1. health and fitness
2. exercise

AVULSION
THE
CASE
OF
FOR
OPEN
J.
From
THE
R.
REDUCTION
WOOTFON,
North
ISCHIAL
M.
Sydney
AND
J. CROSS,
Orthopaedic
APOPHYSIS
INTERNAL
K.
and
W.
Sports
G.
FIXATION
HOLT
Medicine
Centre
We report three cases of avulsion of the LSChiaI tuberosity
with marked
chronic disability
after delay in
and non-union
of the fracture.
All were treated
by open reduction
and internal
fixation
with return
to full function,
allowing in one case, athletic performances
of Olympic
standard.
We also report one patient
with an acute
apophyseal
avulsion
treated
by early reduction
and internal
fixation
with restoration
of full
function.
diagnosis
The
apophysis
ischial
may
suffer
avulsion
from
the
innominate
bone from around
puberty
up to 25 years of
age, by which
time it has generally
fused
(Milch
1926;
Schlonsky
1981).
and
The
contraction
body
Olix
of the
ofthe
ligaments
1972;
mechanism
being
to the
sacrum
and
injury
hamstrings
ischium
commonly
engaged
a high contraction
Fernbach
of
is
or adductor
stabilised
by the
(Abbate
1945).
Patients
such as sprinting,
long jumping
or hurdling
and Rida 1963 ; Schlonsky
and Olix 1972).
Martin
and
Pipkin
into
apophysiolysis
(acute),
and old
doubt
from
Howard
and
Metzmaker
ment
leads
than
Piha
1965;
the
Where
there
the
and
(MacLeod
and Lewin
Pipkin
1957; Hamada
is wide
natural
are
fractures
fractures
and there is little
and Rida 1963;
Pipkin
and Pappas
1985) that conservative
to good results
if displacement
fragments,
can
quently
surgical
and Piha (1965)
there is
stretch
avulsion
Martin
flexion
1957;
manageis no more
separation
history
is less
of the
certain
1929 ; Labuz
1946 ; Martin
and Rida 1963; Howard
and
and
Piha
result
2 cm
displacement
fixation
; those
Even
(Hamada
classified
ununited
avulsions
previous
reports
(Hamada
minimal.
fracture
(1957)
(undisplaced),
likely
the
sacrotuberous
in strenuous
activities
where
rate or a forceful
hamstring
I 98 1). While
is more
and Pipkin
1957; Schlonsky
and Olix 1972); this
painful,
and may enlarge
to form an ischial
mass
and Hinds
1972);
significant
weakness
of knee
sudden
magnus,
1980 ; Fernbach
and Wilkinson
may occur, fibrous non-union
(Martin
is often
(Barnes
Wilkinson
usually
1965 ; Wray
bony union
(Wilson
1976;
intervention
suggested
needed
with
when
1976).
operative
less could
a case
Watts
may be indicated
that avulsions
with
more
than
reduction
be treated
for surgery
Conse; Howard
and
conservatively.
can
be established,
the
actual technique
has not yet been well defined,
and too
few cases have been reported
to compare
the results of
internal
fixation
of the ununited
fragment,
with those of
excision
of the fragment
and re-attachment
of the
hamstring
this condition
and Olix
reduction
origin.
It is uncertain
can recover
fully
1972).
and
We therefore
present
internal
fixation
in
disability
marked
report
whether
an athlete
with
after operation
(Schlonsky
a patient
after
with
which
early operation
the
three
conservative
treatment.
wide displacement
we now advise.
CASE
results
of open
patients
with
treated
We
also
by the
REPORTS
1. A 15-year-old
male sprinter
presented
in 1977
following
an injury sustained
whilst sprinting
six months
previously.
At the time of injury he heard
two cracks
Case
J. R. Wootton,
BSc, FRCS,
Senior
Orthopaedic
Registrar
Robert
Jones
& Agnes
Hunt
Orthopaedic
Hospital,
Oswestry,
shire,
SY1O lAG,
England.
