Indirect avulsion of the iliac crest epiphysis: a rare lesion

Abstracts

A avulsão da cartilagem da crista ilíaca é uma lesão infreqüente e raramente é descrita na literatura. Atletas jovens e adolescentes são os indivíduos mais predispostos à lesão. O trauma indireto causado pela contração da musculatura aderida à crista ilíaca e o movimento de angulação do tronco em sentido oposto ao da contração é o mecanismo mais comum de arrancamento da cartilagem. Como na maioria dos casos não existe trauma direto, esses podem não ser diagnosticados se não considerarmos essa possibilidade de lesão. Relatamos dois casos atendidos em nosso Serviço, que apresentaram lesão na cartilagem devido a um trauma indireto (contração muscular abrupta). Ambos foram tratados de maneira incruenta, com excelente evolução.

Epífise; ilíaco; crista; avulsão; indireta; trauma

RELATO DE CASO

Indirect avulsion of the iliac crest epiphysis. A rare lesion

Gilberto José Cação Pereira^I; Hamilton da Rosa Pereira^II; Márcio Cruz^II

^IAssistant Professor

^IIAssistant Professor Doctor

^IIIResident

^{Correspondence}

SUMMARY

Avulsion of the iliac crest cartilage is an infrequent, rarely described lesion. Young and adolescent athletes are prone to this lesion. Indirect trauma caused by contraction of the muscles inserted at the iliac crest and the angulation movement of the trunk in direction opposite to the contraction is the most common mechanism causing cartilage tearing. As most of the cases do not present direct trauma, diagnosis can be missed if that possibility is not considered.

Two cases attended by our Service are described. Lesion in the cartilage was observed due to an indirect trauma (abrupt muscular contraction). Both cases were treated and the evolution was excellent.

Key Words: Epiphysis; iliac; crest; avulsion; indirect; trauma.

INTRODUCTION

Avulsion of the iliac crest epiphysis is an infrequent lesion, rarely described in the literature. In general, it occurs in young athletes and can be caused by direct or indirect trauma. In most of the cases, it is a consequence of indirect trauma, which can be repetitive muscular stress or abrupt contraction of the muscles inserted into that site^(1.2).

We report two cases with indirect avulsion of that cartilage.

CASE 1

A 15 year-old female patient was attended in our Emergency Service, complaining of intense pain in the left iliac crest, which started during a gymnastics class when she made an abrupt trunk inclination to the right with the hip in the opposite direction. According to the patient no direct trauma took place.

During the clinical examination, palpation of the left iliac crest caused intense pain. The left hip articulation presented passive free movements but moderate pain with hip adduction; the patient walked with great difficulty due to pain in the left iliac crest.

The radiological examination (Figure 1) revealed avulsion in the anterior part of the left iliac crest epiphysis. In figure 2, X-rays carried out with two focus of light provided a more detailed observation and comparison of the epiphysis.

Iliac crest epiphysis avulsion was confirmed; analgesics were prescribed during 3 days and bed rest during 7 days to alleviate pain. After that period, the patient showed improvement as concerned pain, crutches were recommended to walk during 7 days, and physical activities were restricted during 15 days.

After treatment, no pain or limitation of movement were observed, and the X-rays detected signs of fusion in the left iliac crest epiphysis (Figure 3).

CASE 2

A 14 year-old female patient was attended by the Service complaining of intense pain in the right iliac crest, starting abruptly after a sudden trunk angulation for the left during a dance class. No trauma had occurred at that site.

The orthopedic examination revealed intense pain due to palpation of the right iliac crest and difficulty to move the correspondent lower limb due to pain in the iliac region. She needed help to walk and pain was more intense when she rested on the right lower limb The X-rays revealed avulsion of the anterior part of the right iliac crest epiphysis (Figure 4 and 5)

Figure 5

The radiological examination confirmed the diagnosis: avulsion of the iliac crest epiphysis and the same treatment was prescribed as for Case 1.

After ninety days, walking and active movements of the right lower limb were normal and no pain was observed on palpation of the right iliac crest. X-rays with focus of light (Figure 6) showed signs of fusion in the right iliac crest epiphysis.

DISCUSSION

Ossification of the iliac epiphysis is gradual and usually occurs anteriorly to posteriorly and all cartilage will ossify about the age of 14 in females and 15 in males⁽⁴⁾. Notwithstanding, fusion of the ossified cartilage with the iliac bone will only happen about the age of 18, and during that interval direct or indirect trauma can cause its displacement.

Indirect trauma is the most common cause of harm to that cartilage and it is frequently consequence of an abrupt contraction of the muscles at that point inserted (abdominal transverse, internal oblique and external oblique) in association with a rotational or inclination movement of the trunk in the opposite direction^(1,2).

Lesions in the iliac epiphysis in general occur anteriorly to the cartilage. It is considered a rare lesion and the medical papers published in the English language have only described ten cases provoked by indirect trauma all of them due to the practice of sports^(1,2,5).

Considering both cases clinical history, the mechanism of the lesion was an indirect trauma, that is, an angulation of the hip in one direction and a sudden contraction of the muscles inserted in the epiphysis in the opposite direction, causing its displacement. We think that lack of synchrony of trunk and hip at the moment of muscle contraction was a very important element in the lesion mechanism.

Avulsion of the iliac crest epiphysis can cause a greater or smaller degree displacement. When displacement surpasses 3 cm open reduction and fixation may be necessary to avoid future deformities; smaller displacements can be treated by non-surgical methods⁽³⁾.

Recommended non-surgical treatment is bed rest and medication to alleviate pain during the first days, walking with crutches, avoiding to stand on the correspondent lower limb during approximately seven days in order that additional displacement does not occur. After that period, the patient can gradually stand, however physical activities are restricted for four weeks^(1,2).

We consider interesting these cases because of the trauma mechanism and also because they call our attention to the possibility of having that kind of lesion at that site, since as direct trauma does not occur the lesion can pass unnoticed.

The reported cases had excellent evolution and two months after the trauma the patients did not present pain or iliac crest deformity and could walk normally.

REFERÊNCIAS BIBLIOGRÁFICAS

Trabalho recebido em 01/11/2001. Aprovado em 28/03/2002

*Work performed at the Faculdade de Medicina de Botucatu - UNESP

• 1. Godshall, R.W., Hansen, C.A.: Incomplete avulsion of a portion of the iliac epiphysis. An injury of young athletes. J. Bone Joint Surg Am 55(6): 1301-2, 1973.
• 2. Lambert, M.J., Fligner, D.J.: Avulsion of the iliac crest apophysis: A rare fracture in adolescent athletes. Ann Emerg Med 22(7): 1218-20, 1993.
• 3. Lombardo, S.J., Retting, A.C., Kerlan, R.K.: Radiografic abnormalities of the iliac apophysis in adolescent athletes. J. Bone Joint Surg Am 65(4): 444-6, 1983.
• 4. Tachdjian, M.O.: Scoliosis; In: Pediatric Orthopaedics, Philadelphia, W. B. Saunders, 1990, p.2265-379,
• 5. Winkler, A.R., Barnes, J.C., Ogden, J.A.: Break dance hip: Chronic avulsion of the anterior superior iliac spine. Pediatr Radiol 17:501-2, 1987.

Correspondence to

Departamento de Cirurgia e Ortopedia

Faculdade de Medicina de Botucatu - UNESP

CEP 18618-970 - Botucatu - SP

Publication Dates

• Publication in this collection
  05 Sept 2005
• Date of issue
  June 2002

History

• Accepted
  28 Mar 2002
• Received
  01 Nov 2001