Won-Sik Choy; Yonghan Cha; Jung-Taek Kim; Jun-Il Yoo; Jin-Woo Kim

doi:10.12671/jmt.2025.00010

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Avulsion fractures around the hip joint and pelvis: Won-Sik Choy, MD¹, Yonghan Cha, MD¹, Jung-Taek Kim, MD², Jun-Il Yoo, MD³, Jin-Woo Kim, MD⁴; DOI: https://doi.org/10.12671/jmt.2025.00010
Published online: March 24, 2025

¹Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Korea

²Department of Orthopedic Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea

³Department of Orthopedic Surgery, Inha University Hospital, Incheon, Korea

⁴Department of Orthopedic Surgery, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea

Correspondence to: Yonghan Cha, MD Department of Orthopedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: +82-42-611-3280 E-mail: cyh@eulji.ac.kr

• Received: December 18, 2024 • Revised: January 13, 2025 • Accepted: January 22, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Introduction
Avulsion Fractures Around the Pelvis
Avulsion Fractures around the Proximal Femur
Conclusions
Article Information
References

Abstract

Avulsion fractures occur when tendons or ligaments are subjected to forces greater than they can withstand at the apophysis or enthesis, regardless of fusion status. The pelvis and hip joint are vulnerable to these injuries due to the diverse muscular structures in these structures, which serve as origins for multiple muscles leading to the lower extremities. Pelvic avulsion fractures commonly affect young athletes, but can also occur in adults. The diagnosis typically involves assessing trauma history, a clinical examination, and radiographic imaging. If the diagnosis is unclear, additional tests such as computed tomography and magnetic resonance imaging may assist in the diagnosis and provide useful information for treatment decisions. While most avulsion fractures respond well to conservative treatment, surgical intervention may be preferred in severe displacements, cases of significant retraction in active athletes, or when a faster recovery is necessary. Chronic or neglected injuries may lead to excessive osseous formation around the pelvis, causing impingement syndromes. Recognizing characteristic radiological findings based on pelvic anatomy helps to make an accurate diagnosis, as chronic injuries can mimic tumors or infectious conditions, necessitating a careful differential diagnosis.
Keywords: Bone fractures, Avulsion fractures, Hip joint, Pelvis

Introduction

An avulsion fracture typically occurs at an apophysis or enthesis when the tensile forces on a tendon or ligament exceed the limits of resistance, irrespective of fusion status. This phenomenon is observed around the pelvis and hip as well [1]. Anatomically, the site where a tendon or ligament attaches to bone is referred to as the enthesis, which plays a critical role in the concentration and transmission of forces between two distinct types of tissue [2,3]. Various muscle structures surround the pelvis and hip, and since these areas serve as origins for multiple muscles extending to lower extremity joints, they are particularly vulnerable to such injuries (Fig. 1) [1]. While avulsion fractures may occur as a result of a single acute trauma, they can also progress chronically due to repetitive stress. In adults, avulsions are primarily seen in soft tissues, whereas in adolescents, they typically present with displaced bone fragments or apophyseal injuries [1].

Imaging modalities are essential for diagnosing avulsion fractures around the pelvis and hip. Radiographs should be the first step in the diagnostic process, as they can reveal displaced bone fragments or apophyseal injuries; however, caution is necessary to avoid overlooking lesions obscured by around structures. Although diagnosis can often be achieved with typical trauma history, physical examination, and radiographic findings, computed tomography (CT) or magnetic resonance imaging (MRI) may be utilized to gain a more detailed understanding of the anatomical configuration of the injured area. CT is particularly effective for assessing the presence and morphology of displaced apophyses or bone fragments, as well as identifying callus or heterotopic ossification that aids in distinguishing between acute and chronic avulsion fractures. MRI provides superior visualization of bone marrow edema, hematomas, and soft tissue injuries, and it is valuable for assessing the degree of tendon retraction, which can be crucial in determining the need for surgical intervention. Although ultrasound is a highly effective tool for diagnosing acute avulsion injuries, its accuracy can be significantly influenced by the examiner's expertise, and it may pose challenges in visualizing the anatomical relationships among damaged structures.

