Avulsion fractures of the appendicular skeleton are as ubiquitous in daily practice as the traumatic injuries that precede them. Strong association with anterior cruciate ligament (ACL) tear. (a) Sagittal fast spin-echo proton-density–weighted MR image shows an avulsion of the semimembranosus tendon (arrow) at its insertion site on the posteromedial aspect of the tibia. The knee joint remains particularly susceptible to avulsion fractures due to its numerous tendinous, ligamentous, and meniscal attachments. It is usually appreciated only on the lateral view and appears as a tiny avulsed bone fragment displaced posterosuperiorly from its insertion on the tibia (,28). More recent cadaveric studies have suggested that the pathophysiology of Segond fracture is complex and may involve avulsion of the iliotibial tract and anterior oblique band as well (,3). 43, No. (a) Anteroposterior oblique radiograph of the left knee shows a bone fragment (arrow) within the knee joint. Figure 1b. The wide variation in clinical management of this condition, ranging from immobilization and casting to local steroid injection or rarely surgical management, reflects the continuing controversy about the exact etiology of this entity. The fragment is not as well seen because it is superimposed on the posterior tibial plateau.Download as PowerPointOpen in Image At conventional radiography, these fractures are often best appreciated on the lateral view, where comminuted bone fragments arising from the superior aspect of the patella are frequently seen. Inferior patellar pole fragmentation in children: just a normal variant? Proposed causes include external rotation and abduction of a flexed knee, varus force applied to the flexed knee, and valgus force applied to the tibia (,28–,30). 4. 3, Diagnostic and Interventional Imaging, Vol. Viewer. (b) Lateral radiograph shows the avulsed fracture fragment (arrow). (b) Coronal fast spin-echo proton-density–weighted MR image shows the tiny bone fragment (white arrow), which represents an avulsion of the deep capsular component of the medial collateral ligament. clear delineation of fracture pattern; MRI indications when x … This is particularly true when the mechanism of injury involves severe rotational forces. Viewer 3, Radiologic Clinics of North America, Vol. 1, 25 February 2017 | Skeletal Radiology, Vol. Sagittal fast spin-echo proton-density–weighted (a) and fat-suppressed T2-weighted (b) MR images show a bone fragment avulsed from the tibia (arrow) with an intact ACL and adjacent marrow edema.Download as PowerPointOpen in Image Findings can be subtle and confusing, particularly if the fragment is not significantly displaced , Fig 20). (a) Lateral radiograph of the right knee shows chronic avulsion of the quadriceps tendon, which contains calcification (arrow). 1% (104/7047) 2. Figure 11c. The knee is a remarkably intricate joint with numerous tendinous, ligamentous, and meniscal attachments, which leave it particularly vulnerable to complex injuries after trauma. Osgood-Schlatter disease. Proximal fibular fracture or proximal tibiofibular ... MRI or CT arthrography can evaluate communication between a ... Neurotrophic factor treatment after spinal root avulsion injury. 93, No. 32, No. Figure 1 X-ray notch and lateral roentgenogram. (a) Anteroposterior radiograph of the right knee shows an elliptic bone fragment (arrow) arising from the medial tibial plateau. The fragment is not as well seen because it is superimposed on the posterior tibial plateau. Viewer 4, Journal de Radiologie Diagnostique et Interventionnelle, Vol. (b, c) Sagittal fast spin-echo proton-density–weighted (b) and fat-suppressed T2-weighted (c) MR images obtained in another patient show an avulsion fracture of the tibial tuberosity (arrow) with mild adjacent soft-tissue swelling, a small joint effusion, and infrapatellar bursitis.Download as PowerPointOpen in Image (b) Coronal fast spin-echo proton-density–weighted MR image shows the tiny bone fragment (white arrow), which represents an avulsion of the deep capsular component of the medial collateral ligament. 36, No. Anteroposterior (a) and lateral (b) radiographs of the left knee show a bone fragment in the intercondylar notch (arrow). may see avulsion fractures with acute injuries; assess for posterior tibiofemoral subluxation; medial and patellofemoral compartment arthrosis may be present with chronic injuries ; lateral stress view . 1A and B). 1, 19 April 2017 | BMC Musculoskeletal Disorders, Vol. There is edema within the adjacent bone marrow. Displaced injury leads to PCL deficiency & hence disability & pain. MRI scans have been shown to be less optimal in the assessment of chronic PCL injuries … 198, No. ... Additional injuries that are associated with PCL avulsion fracture include disruption of the medial and lateral collateral ligament complexes, medial and lateral meniscal tears, and focal bone contusions of the anterior tibia and lateral femoral condyle (, 16). A large joint effusion is also present.Download as PowerPointOpen in Image (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the fibula. 