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Hip disorders in children

CHAPTER CONTENTS
Congenital dislocation of the hip . . . . . . . . . . . e256
Clinical tests . . . . . . . . . . . . . . . . . . . . . e256
Technical investigations . . . . . . . . . . . . . . . e257
Treatment . . . . . . . . . . . . . . . . . . . . . . e258
Congenital limitation of extension . . . . . . . . . . . e258
Arthritis of the hip in children . . . . . . . . . . . . . e258
Transient synovitis . . . . . . . . . . . . . . . . . . e258
Septic arthritis . . . . . . . . . . . . . . . . . . . . e258
Tuberculosis of the hip . . . . . . . . . . . . . . . e258
Haemarthrosis . . . . . . . . . . . . . . . . . . . . e258
Perthes disease (pseudocoxalgia) . . . . . . . . . . e258
Slipped epiphysis . . . . . . . . . . . . . . . . . . . . e259
Avulsion fractures about the hip . . . . . . . . . . . . e259
Every complaint of groin, thigh or knee pain in a child should
be taken seriously and examined very carefully without delay.
Furthermore, any child who limps or shows limitation of move-
ment at the hip joint should undergo a thorough examination.
Most hip lesions in children can be diagnosed adequately with
the help of a radiograph. For almost all these lesions, there are
good and effective treatments, provided the diagnosis is made
early enough.
Congenital dislocation of the hip
The incidence of congenital dislocation is between 1 and 2
cases per 1000, but it is four times as frequent in girls as in
boys.
1
There seems to be a hereditary factor, because there is
about a 5% chance of a second child being affected. This rises
to 36% if one of the parents also had congenital dislocation of
the hip.
2
Although there are still questions about its aetiology, the
condition seems to occur in the presence of some weakness of
the joint capsule and elongation of the ligamentum teres.
3
A
deciency of the rim of the acetabulum may also contribute
in the development of the disease.
4
However, the most impor-
tant aetiological factor seems to be an imbalance between the
action of the psoas muscle and the hip extensors.
5
A relative
shortening of the psoas presses the head of the femur upwards
and laterally when the hip is extended by the contraction of
the stronger hip extensors. In the presence of a weakness of
the capsule, dislocation then occurs.
It is vital to make the diagnosis of a congenital dislocation
as soon after birth as possible. Conservative treatment with an
abduction brace
6
before the child begins to walk is completely
adequate, but after the age of 4 even surgical repositioning is
difcult and after the age of 7 it is almost impossible. Without
treatment the dislocation may lead to a shorter leg, the forma-
tion of a neoacetabulum at the blade of the ilium and the
supervention of early arthrosis.
Radiographs are not reliable in making the diagnosis of con-
genital hip dislocation in newborn babies. Early diagnosis,
therefore, relies entirely on clinical tests. Those most used are
known as Ortolanis and Barlows tests.
7,8
It should be remem-
bered, however, that positive tests only indicate a capsular
laxity and therefore the possibility of dislocation. For instance,
the incidence of positive Ortolanis and Barlows signs in new-
borns is about 1020 per 1000, which is 10 times more than
at the age of 2 months, which suggests that there is a tendency
towards resolution of the capsular laxity.
9
Clinical tests
Ortolanis test
During this test the luxated hip is replaced manually.
Technique
The baby lies on the back, hips exed to 90 and the knees
completely exed (Fig. 1a). The examiner grasps the leg with
Hip disorders in children
e257
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Technical investigations
The diagnosis can usually be made with plain radiographs.
However, during recent decades sonographic screening exami-
nations have been shown to be superior in the early detection
of congenital dislocations of the hip.
10,11
In a study of sono-
graphic screening examinations on 4177 newborns, all cases of
congenital dislocation of the hip joint were found and classi-
ed.
12
Consequently, ultrasound screening is currently offered
to all newborns in Austria and Germany and to newborns with
selected risk factors in the United Kingdom, Scandinavia, Italy
and France.
12,13,14
the contralateral hand in such a way that the thumb presses
on the inner side of the thigh. The ring and middle ngers are
placed along the outer thigh, so that the ngertips touch the
trochanter. The other hand xes the opposite hip. Abduction
of the hip is now performed (Fig. 1b). In a subluxated hip,
resistance will be felt at 4560. The moment the resistance
is overcome, the femoral head rides over the acetabular edge
and reduces. This is felt by the examiner. This sensation
has wrongly been called a click, whereas the feeling is rather
that of moving two knuckles of the wrist over each other.