There are various types of avulsion fractures around the hip joint and pelvis, most of which are uncommon. While appropriate treatment methods based on fracture type have been proposed for some relatively common fractures, many others lack such guidelines. Due to their low incidence, there is a lack of reported literature or reviews, as well as insufficient evidence regarding treatment methods. Thus, the purpose of this review is to summarize the clinical and radiological findings of various types of avulsion fractures occurring around the pelvis and hip, based on existing literature, and to present appropriate treatment options.

Avulsion Fractures Around the Pelvis

Ethics Statement

This review was approved by the Institutional Review Board (IRB) of Daejeon Eulji Medical Center (IRB No. EMC 2024-11-005). Written informed consent was waived for all patients involved in this review.

Avulsion Fractures of the Iliac Crest

The iliac crest extends from the anterior superior iliac spine (ASIS) to the posterior superior iliac spine and serves as an attachment site for the anterior abdominal wall muscles. Avulsion fractures of the iliac crest typically result from excessive tension and contraction of the abdominal muscles during lateral bending and rotational movements of the trunk [4]. However, such injuries are rare, accounting for only about 1%–2% of avulsion fractures around the pelvis and hip [5].

On physical examination, patients with iliac crest avulsion fractures may report tenderness over the iliac crest. Radiographs can reveal asymmetry at the iliac crest, while MRI may show edema, bone separation, and avulsion at the attachment site of the anterior abdominal wall muscles [6,7].

In most cases, conservative treatment yields excellent outcomes. However, surgical intervention may be considered if there is significant displacement greater than 3 cm, or if the patient requires rapid rehabilitation and return to sports [8,9].

Avulsion Fractures of the ASIS

The sartorius muscle originates from the ASIS, with part of the tensor fascia lata attaching nearby. Avulsion fractures at the ASIS are relatively common, accounting for approximately 28% of pelvic avulsion injuries, and are typically triggered by sudden and rapid hip extension during activities such as running or jumping [10]. On physical examination, patients often exhibit tenderness over the ASIS, and in some cases, the avulsed fragment may be palpable [7]. The displaced fragment tends to migrate inferolaterally and can sometimes be mistaken for an avulsion injury of the anterior inferior iliac spine (AIIS).

Although diagnosis can generally be made based on clinical presentation and radiographs alone, additional imaging with CT or MRI may be necessary when radiographs are inconclusive or when the patient presents later after the injury (Fig. 2) [11,12]. In rare instances, a hematoma or excessive bone formation following an avulsion fracture may compress the lateral femoral cutaneous nerve, potentially leading to meralgia paresthetica [13,14]. Cases have also been reported where avulsion fractures were initially mistaken for bony tumors invading the soft tissues [15].

Most avulsion fractures with minimal displacement can be managed successfully with conservative treatment, which is widely recommended in the literature [16]. Typically, patients undergo partial weight-bearing for approximately 3 weeks, followed by full weight-bearing within the next 3 weeks, with return to sports activities around 3 months post-injury. However, surgical intervention, such as open reduction and screw fixation, may be considered in cases of displacement greater than 1.5 to 2 cm, large fragment size, or patient preference for rapid recovery [16,17]. Akhter et al. [16] proposed a surgical approach using suture anchors and lag screws to minimize irritation caused by hardware protrusion. Eberbach et al. [10] and Kautzner et al. [18] reported heterotopic ossification in five out of 13 patients who underwent surgical treatment, a rate higher than in those treated conservatively. While surgical management may provide a shorter initial recovery period, long-term outcomes between conservative and surgical treatments may not differ significantly [10,18-20].

Avulsion Fractures of the AIIS

The straight head of the rectus femoris originates from the AIIS and spans both the hip and knee joints. Since the rectus femoris functions to flex the hip and extend the knee, avulsion fractures of the AIIS are often caused by hip extension injuries, similar to avulsion fractures of the ASIS. These fractures typically occur during activities involving running, jumping, or kicking, making them common injuries in sports such as soccer. AIIS avulsion fractures, like those of the ASIS, are relatively frequent and are reported to account for approximately 20%–25% of pelvic avulsion fractures [21].

