Diagnostic and Interventional Imaging (2014) 95, 551—560

REVIEW / Musculoskeletal imaging

Acute traumatic knee radiographs: Beware

of lesions of little expression but of great
significance
A. Venkatasamy a, M. Ehlinger b, G. Bierry a,∗

a
Department of Radiology, MSK imaging, University Hospital of Strasbourg, 10, avenue
Molière, 67098 Strasbourg, France
b
Department of Orthopedic Surgery and Traumatology, University Hospital of Strasbourg, 10,
avenue Molière, 67098 Strasbourg, France

KEYWORDS Abstract Knee radiographs are the first imaging modality performed in acute knee trauma,
Trauma; and in most of cases, the findings are obvious. Nevertheless, sometimes, only subtle clues
Knee; can indicate a potentially more severe underlying abnormality, such as ligamentous, tendinous
Radiographs; or meniscal tears. Knowledge of the origin of such signs and of the related underlying injury
MRI mechanism, might lead to additional imaging investigation, which may facilitate appropriate
patient work-up and prevent consequences of delayed treatment.
© 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Knee radiographs, including frontal (antero-posterior) and lateral views, are the first
imaging modality performed in acute knee trauma, its prescription being guided by two
main validated clinical decision rules, which are the Ottawa knee rules and the Pittsburg
decision rules [1,2] (Boxed text 1 and Boxed text 2). Plain radiographic findings in the
acutely injured knee are most of the time obvious, however, sometimes only subtle clues
indicate an underlying abnormality, which can be potentially severe [3]. Knowledge of
normal knee anatomy and of a few key anatomic sites refines the detection of less appar-
ent signs of some fractures, avulsion fractures, musculotendinous and ligamentous injury
(Fig. 1). Early recognition of knee injuries both facilitates appropriate patient work-up and
prevents long-term consequences of delayed treatment [4].

∗ Corresponding author.
E-mail address: guillaume.bierry@chru-strasbourg.fr
(G. Bierry).