Ortoloni described this as a segno dello scatto (ridge sign).
Under this denition, the sensation has to be felt rather
than heard.
Barlows test
The purpose here is to dislocate the hip rst and then replace
it. The hips of the baby are grasped in the same way as
Ortolanis test.
Technique
In this test, the thumb is placed further proximally on the
femur. If the capsule is elongated or weak, the examiner can
easily push the femoral head over the posterior rim of the
acetabulum. This is indicated by a click.
Pressure with the middle nger behind the trochanter then
moves the head anteriorly, where it comes to lie in the acetabu-
lum again (Fig. 2). This to-and-fro movement of the femoral
head over the acetabular rim indicates that the joint is
unstable.
Fig 1 Ortolanis test for congenital dislocation of the hip: (a) position of the baby, (b) reposition of the dislocated hip by abduction.
(b)
(a)
Fig 2 Barlows test for congenital dislocation of the hip.
The Hip and Buttock
e258
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completely and without sequelae after a few weeks of bed
rest.
28
Septic arthritis
The differential diagnosis with a transient synovitis is dif-
cult.
29
A septic arthritis of the hip may have similar early
symptoms as a transient synovitis, with the spontaneous onset
of progressive hip, groin, or thigh pain; limp or inability to bear
weight, fever and irritability.
30
Clinical examination shows a
capsular pattern. A variety of clinical, laboratory, and radio-
graphic criteria are used to help differentiate septic arthritis
from transient synovitis. The four clinical predictors to dif-
ferentiate between septic arthritis and transient synovitis are:
history of fever, pain at rest, erythrocyte sedimentation rate of
at least 40 mm per hour, and serum white blood-cell count of
more than 12 000 cells per mm
3
.
31
In cases of doubt, hip aspira-
tion should be performed.
Tuberculosis of the hip
The child complains of pain in the groin, thigh and knee, and
limps. Clinical examination shows a gross capsular pattern,
sometimes to such an extent that the hip is xed in exion,
abduction and lateral rotation. There is considerable wasting
of the thigh muscles. Symptoms of general illness, with slight
fever and fatigue complete the picture. Radiography and exam-
ination of articular uid give a decisive answer.
Haemarthrosis
The hip is very rarely affected in haemophilia. Acute hip pain
and gross articular pattern in a haemophiliac reveal the diag-
nosis. Prompt aspiration and specic anti-haemophiliac meas-
ures must be taken in order to protect the cartilage against the
erosive effects of the presence of the blood.
Perthes disease (pseudocoxalgia)
Perthes disease, an idiopathic avascular necrosis/osteonecrosis
of the femoral epiphysis, was described in 1910 by Legg as an
obscure affection of the hip joint,
32
by Calv as pseudocoxal-
gia
33
and by Perthes as arthritis deformans juvenilis.
34
The
disease affects 4 to 10 year olds, peaking between 5 and 7
years. It affects about four boys for each girl and is bilateral in
10%. Although it is generally accepted that the necrosis is the
result of a change in the blood supply to the femoral head,
35

there still remains much controversy about the way this occurs.
There have been reports suggesting retarded skeletal ageing
in relation to the chronological age.
36
Some studies have also
demonstrated an association with pituitary growth hormone
deciency.
37
However the most likely aetiology for Legg
CalvPerthes disease seems to be the hypothesis of clotting
abnormalities with vascular thrombosis.
38,39
In the early stage, the only symptom is a slight limp or pain
in the hip, thigh or knee. Examination of the knee is normal
Treatment
The majority of unstable hips at birth stabilize in a very short
time,
15
but since the outcome of an unstable hip is impossible
to predict, all cases of hip instability in newborns must be taken
seriously and treated. Hence, as soon as a positive Ortolanis
or Barlows test is found, an abduction brace is given until these
clinical signs disappear.
1618
If the diagnosis is made when the child starts to walk, surgi-
cal repositioning is required. Surgical reduction is almost
impossible after the age of 7 years. If a false acetabulum
develops at the iliac bone, the functional disability may be
small, especially if the disorder is bilateral.
19
Pain and serious
disability then start only in the fourth or fth decade, when
pseudarthrosis has occurred. If pain is not too severe, treat-
ment can be conservative;
20
often some relief is obtained by
one or two inltrations with 50 ml of procaine 0.5% at the
posterior aspect of the capsule.