On clinical examination, patients often present with anterior hip or groin pain and tenderness. Pain may be elicited during resisted hip flexion or knee extension combined with hip flexion. While a small bone fragment may be visible on standard anteroposterior pelvic radiographs, an oblique view can be helpful for confirming the diagnosis. Ultrasound and MRI may also be used as additional diagnostic tools, with MRI particularly valuable for assessing soft tissue injuries and the degree of muscle retraction (Fig. 3). Excessive heterotopic callus formation can lead to a reduced distance between the greater trochanter and the acetabular roof, potentially resulting in femoroacetabular impingement, which may cause chronic hip pain [22].

Both AIIS and ASIS avulsion fractures generally produce milder symptoms and functional limitations and have a shorter recovery period compared to avulsion fractures of the ischial tuberosity (Fig. 4) [1].

Maalouly et al. [23] reported a case of an avulsion fracture of the AIIS following hip arthroscopy for femoroacetabular impingement. The procedure was performed on a traction table, with cam and pincer lesions removed using a burr. Since the acetabular labrum was stable, no additional fixation was required. Eleven months postoperatively, an avulsion fracture of the AIIS was identified, and open reduction and internal fixation were performed, yielding satisfactory results. Conservative treatment for AIIS avulsion fractures typically involves protected weight-bearing for 6–8 weeks [24]. Hsu et al. [25] reported on two American football players who were treated conservatively, achieving normal activity by 6 weeks. Gamradt et al. [26] also reported cases of AIIS avulsion fractures in 11 American football players, all of whom successfully returned to sport with conservative management. Conversely, Irmola et al. [27] presented five cases in four American football players who underwent surgical treatment and were able to return to sport after 9 months, although two cases experienced lateral femoral cutaneous nerve palsy.

Avulsion Fractures of the Ischial Tuberosity

Rossi and Dragoni [5] reported that the ischial tuberosity is the most common site of pelvic avulsion fractures in adolescents. The ischial tuberosity serves as the insertion point for the hamstring muscles, including the long head of the biceps femoris, semitendinosus, and semimembranosus. Avulsion fractures in this area can occur during intense hip flexion and knee extension or as a result of excessive, sudden leg traction, particularly among athletes such as soccer players, runners, and dancers [28]. Patients typically present with characteristic buttock pain that worsens when sitting rather than standing, along with gait disturbances and localized swelling. Despite the typical injury mechanism and symptoms, delayed diagnosis may occur, necessitating careful attention.

Radiographically, acute fractures are seen as bone fragments with curved, sharp borders, while non-displaced fractures may require differentiation from tumor-related bone formations (Fig. 5) [29]. Although radiographs may suffice for diagnosis, ultrasound and MRI can be useful for assessing associated injuries or hematoma formation.

Currently, there are no definitive guidelines for treating this type of fracture, but conservative management is generally recommended [24]. Surgical intervention with open reduction and internal fixation is considered only in cases of significant fragment displacement. Eberbach et al. [10] and Ferlic et al. [30] reported that surgical treatment is indicated when displacement exceeds 1.5 cm. In conservative management, it is important to prevent hip flexion and maintain the knee in a flexed position, which may require a brace [24]. Return to sports is typically advised after 1.5 to 3 months. The surgical approach can involve the Kocher-Langenbeck approach or an incision along the gluteal crease, using metal plates, screws, or suture anchors, or creating a bone tunnel for suturing [31]. Postoperatively, weight-bearing should be gradually resumed to avoid complications with hardware failure. A brace should limit excessive hamstring tension for 6–12 weeks, with return to full activity usually allowed after 5–6 months, as rehabilitation takes longer than for other pelvic avulsion fractures.

Complications of this fracture include neuralgia due to sciatic nerve irritation from fracture fragments, callus formation, or heterotopic ossification [32]. Other complications include excessive bone formation around the ischial tuberosity or decreased space between the ischium and femur, which may lead to ischiofemoral impingement syndrome, where the quadratus femoris muscle becomes compressed [33]. Delayed diagnosis may result in sciatic nerve palsy caused by the displaced bone fragment [24].

Avulsion Fractures of the Pubic Ramus and Symphysis Pubis

The hip adductor muscles, including the adductor longus, adductor brevis, gracilis, and the distal rectus abdominis, originate from the pubic body, pubic symphysis, and the inferior pubic ramus [34]. Among these, the adductor longus is the most frequently injured, followed by the adductor brevis and the pectineus muscle [35]. In contrast, the gracilis and adductor magnus are less prone to injury. Avulsion fractures caused by the adductors typically result from chronic overuse and accumulation of repeated microtraumas, with acute injuries from sudden contractions being rare. Such injuries are common in athletes, particularly soccer, ice hockey, and tennis players.

