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direct stroke. The femoral muscle fascia and the inguinal
ligament restrict significant movements of bone fragments.
The patient senses an abrupt, sharp pain in the hip area.
Although the patient is able to walk, any active flexing of
the hip, especially against resistance, and stepping on stairs
cause severe pain [8]. The injured part is swollen and
painful when palpated. Paresthesia may occur on the lat-
eral part of the thigh (meralgia paraesthetica) [10]. If the
patient does not seek professional help immediately after
the injury, tissue thickening may occur which resembles a
neoplasm [7]. The roentgenogram will show a smaller or
larger bone fragment, which is displaced a few centimeters
lower (Fig.1).
Patients and methods
Fig.3 X-ray of the iliac crest after implant removal
From 1987 to 1996, we surgically treated 6 patients due to avul-
sion fractures of the anterior superior iliac spine. All of them were
male athletes, aged from 15 to 18 years (average 16 years). Two of
them were soccer players, one a basketball player, one a high
jumper, one a sprinter, and one a bicyclist. The surgery took place
2–7 days after the injury.
A 6-cm cutaneous incision was made from the iliac crest down-
wards over the broken spine. The muscles are obtusely removed
from both sides of the ilium. Beneath the spine, two holes are made
in the ilium, and the wire is inserted through the holes in such a
manner that the ends of the wire are left on the outer side of the il-
ium. The bone fragment is then repositioned and fixated with two
Kirschner wires. A wire loop is put around the bent ends of the
wire following the principle of dynamic tightened loop (Fig.2).
Drains are inserted, and the surgical wound is closed in layers.
The first day after surgery, the patient gets up and is taught to
get about on crutches. On the 3rd day, the drains are removed, and
the patient starts to practice exercises that will improve hip mobil-
ity. One week after the operation, the patient starts to gradually
discontinue the use of crutches, and 3 weeks after the operation, he
can start practising easy and apportioned sporting exercise. Six
weeks after the operation, he can return to normal training and
competition routine. Osteosynthetic material is removed 6 months
after the operation (Fig.3).
Results
There were no complications recorded with these patients.
The last inspections showed no difficulties. All six patients
remained active athletes.
Discussion
Avulsion fractures of the anterior superior iliac spine are
uncommon injuries, for which the majority of authors rec-
ommend conservative treatment. A 3-week immobiliza-
tion period is recommended with a Browne splint, the hip
being flexed at 60°. The use of crutches is prolonged. The
complete therapy may last up to 12 weeks [8]. The frac-
ture is healed in a displaced position, mostly without any
functional disorder [5, 11]. Very few authors describe op-
erative treatment for this specific injury [3, 8]. There is
less time needed to achieve full recovery, so surgery is
recommended for athletes requiring a short period of re-
habilitation [2, 3]. Veselko et al. report the successful use
of spongiose screws for the fixation of a spine fragment
[3, 11]. In our institution, we apply fixation by the princi-
ple of dynamic osteosynthesis with a tightened loop, which
does not require additional protection and enables imme-
diate active rehabilitation [4].
Despite the good results of conservative treatment, we
recommend operative treatment of avulsion fractures of
the anterior superior iliac spine in young athletes. We rec-
ommend the osteosynthesis method with two Kirschner
wires and a wire loop. In this way, an early rehabilitation
is made possible, and the athlete can return to his normal
sports activities 6 weeks after the injury.
Fig.2 Operative fixation of the avulsion of the anterior superior
iliac spine by the principle of dynamic osteosynthesis with tension
band wire
Funke
