Apophyseal Avulsion Injuries

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An apophyseal avulsion fracture of the pelvis is a fracture through the physis of a secondary center of ossification. These commonly involve the anterior superior iliac spine, anterior inferior iliac spine, and ischial tuberosity apophysis. These fractures occur almost exclusively in 11- to 17-year-old patients. They are most commonly seen in soccer, track, football, and baseball. In most cases, these fractures occur during fast running, hurdling, pitching, or sprinting.15 These injuries usually do not occur due to direct trauma. They may occur as a consequence to a hip dislocation. Fractures of the anterior superior iliac spine result from the pull of the sartorius and the tensor fascia lata muscles. Fractures through the anterior inferior iliac spine result from pull of the straight head of the rectus femoris muscle. A forceful sprint or a swing of a baseball bat will typically avulse the anterior superior iliac spine.

The injured athlete will frequently recall an associated "pop" at the moment of injury. Then acute lower extremity, hip, and groin pain with restricted range of motion and inability to bear weight will follow. Transient meralgia paresthetica may be seen due to the swelling around the lateral femoral cutaneous nerve. A displaced apophysis is usually apparent on plain radiographs, but if the clinician is not keen to the injury, a subtle opacity may be missed. An astute clinician may make the presumptive diagnosis despite "negative" radiographs. In cases of anterior inferior iliac spine avulsions, an oblique plain radiograph projection may be necessary to appreciate a subtle displacement. Despite the occasional delay in diagnosis, there is usually no major problem from wrongly receiving acute treatment for a strain instead of a fracture. On the other hand, a robust formation of callus may lead to inadvertent overtreatment due to the concern for Ewing's tumor or osteomyelitis.

The treatment of most avulsion fractures is nonoperative. The treatment can include rest and protected weight bearing with crutches followed by a supervised rehabilitation and a home exercise program. Most authors have reported excellent results following nonoperative treatment.16 Without adequate protection, a symptomatic nonunion is possible; therefore, nonweight bearing or protected weight bearing for up to 3 weeks is a prudent decision. Despite the massive callus that frequently forms, an excellent result is likely. The most common complication of nonoperative treatment is a tender exostosis-like formation at the fracture site. Rarely will these exostosis-like lesions require surgical removal. Surgery may be considered in the case of a severely displaced fracture in a high-level athlete. A displaced fracture may create a shortened muscle and as a consequence a theoretical decrease in muscular power. Indications for open treatment and internal fixation are not well defined. Open treatment and internal fixation may be considered in a high-level athlete with displaced (>3cm) fractures or in cases associated with hip dislocations. Reports on surgical fixation are few, and no improvement in outcome has been proven. When surgery is chosen, the apophysis is reduced and fixated using wiring and/or screw fixation.17 Potential complications are the same as those associated with adult fracture treatment including cutaneous nerve injury, misguided hardware, hemorrhage, infection, and hip joint damage. Complete recovery, return to sports, and no long-term sequelae may be anticipated following most apophyseal fractures, regardless of the type of treatment chosen.

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Baseball For Boys

Baseball For Boys

Since World War II, there has been a tremendous change in the makeup and direction of kid baseball, as it is called. Adults, showing an unprecedented interest in the activity, have initiated and developed programs in thousands of towns across the United States programs that providebr wholesome recreation for millions of youngsters and are often a source of pride and joy to the community in which they exist.

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