A Surgical Approach for an Avulsion Fracture of the Ischial Tuberosity

Abstract

We report a case of an avulsion fracture of the ischial tuberosity treated with a new surgical approach early after injury. Although surgical treatment of this fracture is usually avoided because of the difficulty of the procedure and the risk of sciatic nerve complication, we believe our subgluteal approach is simple and safe. We therefore recommend it for treating avulsion fractures of the ischial tuberosity, especially when the fragment is displaced by >2 cm and the sciatic nerve is not involved. If there is clinical evidence of sciatic nerve disturbance, it is likewise an indication for surgery. However, the incision needs to be deepened to approach the nerve, along the lines of the incisions advocated by both Miller and Spinner.

Chronic (Ten Years) Ischial Tuberosity Avulsion Fracture Nonunion Treated with Fragment Excision and Simultaneous Primary Repair of the Hamstring Tendon

“…Fractures displaced less than 2 cm often respond well to conservative treatment with rest, analgesics, and cessation of sporting activities until symptoms subside 2,[5][6][7][8]11 . Alternatively, many authors agree that fractures with greater than 2-cm displacement will benefit from surgical intervention in order to prevent nonunion, fibrosis, or overgrowth of the ischium 2,3,7,8,11,12 . Many case reports have documented the morbidity associated with ischial tuberosity avulsion fracture nonunion, including chronic pain with prolonged sitting and walking, weakness, and inability to engage in sports 1,2,7,8 .…”

“…This can be accomplished through a subgluteal or Kocher-Langenbeck approach 2,3,11,12 . There are several case reports that describe this method, with successful resolution of symptoms and return to sports 3,6,11 . Alternatively, if open reduction and internal fixation proves to be unfeasible, some authors have referenced the possibility of resecting the ischial apophysis and then reattaching the hamstring tendon directly to the ischium 2,15 .…”

“…To our knowledge, three years is the longest time span reported in the literature between ischial tuberosity avulsion fracture injury and nonunion repair 1,2,8,9,11,12 . We present a case of a chronic ischial tuberosity avulsion fracture nonunion with a ten-year delay between the initial injury and definitive surgical management via fragment excision and primary hamstring repair.…”

Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports

“…Because the cartilaginous growth plates at the apophyses of the adolescents are more prone to trauma than the musculotendinous units, they may fail resulting in a avulsion fracture of the pelvis [3]. Patients usually report a crack in the pelvic region during an activity with a sudden onset of pain [4, 5]. The pain is more severe during activity and decreases with rest.…”

Diagnosis and Treatment of Apophyseal Injuries of the Pelvis in Adolescents

“…Other reports can be found in the literature supporting this assumption. 14 In some case operative treatment may also become necessary following initial conservative treatment (►Figs. 2 and 3).…”