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Two cases
of a comparatively uncommon entity, avulsion of anterior inferior iliac
spine (AIIS) are reported. Two male
adolescents reported to us with sudden onset pain over the iliac crest
and limp while running on the sports day at school.
X-rays revealed avulsion injury to the AIIS. Patients were treated with
bed rest and analgesics, the results were an early
return to full painless function. |
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| INTRODUCTION |
Avulsion fractures
of the apophysis of the pelvis and the femur are caused by vigorous and
uncoordinated activity.
Apophysis is a secondary centre of ossification, which contributes to the
contour, and size of the bone, but not the length. To emphasize the similarity
the apophysial injuries to those of the epiphysis, Milch1,5 introduced
the word apophysiolysis to parallel the injury called epiphysiolysis.
In children and adolescents, the ligaments are able to withstand more
force than the bones. The physis is the weakest part of the bone and is
vulnerable to both direct trauma and avulsion injuries.
There are two tendons of origin of the rectus femoris muscle; the anterior
or straight head arising from the anterior inferior iliac spine (AIIS),
and the posterior or refiected head arises from the groove at the brim
of the acetabulum. Gluteus medius insertion covers most of the surface
of greater trochanter, the gemelli, pyriformis, and the obturator internus
muscle insert above the gluteus. The muscles constitute the hamstrings
are the long head of biceps, the gracillis, the semimembranosus, and the
semitendinous.4 |
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| CASE REPORT |
| Two school going
children aged sixteen and eighteen years reported to us with sudden onset
pain over the iliac crest and limp while running on the sports day, at
school. They had tenderness over the AIIS, hip movements were terminally
painful, with antalgic gait. X-rays and MRI pelvis (Figs. 1 and 2) revealed
avulsion injury to the AIIS.6,7 Patients were treated with bed rest and
analgesics; the results were uneventful by the end of three weeks.8-10 |
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| DISCUSSION |
The
peak incidence of avulsion of the apophysis is second decade in
life, but it has been described in individuals of upto third decade
of life. The injury is related to athletic activity, some authors
have found
that it is common in athletes who have not observed a proper warm
up period. A powerful force, i.e. muscular extension unbalanced
by other normal forces, causes them. Stanisavljevic7 measured
the forces necessary to produce avulsion of AIIS in cadavers.
He concluded a quick applied force more easily injures the physis
than one of equal amount applied more gradually. Both of our patients
were able to maintain normal level of activity. Until proof of
better function following surgical treatment is established, these
injuries should be treated conservatively.
The prognosis of these avulsion fractures is good, mild symptoms
which recur with activity but may be relieved with aspirin or
other NSAIDs.3 No loss of function is expected.
|
Fig. 1 : X-ray
pelvis showing avulsion of left anterior inferior
iliac spine. |
Fig. 2 : MRI
of pelvis showing avulsion of left anterior inferior
iliac spine. |
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| CONCLUSION |
| At each apophysis
there is a characteristic appearance to the acute and healing phase. The
fragments were generally 1.5-3.0 cm in size and are displaced inferiorly
and laterally from the ileum. Out of two patients one was less painful
than the other was and he presented two days later to us than the first
patient. The healing of such cases can result in an exostosis like appearance.2,11 |
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| ACKNOWLEDGEMENTS |
| We thank the Dean,
Dr. ME Yeolekar, LTMGH and the Head of Department of Orthopedics, Dr.
AB Goregaonkar, LTMGH, Sion Hospital for giving us permission to publish
the above data and our residents Dr. Ashish and Dr. Shailendra for maintaining
records. |
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| REFERENCES |
| 1. |
Milch
H. Ischial apophysiolysis : a new syndrome. Bull Hospital Joint
Dis 1953; 14 : 188-93. |
| 2. |
Irving
MH. Exostosis formation after traumatic avulsion of anterior inferior
iliac spine. J Bone Joint Surg (Br)
1964; 46 : 720-22. |
| 3. |
Finby
N, Begg CF. Traumatic avulsion of ischial epiphysis simulating
neoplasm. NY State J Med 1967; 67 : 2428-90. |
| 4. |
MacCleod
S, Lewin P. Avulsion of tuberosity of ischium. JAMA 1929; 92 :
1597. |
| 5. |
Clancy
WG, Foltz AS. IIiac apophysitis and stress fractures in adolescent
runners. Am J Sports Med 1976; 4 : 214-18. |
| 6. |
Christopher
F. Fracture of the anterior superior spine of ileum. JAMA 1933;
100 : 113-14. |
| 7. |
Stanisavljevic
S. Fracture of anterior inferior spine of ileum. Arch Ortop 1953;
71 : 626-30. |
| 8. |
Pennel
GF, Sutherland G. Fractures of the pelvis. AAOS Instructional
motion picture, 1961. |
| 9. |
Quinby
WC. Fractures of the pelvis and associate injuries in children.
J Pediat Surg 1966; 1 : 353. |
| 10. |
Rang
M. Children’s fractures. Philadelphia, JB Lippincott Co.
1974; 150-54. |
| 11. |
Schlonsky
J, Olix ML. Functional disability following fracture of the ischial
epiphysis. J Bone Joint Surg (Am) 1972; 54 : 641-44. |
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MEDITERRANEAN
DIET AND MORTALITY
One that is high in vegetables, legumes, fruits and nuts, and
fish and low in meat and high-fat dairy products and that includes
moderate intake of alcohol is believed to have health benefits.
These data provide more evidence of the health benefits of a Mediterranean
diet.
N Engl J Med, 2003; 348 : 2599. |
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