Segond fracture
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View Frank Gaillard's current disclosuresAt the time the article was last revised Sonam Vadera had no financial relationships to ineligible companies to disclose.
View Sonam Vadera's current disclosures- Segond's fracture
- Lateral capsular sign
Segond fracture is an avulsion fracture of the knee that involves the lateral aspect of the tibial plateau and is very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament (ACL). On the frontal knee radiograph, it may be referred to as the lateral capsular sign.
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Clinical presentation
Contrary to the more common causes of an ACL tear, which typically involves valgus stress 3, a Segond fracture usually occurs as a result of internal rotation and varus stress 1,4. Typically these injuries are seen in two settings:
falls
sports: especially soccer, skiing, basketball and baseball 4,10
Pathology
Somewhat surprisingly, the exact cause of a Segond fracture continues to be contentious. The conventional teaching has been that it is the result of avulsion of the middle third of the lateral capsular ligaments 7. Other candidate structures include the iliotibial band and anterior oblique band of the fibular collateral ligament 3.
In 2017, the Anterolateral Ligament Expert Group released a consensus paper 8 recognising the presence of the anterolateral ligament (ALL) 9 and noted a constant attachment to the lateral meniscus. However, the ALL is inconsistently identified on MRI 7.
A 2017 MRI study of 36 Segond fractures associated with ACL injury showed that the fracture fragment is almost always attached to the posterior fibres of the ITB and the lateral capsule 12. They were unable to demonstrate attachment to the ALL.
Radiographic features
Plain radiograph
The classical appearance of a Segond fracture is that of a curvilinear or elliptic bone fragment projected parallel to the lateral aspect of the tibial plateau. This has been referred to as the lateral capsular sign 1, which is best seen on the anteroposterior view of the knee.
MRI
MRI is essential in all cases of Segond fractures to identify internal derangement. Disruption of the ACL is the most common, however, there are additional frequently encountered injuries. Associated injuries include 1,3:
-
ACL tear
most common associated injury
75-100% of cases 6
-
medial or lateral meniscal tear
66-75% of cases 6
posterior horn most common
avulsion of ACL from the tibial attachment: rare
avulsion of fibular attachment of the long head of biceps femoris
avulsion of the fibular collateral ligament
Treatment and prognosis
Although the fracture itself is small, the extensive ligamentous injury associated with it usually requires surgical intervention, to correct anterior rotational instability 4. Spontaneous healing of the Segond fracture may occur following ACL reconstruction 11 and is associated with a particular bone excrescence arising below the lateral tibial plateau.
History and etymology
First described by Paul Ferdinand Segond, French surgeon (1851-1912) based on cadaveric experiments 1,2,4.
Differential diagnosis
Imaging differential considerations include:
-
arcuate sign: avulsion fracture of the head of the fibula 5
fragment orientated more horizontally
Quiz questions
References
- 1. Gottsegen CJ, Eyer BA, White EA et-al. Avulsion fractures of the knee: imaging findings and clinical significance. Radiographics. 2008;28 (6): 1755-70. doi:10.1148/rg.286085503 - Pubmed citation
- 2. Somford MP, Nieuwe Weme RA, Hoornenborg D, Wiegerinck JI, van Raay JJAM, Brouwer RW, Williams A. Biographical background and origin of common eponymous terms in orthopedic surgery: anatomy and fractures in knee surgery. (2018) European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 28 (1): 79-84. doi:10.1007/s00590-017-2005-x - Pubmed
- 3. 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. doi:10.1016/j.rcl.2007.08.007 - Pubmed citation
- 4. 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): 1163-7. AJR Am J Roentgenol (abstract) - Pubmed citation
- 5. 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. AJR Am J Roentgenol. 2003;180 (2): 381-7. AJR Am J Roentgenol (full text) - Pubmed citation
- 6. Campos JC, Chung CB, Lektrakul N et-al. Pathogenesis of the Segond fracture: anatomic and MR imaging evidence of an iliotibial tract or anterior oblique band avulsion. Radiology. 2001;219 (2): 381-6. Radiology (full text) - Pubmed citation
- 7. Humza Shaikh, Elmar Herbst, Ata Amir Rahnemai-Azar, Marcio Bottene Villa Albers, Jan-Hendrik Naendrup, Volker Musahl, James J. Irrgang, Freddie H. Fu. The Segond Fracture Is an Avulsion of the Anterolateral Complex:. (2017) The American Journal of Sports Medicine. 45 (10): 2247-2252. doi:10.1177/0363546517704845 - Pubmed
- 8. Bertrand Sonnery-Cottet, Matthew Daggett, Jean-Marie Fayard, Andrea Ferretti, Camilo Partezani Helito, Martin Lind, Edoardo Monaco, Vitor Barion Castro de Pádua, Mathieu Thaunat, Adrian Wilson, Stefano Zaffagnini, Jacco Zijl, Steven Claes. Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee. (2017) Journal of Orthopaedics and Traumatology. 18 (2): 91. doi:10.1007/s10195-017-0449-8 - Pubmed
- 9. Steven Claes, Evie Vereecke, Michael Maes, Jan Victor, Peter Verdonk, Johan Bellemans. Anatomy of the anterolateral ligament of the knee. (2013) Journal of Anatomy. 223 (4): 321. doi:10.1111/joa.12087 - Pubmed
- 10. Slagstad I, Slagstad PA, Slagstad ST, Slagstad IE, Slagstad. Incidence and Prognostic Significance of the Segond Fracture in Patients Undergoing Anterior Cruciate Ligament Reconstruction. (2020) The American journal of sports medicine. doi:10.1177/0363546520905557 - Pubmed
- 11. Kumahara R, Kimura Y, Sasaki S et al. Prevalence of Segond Fractures Associated with Anterior Cruciate Ligament Injuries and Their Influence on Knee Joint Stability; A Case-Control Study. BMC Musculoskelet Disord. 2022;23(1):180. doi:10.1186/s12891-022-05127-w - Pubmed
- 12. Shaikh H, Herbst E, Rahnemai-Azar A et al. The Segond Fracture Is an Avulsion of the Anterolateral Complex. Am J Sports Med. 2017;45(10):2247-52. doi:10.1177/0363546517704845 - Pubmed
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