2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.diii.2013.09.012
552
Boxed text 1 Ottawa decision rules.
Radiograph of the knee indicated if one of the following
is present:
• age > 55;
• tenderness of the head of the fibula;
• isolated tenderness of the patella;
• inability to flex at 90◦ ;
• inability to bear weight in ED (4 steps).
Boxed text 2 Pittsburgh decision rules.
Radiograph of the knee indicated if one of the following
is present:
• mechanism: blunt trauma or fall;
• age < 12;
• age > 50;
• inability to bear weight in ED (4 steps).
Lipohemarthrosis
Lipohemarthrosis refers to the presence of fat and blood in
a joint and is a definite proof of an intra-articular fracture,
even though the fracture may be radiographically occult.
Lipohemarthrosis occurs in approximately 40% of all the
intra-articular fractures of the knee joint and appears within
3 h after the trauma [5]. A fat fluid level (characteristic
double fluid—fluid layer) in the supra-patellar pouch and in
Hoffa’s fat pouch, seen on a lateral knee radiograph, reveals
the intra-articular fracture, as fat and blood enter the joint
from a marrow space through an osteochondral defect at
the articular surface of the joint (Fig. 2). Three bands can
usually be distinguished in typical cases: the top one con-
sisting of fat, the one just below in serum and serous joint
effusion and the lowest consists of the cellular part of the
blood, due to the loculation of the supra-patellar space. It
should be mentioned that a conventional lateral view radio-
graph is sometimes not capable of depicting the fluid—fluid
Figure 1. Schematic representation of the knee (frontal view in A, lateral view in B) demonstrating the different keys sites to be checked
on traumatic knee radiograph.
A. Venkatasamy et al.
level. A horizontal radiograph is needed to distinguish fat
from serum.
Hemarthrosis
An immediate post-traumatic knee effusion indicates an
intra-capsular injury, such as a ligament tear, but not nec-
essarily a fracture [6]. On lateral radiograph, the effusion
appears as soft tissue opacity. This is due to hemorrhage
or hematoma around the patellar tendon and associated
increased opacity of the retropatellar fat pad (Fig. 3). The
normal sharp soft tissue-fat interface between the patellar
tendon and the retropatellar fat pad is obliterated. In sub-
tle effusion, a variable amount of fluid can be seen in the
supra patella pouch and in Hoffa’s triangle while, in large
effusion, the patella can be displaced anteriorly and angled
due to the pressure exerted by the fluid in the supra-patellar
pouch.
Cruciate ligaments avulsion of the tibia
eminence
Most avulsion injuries of the anterior or posterior cruciate
ligaments occur distally, on their insertion on the anterior or
posterior tibial eminence, rather than on their insertion site
on the lateral and medial femoral condyles [7]. Avulsion of
the tibial eminence can be associated with other injuries,
including collateral ligament and meniscal tears and focal
bone contusions. Diagnosis at radiography can be difficult
and often requires additional tunnel-view and oblique imag-
ing. CT and MR imaging can display the fracture site to
greater advantage; MRI enables visualization of associated
ligament and meniscal tears [8].
Fracture fragments near the anterior tibial eminence,
particularly with the involvement of the tibial spines may
suggest anterior cruciate ligament injury or avulsion. In
this case, an antero-posterior radiograph may show a bony
fragment projecting in the intercondylar notch with cor-
tical irregularity of the adjacent tibial eminence, and the
Acute traumatic knee radiographs
Figure 2. Lipohemarthrosis in a 41-year-old man; knee horizontal radiograph (a), axial CT (b), axial fat-saturated T2-weighted MR image
(c). Fluid—fluid aspect is visible as an interface between fat (white arrow) and fluid (arrowhead). MR image allows visualization of an
additional interface between fluid and sediment clots (black arrow).
Figure 3. Hemarthrosis in a 40-year-old woman; standing lateral
radiograph of the right knee. Fluid density is present behind the
patellar tendon and around patella tip (arrows); note patella tilting
(arrowhead) due to abundant effusion.
lateral view may reveal its anterior origin (Fig. 4). The usual
mechanism of injury for avulsion fractures of the ACL is
hyperflexion of the knee with tibial internal rotation, or
hyperextension of the knee. This fracture is frequently asso-
ciated with tears of the menisci, posterior cruciate ligament
and collateral ligaments [9].
Fracture fragments near the posterior tibial eminence
may indicate posterior cruciate ligament injury or avul-
sion. The usual mechanism of injury for avulsion fractures
of the PCL is sudden hyperextension of the knee, or a vio-
lent posterior displacement of the tibia while the knee is
flexed. Isolated posterior cruciate ligament avulsion is best
observed on a lateral radiograph, and appears as a focal
discontinuity of the posterior tibial articular surface with a
bone fragment that might migrate within the posterior inter-
condylar space (Fig. 5). Common associated injuries are ACL
sprain/tear, midportion PCL sprain/tear, medial collateral
553
ligament sprain/tear, fibular collateral ligament sprain/tear
and meniscal tears [10].
Laterally sided signs
Lateral femoral condyle notch
The femoral condyle is normally divided in anterior and
posterior halves by a small indentation, which normally
measures 0.45 mm depth, called lateral femoral notch or
lateral condyle sulcus.
An abnormally deep sulcus, 1.5 mm or deeper, corre-
sponds to a transchondral fracture with a high likelihood
of an anterior cruciate ligament rupture [11] (Fig. 6). Due
to the anterior displacement of the tibia after anterior cru-
ciate ligament rupture, the posterior aspect of the lateral
plateau of the tibia strikes the lateral femoral condyle in
the region of the condyle sulcus, causing bone oedema and
a potential transchondral impaction facture that results in
the deepening of the lateral femoral notch. Therefore, when
a deep femoral condyle notch is seen, an anterior cruciate
ligament tear must be suspected.
Segond fracture
The Segond fracture is a small vertical avulsion fracture of
the tibial insertion of the central portion of the lateral cap-
sule [12]. This fracture, resulting from a combination of
internal rotation of the knee and varus stress, is associated
in 75% of the cases with injury of the anterior cruciate lig-
ament and is also frequently associated with meniscus tear
[13]. On conventional radiographs, this fracture appears as
an elliptic fragment of bone (approximately 10 × 3 mm in
size), usually 3—6 mm distal to the lateral tibial plateau,
termed the ‘‘lateral capsular sign’’, which can be asso-
ciated with irregularity on the proximal tibia (donor site)
(Fig. 7). The tiny detached bone fragment is best seen on the
antero-posterior view on plain radiographs. A Segond frac-
ture may be associated with avulsions of the fibular head at
the insertion of the biceps muscle of the thigh and the fibu-
lar collateral ligament [14]. Therefore, fibular head avulsion
fractures could be mistaken for a Segond fracture if solely
visualised on anterior-posterior view.
554 A. Venkatasamy et al.

