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Avulsion Fractures of the Pelvis

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Other Names

  • Avulsion Fractures of the Trochanters
  • Greater Trochanter Avulsion Fracture
  • Lesser Trochanter Avulsion Fracture
  • Avulsion Fractures of the Ilium
  • Iliac Crest Avulsion Fracture
  • Anterior Superior Iliac Spine Avulsion Fracture (ASIS)
  • Anterior Inferior Iliac Spine Avulsion Fracture (AIIS)
  • Ischial Tuberosity Avulsion Fracture
  • Apophyseal avulsion fractures of the pelvis

Background

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Avulsion Fractures of the Pelvis - Review Pod
  • This page covers avulsion fractures of the pelvis and hip, typically seen in adolescent athletes along vulnerable physis

History

  • Needs to be updated

Epidemiology

  • 3-5% of Adolescent injuries involve the groin[1]
  • Age range is 13 to 17 years[2]
  • 68.5% to 76% of patients are male[3]

Introduction

The main locations of avulsion fractures occurring around the pelvis and hip joints. (A) Anterior view. (B) Posterior view. IC, iliac crest; ASIS, anterior superior iliac spine; AIIS, anterior inferior iliac spine; IT, ischial tuberosity; PT, pubic tubercle; LT, lesser trochanter; GT, greater trochanter; OE, obturator externus muscle insertion.[4]
Sites of avulsion fractures of the pelvis and proximal femur. (1) inferior pubic ramus, (2) anterior inferior iliac spine, (3) anterior superior iliac spine, (4) pubic symphysis, (5) iliac crest, (6) greater trochanter, (7) lesser trochanter[5]
Schema of the most frequent sites of pelvic apophyseal avulsion fractures. a = iliac crest (insertions of the abdominal muscles, the tensor of fascia lata and of the gluteus medius); b = anterior superior iliac spine (insertion of sartorius); c = anterior inferior iliac spine (insertion of rectus femoris); d = superior corner of pubic symphysis (insertion of rectus abdominis); e = ischial tuberosity (insertion of hamstrings muscles = semitendinous, semimembranous and long head of the biceps femoris muscles); f = lesser trochanter (insertion of iliopsoas muscle).[6]
A 17-year-old male patient presented to the emergency department with sudden pelvic pain while running. (A) A radiograph of the patient's pelvis revealed an avulsion fracture at the left anterior superior iliac spine. (B) Conservative treatment led to healing with anterior displacement but union of the fracture.[4]
An 11-year-old male patient presented to the clinic with right hip pain after playing soccer. (A) A radiograph of the hip joint showed an avulsion fracture at the right lesser trochanter (arrow). (B) After 3 months of conservative treatment, radiographs demonstrated bone union (arrow). (C) Seven years after the injury, no specific imaging concerns related to growth were noted, and bone remodeling proceeded well (arrow).[4]
A 31-year-old male patient presented to the outpatient clinic with persistent pain around the left iliac tuberosity following an injury. Radiographs revealed an avulsion fracture at the left iliac tuberosity with a non-sharp margin, indicating a healed, non-displaced configuration. Symptoms improved with conservative treatment.[4]
Pelvis outlet radiograph showing avulsion fracture of ischial tuberosity with fragment displacement of 1.5 cm (arrow).[7]
Ischial tuberosity avulsion fracture. A, This pelvis radiograph shows a displaced ischial tuberosity avulsion fracture in an adolescent football player. B, This pelvis radiograph shows interval open reduction internal fixation using 2 cannulated 6.5-mm diameter partially threaded cancellous screws.[8]

General

  • Avulsion fractures of the pelvis/hip region are uncommon injuries typically seen in adolescent athletes
  • Scarctity of injuries makes them a particular challenge for orthopedists
  • Diagnosis is often overlooked as symptoms are dismissed as a muscular or tendinous injury without radiographs
  • Surgical vs nonsurgical management remains debated

Etiology

  • Occurs sports that require quick change of direction, running, jumping, and other athletic movements that require intense and sudden strain
  • Examples include: skiing, soccer, American football, boxing, track and field, and ice hockey[9]
  • Less commonly, direct trauma
  • Less commonly, overuse with the onset of a stress injury

Pathophysiology

  • Caused by forceful muscle contraction or sudden and excessive passive muscle stretching
  • Typically occur in young athletes whose cartilaginous growth plates are not ossified[10]
  • Secondary ossification centers are weaker than the muscular–tendinous unit until they ossify
  • This is why avulsion fractures are more likely to occur than a tendon or muscle injury

