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Cruciate ligament avulsion fractures: Anatomy, biomechanics, injury patterns, and approach to management

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Abstract

Injury to the ACL or PCL of the knee most commonly involves a tear of the collagenous fibers of the ligament. Less frequently, a cruciate ligament injury involves an avulsion fracture at the origin or insertion of the ligament, usually from the insertion site on the tibial surface. Avulsion fractures of the cruciate ligaments are important, as they can be identified on radiographs, allowing a specific diagnosis. Although more common in children, when they occur in adults, they are more commonly associated with other injuries. The treatment of cruciate ligament avulsion fractures is different than the treatment of intrasubstance tears of the cruciate ligaments. These injuries can be treated conservatively or surgically with good outcomes. Recently arthroscopic fixation of these injuries with various fixation devices has become more frequent. Treatment largely depends on the type of fracture, particularly, the size, displacement, comminution, and orientation of the avulsed fracture fragment, in addition to the integrity of the attached cruciate ligament. This review article covers the anatomy and biomechanics of the cruciate ligaments, their injury patterns, and approach to management.

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References

  1. Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D (2008) Avulsion fractures of the knee: imaging findings and clinical significance. Radiographics: Review Publ Radiol Soc N Am Inc 28(6):1755–1770. doi:10.1148/rg.286085503

    Google Scholar 

  2. Matherne TH, Monu JU, Schruff L, Neitzschman HR (2005) Avulsions around the knee portend instability. Emerg Radiol 11(4):213–218. doi:10.1007/s10140-005-0415-2

    Article  PubMed  Google Scholar 

  3. Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Menetrey J (2006) Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 14(3):204–213. doi:10.1007/s00167-005-0679-9

    Article  PubMed  CAS  Google Scholar 

  4. Girgis FG, Marshall JL, Monajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231

    Article  PubMed  Google Scholar 

  5. Kennedy JC, Weinberg HW, Wilson AS (1974) The anatomy and function of the anterior cruciate ligament, As determined by clinical and morphological studies. J Bone Joint Surg Am 56(2):223–235

    PubMed  CAS  Google Scholar 

  6. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr (2000) Mechanisms of anterior cruciate ligament injury. Orthopedics 23(6):573–578

    PubMed  CAS  Google Scholar 

  7. Sakane M, Livesay GA, Fox RJ, Rudy TW, Runco TJ, Woo SL (1999) Relative contribution of the ACL, MCL, and bony contact to the anterior stability of the knee. Knee Surg Sports Traumatol Arthrosc 7(2):93–97

    Article  PubMed  CAS  Google Scholar 

  8. Woo SL, Fisher MB (2009) Evaluation of knee stability with use of a robotic system. J Bone Joint Surg Am 91(Suppl 1):78–84. doi:10.2106/JBJS.H.01371

    Article  PubMed  Google Scholar 

  9. Bengtson H, Giangarra C (2011) Osteochondral avulsion fracture of the anterior cruciate ligament femoral origin in a 10-year-old child: a case report. J Athl Train 46(4):451–455

    PubMed  Google Scholar 

  10. Beynnon BD, Fleming BC, Labovitch R, Parsons B (2002) Chronic anterior cruciate ligament deficiency is associated with increased anterior translation of the tibia during the transition from non-weightbearing to weightbearing. J Orthop Res 20(2):332–337. doi:10.1016/S0736-0266(01)00115-2

    Article  PubMed  Google Scholar 

  11. Gelber AC, Hochberg MC, Mead LA, Wang NY, Wigley FM, Klag MJ (2000) Joint injury in young adults and risk for subsequent knee and hip osteoarthritis. Ann Intern Med 133(5):321–328

    Article  PubMed  CAS  Google Scholar 

  12. Murrell GA, Maddali S, Horovitz L, Oakley SP, Warren RF (2001) The effects of time course after anterior cruciate ligament injury in correlation with meniscal and cartilage loss. Am J Sports Med 29(1):9–14

    PubMed  CAS  Google Scholar 

  13. Lubowitz JH, Elson WS, Guttmann D (2005) Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy 21(1):86–92. doi:10.1016/j.arthro.2004.09.031

