draper DO, Dustman AJ. Avulsion fracture of the anterior superior iliac spine in a collegiate distance runner. Arch Phys Med Rehabil 1992;73:881–2. [11] Cimerman M, Smrkolj V, Veselko M. Avulsion of the anterior superior iliac spine in two adolescent sisters: operative versus conservative treatment. Unfallchirurg 1995;98:530–1.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Results of operative treatment of avulsion fractures of the iliac crest apophysis in adolescents Xigong Li, Sanzhong Xu *, Xiangjin Lin, Quan Wang, Jun Pan Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhejiang University, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 6 October 2013
Background: Avulsion fracture of the iliac crest apophysis is a rare condition that commonly occurs in adolescent athletes. Conservative treatment for this injury can produce excellent functional outcomes. However, the rehabilitation process requires a rather long immobilisation period. This study aimed to evaluate the use of cannulated screws for fixation of avulsion fractures of iliac crest apophysis. Methods: Ten patients with avulsion fractures of iliac crest apophysis were treated by open reduction and internal fixation using cannulated screws. Results: The mean age of patients was 14.6 years (range, 13–15 years). The mean intraoperative blood loss was 14.9 ml (range, 10–25 ml). The mean operative time was 40.3 min (range, 33–52 min). The mean follow-up period was 11.2 months (range, 6–20 months). At the 4-week follow-up, all patients returned to previously normal activity without pain and had no evidence of lower extremity muscle weakness. At the final follow-up, all patients resumed their athletic activity without any complications. Conclusion: Open reduction and internal fixation for the treatment of avulsion fracture of iliac crest apophysis can be recommended for patients requiring rapid rehabilitation. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Iliac crest apophysis Avulsion fracture Adolescents Operative treatment Rapid rehabilitation
Introduction Avulsion fracture of the iliac crest apophysis is a rare condition that commonly occurs in adolescent athletes [1]. As the cartilaginous growth plate of iliac crest apophysis during adolescence remains weaker than the attached musculotendinous unit, a sudden forceful contraction or repetitive actions of the sartorius and the tensor fasciae latae may result in avulsion fractures of the iliac crest apophysis [2]. The characteristic presentation of avulsion fractures of the iliac crest apophysis is a suddenly sharp pain localised to the anterior pelvic area, and the injured area is usually swollen and tender to pressure. Despite patients are able to walk, any active extension of the hip, especially against resistance causes severe pain [3]. Currently, the mainstay of treatment for this injury remains conservative, including analgesics, bed rest, immobilisation of the lower extremity in a Bohler Braun splint, and physical rehabilitation [4–6]. However, this process of clinical recovery is time-consuming, generally lasting for a period of 6–10 weeks or even 12 weeks [7], which do not meet some active cases’ rehabilitation requirements.
* Corresponding author at: Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhejiang University, Qingchun Road 79, Hangzhou, Zhejiang Province 310003, China. Tel.: +86 571 87236848. E-mail address: [email protected] (S. Xu). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.005
In this study, we present a series of 10 patients surgically treated at our institution for avulsion fractures of the iliac crest apophysis. The rehabilitation period is considerably shortened, patients can begin active exercise of the hip 2 days after surgery, and return to their full athletic activities 4 weeks after the injury.
Patients and methods From January 2009 to February 2011, the authors’ institution had 10 patients with avulsion fractures of iliac crest apophysis who had been treated with internal fixation using cannulated screws only. All of the 10 fractures, involving nine men and one woman, were unilateral. The mean age of these patients at surgery was 14.6 years (range, 13–15 years). All patients were injured while taking part in running sports. Preoperatively, patients were evaluated with one anteroposterior pelvic radiograph and computed tomography with threedimensional reconstruction (Fig. 1a–c). Surgery was performed 2– 5 days after injury. Patients were positioned supine with the affected hip in flexion (Fig. 2). A 6-cm incision was made at the region of the broken iliac crest apophysis, and the fractured fragment was exposed. During the operation, an avulsed bony fracture of iliac crest coexisting with part of the apophysis was commonly noted (Fig. 3). The size of the entire mass was larger than that of the fractured fragment initially measured on
722
X. Li et al. / Injury, Int. J. Care Injured 45 (2014) 721–724
Fig. 2. Positioning of patient in the operation theatre.
Fig. 3. Intraoperative findings showed an avulsed bony fracture coexisting with part of the apophysis (arrow head).
Fig. 4. The patient underwent the operation by open reduction and internal fixation using cannulated screws.
Fig. 1. A 15-year-old girl injured while sprinting. Preoperative anteroposterior radiograph (a) and CT scan with three-dimension reconstruction (b) and (c) showed an avulsion fracture of right avulsion.
computed tomography. Then the avulsed fragments were reduced with minimal stripping of the soft tissue and temporarily fixed with Kirschner wires. Two to four 4.0 mm cannulated screws with washers (Stryker Trauma AG, Selzach, Switzerland) were ultimately inserted to fix a fracture according to the size of the fragment (Fig. 4). Intraoperative fluoroscopy was used to check the screw length and position. Drains were inserted, and the surgical wound was closed in layers. On the second day after surgery, the drains were removed, and patients began to get up and walk with partial weight bearing after
X. Li et al. / Injury, Int. J. Care Injured 45 (2014) 721–724
Fig. 5. At the 20-month follow-up, the patient resumed her athletic activity and surgical removal of the screws was performed.
