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Acute Knee Injury:

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Monica Khanna

on 28 May 2014

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Transcript of Acute Knee Injury:

Monica Khanna
Imperial College Healthcare NHS Trust
London, UK
monica.khanna@imperial.nhs.uk

RAPID FIRE - PELVIS
Apophyseal and Avulsion Injuries

BSSR
2014

ANTERIOR SUPERIOR
ILIAC SPINE

SARTORIUS/ TFL
RECTUS FEMORIS
ANTERIOR INFERIOR
ILIAC SPINE

ILIOPSOAS
LESSER TROCHANTER
COMMON HAMSTRING
ISCHIAL TUBEROSITY
GLUTEUS MEDIUS/MINIMUS
GREATER TROCHANTER
ADDUCTORS
INFERIOR PUBIC RAMUS
CREST OF ILIUM
What is an apophysis?


5 Apophyses appear at the pelvis by puberty fusing by the age of 25

QUADRATUS LUMBORUM
But also may represent a TFL avulsion.......
An Apophysis is a secondary ossification centre that contributes to the growth of the bone but is not related to a joint
Apophyseal Injuries
Young active athlete age 14-25

Violent forceful or unbalanced contraction of the musculotendinous unit

Jumping, sprinting or running

footballers, cheerleaders and gymnasts

Chronic stress
Chronic repetitive stress may also place the growth plate of a particular apophysis at risk of an acute injury
Symtoms
~Localised pain and swelling
~Pain exacerbated by use of the particular muscle involved
Management
~Majority are treated conservatively with initial rest
~Surgical ~ ORIF~ if avulsed fracture fragment >2cm.
Imaging

~
Radiographs
- ususally adequate to establish the diagnosis
apophyses occur in anatomically predictable locations avulsed fragment adjacent to the parent bone.
Subtle ~if apophysis is minimally displaced
comparison with contralateral side
~
MR
If radiographs indeterminate
Helpful in minimally displaced or even non displaced apophyseal injuries
Fluid/oedema may be visualised within the cartilage growth plate of the apophysis or tracking along the proximal tendon
Site of Origin
Semi-membranosus
Semitendinosus
Adductor Magnus
Long head of Biceps Femoris
Cause
Intense athletic activity such as sprinting
Excessive passive lengthening of the hamstrings : cheerleaders, gymnasts
Radiographs
Usually demonstrate a large avulsion fragment >2cm displacement may lead to fibrous union ORIF
size, location, extent of retraction should be noted
Chronic avulsive injuries
Extensive callus formation
Adjacent heterotopic bone formation
Enlargement or prominence of the ischial tuberosity
Should not be misinterpreted as a a sign of a more aggressive lesion
Exuberant callus formation around a healing avulsed ischial tuberosity fracture in a 16 year old hurdler
MR imaging
Evaluation of the sciatic nerve
Stretching injuries.
Change in morphology
Change in signal intensity
Discontinuity
Apophyses most likely to avulse due to their inherent weakness at the cartilaginous growth plate.
Since they appear at puberty they tend to avulse at puberty
~
US
Useful in identifying avulsion injuries of the ASIS and AIIS in adolescent athletes
Distribution of Injuries
1,238 xrays of the pelvis taken for focal traumatic symptoms in athletes
11-35 years
Over a period of 22 years reviewed
203 acute apophyseal avulsion fractures were identified (16.4%)
Greater and lesser trochanter fractures are rare
Site of Origin
Sartorius
Tensor Fascia Lata
Causes
Sprinters
Symptoms typically less severe and less debilitating than avulsions of the IT
Radiographs
Triangular cortical avulsion fracture of the ASIS
Smaller than avulsion fragments from IT
AP Radiograph - retracted avulsion of the ASIS
If the fragment is only minially displaced or non displaced, the abnormality may be subtle and overlooked on the radiograph......
50 year old gentleman, running and felt pain at the ASIS, radiograph reported as normal.....
Sag PD FS imaging of the ASIS demonstrating cortical avulsion of the sartorius tendon with retraction
US demonstrates cortical avulsion with a corticated fragment with the sartorius tendon attached
CT can demonstrate clearly the avulsed fragment
Defintiion of two types of anterior superior spine avulsion fractures.
KK White et al, Journal of Paediatric orthopaedics. 2002 22:578-582
.
ASIS Sartorius
Sprinters, smaller fragment displaced anteriorly
ASIS TFL
Baseball players, larger fragment displaced laterally
Twisting injury
Chronic low grade pain at the affected site for several months related to a prior apohysitis
Site of Origin
Rectus femoris tendon
direct head
Relected head inserts onto the superior acetabular lip
Causes
Similar to ASIS causes, occuring during forceful extension of the hip
Pain and point tenderness directly overlying the site of injury
Radiographs
Small cortial avulsion proximal and lateral to the acetabular rim
May be difficult to detect on radiographs
14 year old
patient presents with acute onset of pain after running
60 year old right hip pain
AP radiograph demonstrates heteroptopic bone within the proximal rectus femoris as the sequalae of an old avulsion injury
T1 Coronal
STIR ax

