Apophysiolysis of the pelvic area in adolescents.

Transcription

1 Apophysiolysis of the pelvic area in adolescents. Poster No.: C-0077 Congress: ECR 2014 Type: Educational Exhibit Authors: R. Derks, R. E. Westerbeek, R. Van Dijk; Deventer/NL Keywords: Musculoskeletal bone, Conventional radiography, Fractal analysis, Athletic injuries DOI: /ecr2014/C-0077 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 26

2 Learning objectives To review the anatomical locations of apophyseolysis of the pelvic area in adolescents, focusing on conventional roentgenogram features. Page 2 of 26

3 Images for this section: Fig. 1: anatomical positions of pelvic apophyses Page 3 of 26

4 Background Apophyseolysis of the pelvic is a common injury seen among young atheltes in the age group of years. At this age the apophyses is the weakest point in the tendon bone connection during contraction. There is a slight male predominance of 2:1. Probably because apophyseolysis is commonly seen in soccer/football players, atheletes, gymnasts and basketball players. During sports activity a sudden forcefull eccentric contraction can result in an avulsion of the unossified growth centre. The patient will complain of acute pain after kicking, starting a sprint or jumping. Limbing is also a common symptom. Normally the diagnosis can be made on a conventional roentgenogram, but the dislocation of the growth centre can be very subtle. In such cases ultrasound or MRI can be helpfull. Initial treatment of an apophyseolysis is conservative. Rest and gradually increase of weight baring of the leg, will result in full recovery within 4-6 weeks. A missed apophyseolysis can develope in non-union with chornic pain and movement impairment. Which can be treated with a surgical intervention. Pelvic apophyses: There are seven apophyses of the pelvis (figure 1). They will be discussed in order of appearance in apophyseolysis. 1. Ischial tuber It is the attachment site of the semimebranosis, semitendinosis and femoral biceps muscle (from medial to lateral) (figure 2 and 3). There is a close relationship with the ischial nerve, which can get affected during injury. Entrapment or compression of the ischial nerve is commonly seen in cases of a chronic apophyseolysis. 2. Inferior anterior iliac spine (IAIS) The straight head of the rectus femoris muscle attaches on this apophysis. Forceful extension of the hip (kicking a ball) results in an avulsion (figure 4). Figure 5 till 8 shows a chronic avulsion of the IAIS in case of 15 year old soccer player. 3. Superior anterior iliac spine (SIAS) The sartorius muscle and the tensor fascia lata attaches on this site. The tensor fascia lata is a stabilizer of the hip and knee, so injury to this site can also result in knee pain. Figure 9 shows an apophyseolysis od the SIAS. A large displacement of a SIAS avulsion can simmulate an IAIS avulsion. Page 4 of 26

5 4. Pubic symphysis The adductor brevis, longus and gracilis muscle attache on this site, from superior to inferior respectively. Injury at this site is mainly seen in dancers and football players. Apophyseolysis of the pubic symphysis is very difficult to diagnose on roentgenogram, figure iliac crest All the abdominal muscles attache on this site. Injury is mainly in long distance runners, because of repetitive twisting of the lumbar area. Apophyseolysis of the iliac crest is the most difficult to diagnose, because bilateral widening of the apophysis is a normal variant. So is fragmentation. The only clue on roentgenogram is asymmetrical widening (figure 11). If unsure about the diagnosis on roentgenogram a MR is strongly adviced. 6. Minor trochanter The iliopsoas muscle insert at the minor trochanter. It is a rare type of apophyseolysis. Figure 12 shows a apophyseolysis in a 13 year old boy. He recoverd within 6 weeks. The roentgenogram taken 6 months after the trauma shows a fully consolidated apophyses (figure 13). 7. Major trochanter The gluteus medius and minimus muscle insert at this site. A benign avulsion of this apophysis is extremely rare. It is mainly seen in case of a tumor/metastasis. Page 5 of 26