Challenges

  • Many publications are limited to case reports and case series
  • Due to the low frequency of avulsion fractures of the hip and pelvis, evidence based guidelines are lacking
  • There is not a consensus about which patients should be managed surgically and non surgically
  • Further, not all publications are consistent with terminology and inclusiveness

Location

  • The most common site of injury is[2][11]
    • Anterior superior iliac spine (30% to 37%)
    • Anterior inferior iliac spine (31% to 49%)
    • Ischial tuberosity (11% to 14%)
    • Lesser trochanter (9%)
    • Iliac crest (8% to 10%)
    • Superior corner of the pubic symphysis (1%)
  • Using the Risser classification to grade skeletal maturity[12]
    • Older patients more likely to suffer injuries to iliac apophysis
    • Younger patients more likely to sustain injury to AIIS, ischial tuberosity
    • Timining of complete ossification of the apophysis is likely accountable for these differences
    • AIIS closes first, Iliac crest closes last[13]

Avulsion Fractures of the Anterior Inferior Iliac Spine

  • Insertion of Rectus Femoris, a diarthrodial muscle of the hip and knee joints
  • Mechanism: Kicking, jumping, sudden hip extension
    • Can occur with a concentric or eccentric contraction of the rectus femoris
    • Most commonly occurs during acceleration phase of sprinting, jump or a kick
  • Less commonly, passive elongation of the musculotendinous unit during gymnastic movements[14]
  • Relatively common accounting for 20-25% of pelvic avulsion fractures[15]

Avulsion Fractures of the Ischial Tuberosity

  • Insertion of Hamstring Muscle Group
  • Mechanism: Sprinting, hip flexion with knee extension
    • Indirect avulsion fractures can result from vigorous flexion with the knee in extension
    • Concomitant activation of hamstring muscles
    • Patients will report a crack, followed by pain of the proximal/posterior thigh
  • Most common site of pelvic avulsion fracture in adolescents
  • Delays in diagnosis are common as these are often considered hamstring sprains initially

Avulsion Fractures of the Iliac Crest

  • Iliac Crest
    • Extends from ASIS to PSIS
    • Serves as attachment site of multiple abdominal muscles
  • Account for only 1-2% of avulsion fractures of the pelvis/hip
  • Insertion of the Tensor Fascia Latae
    • Massive/repetitive contractions can lead to avulsion injuries
    • Patients present with sharp, localized anterolateral pelvic pain
    • Typically there is swelling, tenderness, trouble walking

Avulsion Fractures of the Pubic Symphysis and Pubic Ramus

  • Insertion of the Rectus Abdominis, gracilis, adductor longus, adductor brevis
    • Adductor longus is the most frequently injured, followed by adductor brevis, pectineus
  • Mechanism: Forceful adduction or trunk flexion
    • Most commonly from chronic overuse, accumulated repetitive microtrauma
    • Sudden, forceful contractions are less commonly
  • Often seen in soccer, ice hockey, tennis

Avulsion Fractures of the Lesser Trochanter

  • Insertion site of Iliopsoas
  • Mechanism: Forceful hip flexion
    • Case reports of it also occurring after a tonic-clonic seizure
  • Seen in track and field, soccer ages 13 to 18
  • Relatively rare, accounting for 1-3% of hip avulsion fractures

Avulsion Fractures of the Anterior Superior Iliac Spine

  • Attachment of Sartorious
  • Mechanism: Sprinting, sudden hip flexion/abduction
    • Triggered by sudden, rapid hip extension during running/ jumping[16]
  • Relatively common, account for 28% of pelvic avulsion injuries
  • Displaced fragment tends to migrate inferolaterally, can be mistaken for AIIS avulsion
  • Can transiently lead to Meralgia Paresthetica due to hematoma formation[17]

Avulsion Fractures of the Obturator Externus Muscle

  • Obturator Externus originates on the obturator foramen, inserts on the greater trochanter of the femur
  • Mechanism of injury is not well understood
  • Rare form of pelvic avulsion injury, more often muscle strain[18]
  • Characteristically seen in elite soccer players with anterior hip pain, worsening by internal/external rotation

Avulsion Fracture of the Greater Trochanter

  • Muscles: hip external rotators, abductors
  • Avulsion fractures are rare
  • Patients present with pain and tenderness at the greater trochanter, worse with abduction/adduction

Risk Factors

Sports

Differential Diagnosis

Differential Diagnosis Groin Pain

Differential Diagnosis Hip Pain

Clinical Features

History

  • Patients usually report feeling an abrupt crack/pain at onset
  • It is more severe with exercise or activity, improves with rest
  • Pain localizes to the affected muscle/bone