Figure 4. Avulsion of anterior spine in a 32-year-old man. Lateral radiograph (a) of the right knee show a completely detached avulsion
fracture (arrow) of the tibial spine, displaced in the intercondylar notch. Sagittal fat-saturated T2-weighted MR image (b) shows an ACL
with increased signal but still attached to the avulsed fragment (arrow).

Figure 5. Avulsion of posterior spine in 20-year-old man. Lateral radiograph of the right knee (a) shows the non-displaced fracture
fragment in the posterior tibial plateau (white arrow) with underlying fracture gap (black arrow). Sagittal T1-weighted MR image (b) shows
a buckled PCL attached to a proximally displaced fracture fragment (white arrow).

The presence of a Segond fracture should lead to further
imaging evaluation of the patient’s knee with the completion
of an MRI to evaluate the extent of the suspected underlying
anterior cruciate ligament injury [15].
Arcuate complex avulsion fracture
The arcuate complex consists of the lateral collateral liga-
ment, the biceps femoris tendon, the popliteus muscle and
tendon, the politeal meniscal ligament, the popliteal fibular
ligament, the oblique popliteal, arcuate and fabello-fibular
ligaments and the lateral gastrocnemius muscle, that inserts
on the fibular head [14,16]. It provides stabilization of the
postero-lateral corner of the knee. Different mechanisms of
injury exist, such as sudden hyperextension, varus force to
an externally rotated tibia or trauma to the antero-medial
tibia on an extended knee.
The ‘‘arcuate sign’’ described on conventional radio-
graphs is an avulsed elliptic bone fragment arising from the
insertion of the arcuate complex at the styloïd process of
the fibular head [17] (Fig. 8). This avulsion fracture is best
seen on the anterio-posterior knee radiograph where the
long axis of the elliptic bone fragment is orientated hori-
zontally, which helps to differentiate this avulsion fracture
form the biceps femoris tendon avulsion fracture.
Avulsion fractures of the arcuate complex are often asso-
ciated with traumatic injuries of other stabilizing knee
structures, such as the anterior cruciate ligament or the
posterior cruciate ligament. MRI imaging is used to confirm
the exact origin of the fracture and to identify associated
damage to the ilio-tibial band or cruciate ligament [18].
Acute traumatic knee radiographs 555

Figure 6. Post-traumatic lateral condyle notch in a 22-year-old man. On lateral radiograph (a), a notch deeper than 2 mm is seen on
the lateral condyle (arrow). Sagittal fat-saturated T2-weighted MR images (b, c) confirmed the notch localization with subchondral marrow
oedema (arrow), associated with full thickness anterior cruciate ligament (arrowhead).

Figure 7. Segond fracture in a 44-year-old man, antero-posterior radiograph of the right knee (a) and coronal fat-saturated T2-weighted
MR image (b). A small fracture fragment of the lateral aspect of the lateral tibia plateau is seen (arrow). MR image confirms the relationship
between the fragment (arrow) by the lateral capsule.

Ilio-tibial band injury
Avulsion fractures of the ilio-tibial band (ITB) generally
occur at the tibial insertion on Gerdy’s tubercle of the
proximal tibia. Conventional radiographs show a small bone
fragment along the anterolateral aspect of the proximal
tibia. The fracture can be mistaken for a Segond fracture,
which usually occurs superior and posterior to Gerdy’s tuber-
cle, but avulsion is frequently associated with this finding
[15,19]. ITB avulsion fracture raises the suspicion of an asso-
ciated lateral collateral ligament injury.
Biceps femoris tendon avulsion fracture
The biceps femoris tendon is a two-headed tendon, the
longest head inserts on the postero-lateral aspect of the
fibular head and the shortest just medially to the longest.
It forms a conjoined tendon with the lateral collateral liga-
ment at its insertion and attaches to the lateral margin of
the fibular head, opposite to the insertion of the arcuate
complex.
Biceps femoris tendon avulsion fractures appear as an
irregular bone fragment arising from the fibular head [20].
It may be difficult to distinguish a biceps femoris tendon
avulsion fracture from an ‘‘arcuate sign’’ on conventional
radiographs as it only slightly differs on orientation and
appearance of the fragment: elliptic in the ‘‘arcuate sign’’
versus irregular in the biceps femoris avulsion fracture, long
axis orientated horizontally in the ‘‘arcuate sign’’ versus no
clear orientation. Further MRI investigation can display the
fracture site to a greater advantage and review potentially
associated capsular lesions [19].
556 A. Venkatasamy et al.

