What Is A Pelvic Avulsion Fracture

Pelvic Avulsion Fractures in Youth Athletes: When Bad News is the Best Treatment

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Background

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With the soaring popularity and competitiveness of youth sports, year round training, and sports specializations, adolescent injuries are also rising.¹ In this population, 3-5% of injuries are in the groin.² Pelvic avulsion fractures are due to muscles attached at the pelvis, pulling and separating pieces of boney attachment before it has ossified. Avulsion fractures mimic common muscle strains, which complicates the diagnosis and treatment of these individuals. Incorrect diagnosis may lead to worsening of the avulsion and longer prognosis for recovery. 

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  Avulsion injuries can happen due to quick, sharp forces via the attachment of the muscle pulling away pieces of the cartilaginous growth plates of youth athletes. This most frequently happens in sports requiring sharp cutting, jumping, or change of direction, such as football, basketball, track and field, etc. The most common sites for avulsion fractures in the pelvis are at the anterior inferior iliac spine (AIIS) via the rectus femoris, anterior superior iliac spine (ASIS) via the sartorius or tensor fascia lata, or ischial tuberosity via the hamstrings or adductors.³ At the time of injury the athlete may feel a pop or crack in the hip.⁴ This is followed by significant pain with activity that improves with rest. 

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Diagnosis

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 If a subjective exam reveals a pop during injury, diagnostic priority should be given to the hypothesis of avulsion fracture. A targeted clinical exam will demonstrate point tenderness along the bony prominence, weakness/pain of the muscle implicated during strength and ROM testing, and possibly gait deficits due to pain. Differential diagnosis of pelvic avulsion fractures include muscular strains, apophysitis, tendon ruptures, and bony fracture. An X-ray can rule in the significant avulsion, but MRI or CT will better rule out these fractures.⁶

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Treatment

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     Treatment will include either conservative management or surgical intervention.⁷ If the fracture is displaced and larger than 15mm, surgical intervention is appropriate.⁸ Typically, a screw is driven through the avulsed bone to reattach it to the site of injury. Surgical intervention may expedite the return to sport time line.⁹ Conservative treatment should include a period of partial or non-weight bearing for up to 4 weeks with a progression towards full weight bearing.¹⁰ Full return to activity may take up to 3 months or greater.

Conservative treatment with Physical Therapy and limited weight bearing leads to a positive outcome in 80% of cases, including a return to sport. In avulsion fractures greater than 15mm, this decreases to 50% successful outcomes without surgical intervention.⁹ Treatment with activity modification, rehabilitative exercise, and proper weight-bearing progression will improve the chances of a proper recovery while mis-diagnosis, ignorance, and unfamiliarity with this condition can lead to a worsening of the fracture, pseudo arthritis, and longer activity restriction. ^8,11

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Conclusion

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Injuries in youth athletes are usually simple to manage. Relative rest, strengthening, and time will improve many sprains and strains. Injuries such as avulsion fractures will mimic these simple injuries, but with a twist. Inappropriate management, without initial limited weight bearing and proper activity progression can lead to a worsening of the fracture, delayed healing, and further complications in recovery.¹¹ Although removing youth from participation in sports can be devastating, in these cases it is the best treatment. 

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AUTHOR

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Ty Zimmerman, DPT, OCS, FAAOMPT, CSCS, Cert. SMT

Physical Therapist/Owner, Amplified PT 

Mukwonago, WI

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REFERENCES

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1. Pasulka, J., Jayanthi, N., McCann, A., Dugas, L. R., & LaBella, C. (2017). Specialization patterns across various youth sports and relationship to injury risk. The Physician and sportsmedicine, 45(3), 344–352. https://doi.org/10.1080/00913847.2017.1313077
2. Morelli, V., & Smith, V. (2001). Groin injuries in athletes. American family physician, 64(8), 1405–1414.
3. Porr, J., Lucaciu, C., & Birkett, S. (2011). Avulsion fractures of the pelvis - a qualitative systematic review of the literature. The Journal of the Canadian Chiropractic Association, 55(4), 247–255.
4. Di Maria, F., Testa, G., Sammartino, F., Sorrentino, M., Petrantoni, V., & Pavone, V. (2022). Treatment of avulsion fractures of the pelvis in adolescent athletes: A scoping literature review. Frontiers in pediatrics, 10, 947463. https://doi.org/10.3389/fped.2022.947463
5. Sanders, T. G., & Zlatkin, M. B. (2008). Avulsion injuries of the pelvis. Seminars in musculoskeletal radiology, 12(1), 42–53. https://doi.org/10.1055/s-2008-1067936
6. Albtoush, O. M., Bani-Issa, J., Zitzelsberger, T., & Springer, F. (2020). Avulsion Injuries of the Pelvis and Hip. Avulsionsverletzungen von Becken und Hüfte. RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin, 192(5), 431–440. https://doi.org/10.1055/a-1082-1598
7. Ferlic, P. W., Sadoghi, P., Singer, G., Kraus, T., & Eberl, R. (2014). Treatment for ischial tuberosity avulsion fractures in adolescent athletes. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 22(4), 893–897. https://doi.org/10.1007/s00167-013-2570-4
8. Serbest, S., Tosun, H. B., Tiftikçi, U., Oktas, B., & Kesgin, E. (2015). Anterior inferior iliac spine avulsion fracture: a series of 5 cases. Medicine, 94(7), e562. https://doi.org/10.1097/MD.0000000000000562
9. Eberbach, H., Hohloch, L., Feucht, M. J., Konstantinidis, L., Südkamp, N. P., & Zwingmann, J. (2017). Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports. BMC musculoskeletal disorders, 18(1), 162. https://doi.org/10.1186/s12891-017-1527-z
10. Metzmaker, J. N., & Pappas, A. M. (1985). Avulsion fractures of the pelvis. The American journal of sports medicine, 13(5), 349–358. https://doi.org/10.1177/036354658501300510
11. Moeller J. L. (2003). Pelvic and hip apophyseal avulsion injuries in young athletes. Current sports medicine reports, 2(2), 110–115. https://doi.org/10.1249/00149619-200304000-00011

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