    Article  PubMed  Google Scholar 

  14. Capps GW, Hayes CW (1994) Easily missed injuries around the knee. Radiographics: Review Publ Radiol Soc N Am Inc 14(6):1191–1210

    CAS  Google Scholar 

  15. Stevens MA, El-Khoury GY, Kathol MH, Brandser EA, Chow S (1999) Imaging features of avulsion injuries. Radiographics: Review Publ Radiol Soc N Am Inc 19(3):655–672

    CAS  Google Scholar 

  16. Delzell PB, Schils JP, Recht MP (1996) Subtle fractures about the knee: innocuous-appearing yet indicative of significant internal derangement. AJR American J Roentgenol 167(3):699–703

    Article  CAS  Google Scholar 

  17. Griffith JF, Antonio GE, Tong CW, Ming CK (2004) Cruciate ligament avulsion fractures. Arthroscopy 20(8):803–812. doi:10.1016/j.arthro.2004.06.007

    PubMed  Google Scholar 

  18. Meyers MH, McKeever FM (1970) Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 52(8):1677–1684

    PubMed  CAS  Google Scholar 

  19. McLennan JG (1982) The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br Vol 64(4):477–480

    CAS  Google Scholar 

  20. Kendall NS, Hsu SY, Chan KM (1992) Fracture of the tibial spine in adults and children. A review of 31 cases. J Bone Joint Surg Br 74(6):848–852

    PubMed  CAS  Google Scholar 

  21. Kocher MS, Foreman ES, Micheli LJ (2003) Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children. Arthroscopy 19(10):1085–1090. doi:10.1016/j.arthro.2003.10.014

    Article  PubMed  Google Scholar 

  22. Vinson EN, Major NM, Helms CA (2008) The posterolateral corner of the knee. AJR Am J Roentgenol 190(2):449–458. doi:10.2214/AJR.07.2051

    Article  PubMed  Google Scholar 

  23. Baums MH, Klinger HM, Harer T (2004) Treatment of malunited fractures of the anterior tibial spine. Knee Surg Sports Traumatol Arthrosc 12(2):159–161. doi:10.1007/s00167-003-0387-2

    Article  PubMed  CAS  Google Scholar 

  24. Chandrasekaran S, Ma D, Scarvell JM, Woods KR, Smith PN (2012) A review of the anatomical, biomechanical and kinematic findings of posterior cruciate ligament injury with respect to non-operative management. Knee 19(6):738–745. doi:10.1016/j.knee.2012.09.005

    Article  PubMed  Google Scholar 

  25. Sonin AH, Fitzgerald SW, Hoff FL, Friedman H, Bresler ME (1995) MR imaging of the posterior cruciate ligament: normal, abnormal, and associated injury patterns. Radiographics: Review Publ Radiol Soc N Am Inc 15(3):551–561

    CAS  Google Scholar 

  26. Harner CD, Xerogeanes JW, Livesay GA, Carlin GJ, Smith BA, Kusayama T, Kashiwaguchi S, Woo SL (1995) The human posterior cruciate ligament complex: an interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 23(6):736–745

    Article  PubMed  CAS  Google Scholar 

  27. Castle TH Jr, Noyes FR, Grood ES (1992) Posterior tibial subluxation of the posterior cruciate-deficient knee. Clin Orthop Relat Res 284:193–202

    PubMed  Google Scholar 

  28. Race A, Amis AA (1994) The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech 27(1):13–24

    Article  PubMed  CAS  Google Scholar 

  29. Li G, Gill TJ, DeFrate LE, Zayontz S, Glatt V, Zarins B (2002) Biomechanical consequences of PCL deficiency in the knee under simulated muscle loads—an in vitro experimental study. J Orthop Res 20(4):887–892. doi:10.1016/S0736-0266(01)00184-X

    Article  PubMed  Google Scholar 

  30. Wilk KE (1994) Rehabilitation of isolated and combined posterior cruciate ligament injuries. Clin Sports Med 13(3):649–677

    PubMed  CAS  Google Scholar 

  31. Van Dommelen BA, Fowler PJ (1989) Anatomy of the posterior cruciate ligament. A review. Am J Sports Med 17(1):24–29

    Article  PubMed  Google Scholar 

  32. Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL (2012) Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med 40(1):222–231. doi:10.1177/0363546511416316