Figure 8. Arcuate sign in a 21-year-old man who sustained a high velocity motorcycle accident. Antero-posterior radiograph of the right
knee (a) shows a fracture fragment superior to the fibular head (arrow). Sagittal fat-saturated T2-weighted MR image (b) demonstrates the
avulsion donor site (arrow).

Popliteus tendon avulsion
Rarely, the insertion of the popliteus tendon avulses from
the femur. This injury results from posterior subluxation of
the tibia with respect to the femur and is commonly associ-
ated with tears of the menisci, the PCL, or lateral capsular
structures [21].
Medially sided signs
Medial collateral ligament femoral avulsion
Avulsion fractures at attachment sites of the MCL are uncom-
mon. The avulsion of the medial collateral ligament at its
insertion site on the medial femoral condyle after a valgus
stress, results in a bony fragment arising from the poste-
rior aspect of the medial femoral condyle associated with
irregularity of the donor site [18] (Fig. 9). After an MCL tear,
ossification of the MCL called Pellegrini—Stieda disease can
be observed at the proximal margin of the medial femoral
condyle [22]. MR imaging is best suited for the detection
of MCL avulsions and associated injuries of the cruciate and
meniscus.
Reverse Segond fracture
The reverse Segond fracture is an avulsion of the deep cap-
sular component of the medial collateral ligament and is
often associated with posterior cruciate ligament tears and

Figure 9. Avulsion of the femoral attachment of medial collateral ligament (MCL) in 28-year-old man with an avulsion fracture of the
medial collateral ligament (MCL). Antero-posterior radiograph of the left knee (a) and coronal CT image (b) show a non-displaced avulsion
fracture of the medial femoral condyle (arrow). Coronal T1-weighted MR image (c) confirms the continuity of the fracture fragment with
the MCL (arrow).
Acute traumatic knee radiographs
Figure 10. ‘‘Reverse Segond’’ fracture in a 33-year-old woman.
Antero-posterior radiograph of the left knee shows a small fracture
fragment along the medial tibial rim (arrow).
avulsion as well as tears in the medial meniscus [23]. This
fracture results from excessive external rotation of the knee
and valgus stress (opposite mechanism of injury to that of
the Segond fracture). The reverse Segond fracture results in
a thin sliver of bone similar to that of the Segond fracture
but located on the other side of the knee. It appears on con-
ventional radiographs as an elliptic fragment of bone avulsed
from the medial aspect of the proximal tibia, a mirror image
of a Segond fracture (Fig. 10). If there is a reverse Segond
fracture, a further MRI evaluation of the patient’s knee is
recommended in order to evaluate the potential damage to
PCL or medial meniscus [24].
Figure 11. Avulsion of semi-membranous tendon in a 31-year-old man. Lateral radiograph of the right knee (a) reveals a subtle irregularity
of the posterior margin of the tibial plateau (arrow). Sagittal fat-saturated T2-weighted MR image (b) confirms the non-displaced avulsion
in continuity with semimembranosus tendon (arrow).
557
Semi-membranous tendon avulsion fracture
The posteromedial corner of the knee consists of three main
structures: the semi-membranous tendon whose central part
inserts on the infraglenoid tubercle of the posteromedial
tibia, the posterior joint capsule and the posterior oblique
ligament [25]. Different mechanism of injury may cause a
semi-membranous tendon avulsion fracture, such as exter-
nal rotation and abduction of the flexed knee, varus force
applied to the flexed knee and valgus force applied to the
tibia. The semi-membranous tendon avulsion fracture is
rather difficult to detect on conventional radiographs and is
best seen on a lateral view. This avulsion fracture appears as
a tiny avulsed bone fragment arising postero-superiorly from
its insertion on the tibia [25] (Fig. 11). MRI imaging is used to
confirm the avulsion fracture and to identify the associated
damage to the neighbouring structures, especially injuries
of the anterior cruciate ligament and of the posterior horn
of the medial meniscus [26].
Patella related signs
Patella alta and patella baja
The patellar tendon attaches the patella to the upper tibia
at the tibial tuberosity and can be ruptured secondary to
a violent active extension of the knee or a violent passive
flexion of the knee against a tightly contracted quadriceps. A
patella alta describes a superior displacement of the patella
with respect to the femur (Fig. 12). The length of the patel-
lar tendon is 50% or greater than the length of the patella,
as the patella is pulled superiorly by the quadriceps muscle
[27]. The lateral radiograph of the knee should be performed
on a 30◦ -flexed knee, as on a fully extended knee, the patella
may be normally positioned despite the rupture. In addition,
patella alta can be related to an avulsion fracture of the
tibial tuberosity [28].
558 A. Venkatasamy et al.

