- Diagnosis of both injuries can be made with plain
radiographs. Treatment is conservative including
symptom-limited weight-bearing until pain free, fol-
lowed by gradual return to activities. - Recovery from an avulsion injury of the AIIS injury is
typically more prolonged than that of an ASIS injury. - Abrupt contraction of the abdominal muscles, as with a
rapid direction change, can lead to avulsion of the iliac
crest. Direct trauma can also fracture the iliac crest
apophysis. This commonly occurs when an athlete is
tackled in football. Plain radiographs may not be as
useful for diagnosis in this injury, as displacement may
be minimal. MRI or bone scan may be helpful in diag-
nosing iliac crest avulsion. Treatment is conservative
and includes protected weight bearing until the athlete
is not in pain followed by progressive return to activity. - Other sites of avulsion injury in the hip and pelvis
include the greater trochanter, lesser trochanter, and
ischial tuberosity. Diagnosis and treatment are similar
to that mentioned for ASIS and AIIS injuries.
•Tibial tubercle avulsions typically occur while an ath-
lete is jumping, as a result of a violent contraction of
the quadriceps. Excessive bleeding and swelling can
cause an anterior compartment syndrome, so a careful
neurovascular examinaton is essential. Diagnosis can
be made with plain radiographs. Long leg cast immo-
bilization with the knee in extension for 3–4 weeks is
adequate treatment for nondisplaced fractures. Open
reduction with internal fixation is required if there is
significant displacement of the fracture fragment.
•Avulsions of the medial epicondyle are common in
throwing athletes. The athlete typically reports
feeling a snap or pop during the throwing motion.
Anteroposterior(AP) and lateral elbow radiographs
will demonstrate the avulsion. Minimally displaced
fractures can be treated with immobilization, while
fractures displaced more than 5 mm should receive
surgical referral (Wheeless, 2003).
•Vertebral end plate fractures are an avulsion of the
ring apophysis of the vertebra. If the avulsion is from
the posterior inferior portion of the vertebra, the
apophyseal attachment of the associated disc and the
apophysis can be displaced into the vertebral canal,
causing neurologic symptoms. This injury can be dif-
ficult to distinguish from disc herniation. Plain radi-
ographs can show the separated bony fragment, and
MRI can demonstrate marrow edema. Treatment is
operative removal of the disc and bony fragment.
TORUS FRACTURES
•Torus or buckle fractures are compressive fractures
that lead to failure of the bone at the junction of the
metaphysis and diaphysis.
- This type of injury only occurs in children, and is pos-
sible because of the porous nature of their bones.
•Torus fractures are stable and heal well. They can be
treated with splinting or casting for comfort.
GREENSTICK FRACTURES- Another fracture that only occurs in children, the
greenstick fracture refers to an incomplete fracture in
the shaft of a long bone. There is disruption of one
cortex of the bone and bending on the other. The abil-
ity of the pediatric bone to plastically deform allows
for the occurrence of this type of fracture. - Greenstick fractures with minimal angulation can be
treated with immobilization.
•Surgical intervention may be required for fractures
with significant angulation.
SUPRACONDYLAR FRACTURES- Supracondylar fractures are very common among
3–11-year-old children. - Supracondylar factures are the pediatric fractures with
the highest risk of complications, particularly neu-
rovascular complications. - These fractures are usually sustained from a fall on an
outstretched hand, but can also occur as a result of
direct trauma. A thorough neurovascular examinaton
is imperative if a supracondylar fracture is suspected. - The diagnosis can typically be made with plain AP
and lateral radiographs of the elbow.
•Any child with a supracondylar fracture should be
referred for evaluation by a pediatric orthopedist, as
many require surgical fixation.
OVERUSE INJURIES•Overuse injuries have become more common in chil-
dren with the growth of competitive youth sports pro-
grams (Difiori, 1999).- Risk factors for overuse injuries are often divided into
intrinsic and extrinsic factors.
INTRINSIC RISKS FOR OVERUSE INJURIES- Some issues specific to immature skeletons contribute
to the risk for overuse injuries in children. For
instance, children have growth cartilage in several
areas of the skeleton, and it is particularly susceptible
to injury from repetitive stress.
560 SECTION 7 • SPECIAL POPULATIONS