200, No. After the initial report in 1997 (,8), there have been an increasing number of case reports of this type of fracture over the past decade. PCL avulsion fracture. The exact origin of the fragment is difficult to discern on this view. 14 Boynton followed up 38 patients with isolated PCL injury for a mean follow up of 13.4 years and he suggested “the prognosis for the isolated posterior cruciate ligament-deficient knee varies. Part 2—Areas of Weakness Beyond Bone and Cartilage Transitions, Clinical and Arthroscopic Evaluation of Posterior Cruciate Ligament and Posterolateral Corner Injuries of the Knee, Magnetic Resonance Imaging of Posterior Cruciate and Posterolateral Corner Injuries of the Knee, What’s in a name? 10, 24 September 2011 | Skeletal Radiology, Vol. Thickening of the patellar tendon is often identified without definite evidence of tear or avulsion (,4). The bone fragment arises from the tibial insertion of the ACL. Figure 7b. While the significance of the complex structures of the posterolateral corner of the knee is well documented, the posteromedial corner of the knee is also crucial to the stability of the knee joint. 77, No. Figure 5a. This injury tends to manifest as an aching, flexed knee and signs of anterior instability (,11). Avulsion fractures at the pelvis can occur at two locations – at the attachment of quads (rectus femoris) and sartorius muscles to the front and at the attachment of hamstrings muscle to the pelvis (at the ischial spine) behind. Biceps femoris tendon avulsion fracture. (a, b) Coronal fast spin-echo proton-density–weighted (a) and fat-suppressed T2-weighted (b) MR images show avulsion of the arcuate complex (arrow) from the styloid process of the fibular head (the arcuate sign). Viewer (a, b) Coronal fast spin-echo proton-density–weighted (a) and fat-suppressed T2-weighted (b) MR images show avulsion and retraction of the biceps femoris tendon (arrow) from its insertion on the lateral fibular head. Figure 5a. In addition, Segond fractures may also be associated with avulsion of the fibular attachment of the long head of the biceps femoris tendon and the fibular collateral ligament (,7) and rarely can be seen with avulsion of the ACL from its insertion anterior to the tibial eminence. Figure 4a. Their unique composition and design allows bones to be relatively hard and strong, while remaining lightweight.. Viewer The central tendon of the semimembranosus muscle inserts on the infraglenoid tubercle of the posteromedial tibia. (a, b) Coronal fast spin-echo proton-density–weighted (a) and fat-suppressed T2-weighted (b) MR images show avulsion of the arcuate complex (arrow) from the styloid process of the fibular head (the arcuate sign). (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the fibula. (a) Anteroposterior radiograph of the right knee shows an elliptic bone fragment (arrow) arising from the medial tibial plateau. to cruciate and collateral ligaments) occur in approximately 10% of patients. The mechanism of this injury is often the result of internal rotation of the knee and varus stress (,4), a motion that produces abnormal tension on the central portion of the lateral capsular ligament (,5). An avulsion fracture involves the detachment of a bone fragment that results from the pulling away of a ligament, tendon, or joint capsule from its point of attachment on a bone. On conventional radiographs, avulsion fractures of the ACL may be difficult to recognize. (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the fibula. 56, No. Note the difference in orientation and appearance of the fragment in comparison with those of the arcuate sign (cf ,Fig 8,,,). (b, c) Sagittal fast spin-echo proton-density–weighted (b) and fat-suppressed proton-density–weighted (c) MR images show avulsion of the quadriceps tendon (arrow) from its attachment site along the superior aspect of the patella. Figure 13a. 1984;142 (6): 1181-6. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. The avulsed bone fragment has a characteristic appearance as an elliptic piece of bone arising from the fibular styloid process with its long axis oriented horizontally on the anteroposterior knee radiograph (,Fig 7a,) (,18,,23). Figure 10b. Tibial plateau fractures were originally termed a bumper or fender fracture but only 25% of tibial plateau fractures result from impact with automobile bumpers. 50, No. The mechanism of injury for this fracture is nebulous as well. Figure 2b. 3, Acta Orthopaedica et Traumatologica Turcica, Vol. The bone fragment arises from the tibial insertion of the ACL. 21, No. Therefore, posterior cervical line (PCL) cannot be applied. 4, 21 October 2014 | Pediatric Radiology, Vol. Thus, it is crucial for the radiologist to identify the site and pattern of injury in these patients so that they may be worked up appropriately, including consultation with an orthopedic surgeon and additional imaging as circumstances dictate. (b) Sagittal fast spin-echo fat-suppressed T2-weighted MR image shows the avulsed fragment (arrow) with adjacent marrow edema and a moderate-sized joint effusion. Figure 4b. With chronic avulsion, calcifications may be visualized within the distal aspect of the retracted quadriceps tendon (,Fig 13a,,). 