6 Images for this section: Fig. 1: anatomical positions of pelvic apophyses Page 6 of 26

7 Fig. 2: subtle apophyseolysis of the ischial tuber Deventer Ziekenhuis - Deventer/NL Page 7 of 26

8 Fig. 3: apophyseolysis of the ischial tuber. Deventer Ziekenhuis - Deventer/NL Page 8 of 26

9 Fig. 4: apophyseolysis of the inferior anterior iliac spine Deventer Ziekenhuis - Deventer/NL Page 9 of 26

10 Fig. 5: Chronic apophyseolysis of the inferior anterior iliac spine (IAIS). Deventer Ziekenhuis - Deventer/NL Page 10 of 26

11 Fig. 6: apophyseolysis of the IAIS on US, comparison with the contralateral side. Deventer Ziekenhuis - Deventer/NL Page 11 of 26

12 Fig. 7: coronal T2 of a chronic apophyseolysis of the IAIS Deventer Ziekenhuis - Deventer/NL Page 12 of 26

13 Fig. 8: axial STIR of a chronic apophyseolysis of the IAIS. Deventer Ziekenhuis - Deventer/NL Page 13 of 26

14 Fig. 9: apophyseolysis of the superior anterior iliac spine Page 14 of 26

15 Fig. 10: apophyseolysis of the symfysis. Stevens M A et al. Radiographics 1999;19: Page 15 of 26

16 Fig. 11: apophyseolysis of iliac crest. Page 16 of 26

17 Fig. 12: apophyseolysis of the minor trochanter. Deventer Ziekenhuis - Deventer/NL Page 17 of 26

18 Fig. 13: 6 months follow up after apophyseolysis of the minor trochanter. Deventer Ziekenhuis - Deventer/NL Page 18 of 26

19 Findings and procedure details Roentgenogram is the imaging modality of choice. The avulsion of the apophysis can be recognized by widening of the apophysis or dislocation of the partially ossified growth centre (figure 4). A standard anterio-posterior view is usually sufficient. In case of the inferior anterior iliac spine (IAIS) a additional Laustein-view can be helpfull. An axial view of the hip can reveal subtle ischial tuber apophyseolysis. Ultrasound can be used in cases of apophyseolysis of the IAIS and the superior anterior iliac spine (SIAS), because of their superficial position (figure 6). Our MR protocol consisted of axial T1, T2, STIR and an additional coronal T2 acquisition, scanned on a 1,5 Tesla MR. It will show (bone) oedema around the apophysis. The dislocation of the growth centre may be visible. In case of a chronic apophyseolysis extensive callus formation is seen (figure 8 and 9). Page 19 of 26

20 Images for this section: Fig. 4: apophyseolysis of the inferior anterior iliac spine Deventer Ziekenhuis - Deventer/NL Page 20 of 26

21 Fig. 6: apophyseolysis of the IAIS on US, comparison with the contralateral side. Deventer Ziekenhuis - Deventer/NL Page 21 of 26

22 Fig. 7: coronal T2 of a chronic apophyseolysis of the IAIS Deventer Ziekenhuis - Deventer/NL Page 22 of 26

23 Fig. 8: axial STIR of a chronic apophyseolysis of the IAIS. Deventer Ziekenhuis - Deventer/NL Page 23 of 26

24 Conclusion Pelvic apophyseolysis in adolescents is a common sports injury. The features of an acute apophyseolysis on roentgenogram are clear but can be very subtle. In case of doubt ultrasound and MRI can be helpfull. Chronic apophyseolysis can have an agressive apperance on roentgenogram, but with the correct knowledge of the anatomical locations and a history of a sportstrauma the diagnosis can be made easily on conventional roentgenogram. Page 24 of 26

25 Personal information Rosalie Derks, radiology resident. Deventer Ziekenhuis, the Netherlands. Page 25 of 26

26 References 1. Imaging features of avulsion injuries. Stevens et al. radiographics 1999;19: Avulsions of the pelvic, Timothy G. Sanders, Michael B. Zlatkin. Semin Musculoskelet Radiol 2008; 12(1): Apofysis avulsion of the hip and pelvis, McKiney et al. orthopedics 2009;32(1) 4. Avulsion fractures of the pelvis - a qualitative systemativ review of the literature. Porr et al. JCCA 2011;55(4): Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected. Rossi, Dragoni. Skeletal radiology 2001;30(3): Page 26 of 26