Arcuate sign (knee)
The arcuate sign is often a subtle but important finding on knee x-rays and represents an avulsion fracture of the proximal fibula at the site of insertion of the arcuate ligament complex, and is usually associated with cruciate ligament injury (~90% of cases) 2. The fracture fragment is attached to the lateral (fibular) collateral ligament, the biceps femoris tendon, or both.
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Clinical presentation
The fracture results most often from a direct blow to the anteromedial tibia when the knee is extended, resulting in posterolateral subluxation of the tibia in external rotation 1,3. Alternatively, sudden hyperextension of the knee with the tibia internally rotated may cause the same injury 1.
The importance of this injury is that if it is not diagnosed acutely, posterolateral instability may develop which is challenging to correct, and may result in failed cruciate ligament reconstruction 1,3.
Radiographic features
The shape and size of the avulsed fracture vary according to which ligaments are responsible.
Plain radiograph
The avulsion fracture is usually small, <1 cm in size, and involves the styloid process of the fibula. It is displaced superiorly and medially. Occasionally the fracture may be larger and extends to include the lateral aspect of the proximal fibula.
Slight internal rotation AP films are usually best to radiographically demonstrate this injury 3.
MRI
MRI can delineate the soft tissue component of the injury as well as to evaluate associated injuries that are common. Associated findings include 2:
- cruciate ligament injuries
- especially posterior cruciate ligament 3
- bone bruises
- anteromedial femoral condyle: 50%
- anteromedial tibial plateau: 28%
-
meniscal tears
- medial meniscus: 28%
- lateral meniscus: 22%
- popliteus muscle injury: 33%
- medial collateral ligament injury: common 3
Differential diagnosis
-
Segond fracture
- avulsion is from the tibia
- fragment more medial and anterior
Related Radiopaedia articles
Knee pathology
The knee is a complex synovial joint that can be affected by a range of pathologies:
- bone and cartilage
-
knee fractures
- distal femoral condyle fracture
- tibial plateau fracture (classification)
- patella fracture
-
avulsion fractures of the knee
- arcuate complex avulsion fracture (arcuate sign)
- anterior cruciate ligament avulsion fracture
- biceps femoris avulsion fracture
- iliotibial band avulsion fracture
- patella fracture
- posterior cruciate ligament avulsion fracture
- reverse Segond fracture
- Segond fracture
- semimembranosus tendon avulsion fracture
- Stieda fracturechronic avulsion injuries
- dislocation
- chondromalacia patellae
- osteoarthritis of the knee
- osteochondral defects
- osteochondritis dissecans of the knee
- patterns of bone bruise in knee injury
-
knee fractures
- ligaments
- anterior cruciate ligament tear
- anterior cruciate ligament ganglion cyst
- anterior cruciate ligament mucoid degeneration
- posterior cruciate ligament tear
- medial collateral ligament tear
- lateral collateral ligament tear
- medial patellofemoral ligament tear
- posterolateral corner injury
- posteromedial corner injury
- tendons
- meniscal lesions
- bursosynovial lesions
- fat pad
- popliteal fossa
- fascia
- alignment
- knee
- patellofemoral
- gamut