A 45-year-old male presents with right knee pain after he pivoted and felt a “pop” while making a move playing pickup basketball. You obtain knee x-rays and see a lateral irregularity in the AP view (photo courtesy of Dr. Gerry Gardner at Radiopaedia.org).
What is the most likely diagnosis, commonly associated injury, and appropriate management plan?
This fracture is pathognomonic for an ACL injury (75-100% association). Contrary to popular belief, it is not an avulsion of the ACL insertion. There is additionally an association with a meniscal tear (66-75%).1
Nonsteroidal anti-inflammatories (NSAIDs) for pain relief and crutches if non-ambulatory. Hinged knee brace (not a knee immobilizer) is preferred for stability and non-impact range of motion (ROM) exercises should be encouraged. If a hinged knee brace is not available and multi-ligamentous injury is very unlikely, crutches and a soft neoprene sleeve are recommended.
Weight bear as tolerated with crutches and follow up with an Orthopedics or Sports Medicine clinic in the next 1-2 weeks for imaging and definitive management after swelling improves. The patient will likely require surgery given the avulsion fracture indicates additional lateral instability beyond an ACL tear.
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Goldman AB, Pavlov H, Rubenstein D. The Segond fracture of the proximal tibia: a small avulsion that reflects major ligamentous damage. AJR Am J Roentgenol. 1988;151(6):1163-1167. PMID: 3263770
Huang GS, Yu JS, Munshi M et-al. Avulsion fracture of the head of the fibula (the “arcuate” sign): MR imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament. Am J Roentgenol. 2003;180(2):381-387. PMID: 12540438
Gottsegen CJ, Eyer BA, White EA et al. Avulsion fractures of the knee: Imaging findings and clinical significance. Radiographics.2008;28(6):1755-1770. PMID: 18936034
Roberts CC, Towers JD, Spangehl MJ et-al. Advanced MR imaging of the cruciate ligaments. Radiol. Clin. North Am. 2007;45(6):1003-16, vi-vii. PMID: 17981180