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Fracture, Avulsion: ASIS, AIIS, Ischial Tuberosity, Iliac Crest

Ovid: 5-Minute Sports Medicine Consult, The

Fracture, Avulsion: ASIS, AIIS, Ischial Tuberosity, Iliac Crest
K. Michele Kirk
Jason Mogonye
Tomoya Sakai
  • Injury that typically occurs at the unfused apophysis (secondary growth center) in an adolescent athlete
  • Results from sudden, forceful, concentric or eccentric muscular contraction without external trauma
  • Also may occur from sudden excessive passive lengthening of a muscle
  • Chronic injury may occur as a result of repetitive microtrauma or overuse.
  • Account for 13–40% of pediatric pelvic fractures
  • Ischial tuberosity most commonly avulsed and accounts for 38% of all pelvic avulsion fractures.
  • Anterosuperior iliac spine (ASIS) accounts for 32% and anteroinferior iliac spine (AIIS) for 18% (1).
  • Generally more common in males but also common in female gymnasts (2).
  • More common among adolescents than young children or adults
  • May occur in adults (“weekend warriors”)
  • Can occur bilaterally
Risk Factors
  • Athletes involved in strenuous sporting activities (soccer, football)
  • Sprinters (ASIS type I, AIIS) (1)
  • Batting in baseball (ASIS type II) (1)
  • Gymnasts, hurdlers, long jumpers, tennis players (ischial tuberosity) (3)
  • “Weekend warriors”
  • ASIS:
    • Type I: Sudden, forceful contraction of sartorius muscle with hip in extension and knee in flexion (1)
    • Type II: Sudden, forceful contraction of tensor fasciae latae (1)
  • Ischial tuberosity: Sudden, forceful contraction of hamstring with knee extended and hip flexed (3)
  • Iliac crest: Avulsion of abdominal muscles
  • Athlete often reports popping or snapping with immediate onset of severe pain.
  • Acute injury may be preceded by prodrome of low-level pain for up to several months owing to chronic apophysitis (1).
  • Activity at time of injury helps to define mechanism of injury.
    • Attempting to kick a ball (ASIS)
    • Clearing a hurdle (ischial tuberosity)
    • Being tackled from behind (iliac crest) (4)
  • Pattern of pain helps to localize site of avulsion fracture.
    • Ischial tuberosity avulsion fracture may radiate to posterior thigh.
    • AIIS avulsion fracture may radiate to anterior thigh.
Physical Exam
  • Signs and symptoms include:
    • Pain with localized tenderness and swelling at avulsion site
    • Limitation of motion about the site of avulsion injury
    • Difficulty (sometimes inability) bearing weight
  • Physical examination includes the following:
    • Palpate regions of suspected avulsion. Acute localized tenderness to palpation is present over involved apophysis; avulsed apophyseal fragment may be palpated.
    • Assess active and passive range of motion of involved muscle(s).
      • ASIS type I: Pain with passive extension or active flexion of hip; also pain with passive internal rotation and active external rotation of hip
      • ASIS type II: Pain with passive extension and active flexion of hip; also pain with passive external rotation and active internal rotation; pain also can be seen with active abduction and passive adduction of hip.
      • AIIS: Pain with passive extension and active flexion of hip; also pain with passive knee flexion and active knee extension
      • Ischial tuberosity: Pain with passive hip flexion and active hip extension
      • Iliac crest: Pain with contraction of abdominal muscles, lateral bending of torso, resisted hip abduction


Diagnostic Tests & Interpretation
  • Anteroposterior view of pelvis: May demonstrate avulsion of a portion of involved apophysis; fragments may be mildly to severely displaced. Chronic avulsions may result in prominent bone formation and nonunion. Radiographic appearance of exostosis may be confused with osseous malignancy or osteomyelitis.
  • Oblique view of pelvis: May better demonstrate avulsions of iliac crest
  • CT scan: May be helpful in chronic cases or those without a clear history; may aid in management of ischial tuberosity avulsions complicated by impingement of sciatic nerve (4)
  • US: May visualize ASIS or AIIS avulsion fractures
Differential Diagnosis
  • Apophysitis
  • Muscle strain
  • Tendon avulsion without fracture
  • Malignancy, especially in an adult with nontraumatic pelvic avulsion fracture (4)
Ongoing Care
Follow-Up Recommendations
Most fractures heal with conservative treatment.
Athletes typically are able to return to full activity without restrictions or long-term sequelae; however, this may take up to 6 mos.
  • 808.41 Closed fracture of ilium
  • 808.42 Closed fracture of ischium

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