Patients usually present with unilateral groin pain, which may be nonspecific, and chronic cases are referred to as "Athletic Pubalgia." Differential diagnosis should consider osteitis pubis, sports hernia (core muscle injury), acetabular labral tear, and spinal disorders [36,37].

Since adductor injuries primarily involve soft tissue and avulsion fractures are rare, diagnosis is challenging through radiographs and physical examination alone. MRI can be particularly helpful in identifying the type and extent of the injured adductor muscles [38,39]. Treatment typically involves conservative management, with recommendations to cease sports activities and avoid weight-bearing for several weeks.

Avulsion Fractures of the Obturator Externus Muscle

The obturator externus muscle originates from the outer rim of the obturator foramen and the obturator membrane, attaching to the piriformis fossa on the medial aspect of the femoral greater trochanter. While the exact mechanism of avulsion fractures in this area is unclear, these injuries are rare and are more often muscle strains than true avulsion fractures [35]. They are characteristically seen in high-level athletes, such as professional soccer players, presenting with anterior hip pain that is exacerbated by internal and external rotation of the flexed hip [40]. Recovery is generally swift, allowing athletes to return to sports relatively quickly.

Avulsion Fractures around the Proximal Femur

Avulsion Fractures of the Greater Trochanter

The muscles attaching to the greater trochanter include the hip external rotators and abductors, and avulsion fractures in this area are extremely rare, typically occurring during sudden, forceful directional changes. Radiographs may reveal displacement of the fracture, while MRI can show widening of the growth plate gap and edema. Clinically, patients present with pain and tenderness at the greater trochanter, with pain worsening during abduction and adduction movements.

As this is a very rare injury, there is no clear evidence supporting a specific treatment protocol. In adolescents, conservative treatment typically involves limiting movement and gradually increasing stress over a 6-week period [21]. Open reduction and internal fixation may be considered in cases of significant displacement, particularly in older individuals where direct trauma from a fall might occur. For apparent avulsion fractures of the greater trochanter in the elderly, the differential diagnosis should include occult intertrochanteric fractures [41]. In many cases, the avulsion fragments are only part of the fracture, and an incomplete intertrochanteric fracture may be present, which can be detected using MRI [41].

There have been reports of avascular necrosis of the femoral head following avulsion fractures of the greater trochanter, likely due to damage to the associated blood vessels, such as the medial circumflex artery and the cervical branches [42-44]. Khalifa et al. [45] reported the case of a 13-year-old boy who sustained an avulsion fracture of the greater trochanter of the left femur along with an open dislocation of the hip following a tractor accident. The fracture was easily reduced with traction, and non-surgical treatment was successfully implemented. However, severe heterotopic ossification around the hip joint limited its range of motion, and after 3 years, avascular necrosis of the femoral head developed, ultimately leading to the need for total hip replacement surgery at the age of 18. Giles et al. [46] reported a case of apophyseal avulsion of the greater trochanter in a 14-year-old boy that occurred during a soccer game after being tackled. They applied a hip abduction brace (with the hip in 30° of flexion and 20° of abduction) for 8 weeks, followed by gradual weight-bearing. The patient was allowed to return to sports activities 6 months after the injury [46].

Avulsion Fractures of the Lesser Trochanter

Avulsion fractures of the lesser trochanter are rare injuries that can occur in competitive young athletes, such as track and field and soccer players, accounting for 1%–3% of hip avulsion fractures [10,21]. These fractures typically occur between the ages of 13 and 18, with very few cases observed in healthy adults [47,48]. The iliopsoas muscles attach to the lesser trochanter, and the fracture usually results from a strong contraction of the iliopsoas. It can also occur after a tonic-clonic seizure [49]. The fracture is associated with significant pain and functional impairment, with relief often occurring in the hip flexion position. Tenderness is noted along the medial thigh, and hip flexion is not possible under resistance.