postoperative anteroposterior pelvic radiograph confirming fracture reduction and fixation. The sutures were removed 10 days postoperatively, and patients were discharged from our hospital. Results All the operations were done by the same surgeon (SZX). The mean intraoperative blood loss was 14.9 ml (range, 10–25 ml). The mean operative time was 40.3 min (range, 33–52 min). The mean follow-up period was 11.2 months (range, 6–20 months). Generally, patients were allowed full weight bearing activity 2 weeks later. Four weeks after surgery, all patients returned to their previously athletic activity without pain and had no evidence of lower extremity muscle weakness. At the final follow-up, all patients resumed their athletic activity, and there were no complications recorded with these patients. Routine anteroposterior pelvic radiographs showed the avulsed fragments in the same position as immediately taken after the surgery but with signs of fracture healing. Three patients returned to our department for surgical removal of fixation screws and their avulsed iliac crest apophyses were fully fused (Fig. 5). Discussion The anterior superior iliac spine which develops from an anterior apophysis of the iliac crest, is the site of origin of the sartorius muscle and part of the tensor fasciae latae. Larger tension forces produced by these muscles, are translated to their apophyseal plate insertion at the iliac crest and result in avulsion fractures. Mostly, such injuries occurred in adolescent competitive athletes who often perform excessive range of movements and sudden changes in direction. The prognosis of iliac crest apophysis avulsion fractures treated conservatively is usually satisfactory. The protocol of conservative treatment is composed of a 3-week bed rest, and immobilisation of the lower extremity in a Bohler Braun splint with the hip being flexed at 608, followed by walking with crutches for an average of 5 weeks. The whole treatment progress lasts for a period of 6–10 weeks or even 12 weeks [7]. It is a relatively long convalescence that adversely disrupts the
723
regular training for the competitive athletes and leads to a missing in sports season. Additionally, several complications from conservative treatment of iliac crest apophysis avulsion fractures have been reported, including cosmetically unappealing exostoses or symptomatic malunion [7,8]. Therefore, some authors advocate surgical treatment depending on the individual’s rehabilitation requirements or the degree of fracture displacement [3,5]. In our series, ten adolescent athletes with iliac crest apophysis avulsion fractures were treated by open reduction and internal fixation. Fracture fixation using cannulated screws do not require additional protection and enable immediate active exercise 2 days after surgery. The convalescence is considerably shortened, patients can resume their full athletic activities 4 weeks after injury, with normal hip function and without any complications. However, the present study was not a randomised trial comparing operative and conservative treatment of the iliac crest apophysis avulsion fractures with respect to rapid rehabilitation. One previous study demonstrated that specific physiotherapy of a collegiate distance runner with iliac crest apophysis avulsion fracture allowed early functional restoration even at 3 weeks after injury [10]. This treatment strategy consisted of rest followed by nonweight-bearing graded exercise performed in the pool and on a Schwinn Airdyne, which is so complicated and needed to be individually supervised by therapists. The benefits of this therapy compared to operative treatment also need to be further evaluated. Cimerman et al. had compared the functional results of treatment of identical injuries to the anterior superior iliac spine in two adolescent sisters, one treated operatively and the other conservatively. The final functional results of both treatments were good, but the rehabilitation period of operative treatment was shorter, allowing an earlier return to athletic activity [11]. Their initial surgical experience showed that young athletes with iliac crest apophysis avulsion fractures treated by open reduction and internal fixation could resume sports at three to four weeks after the fracture [5], which was consistent with clinical outcomes in the present study. In our opinion, compared to the conservative treatment, operative treatment of the iliac crest apophysis avulsion fractures enabled athletic patients to earlier return to exercise, which contributed to restoration of the thigh muscle strength and maintenance of cardiorespiratory endurance. Despite there is no evidence of the superiority of surgery in terms of final function, treatment by open reduction and internal fixation can be recommended for patients requiring rapid rehabilitation. Conflict of interest No funds were received in support of this work, and no benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. References [1] Rossi F, Dragoni S. Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Skelet Radiol 2001;30:127–31. [2] White KK, Williams SK, Mubarak SJ. Definition of two types of anterior superioriliac spine avulsion fractures. J Pediatr Orthop 2002;22:578–82. [3] Kosanovic M, Brilej D, Komadina R, Buhanec B, Phili IA, Vlaevic M. Operative treatment of avulsion fractures of the anterior superior iliac spine according to the tension band principle. Arch Orthop Trauma Surg 2002;122:421–3. [4] Rosenberg N, Noiman M, Edelson G. Avulsion fractures of the anterior superior iliac spine in adolescents. J Orthop Trauma 1996;10:440–3. [5] Veselko M, Smrkolj V. Avulsion fractures of the anterior–superior iliac spine in athletes: case reports. J Trauma 1994;36:444–6.
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X. Li et al. / Injury, Int. J. Care Injured 45 (2014) 721–724
[6] Metzmaker JN, Pappas AM. Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349–58. [7] Schwoebel MG. Apophysenfrakturen bei Jugendlichen. Chirurg 1985;56:699– 704. [8] Irving MH. Exostosis formation after traumatic avulsion of the anterior inferior iliac spine. J Bone Joint Surg Br 1964;46:720–2.
[10] Draper DO, Dustman AJ. Avulsion fracture of the anterior superior iliac spine in a collegiate distance runner. Arch Phys Med Rehabil 1992;73:881–2. [11] Cimerman M, Smrkolj V, Veselko M. Avulsion of the anterior superior iliac spine in two adolescent sisters: operative versus conservative treatment. Unfallchirurg 1995;98:530–1.