Avulsion fracture of the ischial tuberosity in adolescents—an easily missed diagnosis
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《英国医生杂志》
1 Department of Orthopaedics and Trauma, St George's Hospital, London SW17 0QT
Correspondence to: S Gidwani, 122 Durham Road, London SW20 0DG samgidwani@yahoo.com
Introduction
The history and clinical picture of avulsion of the ischial apophysis closely mimics that of a hamstring injury. Hamstring rupture seems to have been diagnosed in each of these cases, with the adoption of a "watchful waiting" policy This led to a false sense of security about the patient's likelihood of recovery. Misdiagnosis is more likely if the patient is not examined specifically for tenderness at the ischial hamstring origin.
Recognition of the fracture and the extent of displacement is important, as this will alter the management of the patient. This is the case even with an undisplaced fracture, as a longer period of rehabilitation will be necessary1 and hamstring stretching may have to be avoided for some weeks. Therefore radiography should be done in all patients who exhibit bony tenderness, or a palpable gap, at the site of the hamstring origin. In the absence of a fracture visible on an x ray film, magnetic resonance imaging may also be helpful to show any soft tissue injury that may require repair, such as an avulsion of the conjoined tendon of the hamstring muscles, with or without a sleeve of periosteum.2
If substantial displacement is present, a specialist orthopaedic pelvic surgeon may consider reducing and fixing the avulsed fragment immediately to prevent the development of a mobile non-union and substantial pain and weakness, which prevent the patient returning to sports or even normal pain-free walking.3 4 Several reports have been published about patients with symptoms similar to those described above, either after intentional and aggressive non-operative management or after missed diagnoses.5-7
Perform pelvic radiography in adolescents with history of proximal hamstring injury and current ischial tenderness
Contributors: SG wrote most of the paper, including the introduction and discussion. He reviewed and revised the case histories. JJ wrote the initial case histories and contributed to parts of the discussion. MB proposed the idea for the paper and reviewed and revised the manuscript; he was also the surgeon responsible for the care of the patients involved. He is the guarantor.
Funding: No special funding.
Competing interests: None declared.
References
Kujala UM, Orava S, Jarvinen M. Hamstring injuries. Current trends in treatment and prevention. Sports Med 1997;23: 397-404.
Brandser EA, El-Khoury GY, Kathol MH, Callaghan JJ, Tearse DS. Hamstring injuries: radiographic, CT, and MR imaging characteristics. Radiology 1995;197: 257-62.
Wootton JR, Cross MJ, Holt KWG. Avulsion of the ischial apophysis. The case for open reduction and internal fixation. J Bone Joint Surg Br 1990;72: 625-7.
Servant CT, Jones CB. Displaced avulsion of the ischial apophysis: a hamstring injury requiring internal fixation. Br J Sports Med 1998;32: 255-7.
Hamada G, Rida A. Ischial apophysiolysis (IAL): report of a case and a review of the literature. Clin Orthop 1963;31: 117-30.
Mattick AP, Beattie TF, Macnicol MF. Just a pulled hamstring? Emerg Med J 1999;16: 457-8.
Schlonsky J, Olix ML. Functional disability following avulsion fracture of the ischial epiphysis: a report of two cases. J Bone Joint Surg Am 1972;7: 615-24.(Sam Gidwani, specialist r)
Correspondence to: S Gidwani, 122 Durham Road, London SW20 0DG samgidwani@yahoo.com
Introduction
The history and clinical picture of avulsion of the ischial apophysis closely mimics that of a hamstring injury. Hamstring rupture seems to have been diagnosed in each of these cases, with the adoption of a "watchful waiting" policy This led to a false sense of security about the patient's likelihood of recovery. Misdiagnosis is more likely if the patient is not examined specifically for tenderness at the ischial hamstring origin.
Recognition of the fracture and the extent of displacement is important, as this will alter the management of the patient. This is the case even with an undisplaced fracture, as a longer period of rehabilitation will be necessary1 and hamstring stretching may have to be avoided for some weeks. Therefore radiography should be done in all patients who exhibit bony tenderness, or a palpable gap, at the site of the hamstring origin. In the absence of a fracture visible on an x ray film, magnetic resonance imaging may also be helpful to show any soft tissue injury that may require repair, such as an avulsion of the conjoined tendon of the hamstring muscles, with or without a sleeve of periosteum.2
If substantial displacement is present, a specialist orthopaedic pelvic surgeon may consider reducing and fixing the avulsed fragment immediately to prevent the development of a mobile non-union and substantial pain and weakness, which prevent the patient returning to sports or even normal pain-free walking.3 4 Several reports have been published about patients with symptoms similar to those described above, either after intentional and aggressive non-operative management or after missed diagnoses.5-7
Perform pelvic radiography in adolescents with history of proximal hamstring injury and current ischial tenderness
Contributors: SG wrote most of the paper, including the introduction and discussion. He reviewed and revised the case histories. JJ wrote the initial case histories and contributed to parts of the discussion. MB proposed the idea for the paper and reviewed and revised the manuscript; he was also the surgeon responsible for the care of the patients involved. He is the guarantor.
Funding: No special funding.
Competing interests: None declared.
References
Kujala UM, Orava S, Jarvinen M. Hamstring injuries. Current trends in treatment and prevention. Sports Med 1997;23: 397-404.
Brandser EA, El-Khoury GY, Kathol MH, Callaghan JJ, Tearse DS. Hamstring injuries: radiographic, CT, and MR imaging characteristics. Radiology 1995;197: 257-62.
Wootton JR, Cross MJ, Holt KWG. Avulsion of the ischial apophysis. The case for open reduction and internal fixation. J Bone Joint Surg Br 1990;72: 625-7.
Servant CT, Jones CB. Displaced avulsion of the ischial apophysis: a hamstring injury requiring internal fixation. Br J Sports Med 1998;32: 255-7.
Hamada G, Rida A. Ischial apophysiolysis (IAL): report of a case and a review of the literature. Clin Orthop 1963;31: 117-30.
Mattick AP, Beattie TF, Macnicol MF. Just a pulled hamstring? Emerg Med J 1999;16: 457-8.
Schlonsky J, Olix ML. Functional disability following avulsion fracture of the ischial epiphysis: a report of two cases. J Bone Joint Surg Am 1972;7: 615-24.(Sam Gidwani, specialist r)