21
If pain and disability are too
severe, surgery is required.
22
Congenital limitation of extension
Some children have an excessive forward tilt of the pelvis, as
the result of congenital limitation of extension at the hip joints.
They walk with a hyperlordosis, extending at the back instead
of at their hips. This limitation is probably the result of a
shortening of the psoas muscles.
Treatment consists of stretching the psoas and capsule in
the same way as for early osteoarthrosis (see p. 633).
Arthritis of the hip in children
Transient synovitis
This is the commonest cause of hip pain in children and usually
occurs under the age of 10 years. The child complains of pain
in the groin, thigh and knee after some previous exertion.
Sometimes only knee pain is present. The child limps and
clinical examination of the hip shows a capsular pattern.
Although the pathogenesis of the disorder remains
obscure, the conventional view is that it results from ordinary
overuse. However, a correlation between transient arthritis
and the development of Perthes disease has been shown
repeatedly.
23,24
Sonographic examination, together with X-ray examination,
represent the rst choices in the evaluation of a capsular
pattern in a child and in the follow-up of transient synovitis.
25

In transient synovitis there is effusion but the effusion persists
for less than 2 weeks. In the early stage of LeggCalvPerthes
disease the capsular distension persists for more than 6 weeks.
A differential diagnosis between transient synovitis and Legg
CalvPerthes disease is therefore only possible by observing
the ultrasonographic course of the disease.
26
Treatment is bed rest and non-weight bearing. It is advis-
able, if excessive intra-articular effusion is demonstrated by
ultrasonography, to aspirate the uid.
27
Most cases recover
Hip disorders in children
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Avulsion fractures about the hip
Avulsion fractures occur more commonly in skeletally imma-
ture athletes than in adults because young patients tendons
are stronger than their cartilaginous growth centres. The same
stress that causes a muscle strain in an adult can cause an
avulsion fracture in an adolescent. These fractures occur at
the secondary growth centres, or apophyses, which become
separated from the underlying bone. The fractures do not
become widely displaced because of the surrounding thick
periosteum.
57
The mechanism of injury is a sudden, violent muscle con-
traction or excessive repetitive action across the apophysis. Hip
avulsion fractures are common in young sprinters, soccer
players and jumpers.
58
Patients typically describe local pain and
swelling after an extreme effort and report no external trauma.
Physical examination reveals pain during the resisted move-
ments that activate the contractile structures inserting at or
nearby the fracture line:
The anterior superior iliac spine sartorius
The anterior inferior iliac spine rectus femoris
The ischial tuberosity hamstring
The lesser tubercle psoas.
There is also palpable tenderness (and often ecchymosis) at
the specic bony sites (Fig. 4).
Plain radiographs reveal the avulsion fracture. It is useful to
compare the injured side with the contralateral side. During
the healing phase of an avulsion fracture the abundant reactive
ossication in the soft tissues may clinically and radiographi-
cally be mistaken for neoplasia.
59
Treatment is rest. Most patients can be treated non-
operatively over 612 weeks, although some authors recom-
mend surgery for severely displaced fragments in rare cases.
but there is a capsular pattern of the hip. The Trendelenburg
sign may also be positive: when the patient stands on one leg,
pain in the weight-bearing hip or weakness of the ipsilateral
gluteus medius results in a downwards pelvic tilt on the con-
tralateral side. In a later stage, limitation of adduction during
exion is noticed as passive exion is performed, the knee
gradually moves into abduction. When the exed hip is now
drawn toward the opposite side, limitation, pain and a hard
end-feel are noted.
Radiographs vary with the stage of the disease but may show
evidence of bone necrosis, fragmentation, reossication or
remodelling and healing. The earliest signs include decreased
size or increased density of the proximal femoral epiphyses
on an antero-posterior view and crescent sign (a subchondral
fracture that correlates with the extent of necrosis) on the
lateral view.
Treatment and prognosis depend on the age of onset (the
younger the age of onset the better the prognosis), the physical
signs and the radiological changes.
40
Late sequelae of the disease are leg-length shortening and
degenerative joint disease that develops in the majority of
patients by the sixth or seventh decade of life.