K. W. G. Holt,
Perth,
Western
FRACS,
Australia.
Orthopaedic
Shrop-
followed
tuberosity.
Surgeon
M. J. Cross,
FRACS,
Consultant
Orthopaedic
Surgeon,
Royal
Shore
Hospital,
Sydney
and Director
of North
Sydney
Orthopaedic
Sports
Medicine
Centre
286 Pacific
Highway,
Crows
Nest,
Sydney,
NSW,
Australia.
North
and
Correspondence
Street,
Oswestry,
Brook
should
be sent to Mr J. R. Wootton
Shropshire
SY11 2TB, England.
© 1990 British Editorial
Society
of Bone
030l-620X/90/41
32 $2.00
J Bone Joint Surg [Br]
1990; 72-B : 625-7.
VOL.
72-B, No. 4, JULY
1990
and
Joint
at 31 Upper
Surgery
had
by moderately
His initial
subsided
and then
ever, he continued
buttock
and was
activity.
Clinical
clinic
demonstrated
and
a radiograph
avulsed
ischial
severe
treatment
hamstring
pain over the left ischial
was rest until the pain
rehabilitation.
How-
to have local pain in both groin
and
unable
to run or undertake
any sporting
examination
a gap
showed
tuberosity.
on presentation
to our
in the proximal
hamstrings
gross
displacement
of the
His left thigh
was 4 cm thinner
625
J. R. WOOTFON,
626
than the
measured
right and the power
in the hamstring
by the Orthotron,
was 30% less.
We
performed
fixation
of
the
injury,
using
subsequently
became
staples
healed
painless
time
the
an
open
non-union
over
patient
reduction
after
initial
and
a wire
loop.
by a short
fibrous
The
fracture
union
which
the
during
next
regained
six months,
normal
which
thigh
girth
and
hamstring
power.
He made
a full return
to competition
achieving
his previous
levels
of performance
in the 100
to 800 m events. When
reviewed
two years
later
and
again
12 years
later,
he was
athlete,
Wales
State
sprint
apophysis
playing
internal
the
K. W. G. HOLD
Case 3. A 17-year-old
muscles,
and
10 months
M. J. CROSS,
buttock
He
elsewhere
over
30%
at
loss
tenderness
and
torn hamstring
was made
When
the
we saw
him
hamstrings
palpable
of the
A week
later
fixation.
his hamstrings
unaided
weeks.
and
we performed
Nine
weeks
were
very
tight
with
recovered
his full standard
the Australian
200 m title.
sporting
buttock
activity
due
to weakness
pain.
Radiographs
of the apophysis
(Fig.
union
showed
1).
Open
reduction
and
1
internal
he was
able
to light
to return
operation.
Despite
tender
with some
good
pain
bony
on
persistent
fibrous
non-
Case
A displaced
fixation.
eight months
after the injury
months
his pain on hamstring
and
a wide
Fig.
Figure
internal
to undertake
was
performed
(Fig. 2). Over the next
stretching
disappeared;
running
union
sitting
settled and
at 12 weeks
he remained
of the
six
locally
for 18 months.
These
he was able to return
to
their
removal.
Figure
was
2
with
acutely
apophysis
crack
from
symptoms
eventually
his pre-injury
level of activity.
Most of the local pain was
from the region of the screws
the heads
of which
could
be felt, but he did not consider
that
the symptoms
warranted
ischium.
of 80#{176}
and
rugby
an
with
as he was
straight
mechanism
hamstrings.
of athletic
open
within
one week,
normal
and
achieved
power.
He
of
performance,
player
a
subse-
presented
to us
and
avulsion
fracture
3 cm displacement.
the
and
time
and our
activity
reduction
rehabilitation
league
of injury
was
Because
of the
open
but
leg raise
at 12 weeks,
reduction
sprinting
at
and
running
2
After
-
a
reduction
a straight
hamstring
he had,
Fig.
fracture
a
programme
1
avulsion
fixation
40#{176}.