Radiographs will show displacement of the lesser trochanter, and CT or MRI are generally unnecessary (Fig. 6). However, if an avulsion fracture of the lesser trochanter is observed in an adult, it may indicate a pathological avulsion fracture due to tumor metastasis, so caution is required during diagnosis (Fig. 7) [50,51]. For these patients, careful history taking including cancer histories and considering contrast-enhanced MRI could be helpful.

Conservative treatment typically yields good results, and surgical intervention is rarely required [52,53]. Miyake et al. [54] reported a case of stress avulsion fracture of the lesser trochanter in a 40-year-old male patient. After 2 weeks of non-weight-bearing and 2 weeks of partial weight-bearing, followed by full weight-bearing, the patient responded well to conservative treatment, despite 1.8 cm of displacement and nonunion. However, Anderson et al. [55] suggested that surgical intervention should be considered for displacements greater than 2 cm, while Quarrier and Wightman [56] reported a case of chronic pain due to a lesser trochanter avulsion fracture in an 18-year-old female ballet dancer, where resection of the lesser trochanter was performed after 5 years of symptoms, leading to improvement. Khemka et al. [57] utilized arthroscopy-assisted fixation with metal screws or suture anchors, achieving satisfactory results.

Conclusions

Avulsion fractures around the hip joint and pelvis are common in young athletes but can also occur in adults. Diagnosis is typically based on the patient's history of trauma, clinical examination, and radiographic imaging. If the diagnosis is unclear, additional imaging such as CT or MRI can assist in decision-making regarding treatment and confirming the diagnosis. Most avulsion fractures can be treated conservatively, but surgical intervention may be advantageous in cases of significant displacement, in athletes with substantial tendon retraction, or when rapid recovery is required. Chronic or recurrent injuries can lead to excessive heterotopic ossification around the pelvis, potentially causing impingement syndromes. A solid understanding of pelvic anatomy, along with characteristic radiographic findings, is crucial for accurate diagnosis. Since chronic injuries can mimic tumors or infectious diseases, careful differential diagnosis is necessary.

Article Information

Author contribution

Conceptualization: YC. Data curation: JTK. Formal analysis: JWK. Investigation: JIY. Methodology: YC. Software: WSC. Validation: YC. Visualization: YC. Project administration: YC. Writing–original draft: WSC, JTK, JIY, JWK. Writing–review & editing: YC. All authors read and approved the final manuscript.

Conflict of interests

None.

Funding

None.

Data availability

Contact the corresponding author for data availability.

Acknowledgments

None.

Fig. 1.

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.

Fig. 2.

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.

Fig. 3.

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.

Fig. 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).

Fig. 5.

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.

Fig. 6.

(A) A 60-year-old male patient underwent surgical treatment for a left femoral intertrochanteric fracture. (B) During the second week of postoperative rehabilitation, the patient complained of worsening pain and underwent follow-up radiography. Radiographs revealed an avulsion fracture accompanied by small bone fragments at the left femoral neck region.

Fig. 7.

A 62-year-old male patient undergoing treatment for lung cancer presented to the outpatient clinic 2 days after experiencing persistent right hip pain following coughing. (A) A hip joint radiograph revealed an avulsion fracture of the lesser trochanter of the femur, with observed bone density loss around the fracture site. (B) Computed tomography showed an avulsion fracture of the lesser trochanter accompanied by osteolysis.

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Avulsion fractures around the hip joint and pelvis

DOI: https://doi.org/10.12671/jmt.2025.00010

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Avulsion fractures around the hip joint and pelvis

Fig. 1. 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.

Fig. 2. 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.

Fig. 3. 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.

Fig. 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).

Fig. 5. 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.

Fig. 6. (A) A 60-year-old male patient underwent surgical treatment for a left femoral intertrochanteric fracture. (B) During the second week of postoperative rehabilitation, the patient complained of worsening pain and underwent follow-up radiography. Radiographs revealed an avulsion fracture accompanied by small bone fragments at the left femoral neck region.

Fig. 7. A 62-year-old male patient undergoing treatment for lung cancer presented to the outpatient clinic 2 days after experiencing persistent right hip pain following coughing. (A) A hip joint radiograph revealed an avulsion fracture of the lesser trochanter of the femur, with observed bone density loss around the fracture site. (B) Computed tomography showed an avulsion fracture of the lesser trochanter accompanied by osteolysis.