Simultaneous bilateral avulsion fracture of the anterior superior iliac spine in a young athlete

Abstract

A 16-year-old boy was running a 100 m sprint. About 40 m from the starting line, he felt a sharp snap in his right groin with moderate sudden pain. As he decelerated, there was similar snap with sudden pain in the left groin. He collapsed to the ground with moderate pain over both the groins. He was unable to get up from the ground and had to be carried off on a stretcher.On arrival in the emergency department by ambulance about an hour from the time of injury, the pain was still localised to both the groins and had somewhat subsided with analgesics. On examination, he was of moderate build with good muscular tone. His height was 178 cm and weight 72 kg. He had no obvious bruising or swelling. There was no deformity of the lower limbs, with both being held in neutral rotation. He was tender anteriorly over the hip and the anterior aspect of the iliac crest on both sides. Both hips were held in about 208 of flexion with the knees flexed to about 308. He was unable to straighten his leg. Rotational movements were not possible. Distal sensation and circulation were normal.A radiograph of the pelvis was performed which showed bilateral avulsion of the anterior superior iliac spine (ASIS) with almost symmetrical caudal displacement of the avulsed bony fragment on both the sides by about 2 cm (Figs. 1-3). This was confirmed on MRI scan.Full bone profile laboratory tests, full blood count, full biochemistry tests as well as growth and thyroid hormone levels were all normal.He was treated with analgesia and full bed rest in a semi-flexed hip position in 45-908 flexion for the first 2 weeks. A check X-ray at 2 weeks showed initial signs of callus formation and he was started on a course of gradual physiotherapy with increasing hip extension gaining full weight bearing training by 4 weeks and full ROM at 6 weeks (Figs. 4 and 5). He was kept on crutches until he regained full ROM in both hips at 4 weeks, and he returned to full sports activities and was free from pain by 10 weeks after the injury. Radiographs at 3 months showed both fractures were fully healed (Figs. 6-8).

Comparison of conservative against surgical treatment of anterior–superior iliac spine avulsion fractures in children and adolescents

“…Avulsion fracture of the ASIS is an uncommon injury, accounting for only 1.4 % of injuries to the hip and pelvis [1,2,5,6,10]. It is mostly seen in competitive adolescent athletes and mostly in sprinters, distance runners and soccer players [5][6][7]9].…”

“…It is mostly seen in competitive adolescent athletes and mostly in sprinters, distance runners and soccer players [5][6][7]9]. During adolescence, the iliac crest is the weakest component of the pelvic ring, and sudden muscular contraction that occurs in the beginning phase of the gait during running or springing can result in avulsion of the attached pelvic apophysis.…”

“…Avulsion fractures of the ASIS without neurological symptoms can be treated conservatively [5,6,8]. Conservative treatment is traditionally two to three weeks of limited activities and walking, with partial weight bearing using crutches [1,2,[4][5][6]10], and provides good clinical results.…”

“…Conservative treatment is traditionally two to three weeks of limited activities and walking, with partial weight bearing using crutches [1,2,[4][5][6]10], and provides good clinical results. Severely displaced fragments may cause compression of the lateral cutaneous nerve, causing meralgia paraesthetica [3,7].…”

“…Although there are different treatment options, there are no specific treatment guidelines in the literature. One option is conservative therapy comprising bed rest with the affected lower extremity positioned with the hip and knee in flexion to ensure minimal tension of muscles attaching to the ASIS [5][6][7]. Conservative therapy is generally accepted for minimally displaced fractures in younger children [3,5,8,9].…”