Apophyseal Injuries

Apophyseal avulsion injuries of the pelvis, although rare in adults, are common among adolescents [13]. Although radiography and MR imaging are often used for the detection of suspected avulsion of the pelvic apophyses, sonography can

Iliopsoas Musculotendinous
Fig. 3. Tendinopathy of the iliopsoas tendon. Transverse sonographic image of the iliopsoas tendon at the level of the acetabulum shows a thickened heterogeneous tendon (large arroW). The small arrow depicts the iliopsoas muscle at the level of the musculotendinous junction.

also demonstrate apophyseal avulsion and other physeal and epiphyseal injuries (Fig. 6) [14].

An anteroposterior radiograph of the pelvis should be the first imaging study for patients suspected of having these injuries, because the diagnosis of avulsion injury can be documented without further imaging. Apophyseal avulsions,

Fracture Apophyse Transverse
Fig. 4. Greater trochanteric bursitis. Longitudinal sonographic image shows fluid (large arrow) adjacent to the greater trochanter (small arroW).
Greater Trochanter Stress FractureIliopsoas Bursitis

Fig. 5. Iliopsoas bursitis. (A) Transverse sonographic image shows a fluid collection (measurement marks) adjacent and medial to the iliopsoas tendon (large arroW) and lateral to the femoral vessels (notched arrow). (B) Coronal and (C) axial T2-weighted, fat-suppressed MR images show the right iliopsoas bursal collection (arrows).

however, may be radiographically occult if the apophysis is not ossified, so further imaging may be needed for confirmation. Although MRI can reveal these injuries, sonography is advantageous because of its faster examination time and decreased cost.

When evaluating for apophyseal injuries, four criteria should be used: (1) a hy-poechoic zone in the region of the apophysis extending to the surrounding soft tissue, representing edema or hemorrhage; (2) widening of the normally hypoe-choic physis between the apophysis and the pelvis; (3) tilting and dislocation of the apophysis; and finally, (4) the use of power Doppler to document hyperemia within the affected region of the apophyseal injury [14]. Power Doppler has not documented hyperemia in chronic injuries, however [14]. Mobility of the apophysis on dynamic imaging has also been used as a sign of apophyseal injury [15]. If the sonographic findings are normal or equivocal and the patient continues to have symptoms, MRI may be required for definitive evaluation.

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