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      Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete :

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          Abstract

          <p class="first" id="d5441052e65">Lower extremity avulsion fractures are uncommon in the pediatric population and can be misdiagnosed without proper imaging and/or clinical suspicion for these injuries. The most common locations of avulsion injuries are the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine. Less often, avulsion fractures occur in the tibial tubercle, calcaneus, and greater and lesser trochanters. When treated properly with rest and altered weight bearing, most of these injuries heal without complication. Although surgical intervention is rarely necessary, it has a high degree of success when it is used. However, avulsion injuries are often misdiagnosed as muscle strains or apophysitis and are mistakenly treated with early range of motion. An error in diagnosis and/or management can cause nonunion or further displacement, which may require surgery. Improper identification of these injuries can also lead to nerve irritation, chronic pain, and gait dysfunction. Awareness of these injuries and their natural history is important because healed avulsion fractures may resemble neoplastic bone on radiographs. </p>

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          Most cited references 35

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          Evaluation of the hamstring muscle complex following acute injury.

          To evaluate the imaging findings following acute hamstring injury. We retrospectively reviewed the imaging findings of hamstring muscle complex (HMC) strain in 170 patients referred to our institution over a 3-year period. A total of 179 injuries to the HMC were demonstrated in 170 patients (154 male, 16 female, mean age 28.2 years). The mean duration of symptoms was 4.7 days (range 1-10 days). MR imaging was performed in 97 cases and sonography in 102 cases (both modalities were performed in 20 examinations). Attention was directed to the frequency of muscle involvement, the location of the injury within the muscle-tendon unit, the extent of the injury and discriminating avulsion from muscle injury. Twenty-one patients had proximal tendon injury, with sixteen avulsions and five partial tears. Sixteen of these patients had surgical confirmation of hamstring avulsion from the ischial tuberosity (14 conjoint, 2 biceps femoris alone) and all were reliably diagnosed with MR imaging (16/16), but less so with sonography (7/12). Four distal tendon avulsions were also observed (three semitendinosus, one biceps femoris). With respect to muscle injury, the biceps femoris was most commonly injured (124/154). Semimembranosus was an uncommon muscle injury (21/154) and semitendinosus rare (9/154). Imaging can discriminate a hamstring tendon avulsion from musculotendinous strain and helps identify which patients necessitate surgical management as opposed to conservative treatment.
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            Fractures of the tibial tuberosity in adolescents.

            The cases of fourteen adolescents with fifteen physeal fractures of the tibial tuberosity were reviewed to more accurately define specific fracture patterns, to establish treatment for the different types, and to determine the incidence of complications. A modified classification scheme with a greater emphasis on intra-articular extension of the fracture and communution of the tuberosity was devised. Closed or open reduction, as necessary, gave satisfactory results. The primary indications for surgery were: (1) displacement of one or more fragments of the tuberosity anterosuperiorly, and (2) extension of the fracture through the proximal tibial ossification center into the knee joint, with disruption of the joint surface. There appears to be an increased incidence of pre-existing Osgood-Schlatter disease (ipsilateral and contralateral) in patients who have an acute tuberosity injury. Complications are rare. The theoretical possibility of the subsequent development of genu recurvatum appears unlikely, since most of these injuries occur when the physis of the tuberosity is undergoing normal closure.
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              Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected.

               F. Rossi,  S. Dragoni (2001)
              To describe the prevalence, location and sports distribution of pelvic avulsion fractures in adolescent competitive athletes. One thousand two hundred and thirty-eight radiographs of the pelvis taken for focal traumatic symptoms in athletes with an age range of 11-35 years over a period of 22 years were reviewed. One hundred and ninety-eight adolescent athletes were affected by 203 avulsion fractures of the pelvic apophyses (five cases presented multiple locations). The localisation was the ischial tuberosity (IT) in 109 cases, anterior inferior iliac spine (AIIS) in 45 cases, anterior superior iliac spine (ASIS) in 39 cases, superior corner of pubic symphysis (SCPS) in 7 cases and iliac crest (IC) in 3 cases. Soccer (74 cases) and gymnastics (55 cases) were the sports with the highest number of avulsion fractures documented. Apophyseal avulsion fractures of the pelvis in adolescent competitive athletes are most common in soccer and gymnastics. The lesions are usually the consequence of sudden and forceful muscle-tendon contractions during sport activities. Plain radiographs, are determinant for the diagnosis.
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                Author and article information

                Journal
                Journal of the American Academy of Orthopaedic Surgeons
                Journal of the American Academy of Orthopaedic Surgeons
                Ovid Technologies (Wolters Kluwer Health)
                1067-151X
                2017
                April 2017
                : 25
                : 4
                : 251-259
                Article
                10.5435/JAAOS-D-15-00328
                28291142
                © 2017

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