Crescent sign of osteonecrosis

Last revised by Dr Henry Knipe on 30 Dec 2021

The crescent sign refers to a linear cleft due to subchondral fracture in the setting of osteonecrosis.

It was originally described as a radiographic finding, however, it can also be seen on cross-sectional imaging.

In the setting of Legg-Calve-Perthes disease, it heralds the beginning of the fragmentation phase (stage 2).

The cause of the crescent sign is bone trabeculae failure, leading to subchondral fracture. The fracture may propagate through the subchondral bone plate to the joint space, with a formation of an unstable osteochondral flap.

The crescent sign is most often seen in the femoral and humeral head, as well as the scaphoid, lunate and talus. 

The crescent sign is seen as a curvilinear lucent subchondral line. If articular surface flattening is present, it suggests an impending articular collapse.

In the femoral head, it is present usually in its anterior or anterolateral part. Both frontal and frog-leg views should be obtained for assessment.

A subchondral fracture line is seen. Additionally, a presence of gas may be detected within the fracture cleft.

Subchondral fracture cleft may be filled with fluid. A presence of bone marrow edema distally from the fracture line indicates stress reaction and a very high likelihood of trabeculae collapse.

Various classification systems of osteonecrosis use the presence of the crescent sign in the assessment of the adult femoral head osteonecrosis 5.

Its presence (without more advanced findings) indicates:

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