0:00

Let's spend a little time on this pelvic

0:03

radiograph and talk about the various avulsion

0:05

injuries that can occur in this region.

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I have three progressive plain film

0:12

radiographs for you from various states.

0:14

The first one is from February, the

0:16

next one is from April, and the final

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one is going to be from September.

0:20

So you sort of see the progression of

0:22

what some of these injuries can look like.

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This is the very first exam.

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This was a child who presented

0:28

with right pelvic pain.

0:30

And there are many things to

0:31

look at on this radiograph.

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We want to make sure that there's

0:34

congruity between the joint spaces

0:35

on the right side and the left side.

0:37

We're going to make sure that the growth

0:39

plates are nice and symmetric, that the

0:41

femoral heads don't have any lucencies,

0:44

or sclerosis involved with it.

0:46

And finally, what I do is I look

0:49

at the insertion sites of various

0:51

muscle groups about the pelvis.

0:54

There are insertion sites for abdominal

0:56

muscles, there's insertion sites for Sartorius,

0:58

rectus femoris, adductor groups, and we'll

1:02

go through each one of them separately.

1:04

But one of those problems

1:06

here, we can already see.

1:08

If you pay attention a little bit to the

1:10

symmetry from one side to the other, you

1:12

notice that there's a little fuzziness,

1:14

right at this location, with a little

1:17

bit of what looks like ossification or

1:19

calcification here on the right side.

1:21

Let me zoom up on that for you,

1:22

just so you have a better idea.

1:26

Okay, so here is the area of abnormality.

1:30

And let's just go to the other

1:31

side and show you over here.

1:35

So even this side actually isn't quite normal.

1:39

Do you see this white structure here?

1:41

Let me go and outline that for you.

1:43

So above the femoral head is

1:45

this very sclerotic white line.

1:48

I'm going to draw that

1:49

for you in yellow or gold.

1:52

It's this structure right here.

1:54

Okay?

1:55

Okay?

1:55

That is called the sourcil.

1:58

Sourcil means eyebrow in French, okay?

2:02

That is the weight-bearing

2:04

portion of your acetabulum.

2:06

So all the stuff out here is non-weight-bearing.

2:10

So there has been some chronic

2:12

tugging by a muscle insertion site to

2:15

create that little bony excrescence.

2:17

That's a chronic problem on the left side.

2:20

On the right side, we also

2:22

have this nice sourcil.

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But look how fuzzy, let me make

2:27

it a little different color.

2:29

Look how fuzzy this margin is.

2:32

And you've got little pieces

2:33

of bone right over here.

2:35

So there's a more acute

2:36

problem at that location.

2:38

So this is an example of an avulsion

2:40

injury, particularly involving the

2:44

anterior inferior iliac spine or AIIS.

2:49

And what attaches there?

2:50

It is the rectus femoris muscle.

2:53

Thank you.

2:53

You have several other places

2:55

where you have attachment sites.

2:57

You have one over here, okay, and that

3:01

is the sartorius muscle attachment site,

3:04

and that is the anterior superior iliac spine.

3:08

Where else do you have it?

3:09

You have one over here, in the

3:12

greater trochanter, and that is

3:14

where the gluteus muscles attach.

3:17

You have one down here, in the

3:20

lesser trochanter, and that is where we

3:22

have the attachment site for the iliopsoas.

3:26

We have over here,

3:29

in these two areas, and that is the symphysis

3:33

pubis area and adductor groups attach there.

3:37

And what we can't see here is at the very top.

3:41

Now, over here at the iliac crest, we

3:43

also have abdominal muscle groups that

3:45

attach and cause avulsion injuries.

3:48

And finally, I forgot to mention one last

3:50

one, right down here and down here, that

3:55

is where we have the ischial tuberosity

3:59

and hamstrings attached there and that's

4:01

the avulsion you can get over there.

4:03

So these are the various

4:04

avulsion sites that you can have.

4:06

So it's really important to pay close

4:08

attention to all these areas when you evaluate

4:10

any kind of pelvic injury or pelvic pain.

4:13

Let us now go back to our original image.

4:16

I'm going to zoom out just a little bit.

4:19

And span, and again, here, right here

4:23

is where you have iliac crest, that's

4:24

where I couldn't show you very well.

4:26

That's where we have the abdominal

4:27

muscle musculature attaching

4:29

and can cause avulsion injuries.

4:31

So this was the exam in February.

4:34

Let's see how the healing process develops.

4:36

Same child, in April now, I'm

4:39

going to zoom up just a little bit.

4:41

And you notice that this area is getting

4:43

a little bit more fuzzy, a little

4:44

bit more healing, callus formation.

4:47

Again, we know that's becoming

4:48

a more chronic process.

4:50

And finally, in September,

4:53

further healing has occurred.

4:56

And this is the typical appearance of what

4:58

an avulsion injury as it heals looks like.

5:00

Again, if you notice, you can actually see

5:03

where the margin of the weight-bearing side

5:06

ends because you see this nice white border,

5:10

which is the sore seal on both sides.

5:12

Anything beyond the sore seal is extra bone.