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.

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.

Bilateral anterior superior iliac spine apophysis avulsion fractures in a skeletally mature patient: case report and literature review.

We present a case of bilateral anterior superior iliac spine avulsion fractures in an adult patient who was involved in a road traffic collision. Her injuries were managed conservatively and she has had an uncomplicated recovery with a good outcome. This is, to our knowledge, the only reported case of bilateral simultaneous anterior superior iliac spine apophyseal avulsion fractures in an adult.

Distal biceps femoris avulsions: Associated injuries and neurological sequelae.

BACKGROUND: The aim of this study was to describe associated injuries in cases of distal biceps femoris avulsions (DBFA) as well as the incidence of neurological injury and radiographic abnormalities of the common peroneal nerve (CPN). METHODS: A retrospective chart review was conducted of patients presenting to our office or trauma center with DBFA injuries. Demographic data was obtained as well as mechanism of injury. Assessment of concomitant injuries and presence of neurologic injury was completed via chart review and magnetic resonance imaging (MRI) review. The CPN was evaluated for signs of displacement or neuritis. RESULTS: Sixteen patients were identified (mean age-at-injury 28.6 years, 87.5% male) with DBFA. Three patients (18.8%) sustained their injuries secondary to high energy trauma while 13 (81.3%) had injuries secondary to lower energy trauma. Nine patients (56.3%) initially presented with CPN palsy. All patients presenting with CPN palsy of any kind were found to have a displaced CPN on MRI and no patient with a normal nerve course had a CPN palsy. CONCLUSIONS: This case series demonstrates a strong association between DBFA and CPN palsy as well as multi-ligamentous knee injury (MLKI). These injuries have a higher rate of CPN palsy than that typically reported for MLKI. Furthermore, these findings suggest that CPN displacement on MRI may be a clinically significant indicator of nerve injury. LOE: IV.

Combining pullout suture and retrograde screw fixation for anterior cruciate ligament tibial eminence avulsion fractures: A case report.

This report describes a novel arthroscopic technique for the treatment of anterior cruciate ligament (ACL) tibial eminence avulsion fractures. A 16-year-old boy who was diagnosed with a left ACL tibial eminence avulsion fracture was treated by arthroscopic fixation. Two bone tunnels were created from the anterior tibial cortex into the fracture bed, and a strong suture passed through the ACL just above its insertion was pulled out through them for reduction and fixation. A retrograde cannulated screw fixation was added for stronger fixation. Weight-bearing and range of motion exercises were started immediately after surgery. Radiographically, bone union was obtained 6 months postoperatively. During second-look arthroscopy (24 months postoperatively), there was no loss of reduction and no subsequent meniscal or cartilage injuries. At that point, the Lysholm score was 95, and the International Knee Documentation Committee score was 96.

Missed Sleeve Fracture of the Superior Pole of Patella.

Patellar sleeve fracture is a form of injury in which small osseous fragments avulsed with periosteum and cartilage. 15-year-old male patient, playing in school football team, apllied to our clinic with a history of previously missed patellar superior pole sleeve avulsion fracture. Care must be taken in order not to miss the patellar superior pole sleeve fractures, which are very rare in children. Extra care must be taken in patients, whose X-ray imaging is clean but there is a problem in the extensor mechanism of the knee. INTRODUCTION Since the patella has high mobility and large cartilage surfaces, it's fracture is very rare in children (9). Growing patella is more prone to osteochondral or avulsion fractures (8). Patellar sleeve fracture is a form of injury in which small osseous fragments fractured with periosteum and cartilage (5). Avulsion or sleeve fractures of patella can be seen in inferior and superior patellar poles. Fractures in superior pole is very rare and only a few cases have been described in the literature (2).

Tibial tubercle avulsion fractures in children.

PURPOSE OF REVIEW: To summarize and discuss the fundamentals of pediatric tibial tubercle avulsion fractures (TTAFs) including preferred imaging modalities, systems for fracture classification, frequently associated injuries, treatment options, outcomes, and common complications. RECENT FINDINGS: Although TTAFs amount to fewer than 1% of all physeal injuries in children, the incidence is increasing, likely because of greater participation in high-level athletics. SUMMARY: TTAFs tend to occur in adolescents nearing skeletal maturity who engage in sports with repetitive jumping. The most popular classification system was proposed by Ogden, which defines five fracture types based on the fracture pattern and extent of fragment displacement. Treatment can be nonsurgical or surgical, and indications depend on fracture type. Most fractures are surgical candidates and can be repaired with open reduction and internal fixation (ORIF) or arthroscopy. Arthroscopic approaches can reveal associated soft tissue injuries, such as meniscal tears, and confirm articular reduction. The most common postoperative complication is irritation because of hardware. With proper treatment, both nonsurgical and surgical outcomes are excellent. TTAFs have high rates of union and patients typically return to sports.