Figure 12. Patella alta in a 54-year-old man who sustained acute proximal patellar tendon rupture. Lateral radiograph (a) shows an
ascencionnated patella with mutiple small bone fragment at its distal pole. Sagittal CT image (b) demonstrated the loss of definition of
proximal patellar tendon insertion (arrow) consistent with the rupture.

Figure 13. Acute quadricipital tendon distal insertion rupture in a 34-year-old man. Lateral radiograph of the right knee (a) shows loss of
visualization of the distal part of the quadricipital tendon with increased soft tissue opacity especially of the supra-patellar fat pad (arrow).
Postoperative sagittal fat-saturated T2-weighted MR image (b) showed surgical clips artifacts at the site of tendon reinsertion.

The quadriceps femoris tendon attaches the quadriceps Sinding—Larsen—Johansson syndrome

muscle to the patella. Its rupture can occur after a sud-
den contraction of the quadriceps muscle with the knee
flexed. The patella baja deformity describes an appar-
ent decrease in patellar tendon length, associated with an
inferior displacement of the patella, which occurs after
quadriceps tendon rupture. Nevertheless, a true patella
inferior displacement is rare due to the persistent retinacu-
lum continuity [28]. However, increased soft tissue opacity
at the supra-patellar region especially of the supra-patellar
fat pad due to hemorrage or hematoma and poor definition
of the distal quadriceps tendon can be seen on lateral radio-
graphs, revealing tendon distal rupture (Fig. 13). In the case
of an avulsion fracture of the quadriceps tendon, bone frag-
ments arising from the superior aspect of the patella are
frequently seen (‘‘loose patellar teeth’’), especially on the
lateral view [29,30].
In the Sinding—Larsen—Johansson syndrome, lateral radio-
graph shows one or multiple tiny bone fragments arising
from the inferior aspect of the patella, associated with
patella alta deformity [19]. The mechanism of injury
appears to be due to forceful contraction of the quadri-
ceps muscle against resistance, as in the quadriceps tendon
rupture.
MRI imaging is necessary to differentiate this
entity from a patellar sleeve avulsion fracture. The
Sinding—Larsen—Johansson syndrome is only a bone avul-
sion at the proximal patellar insertion whereas the patellar
sleeve avulsion fracture demonstrates extensive cartilagi-
nous injury to the lower pole of the patella in addition
to osseous deformity. Differentiation between these two
entities is important because the former is often managed
Acute traumatic knee radiographs 559

non-operatively, while the latter is often treated with open
reduction.
Patellar medial avulsion
Lateral patellar dislocation often occurs due to a twisting
movement on a flexed knee in external rotation with inter-
nal rotation of the femur. The impact of the infero-medial
facet of the patella on the anterolateral femoral condyle
may result in fractures or bone contusions (kissing contu-
sions) and soft tissue injuries sometimes severe, such as
complete avulsion or disruption of the medial retinaculum
[31].
In acute lateral patellar dislocation with patellar reti-
naculum avulsion, initial axial radiographs (sunrise view)
showed lateral displacement of the patella with lateral
edge cortical defect and small bony fragment arising
from the lateral aspect of the patella [32]. A post-
reduction radiograph, if considered solely, may only show
the cortical defect and bony fragment (Fig. 14). Fur-
ther MRI investigation is necessarily to confirm patellar
retinaculum injury at thr patellar insertion and to iden-
tify the associated proximal capsular injury, assess the
extent of cartilaginous injury, displacement of fracture
fragments, and helps determine the need for surgery [33]
(Fig. 14).