41
Slipped epiphysis
Due to gravity, a lysis of the proximal epiphysial junction
results in downwards and backwards slipping of the epiphysis
in relation to the neck of the femur. This causes a varus posi-
tion and slight outwards rotation of the leg coxa vara in
adolescence. It is a disorder of teenagers (aged between 12 and
17 years), with an incidence of 510 per 100 000.
42
The epi-
physial junction softens for an unknown reason, although there
is strong suspicion that some hormone imbalance could cause
the weakening.
43,44
Early symptoms can be mild, variable and insidious in onset.
Children presenting with a slipped femoral epiphysis may com-
plain of pain in the affected hip or groin, thigh or knee. The
pain may be mild or intermittent, or so severe that the child
is unable to bear weight.
45,46
Gait abnormality is frequently observed: the child may walk
with a limp and the affected leg in external rotation. Trende-
lenburgs sign is usually present. Clinical examination reveals a
clear non-capsular pattern with limitation of medial rotation
and increase of lateral rotation.
47
This can be observed best
during bilateral medial rotation in the prone lying position.
48

Resisted movements are strong and painless. Diagnosis is con-
rmed by antero-posterior and lateral hip radiographs which
demonstrate the posterior and inferior displacement of the
epiphysis relative to the metaphysis
49
(Fig. 3).
Treatment and prognosis depend largely on the degree of
the slip.
50,51
It is therefore vital to make the diagnosis as soon
as possible, and a child or teenager in whom epiphysiolysis is
suspected should not be allowed to walk around until the result
of radiography is known. Epiphysiolysis is an orthopaedic
medical emergency and requires immediate relief of weight
bearing.
52,53
Treatment is surgical and consists of in situ
cannulated-screw xation
54
of the slipped capital femoral epi-
physis or an open replacement of the femoral head.
55,56
Fig 3 Normal hip (left) and mild slip (right). In a normal hip, a
line drawn along the upper border of the femoral neck bisects a
segment of the epiphysis but not in a slip.
The Hip and Buttock
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Fig 4 Bony sites of the pelvis: 1, anterior superior iliac spine;
59,60
2, anterior inferior iliac spine;
61,62
3, ischial tuberosity; 4, lesser
tubercle.
63

3
3
2
1
References
1. MacKenzie IG, Wilson JG. Problems
encountered in the early diagnosis and
management of congenital dislocation of
the hip. J Bone Joint Surg 1981;63B:38.
2. Wynne-Davies R. Acetabular dysplasia and
familial joint laxity. Two etiological factors
in congenital dislocation of the hip. J Bone
Joint Surg 1970;52B:70416.
3. Catteral A. What is congenital dislocation
of the hip? J Bone Joint Surg
1984;66B:46971.
4. Wilkinson JA. Prime factors in the etiology
of congenital dislocation of the hip. J Bone
Joint Surg l963;45B:26883.
5. McKibbin B. The action of the iliopsoas
muscle in the newborn. J Bone Joint Surg
1968;50B:1615.
6. Frejka B. Pravention der angeborene
Hftgelenkensubluxation durch
Abduktionspolster Wiener Med Wochenschr
1941;91:5234.
7. Ortolani M. Un segno poco noto e sua
importanza per la diagnosi precoce di
prelussazione congenita dellanca. Pediatria
1937;45:129.
8. Barlow TG. Early diagnosis and treatment
of congenital dislocation of the hip. J Bone
Joint Surg 1962;268(45B):292301.
9. Visser JD, Nielsen HKL. Lichamelijk
Onderzoek bij aangeboren
heupontwrichting. Ned Tijdschr Geneeskd
1984;128(26):121720.
10. Graf R. The diagnosis of congenital
hip-joint dislocation by ultrasound
compound treatment. Z Orthop Trauma
Surg 1980;97:11733.
11. Schule B, Wissel H, Neumann W, Merk H.
Follow-up control of ultrasonographic
neonatal screening of the hip. Ultraschall
Med 1999;20(4):1614.
12. Rosendahl K, Toma P. Ultrasound in the
diagnosis of developmental dysplasia of
the hip in newborns. The European
approach. A review of methods, accuracy
and clinical validity. Eur Radiol 2007;17:
19607.
13. Woolacott NF, Puhan MA, Steurer J,
Kleijnen J. Ultrasonography in screening for
developmental dysplasia of the hip in
newborns: systematic review. BMJ
2005;330 :1413.
