Outcomes of Conservative Versus Surgical Treatment of Adolescent Pelvic and Hip Avulsion Fractures: A Systematic Review and Meta-Analysis.

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.