Complete Avulsion of Quadriceps Tendon in a Child with Juvenile Idiopathic Arthritis: A Case Report.

CASE: We report a rare case of complete avulsion of the quadriceps tendon in an 8-year-old child with juvenile idiopathic arthritis (JIA). Our patient presented with acute onset of pain and effusion with a history of feeling a "pop" in the knee after a fall while playing kickball. Although knee radiographs showed a cortical irregularity involving the superior patellar pole, it was assumed that the symptoms were a result of a JIA flare rather than an acute injury. Complete quadriceps disruption was later diagnosed by magnetic resonance imaging, and surgical repair was performed. CONCLUSIONS: Complete rupture of the quadriceps tendon is an unusual, disabling injury in children that necessitates prompt diagnosis and early surgical repair. High index of suspicion and thorough physical evaluation are essential for the diagnosis of such injuries, especially in children with complex medical conditions.

Ipsilateral open anterior hip dislocation and avulsion fracture of the greater trochanter: An unusual case report.

Approximately 3% of all joint dislocations involve the hip joint, and only 8-10% of these will be anterior. Traumatic anterior open dislocation of the hip is rare in children and prone to be associated with injuries, extensive soft tissue damage, and avascular necrosis of the femoral head. We present a case of a 13-year-old boy who had an open anterior dislocation of the hip with ipsilateral avulsion of the greater trochanter after a tractor wheel crush in an agricultural accident. Additional lesions included a diaphyseal closed fracture of the contralateral femur. We report this case because of the rarity and seriousness of this injury due to its progressive complications and difficulties related to its management.

Management of ankle fractures in children.

Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management of these injuries is vital for any doctor or clinician working in the emergency department, orthopaedics or providing community care. This review identifies the important features of high- and low-risk ankle fractures, how to prevent the use of unnecessary radiation and the management of these injuries. Fractures may be at high or low risk of instability and are managed accordingly. Many can be treated with conservative management in a cast, including unstable injuries following reduction. However, particular fracture patterns associated with the tibial growth plate need careful assessment of fracture reduction with cross-sectional imaging before committing to conservative management.

Intra-articular dislocation of the patella: a rare variant to an uncommon injury.

Horizontal intra-articular dislocation of the patella is a very rare traumatic entity. We present an unusual case of horizontal intra-articular dislocation in which the patellar articular surface was facing upwards besides having an avulsion of the quadriceps tendon from the superior pole. There was associated posterolateral knee subluxation, which has not been described with intra-articular dislocation of the patella. A 20-year-old man presented with open patellar dislocation and locked knee after a roadside accident. The patient was managed successfully by open reduction and repair of the quadriceps tendon. There was buttonholing of the medial femoral condyle through the medial retinaculum leading to irreducible dislocation. A special reduction manoeuvre was employed to bring the knee to its normal alignment. Knowledge of this injury pattern is of utmost importance for proper recognition and appropriate allocation of the surgical technique.

Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in adolescents: a case report.

Simultaneous occurrence of tibial tubercle fracture and patellar tendon avulsion is an extremely rare condition. However, they have become more frequent due to increased participation in sports at a younger age. Diagnosis is not always straightforward, and treatment consists of open reduction and internal fixation. Only a few case reports of such injuries were reported in the literature with limited information according to diagnoses, treatment, and outcome in adolescents.

Avulsion fracture of the medial collateral ligament association with Segond fracture.

The Segond fracture is a tibial avulsion injury of the insertion of the middle third of the lateral capsular ligament that is typically associated with anterior cruciate ligament and meniscal tears. The classically assigned mechanism of injury is a combination of internal rotation and varus stress. We report two cases of Segond fractures that presented with a variant pattern including osseous avulsion injuries of the medial collateral ligament at the femoral origin, anterior cruciate ligament tear, and pivot shift-type osseous contusion pattern, suggesting an alternative mechanism of injury that includes dominant valgus stress and external rotation components. Awareness of this pattern may aid radiologists, surgeons, and sport medicine physicians in the accurate diagnosis of this injury complex and initiation of appropriate treatment in a timely fashion.

Repair Technique Using a Combination of Suture Anchor and Miniscrew in Flexor Digitorum Profundus Bony Avulsion Fracture with Bone Fragment in Zone 1.

Avulsion fracture of the volar base of the distal phalanx is a rare injury. Zone 1 flexor tendon injuries can be treated with either internal or external fixation techniques. Pull-out suture repairs are often used for FDP tendon avulsion injuries. However, the pull out suture technique is associated with a number of well documented complications including nail bed injury and pressure necrosis. Despite the variety of techniques available for the repair of acute distal zone 1 flexor tendon injuries, no one technique has proven to be superior to all others. We address our experience with treatment of FDP avulsion injuries using suture anchor and miniscrew. Our technique supplements the suture anchor technique, which often causes a lack of strength, with an additional miniscrew. We introduce two cases of combined method using both suture anchor and miniscrew for treatment of FDP avulsion injuries.