97, No. Their unique composition and design allows bones to be relatively hard and strong, while remaining lightweight.. This type of injury often manifests radiographically as a tiny osseous fragment located adjacent to the expected attachment site of a ligament or tendon, although sometimes large avulsed fragments may be seen instead. In addition, the flexion-extension, internal rotation, and external rotation were approximately … Avulsion fracture of the quadriceps tendon is usually apparent clinically. Semimembranosus tendon avulsion fracture. McGovern Medical School Eleven of the 21 … Arcuate complex avulsion fracture. (a) Anteroposterior radiograph of the left knee shows an elliptic bone fragment (arrow) arising from the lateral tibial plateau (the lateral capsular sign). 6, Avicenna Journal of Clinical Medicine, Vol. Figure 8d. Arthroscopic findings ACL tibial avulsion fractures. 93, No. Routine preoperative knee radiography, computed tomography (CT) and magnetic resonance (MR) imaging were used to confirm the diagnosis of PCL avulsion fractures of the tibia. The fragment is not as well seen because it is superimposed on the posterior tibial plateau. Semimembranosus tendon avulsion fracture. (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the styloid process of the fibula. 26, No. ALL is current understanding of anatomic structure; formerly was said to … Markhardt B, Gross J, Monu J. Schatzker Classification of Tibial Plateau Fractures: Use of CT and MR Imaging Improves Assessment1. Figure 5b. Figure 15a. Viewer A few mechanisms of PCL injuries have been proposed on the basis of the site of damage of the PCL [].The most common mechanism of avulsion fractures of the PCL at the tibial insertion is a dashboard injury, in which the knee is in a flexed position, and a posteriorly directed force is applied to the pretibial area []. (a) Lateral radiograph of the right knee shows an avulsion fracture of the tibial tuberosity (arrow) and soft-tissue swelling, findings consistent with Osgood-Schlatter disease. Figure 1a. 28, No. It is imperative for the radiologist to accurately identify this injury, as classification of ACL avulsion fractures is important with regard to patient treatment. It is also well documented that failure to recognize injuries to the posterolateral corner of the knee is a likely cause of failure after reconstruction of the ACL and PCL, as well as chronic knee instability (,20–,22). This article presents a comprehensive review of some of the most common types with real cases used for imaging correlation. Conveying this information to the referring clinician is crucial and represents the first step toward additional evaluation and probable orthopedic referral. View larger version (385K) Fig. The bone fragment arises from the tibial insertion of the ACL.Download as PowerPointOpen in Image (a, b) Coronal fast spin-echo proton-density–weighted (a) and fat-suppressed T2-weighted (b) MR images show avulsion and retraction of the biceps femoris tendon (arrow) from its insertion on the lateral fibular head. This fracture involves a fragment similar to that of the Segond fracture except that it is located on the opposite side of the knee, arising from the medial aspect of the proximal tibia. Viewer. The goal of therapy is to reduce the fracture and begin early mobilization. Anteroposterior (a) and lateral (b) radiographs of the left knee show a bone fragment in the intercondylar notch (arrow). Figure 11a. Like avulsion fractures of the quadriceps tendon, this injury tends to occur in isolation and has no known associations with damage to the other major stabilizing structures of the knee. Tibial plateau fractures were originally termed a bumper or fender fracture but only 25% of tibial plateau fractures result from impact with automobile bumpers. ACL avulsion fracture. 1. Figure 1b. 44, No. Figure 12b. Although adolescents are particularly vulnerable to such injuries due to the weakness of their apophyses, adults may also be subject to avulsion fractures secondary to minor trauma or more substantial events such as motor vehicle collisions. Radiographics. PCL avulsion fracture. ACL avulsion fracture. In adults, the injury results from severe hyperextension, such as that seen after motor vehicle collisions, and has a higher prevalence of associated injuries, including “kissing” bone contusions and tears of the medial collateral ligament and PCL (,4,,12). Advanced imaging modalities, particularly computed tomography (CT) and magnetic resonance (MR) imaging, are helpful and can provide valuable additional information to adequately define the extent of damage. MR imaging will at the very least demonstrate marrow edema along the lateral tibial rim and in some cases will also show the avulsed fragment (,,Fig 1b). AJR Am J Roentgenol. Christopher C. Dodson . There is edema within the adjacent bone marrow. (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the fibula. CT provides additional information about size and comminution of fracture fragment. The patellar tendon is usually only a few centimeters long, arising from the inferior patella and inserting distally at the tibial tuberosity. For all patients, the affected knees presented as stable at physical examination 3 months after surgery; the Lachmann test and the anterior drawer test results were negative. The exact origin of the fragment is difficult to discern on this view. 4, 25 July 2015 | International Journal of Emergency Medicine, Vol. 5, 2 February 2017 | MUSCULOSKELETAL SURGERY, Vol. By recognizing the significance of these injuries at initial presentation, radiologists can facilitate appropriate patient work-up and prevent the chronic morbidity associated with delayed treatment. Reformatted and three-dimensional CT scans may also assist with the pre-operative planning of surgical approach and method of fixation. The PCL has a smooth contour on the CT image (arrow in a) and is partially torn on the MR image (arrow in b). 