Figure 14. Avulsion of patellar retinaculum in a 16-year-old patient who sustained acute patella dislocation. Initial axial radiographs
of the right knee (a) shows lateral displacement of the patella with lateral edge cortical defect (small arrow) and small bony fragment
(arrowhead). Post-reduction radiograph (b), if considered solely, only showed the cortical defect and bony fragment. Axial fat-saturated
T2-weighted MR images (c, d) confirm patellar reticulum injury at patellar insertion (large arrow) and revealed proximal capsular injury
(black arrow).
560
Conclusion
Imaging evaluation of an acutely injured knee might only
demonstrate subtle abnormalities, such as avulsion fractures
or effusion that are generally easily detected on conven-
tional radiographs. Nevertheless, their recognition by the
physician, coupled with an awareness of their origin and of
the related underlying injury mechanism, might lead to fur-
ther imaging investigation for the detection of co-existent
but less evident fractures and for the evaluation of associ-
ated ligamentous, tendinous or meniscal injuries.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
References
[1] Bauer S, Hollander J, Fuchs S, Thode HJ. A clinical decision
rule in the evaluation of acute knee injuries. J Emerg Med
1995;13:611—5.
[2] Stiell I, Greenberg G, Wells G, et al. Derivation of a deci-
sion rule for the use of radiography in of a decision rule for
the use of radiography in acute knee injuries. Ann Emerg Med
1995;26:405—12.
[3] Capps GW, Hayes CW. Easily missed injuries around the knee.
Radiographics 1994;14:1191—210.
[4] Matherne TH, Monu JU, Schruff L, Neitzschman HR. Avul-
sions around the knee portend instability. Emerg Radiol
2005;11:213—8.
[5] Schick C, Mack MG, Marzi I, Vogl TG. Lipohemarthrosis of the
knee: MRI as an alternative to the puncture of the knee joint.
Eur Radiol 2003;13:1185—7.
[6] LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The postero-
lateral attachments of the knee: a qualitative and quantitative
morphologic analysis of the fibular collateral ligament,
popliteus tendon, popliteofibular ligament, and lateral gas-
trocnemius tendon. Am J Sports Med 2003;31:854—60.
[7] Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament
avulsion fractures. Arthroscopy 2004;20:803—12.
[8] Mellado JM, Ramos A, Salvado E, Camins A, Calmet J, Sauri A.
Avulsion fractures and chronic avulsion injuries of the knee:
role of MR imaging. Eur Radiol 2002;12:2463—73.
[9] Calpur OU, Copuroglu C, Ozcan M. Avulsion fractures of both
anterior and posterior cruciate ligament tibial insertions. Knee
Surg Sports Traumatol Arthrosc 2002;10:223—5.
[10] Kendall NS, Hsu SY, Chan KM. Fracture of the tibial spine in
adults and children. A review of 31 cases. J Bone Joint Surg Br
1992;74:848—52.
[11] Garth Jr WP, Greco J, House MA. The lateral notch sign asso-
ciated with acute anterior cruciate ligament disruption. Am J
Sports Med 2000;28:68—73.
[12] Dietz GW, Wilcox DM, Montgomery JB. Segond tibial
condyle fracture: lateral capsular ligament avulsion. Radiology
1986;159:467—9.
[13] Goldman AB, Pavlov H, Rubenstein D. The Segond fracture of
the proximal tibia: a small avulsion that reflects major liga-
mentous damage. AJR Am J Roentgenol 1988;151:1163—7.
[14] Seebacher JR, Inglis AE, Marshall JL, Warren RF. The structure
of the postero-lateral aspect of the knee. J Bone Joint Surg Am
1982;64:536—41.
A. Venkatasamy et al.
[15] Campos JC, Chung CB, Lektrakul N, Pedowitz R, Trudell D, Yu