Site of origin
site of attachment of abdominal musculature
Iliac crest apophysis begins ossification age 15 fusing by 18 years
Causes
Repetive trauma associated with running or jumping or direct trauma to the iliac crest
Radiographs
Separation and displacement of the apophysis
Comparison with contralateral side often helpful
Potential pitfalls
Bilateral symptomatic iliac crest apophyseal avulsion inury
Segmentation of the apophysis is a known developmental variant
Most occur along the anterior aspect of the iliac crest
Coronal T2 FS
16 year old sustained a football injury.
Avulsion of the apophysis of the anterior superior aspect of the iliac crest, with adjacent soft tissue oedema and BME
Site of origin
Adductor longus
Adductor Brevis
Gracilis
distal attachment of the rectus abdominus
Causes
Acute avulsion injuries rare
Commonly associated with chronic repetitive stress from twisting/turning movements
Site of origin
Iliopsoas
Causes
Uncommon sports related injury
Commonest in adolescent soccer players
Forceful contraction of the iliopsoas muscle while the thigh is fixed in an extended position
Radiographs
Apophyseal avulsion with separation/retraction of the lesser trochanter apophysis
May be subtle and difficult to detect, MR helpful
Site of origin
Gluteus minimus - anterior facet
Gluteus medius - posterior facet
Causes
Rarely occurs in adolescents
Abductor tendon injuries commonly occur in women >65 years
Begins with gluteus medius/minimus tendinopathy
Radiographs
Normal, or difficult to detect minimally dispalced cortical avulsion fractures.
88 year old female
Gluteus medius and minimus tear with proximal retraction and consequent fluid within the trochanteric bursa consistent with a full thickness tear
Cor STIR
45 year old man

Skiing injury
Full thickness tear left
Partial thickness right
Ax STIR
Cor STIR
17 year old
Right acute apophyseal hamstring avulsion injury
Extent of soft tissue injury
Strain/partial thickness/full thickness tear of proximal tendon fibres
Sciatic nerve
13 year old
Sudden onset right hip pain whilst running
MR Imaging
Reflected head
Straight
head
Ax STIR
Sag PDFS
Cor PDFS
Injury to the various muscle attachments "atheltic pubalgia"
Acute avulsion of the adductor longus tendon at its fibrocartilage origin
Pubic apophysis is a thin growth plate covering the anteromedial pubic body separated by fibrocartilage
Fuses late @ age 25
Image from Robinson et al. Seminars in musculoskeletal Radiology. Vol 15 2011
Typically elite sports players
Vigorous sports
Football, ice hockey, Australian rules football
Pelvic avulsion injuries occur in both the skeletally immature and adult populations
Full transcript