ARE SEGOND FRACTURES OF THE TIBIA PATHOGNOMONIC FOR ACL TEARS IN THE PEDIATRIC AND ADOLESCENT POPULATION?

Abstract

Background:Segond fractures (avulsion fractures of the proximal lateral tibia) are considered to be pathognomonic for anterior cruciate ligament (ACL) tears in adult patients.Purpose:To describe the largest case series of pediatric Segond fractures and associated intra-articular injuries of the knee to determine if these fractures are pathognomonic for ACL tears in young patients.Methods:IRB-approved retrospective study of patients under 20 years who presented with Segond fracture to a tertiary children’s hospital between 2009-2019. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected.Results:55 patients (46 males, 9 females) with mean age 15.2 years (11.8-19.1) with Segond fractures of the proximal tibia on radiology imaging were identified (Fig.1.2). Diagnosis of associated injuries was established based on clinical examination, radiology report and findings during arthroscopy. Average Segond fracture size was 2.7 x 9.5mm as measured on standard knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/55(89%) patients. Associated injuries included anterior cruciate ligament (ACL) tears (39 patients, 70.9%), tibial eminence fractures (9, 16.4%), and all other injuries (7, 12.7%) (Table 1.1). Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. When age was compared between the patient group with ACL tears (mean 15.7 years) to the ones with tibial spine fractures ( mean 13.9 years), there was a statistically significant difference(p=0.007). 12/55 (21.8%) had associated articular cartilaginous injuries, 3 of which required surgical intervention. 37/55 (67.3%) patients had meniscal injury. 3 (5.5%) patients suffered multi-ligament injuries. Overall, 87.2% of the patients required surgical management for associated intra-articular injuries of the knee.Conclusion:The Segond (tibial avulsion) fracture is associated with intra-articular injuries the pediatric population, most commonly ACL tears and meniscus tears. However, the largest case series in the pediatric population suggests that they are not pathognomonic for ACL tears as a notable proportion of patients, especially the ones who are younger in age, have tibial eminence fractures or no ACL tears.Figure 1.2.Antero-posterior knee radiograph showing Segond avulsion fracture of the proximal lateral tibia