Journal of Pediatric Orthopaedics - 2026-05-06 - Journal Article
Outcomes of Conservative Versus Surgical Treatment of Adolescent Pelvic and Hip Avulsion Fractures: A Systematic Review and Meta-Analysis.
Molina LL, Block AM, Carsen S, Crepeau AE, Stavinoha TJ, Chau MM, Nepple JJ, PRiSM Hip Research Interest Group
Topics
Key Takeaway
In 852 adolescent pelvic and hip avulsion fractures, both operative and nonoperative management achieved return to sport in nearly all cases, but no validated displacement threshold was identified at which surgical outcomes reliably exceed nonoperative outcomes.
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Summary
This systematic review and meta-analysis compared operative versus nonoperative outcomes for adolescent pelvic and hip avulsion fractures across 24 studies and 852 fractures. Nonoperative management was used in 86.6% of cases; surgically treated ISCH fractures had the longest recovery (6 months) and highest persistent pain rates (27.3%), while ASIS fractures >15 mm displacement showed faster return to sport with surgery. No validated displacement threshold was identified at which surgical intervention reliably produces superior functional outcomes.
Key Limitation
The pooled studies are predominantly retrospective with inconsistent displacement measurement techniques and outcome definitions, making cross-study threshold analysis unreliable.
Original Abstract
BACKGROUND
Avulsion fractures of the pelvis and hip primarily affect active adolescents. Although most cases are successfully treated with nonoperative management, surgical intervention may be indicated as displacement and risk for nonunion increase. The literature remains heterogeneous and limited by small comparative cohorts. This study summarizes available evidence comparing outcomes after nonoperative and operative treatment, with particular attention to displacement.
METHODS
A literature search of Ovid Medline, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov was completed in July 2024. Patient characteristics, type of activity at the time of injury, displacement distance, treatment modality, complications, and patient outcomes were recorded for specific fracture types, as available.
RESULTS
Twenty-four eligible studies were identified and contributed a total of 852 fractures in 849 patients (mean age 14.4±1.7 y, 79% male) for analysis. The most common fracture sites were the anterior superior iliac spine (ASIS, 33.1%) and anterior inferior iliac spine (AIIS, 30.4%), followed by the ischial tuberosity (ISCH, 15.5%), lesser trochanter (LT, 13.5%), and iliac crest (IC, 7.5%). Overall, 86.6% of fractures were managed nonoperatively, and 13.4% were managed surgically. In displacement-stratified cohorts, ISCH fractures with displacement >15 mm achieved high functional scores with both operative and nonoperative treatment, although pseudoarthrosis occurred in some nonoperatively treated cases with minimal functional limitation. ASIS fractures with displacement >15 mm showed similar transient complications before resolution to excellent outcomes in both treatment groups, but faster RTS with the operative management alone. Rates of persistent pain were highest in ISCH fractures (27.3% surgically, 10.9% nonoperatively) and AIIS fractures treated nonoperatively (13.8%). Return to sport was achieved in nearly all cases, with surgically treated ISCH fractures requiring the longest recovery periods (6 mo).
CONCLUSION
Both nonoperative and operative management result in favorable outcomes for most adolescent pelvic avulsion fractures. Although displacement frequently influences surgical decision-making, current evidence does not establish a validated threshold at which outcomes reliably diverge. Before displacement can be considered a reliable surgical indication, higher-quality evidence demonstrating superior outcomes at clear displacement thresholds is needed.
LEVEL OF EVIDENCE
Level III.