Case report: ischial stress fracture non-union in a college football player

Abstract

Stress fractures are common injuries associated with repetitive high-impact activities, often in high-level athletes and military recruits. Although predominantly occurring in the lower extremities, stress fractures may occur wherever there is a sudden increase in frequency or intensity of activity, thereby overloading the yield point of the local bone environment. Ischial stress fractures are a rarely diagnosed cause of pain around the hip and pelvis. Often, patients present with buttock pain with activity, which can be misdiagnosed as proximal hamstring tendonitis or avulsion. Here, we report a case of a college football player who was diagnosed with an ischial stress fracture which went on to symptomatic non-union after extensive conservative management. We treated his ischial non-union with open reduction internal fixation utilizing a tension band plate and screws. This interesting case highlights an uncommon cause of the relatively common presentation of posterior hip pain and describes our technique for addressing a stress fracture non-union in the ischium.

Fig. 1.

(A) AP pelvis radiograph and (B) left hip Dunn lateral radiograph demonstrating a relatively normal appearing ischium. (C) Axial, (D) coronal and (E) sagittal CT revealing a black line and periosteal thickening (arrow) of the ischium representing the stress fracture non-union. MRI of the left hip and pelvis demonstrate in the (F) axial and (G) coronal plane increased edema (arrow head) in the non-weight bearing portion of the ischium and extending into the posterior column.

Fig. 2.

Intraoperative (A) iliac oblique, (B) obdurator oblique and (C) AP fluoroscopy images left hip and ischium of the tension plate construct. The fracture non-union site was cleared of granulation tissue and demineralized bone matrix was placed around the fracture site.

Fig. 3.

(A) AP, (B) outlet and (C) inlet radiographs from 10 weeks post-operative follow-up demonstrating intact hardware. At the patient's last follow-up, he was pain free and cleared to resume summer football activities.