Physical Exam: Physical Exam Hip

  • The location of the avulsion fracture is typically tender
  • Swelling and bruising may be present
  • When affected muscle is activated, the movement is very painful for the patient
    • For example, AIIS avulsion fractures will have painful resisted hip flexion /knee extension

Evaluation

A 40-year-old male patient presented to the emergency department with left hip pain following excessive stretching. (A) A pelvic radiograph of the patient did not reveal any abnormalities. (B) However, a small avulsion fracture at the left lesser trochanter was observed on computed tomography (arrow). (C) Magnetic resonance imaging showed edema around the avulsion fracture at the lesser trochanter and the tendon of the iliopsoas muscle (arrows). The patient improved with conservative treatment over approximately 3 weeks.[4]

Radiographs

  • Standard Radiographs
    • Usually sufficient to make the diagnosis a few days after injury
  • Potential Findings
    • Displaced bone fragments
    • Epiphyseal injuries
    • Fragment size

CT

  • Better evaluation of bony lesions
  • Often not needed/ indicated

MRI

  • Better evaluation of soft tissue lesions
  • Can evaluate for musculotendinous tears that might be associated with the avulsion[19]

Ultrasound

  • Likely has a role evaluating avulsion fractures in pediatrics
  • Role is not well defined in the literature

Classification

  • Not applicable

Management

Nonoperative

  • Indications
    • Vast majority of patients
    • Especially for smaller fragment size/ displacement
  • Activity modification
  • Weight Bearing Suggestions
    • ASIS: Partial weightbearing (3 weeks), full weightbearing (3 weeks), return to sporting activities around 3 months
    • AIIS: protected weight bearing for 6-8 weeks
    • Greater Trochanter: limited movement, gradually increasing over 6 weeks
    • Lesser trochanter: partial weight bearing (2 weeks), followed by full weight bearing
  • Symptomatic management
  • Gradual return to sport

Operative

  • Indications
    • Not entirely clear or agreed upon
    • Failure of conservative management
    • Elite athltes looking to return to sport sooner
    • Large fragments/ displacements
    • Pogliacomi proposed size/cut off greater than 2 cm[20]
    • Ferlic proposed a size/cut off greater than 1.5 cm[21]
  • Technique
    • K-wires
    • Arthroscopy
    • Percutaneous fenestration with plasma rich platelets
    • Open reduction, internal fixation

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Patients generally have good outcomes whether managed surgically or non surgically
    • Overall, complications are lower in the surgical compared to the non-surgical group[2]
  • Conservative management
    • Hsu et al, Gamradt reported good results on American footballers with AIIS fractures having full return to sport[22][23]
  • Systematic Review, Meta Analysis: Patients with displacement greater than 1.5 cm had much better outcomes with surgical management[24]
    • Surgical patients had a faster return to sport (12.6 weeks) compared to conservative (17 weeks)

Complications

  • Heterotopic Ossification
    • The rate is likely higher in patients who undergo surgical treatment[25]
  • Pseudoarthrosis
  • Non-union
    • Risk increases significantly with ischial tuberosity avulsions of more than 1.5 cm
    • This can lead to "hamstring syndrome" which entraps the sciatic nerve
  • Acetabular Labrum Tear
    • Have been described following AIIS avulsion fracture[26]
  • Meralgia Paresthetica
    • Found transiently in patients with ASIS or AIIS avulsions[27]
  • Sciatic Nerve Injury
    • Can be seen in patients with ischial tuberosity avulsions from fracture fragments, callus formation or heterotopic ossification[28]
  • Avascular Necrosis
    • Case reports of avascular necrosis following avulsion fracture of greater trochanter[29]
    • Suspected to be due to damage to circumflex arteries