14. Rosendahl K, Dezateux C, Fosse KR, Aase
H, Aukland SM, Reigstad H, Alsaker T,
Moster D, Lie RT, Markestad T. Immediate
treatment versus sonographic surveillance
for mild hip dysplasia in newborns.
Pediatrics 2010;125(1):e916.
15. Coleman SS. Congenital Dysplasia and
Dislocation of the Hip. St. Louis: Mosby;
1978.
16. Vasser JD. Functional treatment of
congenital dislocation of the hip. Acta
Orthop Scand 1984;55(suppl):206.
17. Lempichi A, Wierusz-Koslowska,
Kruczynski J. Abduction treatment in late
diagnosed congenital dislocation of the hip.
Acta Chir Scand 1990;61(suppl):236.
18. Burger BJ, Burger JD, Bos CF, et al. Frejka
pillow and Becker device for congenital
dislocation of the hip. Acta Orthop Scand
1993;64(3):30511.
19. Crawford AW, Slovek RW. Fate of the
untreated congenitally dislocated hip.
Orthop Trans 1978;2:73.
20. Wedge JH, Wasylenko MJ. The natural
history of congenital disease of the hip.
J Bone Joint Surg 1979;61B:3348.
21. Cyriax JH. Textbook of Orthopaedic
Medicine, Vol I, Diagnosis of Soft Tissue
Lesions. 8th ed. London: Baillire Tindall;
1982. p. 388.
22. Henderson RS. Osteotomy for unreduced
congenital dislocations of the hips in adults.
J Bone Joint Surg 1970;52B:468.
23. Kemp HBS. Perthes disease. Ann R Coll
Surg 1973;5:18.
24. Inoue A, Freeman MAR, Vernon-Roberts B,
Mizuno S. The pathogenesis of Perthes
disease. J Bone Joint Surg 1976;58B:
453.
Hip disorders in children
e261
Copyright 2013 Elsevier, Ltd. All rights reserved.
25. de Pellegrin M, Fracassetti D, Ciampi P.
Coxitis fugax. The role of diagnostic
imaging. Orthopde 1997;26(10):
85867.
26. Konermann W, de Pellegrin M. The
differential diagnosis of juvenile hip pain in
the ultrasonographic picture. Transient
coxitis, LeggCalvPerthes disease,
epiphysiolysis of the femur head. M
Orthopde 1993;22(5):2807.
27. Bernd L, Niethard FU, Graf J, Kaps HP.
Transient hip joint inammation. Z Orthop
Grenzgeb 1992;130(6):52935.
28. Monty CP. Prognosis of observation hip in
children. Archs Dis Child 1962;37:539.
29. Zamzam MM. The role of ultrasound in
differentiating septic arthritis from
transient synovitis of the hip in children. J
Pediatr Orthop B 2006;15(6):41822.
30. Jung ST, Rowe SM, Moon ES, Song EK,
Yoon TR, Seo HY. Signicance of laboratory
and radiologic ndings for differentiating
between septic arthritis and transient
synovitis of the hip. J Pediatr Orthop
2003;23:36872.
31. Kocher MS, Mandiga R, Zurakowski D,
Barnewolt C, Kasser JR. Validation of a
clinical prediction rule for the
differentiation between septic arthritis
and transient synovitis of the hip in
children. J Bone Joint Surg Am 2004;
86-A:162935.
32. Legg AT. An obscure affection of the hip
joint. Boston Med Surg J 1910;162:202.
33. Calv J. Sur une forme particulire de
pseudocoxalgie. Rev Chir 1910;42:54.
34. Perthes GC. ber Arthritis deformans
juvenilis. Dtsch Z Chir 1910;107:111.
35. Trueta J. Normal vascular anatomy of
human femoral head during growth. J Bone
Joint Surg 1975;39B:358.
36. Harrison MHM, Turner MH, Jacobs P.
Skeletal immaturity in Perthes disease. J
Bone Joint Surg 1976;58B:37.
37. Rayner PHW, Schwalbe SL, Hall DJ. An
assessment of endocrine function in boys
with Perthes disease. Clin Orthop
1986;209:1248.
38. Atsumi T, Yamano K, Muraki M, Yoshihara
S, Kajihara T. The blood supply of the
lateral epiphyseal arteries in Perthes
disease. J Bone Joint Surg Br 2000;82:392
8.
39. Wall EJ. LeggCalvPerthes disease. Curr
Opin Pediatr 1999;11(1):769.