After
4. A 14-year-old
of
showed
he began
quently
winning
any
he was still unable
commenced.
at the origin
an open
later
leg raise
the injury
local
of
apophysis.
straight
after
for two
a radiograph
six months
of
South
four
weeks
with
of power
: a diagnosis
only
stretching
the New
ischial
in the
2. An 18-year-old
man was injured
at long jumping.
His initial management
was by rest from running
for two
months followed by hamstring
rehabilitation.
When
seen
Case
time
avulsed
his left
He felt a crack
and rehabilitation
months
a gap
at three
was
5 cm separation
screw
asymptomatic.
to walk
was unable
and
presented
at that
champion,
rugby
football.
recalled
of his right
ischial
He remembered
a
that
; presumably
forceful
displacement,
experience
his right
leg
therefore
stretching
his
with
the
of
high
this
the
level
injury,
and
internal
fixation
was
performed
and within
10 days he was asymptomatic
and able to run. He returned
to full activities
months,
and by then had full hamstring
power.
THE
JOURNAL
OF BONE
AND
JOINT
after two
At three
SURGERY
AVULSION
months
from
operation
an inter-school
he broke
the
OF THE
highjump
record
Nonoperative
management
with fibrous
disability
fractures
prolonged
Martin
and
Pipkin
Wilson
1976 ; Watts
comfortably,
groin
objective
(Howard
strate
that
Pappas
1985).
be restored
can
occur
also shown
in chronically
1985).
Restoration
pain
important
on
factors
Excision
hamstrings
and
Olix
has
these
in regaining
of the
tuberischii
been
reported
that
1972 ; Wray
1980)
and
and
length
and
elimination
normal
function.
to
be
pain
no difficulty
72-B,
No. 4, JULY
1990
disability
and
in any
party
the same
full function.
restore
form have been
related
directly
is
it
We
believe
2 cm,
In
treatment
can
received
or will be received
or indirectly
to the subject
Barnes
ST, Hinds RB. Pseudotumor
ofthe
of avulsion
of the ischial
epiphysis.
54-A :645-7.
Ferubach
fracture
of the ischial
1945; 27 :716-7.
Wilkinson
SK,
Hamada
G, Rida
a review
from a
of this
JAMA
Avulsion
137:581-4.
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literature.
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and
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ischial
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Pain from local pressure,
as in sitting,
persisted
in
our
patients
for variable
lengths
of time.
This
eventually
subsided
and we do not know
if the screws
were responsible
; certainly
in no case did the symptoms
warrant
their removal.
VOL.
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C/inOrthop
if the fragment
the
hamstring
a radiograph
Avulsion
BoneJointSurg
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and
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cases
with separation
of more
than
and
internal
fixation
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CC.
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but it has yet to be established
suspected
Abbate
the
of the
ischial
any
and
symptoms
Macleod
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to relieve
that
which
has
Pappas
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No benefits
commercial
article.
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proximalfemur.AJR
the apophysis.
all
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patients
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restores
normal
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may be indicated
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replacing
ability
demon-
normal
muscles
and
sit
and
absence
of which
(Metzmaker
and
disabled
of hamstring
stretching
to
early
this applies even to elite athletes,
a possibility
previously
been open to question(Metzmakerand
of
should
relieve
1972;
inability
subjective
despite
treatment,
the
as a cause of failure
We have
Olix
and reduced
athletic
Our first three
cases
a result
conservative
suggested
been
can
such
and
1976),
including
buttock
pain,
muscle
weakness
and Piha
1965).
adequate
has
and
Schlonsky
separation
palpable
chronic
of displaced
ischial
apophyunion
may lead to significant
(MacLeod
and Lewin
1929;
1957;
With
always
that
open
DISCUSSION
627
APOPHYSIS
at
meeting.
seal
and
ISCHIAL
of the
pelvis
of
two
in children.
following
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