See Also

Groin

Hip

References

  1. ↑ Morelli, Vincent, and Victoria Smith. "Groin injuries in athletes." American family physician 64.8 (2001): 1405-1415.
  2. ↑ 2.0 2.1 2.2 Di Maria, Fabrizio, et al. "Treatment of avulsion fractures of the pelvis in adolescent athletes: a scoping literature review." Frontiers in Pediatrics 10 (2022): 947463.
  3. ↑ Soprano, Joyce V. "Musculoskeletal injuries in the pediatric and adolescent athlete." Current sports medicine reports 4.6 (2005): 329-334.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Choy, Won-sik, et al. "Avulsion fractures around the hip joint and pelvis." Journal of Musculoskeletal Trauma 38.2 (2025): 53-62.
  5. ↑ Khemka, Aditya, et al. "Arthroscopically assisted fixation of the lesser trochanter fracture: a case series." Journal of hip preservation surgery 1.1 (2014): 27-32.
  6. ↑ Coulier, Bruno. "Acute avulsion of the iliac crest apophysis in an adolescent indoor soccer." Journal of the Belgian Society of Radiology 99.2 (2015): 20.
  7. ↑ Moon, Jun-Ki, et al. "Apophyseal avulsion fracture of ischial tuberosity during soccer: a case report and literature review." The Korean Journal of Sports Medicine 35.3 (2017): 202-205.
  8. ↑ Kovacevic, David, Michael Mariscalco, and Ryan C. Goodwin. "Injuries about the hip in the adolescent athlete." Sports medicine and arthroscopy review 19.1 (2011): 64-74.
  9. ↑ Rossi, F., and Stefano Dragoni. "Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected." Skeletal radiology 30 (2001): 127-131.
  10. ↑ Porr, Jason, Calin Lucaciu, and Sarah Birkett. "Avulsion fractures of the pelvis–a qualitative systematic review of the literature." The Journal of the Canadian Chiropractic Association 55.4 (2011): 247.
  11. ↑ Filippo, Calderazzi, et al. "Apophyseal avulsion fractures of the pelvis. A review." Acta Bio Medica: Atenei Parmensis 89.4 (2018): 470.
  12. ↑ Risser, Joseph C. "The iliac apophysis: an invaluable sign in the management of scoliosis." Clinical Orthopaedics and Related Research® 11 (1958): 111-119.
  13. ↑ Howard, Francis M., and Robert J. Piha. "Fractures of the apophyses in adolescent athletes." JAMA 192.10 (1965): 842-844.
  14. ↑ Serbest, Sancar, et al. "Anterior inferior iliac spine avulsion fracture: a series of 5 cases." Medicine 94.7 (2015): e562.
  15. ↑ Wirth, T. "Apophyseal avulsions of the hip region in adolescents." Der Orthopäde 45 (2016): 213-218.
  16. ↑ Eberbach, H., et al. "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." BMC musculoskeletal disorders 18 (2017): 1-8.
  17. ↑ Hsu, Chia-Yu, et al. "Anterior superior iliac spine avulsion fracture presenting as meralgia paraesthetica in an adolescent sprinter." Journal of Rehabilitation Medicine 46.2 (2014): 188-190.
  18. ↑ Serner, A., et al. "Characteristics of acute groin injuries in the adductor muscles: a detailed MRI study in athletes." Scandinavian journal of medicine & science in sports 28.2 (2018): 667-676.
  19. ↑ Pisacano, Robin Miller, and Theodore T. Miller. "Comparing sonography with MR imaging of apophyseal injuries of the pelvis in four boys." American Journal of Roentgenology 181.1 (2003): 223-230.
  20. ↑ Pogliacomi, Francesco, et al. "Anterior iliac spines fractures in the adolescent athletes: surgical or conservative treatment?." Medicina dello Sport 66.2 (2013): 231-240.
  21. ↑ Ferlic, Peter W., et al. "Treatment for ischial tuberosity avulsion fractures in adolescent athletes." Knee Surgery, Sports Traumatology, Arthroscopy 22 (2014): 893-897.
  22. ↑ Hsu, Jim C., David A. Fischer, and Rick W. Wright. "Proximal rectus femoris avulsions in national football league kickers: a report of 2 cases." The American Journal of Sports Medicine 33.7 (2005): 1085-1087.
  23. ↑ Gamradt, Seth C., et al. "Nonoperative treatment for proximal avulsion of the rectus femoris in professional American football." The American journal of sports medicine 37.7 (2009): 1370-1374.
  24. ↑ Eberbach, H., et al. "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." BMC musculoskeletal disorders 18 (2017): 1-8.
  25. ↑ Eberbach, H., et al. "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." BMC musculoskeletal disorders 18 (2017): 1-8.
  26. ↑ Hosalkar, Harish S., et al. "The hip antero-superior labral tear with avulsion of rectus femoris (HALTAR) lesion: does the SLAP equivalent in the hip exist?." Hip International 22.4 (2012): 391-396.
  27. ↑ Buch, K. A., and J. Campbell. "Acute onset meralgia paraesthetica after fracture of the anterior superior iliac spine." Injury 24.8 (1993): 569-570.
  28. ↑ Miller, A., et al. "Sciatica caused by an avulsion fracture of the ischial tuberosity. A case report." JBJS 69.1 (1987): 143-145.
  29. ↑ Bloome, David M., and J. David Thompson. "Apophyseal fracture of the greater trochanter." Southern medical journal 93.8 (2000): 832-833.
Created by:
John Kiel on 23 June 2025 18:41:35
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Last edited:
10 July 2025 13:32:44
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