J, et al. Pathogenesis of the Segond fracture: anatomic and MR
imaging evidence of an ilio-tibial tract or anterior oblique band
avulsion. Radiology 2001;219:381—6.
[16] Lee J, Papakonstantinou O, Brookenthal KR, Trudell D, Resnick
DL. Arcuate sign of postero-lateral knee injuries: anatomic,
radiographic, and MR imaging data related to patterns of injury.
Skeletal Radiol 2003;32:619—27.
[17] Huang GS, Yu JS, Munshi M, Chan WP, Lee CH, Chen CY, et al.
Avulsion fracture of the head of the fibula (the ‘‘arcuate’’
sign): MR imaging findings predictive of injuries to the postero-
lateral ligaments and posterior cruciate ligament. AJR Am J
Roentgenol 2003;180:381—7.
[18] Beall DP, Googe JD, Moss JT, Ly JQ, Greer BJ, Stapp AM, et al.
Magnetic resonance imaging of the collateral ligaments and
the anatomic quadrants of the knee. Radiol Clin North Am
2007;45:983—1002.
[19] Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D.
Avulsion fractures of the knee: imaging findings and clinical
significance. Radiographics 2008;28:1755—70.
[20] Sebastianelli WJ, Hanks GA, Kalenak A. Isolated avulsion of the
biceps femoris insertion. A case report. Clin Orthop Relat Res
1990;10:200—3.
[21] Feng H, Zhang H, Hong L, Wang XS, Zhang J. The ‘‘lateral gutter
drive-through’’ sign: an arthroscopic indicator of acute femoral
avulsion of the popliteus tendon in knee joints. Arthroscopy
2009;25:1496—9.
[22] Wang JC, Shapiro MS. Pellegrini—Stieda syndrome. Am J Orthop
1995;24:493—7.
[23] Escobedo EM, Mills WJ, Hunter JC. The ‘‘reverse Segond’’
fracture: association with a tear of the posterior cruciate lig-
ament and medial meniscus. AJR Am J Roentgenol 2002;178:
979—83.
[24] Hall FM, Hochman MG. Medial Segond-type fracture: cortical
avulsion off the medial tibial plateau associated with tears of
the posterior cruciate ligament and medial meniscus. Skeletal
Radiol 1997;26:553—5.
[25] Beltran J, Matityahu A, Hwang K, Jbara M, Maimon R, Padron
M, et al. The distal semimembranosus complex: normal MR
anatomy, variants, biomechanics and pathology. Skeletal Radiol
2003;32:435—45.
[26] Yao L, Lee JK. Avulsion of the posteromedial tibial plateau
by the semimembranosus tendon: diagnosis with MR imaging.
Radiology 1989;172:513—4.
[27] Shabshin N, Schweitzer ME, Morrison WB, Parker L. MRI criteria
for patella alta and baja. Skeletal Radiol 2004;33:445—50.
[28] Brooks P. Extensor mechanism ruptures. Orthopedics 2009:32.
[29] Hockings M, Cameron JC. Patella baja following chronic quadri-
ceps tendon rupture. Knee 2004;11:95—7.
[30] Bimmel R, Reddy K. Quadriceps tendon rupture and periosteal
sleeve avulsion fracture of the proximal patella pole in an
active adolescent. Orthopedics 2008;31:716.
[31] Sillanpaa PJ, Peltola E, Mattila VM, Kiuru M, Visuri T, Pih-
lajamaki H. Femoral avulsion of the medial patellofemoral
ligament after primary traumatic patellar dislocation predicts
subsequent instability in men: a mean 7-year nonoperative
follow-up study. Am J Sports Med 2009;37:1513—21.
[32] Kitamura K, Nomura E, Inoue M, Sugiura H, Kobayashi S.
Avulsion-tear type medial patellofemoral ligament injury with
a small bony fragment in lateral patellar dislocation. J Trauma
2009;66:271—3.
[33] Sanders TG, Morrison WB, Singleton BA, Miller MD, Cor-
num KG. Medial patellofemoral ligament injury following
acute transient dislocation of the patella: MR findings with
surgical correlation in 14 patients. J Comp Assist Tomogr
2001;25:957—62.