    Article  PubMed  Google Scholar 

  33. Margheritini F, Mancini L, Mauro CS, Mariani PP (2003) Stress radiography for quantifying posterior cruciate ligament deficiency. Arthroscopy 19(7):706–711

    Article  PubMed  Google Scholar 

  34. Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman GA (1992) Magnetic resonance imaging of the posterior cruciate ligament. Clinical use to improve diagnostic accuracy. Am J Sports Med 20(6):732–737

    Article  PubMed  CAS  Google Scholar 

  35. Karabay N, Sugun TS, Toros T (2009) Ultrasonographic diagnosis of the posterior cruciate ligament injury in a 4-year-old child: a case report. Emerg Radiol 16(5):415–417. doi:10.1007/s10140-008-0755-9

    Article  PubMed  Google Scholar 

  36. Sonin AH, Fitzgerald SW, Friedman H, Hoff FL, Hendrix RW, Rogers LF (1994) Posterior cruciate ligament injury: MR imaging diagnosis and patterns of injury. Radiology 190(2):455–458

    PubMed  CAS  Google Scholar 

  37. Carrino JA, Schweitzer ME (2002) Imaging of sports-related knee injuries. Radiol Clin North Am 40(2):181–202

    Article  PubMed  Google Scholar 

  38. Hunter JC, Chapman JR (1995) Isolated avulsion of the posterior cruciate ligament: an uncommon dashboard injury. AJR Am J Roentgenol 164(5):1190

    Article  PubMed  CAS  Google Scholar 

  39. Wind WM Jr, Bergfeld JA, Parker RD (2004) Evaluation and treatment of posterior cruciate ligament injuries: revisited. Am J Sports Med 32(7):1765–1775

    Article  PubMed  Google Scholar 

  40. Sudasna S, Harnsiriwattanagit K (1990) The ligamentous structures of the posterolateral aspect of the knee. Bull Hosp Jt Dis Orthop Inst 50(1):35–40

    PubMed  CAS  Google Scholar 

  41. Laprade RF, Wentorf FA, Olson EJ, Carlson CS (2006) An in vivo injury model of posterolateral knee instability. Am J Sports Med 34(8):1313–1321. doi:10.1177/0363546506286785

    Article  PubMed  Google Scholar 

  42. Kim SJ, Shin SJ, Choi NH, Cho SK (2001) Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia. J Bone Joint Surg Am 83-A(5):698–708

    PubMed  CAS  Google Scholar 

  43. Berg EE (1993) Comminuted tibial eminence anterior cruciate ligament avulsion fractures: failure of arthroscopic treatment. Arthroscopy 9(4):446–450

    Article  PubMed  CAS  Google Scholar 

  44. Calpur OU, Copuroglu C, Ozcan M (2002) Avulsion fractures of both anterior and posterior cruciate ligament tibial insertions. Knee Surg Sports Traumatol Arthrosc 10(4):223–225. doi:10.1007/s00167-002-0282-2

    PubMed  CAS  Google Scholar 

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Acknowledgment

We acknowledge Matt Skalski for his artistic renderings of the mechanisms of injury and different types of cruciate ligament injuries.

Conflict of interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Department of Radiology, 1500 San Pablo Street, Second Floor Imaging, Los Angeles, CA, 90033, USA

    Eric A. White, Dakshesh B. Patel, George R. Matcuk, Deborah M. Forrester, Ryan B. Lundquist, George F. Rick Hatch III, C. Thomas Vangsness & Christopher J. Gottsegen

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  1. Eric A. White
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  2. Dakshesh B. Patel
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  3. George R. Matcuk
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  4. Deborah M. Forrester
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  8. Christopher J. Gottsegen
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Correspondence to Eric A. White.

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White, E.A., Patel, D.B., Matcuk, G.R. et al. Cruciate ligament avulsion fractures: Anatomy, biomechanics, injury patterns, and approach to management. Emerg Radiol 20, 429–440 (2013). https://doi.org/10.1007/s10140-013-1121-0

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  • DOI: https://doi.org/10.1007/s10140-013-1121-0

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