40. Menelaus MB. Lessons learned in the
management of LeggCalvPerthes
disease. Clin Orthop 1986;209:418.
41. Yrjonen T. Long-term prognosis of
LeggCalvPerthes disease: a meta-
analysis. J Pediatr Orthop 1999;8(3):169
72.
42. Aronsson DD, Loder RT, Breuer GJ,
Weinstein SL. Slipped capital femoral
epiphysis: current concepts. J Am Acad
Orthop Surg 2006;14:66679.
43. Murray AW, Wilson NIL. Changing
incidence of slipped capital femoral
epiphysis: a relationship with obesity? J
Bone Joint Surg 2008;90B:924.
44. Tachdjian MO. Pediatric Orthopedics. 2nd
ed. Philadelphia: Saunders; 1990. p.
101681.
45. Matava MJ, Patton CM, Luhmann S,
Gordon JE, Schoenecker PL. Knee pain as
the initial symptom of slipped capital
femoral epiphysis: an analysis of initial
presentation and treatment. J Pediatr
Orthop 1999;19(4):45560.
46. Jinguishi S, Suenaga E. Slipped capital
femoral epiphysis: etiology and treatment.
J Orthop Sci 2004;9:2149.
47. Van den Berg ME, Keesen W, Van der
Hoeven H. Epiphysiolysis van de heupkop.
Ned Tijdschr Geneeskd 1992;136:
133943.
48. Weigall P, Vladusic S, Torode I. Slipped
upper femoral epiphysis in children
delays to diagnosis. Aust Fam Physician
2010;39(3):151-3
49. Aronsson DD, Loder RT, Breuer GJ,
Weinstein SL. Slipped capital femoral
epiphysis: current concepts. J Am Acad
Orthop Surg 2006;14:66679.
50. Dunn DM. Severe slipped capital femoral
epiphysis and open replacement by cervical
osteotomy. Proceedings of the Third Open
Scientic Meeting of the Hip Society. St.
Louis, 1975:1256.
51. Ordeberg G, Hansson LI, Sandstrm S.
Slipped capital femoral epiphysis in
southern Sweden. Long-term result with
closed reduction and hip plaster. Spica Clin
Orthop 1987;220:14854.
52. Rahme D, Comley A, Foster B, Cundy P.
Consequences of diagnostic delays in
slipped capital epiphysis. Pediatric Orthop
B 2006;15:937.
53. Green DW, Reynolds RAK, Khan SN, Tolo
V. The delay in diagnosis of slipped capital
femoral epiphysis: a review of 102 patients.
HSSJ 2005;1:1036.
54. Givon U, Bowen JR. 1999 Chronic slipped
capital femoral epiphysis: treatment by
pinning in situ. J Pediatr Orthop
1999;8(3):21622.
55. Dunn DM, Angel JC. Replacement of
the femoral head by open operation in
severe adolescent slipping of the upper
femoral epiphysis. J Bone Joint Surg 1978;
60B:394.
56. Aronson DD. Acute slipped capital femoral
epiphysis: the importance of physeal
stability. J Bone Joint Surg Am
1993;75:113440.
57. Gross ML, Nasser S, Finerman GAM. Hip
and pelvis. In: DeLee JC, Drez D Jr,
editors. Orthopaedic Sports Medicine:
Principles and Practice. Philadelphia:
Saunders; 1994. p. 106385.
58. Kling ThF. Pelvic and acetabular fractures.
In: Steinberg ME, editor. The Hip and its
Disorders. Philadelphia: Saunders; 1991. p.
17397.
59. Draper DO, Dustman AJ. Avulsion fracture
of the anterior superior iliac spine in a
collegiate distance runner. Arch Phys Med
Rehabil 1992;73(9):8812.
60. Lambert MJ, Fligner DJ. Avulsion of the
iliac crest apophysis: a rare fracture in
adolescent athletes. Ann Emerg Med 1993;
22(7):121820.
61. Schothorst AE. Avulsion fractures of the
inferioranterior iliac spine. Arch Chir
Neerl 1978;1:559.
62. Mader T. Avulsion of the rectus femoris
tendon: an unusual type of pelvic fracture.
Pediatr Emerg Care 1990;6(3):1989.
63. Theologis TN, Epps H, Latz K, Cole WG.
Isolated fractures of the lesser trochanter in
children. Injury 1997;28(5-6):3634.