18, No. The proposed mechanism of injury involves a pure varus force, which is rarely seen because varus positioning is usually associated with the knee being in flexion and internal rotation (,26). Figure 11b. Figure 11b. Figure 11a. 48, No. (a) Anteroposterior oblique radiograph of the left knee shows a bone fragment (arrow) within the knee joint. 4.1, Journal of Arthroscopy and Joint Surgery, Vol. 205, No. (a) Anteroposterior radiograph of the right knee shows an elliptic bone fragment (arrowhead) with its long axis oriented horizontally arising from the fibular head. This study describes an arthroscopic pullout fixation technique for small and comminuted avulsion fractures of the posterior cruciate ligament from the tibia. Avulsion fracture of the biceps femoris tendon appears simply as an irregular bone fragment arising from the fibular head (,Fig 10,). A 40 year old woman had both PCL and ACL avulsion fracture due to a car accident. (a) Anteroposterior radiograph of the right knee shows an elliptic bone fragment (arrow) arising from the medial tibial plateau. Many of these avulsive knee injuries have characteristic appearances on imaging. Dr. Ellman, most recently with the Steadman Clinic in Vail, is a fellowship trained, board-certified orthopedic surgeon specializing in hip, knee and shoulder injuries. Viewer. PCL avulsion fracture is less common. 4, No. Viewer Injury to the posteromedial corner of the knee is uncommon and is seen most frequently in athletes. The knee is a complex synovial joint that can be affected by a range of pathologies: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Viewer The radiographic posterior drawer is indicative of PCL tear. CT is very helpful in accurately defining the extent of the bony injury and facilitates orthopedic intervention. Originally described by the French surgeon Paul Segond in 1879 after a series of cadaveric experiments (,1), this fracture involves cortical avulsion of the tibial insertion of the middle third of the lateral capsular ligament (,2). These fractures often have a subtle appearance at conventional radiography. Note the difference in orientation and appearance of the fragment in comparison with those of the arcuate sign (cf ,Fig 8,,,). (a) Sagittal fast spin-echo proton-density–weighted MR image shows an avulsion of the semimembranosus tendon (arrow) at its insertion site on the posteromedial aspect of the tibia. 9, 11 December 2017 | Hong Kong Journal of Emergency Medicine, Vol. Anterior aspect of spinous process of C2 commonly misses PCL by 2 mm. The exact origin of the fragment is difficult to discern on this view. Figure 13b. 93, No. (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the fibula. The exact donor site of the fragment cannot be accurately discerned on these views. 50, No. In about 25% of nonunion fracture cases, a fibrous mesh connective tissue is laid down rather than bone. The onus is on the radiologist to identify the pattern of injury and to understand the substantial underlying damage that it frequently represents. List the additional and often occult tendinous, ligamentous, and meniscal injuries associated with these fractures. 4, Operative Techniques in Sports Medicine, Vol. (c, d) Sagittal fast spin-echo proton-density–weighted (c) and fat-suppressed T2-weighted (d) MR images show the avulsed fragment (arrow) arising from the styloid process of the fibula. Tibial plateau fractures: evaluation with multidetector-CT. Radiol Med. Figure 8a. Coronal fast spin-echo proton-density–weighted MR image of the left knee shows avulsion of the iliotibial band (black arrow) from its attachment site on the Gerdy tubercle of the anterior tibia (white arrow). Sinding-Larsen-Johansson syndrome. 3, Journal of the American Academy of Orthopaedic Surgeons, Vol. At MR imaging, sagittal views demonstrate separation of the distal quadriceps tendon from the superior patella as well as marrow edema in the upper patellar pole (,,Fig 13b, ,13c). Some authors have suggested that avulsions of the tibial tuberosity represent an acute avulsion injury in patients with previously diagnosed Osgood-Schlatter disease, whereas others believe that these entities should be distinguished entirely, with Osgood-Schlatter disease involving only the anterior portion of the epiphysis or the ossification center of the tuberosity without involvement of the physis (,4,,11,,35).
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