Fixation of femoral attachment: anterior cruciate ligament avulsion fracture with arthroscopy suture loop technique.

Anterior cruciate ligament (ACL) avulsion fracture is rare and mostly occur in tibial attachment. Avulsion fracture of femoral attachment of ACL was uncommon and mostly reported in skeletally immature patient. This article aims to report an interesting case of femoral attachment-ACL avulsion fracture in skeletally mature patient with arthroscopic suture loop fixation.A 32-year-old man, with no significant medical-surgical history, sustained a right non-contact pivoting knee injury during soccer competition. Plain radiographs of knee joint demonstrated intra-articular bone fragment in the intercondylar notch space. The MRI confirmed femoral attachment-ACL avulsion fracture. Then, we planned to perform fixation of femoral attachment-ACL avulsion fracture with arthroscopy suture loop technique. At 5 months after surgery, patient had no pain and swelling knee. The physical examination demonstrated negative Lachman test, anterior drawer test, pivot shift test and patient can return to preinjury daily activity and sport activities.

Percutaneous fixation of avulsion fracture at the plantar lateral base of the first metatarsal using ZipTight Fixation System: A case report.

Isolated avulsion fracture of the peroneus longus tendon insertion at the base of the first metatarsal without injury of the tarsometatarsal joint is very rare. Similar to most avulsion fractures, this type of injury is caused by strong tension exerted by the peroneus longus tendon. The mechanism leading to this lesion and treatment options are not clearly defined. Several surgical techniques have been advocated for this fracture, including excision of an avulsion fragment and open reduction for internal fixation through the medial aspect of the foot or minimal plantar incision. We have described a method of percutaneous fixing of the avulsion fracture at the plantar lateral base of the first metatarsal using the ZipTight Fixation System (Zimmer Biomet Warsaw, Indiana, USA), which offers the advantage of allowing a rigid fixation and minimal invasive surgical technique for a small fragment.

Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques.

Tibial spine fractures are uncommon injuries affecting the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. The use of MRI can identify entrapped soft tissue that may prevent reduction. Open or arthroscopic repair is indicated in patients with partially displaced fractures (>5 mm) with one third to one half of the avulsed fragment elevated, in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity. Suture fixation and screw fixation have produced successful results. Suture fixation can eliminate the risk of fracture fragment comminution during screw insertion, the risk of neurovascular injury, and the need for hardware removal. Suture fixation is ideal in cases in which existing comminution prevents screw fixation.

[Analysis of the characteristics and clinical diagnosis and treatment of avulsion fracture of the lateral edge of tibial plateau].

OBJECTIVE: To investigate the characteristics and clinical treatment of avulsion fracture of the lateral edge of tibial plateau(segond fracture) in knee joint injuries. METHODS: From January 2011 and December 2015, 29 patients with Segond fracture were treated with minimally invasive arthroscopy technology in intra-articular injuries combined with double anchor nail fixation in avulsion fracture of the lateral edge of tibial plateau, including 17 males and 12 females with an average age of 41 years old ranging from 27 to 62 years old. Among them, there were 20 cases of anterior cruciate ligament rupture (ACL rupture) involving the anterior cruciate ligament tibial eminence avulsion fracture included, 3 cases of posterior cruciate ligament rupture (PCL rupture), 1 case of ACL rupture combined with PCL rupture, 3 cases of medial collateral ligament tear, and 2 cases combined fractures of tibial plateau (1 case of the medial platform fractures and 1 cases of lateral fracture). All the patients were confirmed by X-rays, CT and MRI. The procedures were performed at 5 to 14 days after the injury(means 7 days). Lysholm scores were used to assess the knee function before and after the operation. RESULTS: The operation time was 40 to 125 minutes (means 85 minutes), the intraoperative blood loss was 10 to 30 ml (means 15 ml). All paients were followed up for 12 to 18 months(means 14 months). The Lysholm scores were significantly improved from preoperative 52.0±4.2 to 91.9±1.4(t=-49.24, P<0.05). The results of drawer test, Lachman test and lateral stress test were negative in all 29 cases, all the fractures of 29 patients were bony union. CONCLUSIONS: The avulsion fracture of the lateral tibial plateau suggests that there are knee joint static and stable structures(joint ligament, joint capsule, meniscus, et al) and even intra articular fractures. Therefore, besides conventional imaging examinations, arthroscopic exploration was also necessary to avoid misdiagnose and provide comprehensive assessments and treatment. This can create favorable conditions for the knee joint function restore maximum.