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What is the diagnosis?

Segond Fracture

• Pearl: Segond fractures are lateral proximal tibial avulsion fractures that are most commonly associated with ACL tears and meniscus injuries [1]. The origin of the Segond fracture is still debated. It’s thought to be an avulsion of the lateral capsular ligament, anterolateral ligament, and the iliotibial band are all thought to contribute to the formation of the Segond fracture [2].

Image 2: AP x-ray of the knee with annotation of segond fracture (red circle). Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 9758. Annotation by author. 

What is the mechanism of injury?

Segond fractures typically result from a combination of internal rotation of the tibia and varus stress applied to the knee [1]

What physical exam findings are expected?

Since Segond fractures are nearly pathognomonic for Anterior Cruciate ligament tears the examination is also similar. A positive Lacman’s test and Anterior Drawer test which are sensitive for ACL would likely be positive [3].

*Not all those who have an ACL tear will have a Segond fracture, however nearly everyone who has a Segond fracture will also have an ACL tear; rare exception is pediatric patients [4].

Which imaging modalities can be used?

Segond fractures can be seen on plain radiographs, however due to high rates of concomitant injuries, MRI are also obtained to evaluate for other injuries such as ACL tears. Additionally, MRI can also note subtle Segond fractures that are not apparent or obvious on plain radiographs [3].

Image 3: Coronal Bone window of the MRI showing a subtle lateral tibial plateau fracture (Segond Fracture) Case courtesy of Ahmed Abdrabou Radiopaedia.org, rID: 49527

What is the management in the ED?

Evaluation and suspicion of ACL tear with segond fracture should be high. Management of segond fractures and other concomitant injuries should be managed with supportive care if the knee is stable [5]. RICE (Rest, Ice, Compression, and Elevation), in addition to analgesia, crutches, and hinged knee brace [5]. Have the patient follow up outpatient with Orthopedics where they obtain additional imaging on a non-emergent basis.

• Pearl: The segond fracture itself doesn’t need to be treated. It is an avulsion fracture; however the injuries associated with it such as an ACL tear does require further intervention outpatient. Patients who underwent ACL reconstruction without specific intervention for the Segond fracture still achieved full recovery. Outcomes and surgical success rates were comparable between those who received treatment for the Segond fracture and those who did not [6, 7]. 

When do you consult Orthopedics?

In most situations ACL tears or other soft tissue injuries associated with segond fractures can be managed outpatient with close follow up with orthopedics without requiring emergent consultation. However if there is concern for neurovascular compromise with the injury then a consultation and prompt evaluation by orthopedics is necessary [5].