Introduction
Segond fractures are characterized as lateral proximal tibial fractures of the avulsion type (when a little portion of bone that is linked to a tendon or ligament separates from the main portion of the bone) at the anterolateral ligament (ligament of the knee) attachment. They are particularly significant since an anterior cruciate ligament (ACL- ligament present in the middle of the knee) rupture, a more complicated knee injury, is pathognomonic for them. Given that segond fractures are usually not isolated occurrences, further evaluation and research are required in cases where plain radiographs reveal a segond fracture. The only population where segond fractures have been reported to be isolated injuries is the pediatric population. Nonetheless, since this is unusual, even young children should be thoroughly examined and investigated for knee ligament damage.
What Are the Causes of Segond Fractures?
Segond fractures are frequently brought on by an unnatural internal knee rotation coupled with varus stresses (the application of a force to a joint that moves the distal end of a limb toward the body's midline). Following a cadaveric investigation of knee injuries, Paul Segond first described them in his published writings in 1879. This was eventually linked to ACL ruptures because of the development of more sophisticated imaging methods. Segond also spoke of a fibrous band, now known as the anterolateral ligament, at the site of the avulsion injury. However, more recent MRI scans have not been able to pinpoint any specific ligamentous attachments linked with the anterolateral ligament, although they do demonstrate posterior capsule and iliotibial band (connective tissue running along the thigh to the knee) fiber attachment to the segond fragment. Yet, there is disagreement concerning these results.
What Are the Symptoms and Diagnostic Criteria for Segond Fractures?
It is not surprising that the history and mechanism of injury are the same between segond fractures and ACL tears because there is such a close association between the two injuries. Patients frequently talk about a "pop" after a twisting mechanism. They typically come with soreness, edema, a restricted range of motion in the knee, and mobility issues. Although Segond fractures are typically identified on radiographs of the knee, there is no special physical examination for this condition. Yet, it is crucial to test for an intact ACL because segond fractures are frequently pathognomonic for ACL ruptures. The Lachmann's test (a test to assess and diagnose the injury to the anterior cruciate ligament) is the most accurate physical examination technique for detecting ACL tears; however, the anterior drawer test (a physical examination to test the stability of the anterior cruciate ligament of the knee) is also useful. The integrity of every other knee ligament, including the posterior drawer, varus or valgus stress test, and pivot shift test, should also be evaluated.
How Are Segond Fractures Evaluated?
The radiographic features to evaluate the segond fractures are:
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Plain Radiograph: A curved or elliptic bone fragment that is positioned parallel to the lateral aspect of the tibial plateau (load-bearing area) is the traditional look of a segond fracture. The anteroposterior view of the knee provides the best view of this, often known as the “lateral capsular sign 1."
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MRI (Magnetic Resonance Imaging): To detect internal derangement in all segond fracture cases, MRI is crucial. The most frequent injury is an ACL disruption; however, there are other frequently occurring injuries as well. Injuries that are related include
1. ACL tear.
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The most frequent injury.
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75 to 100 percent of the time.
2. A lateral or medial meniscal tear.
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66 to 75 percent of the time.
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The most typical posterior horn.
3. ACL avulsion from the tibial attachment is uncommon.
4. Avulsion of the long head of the biceps femoris' fibular attachment.
5. Fibular collateral ligament avulsion.
Segond fractures are typically diagnosed without the use of computed tomography. Although a CT scan has a significantly higher sensitivity for detecting fractures, MRI is the preferred imaging technique to pinpoint the precise related ligamentous damage in the knees.
How Are Segond Fractures Treated?
Early medical care should emphasize support. Treatment entails elevating the injured knee whenever feasible, resting it, administering simple analgesics, and icing the knee. Individuals are very likely to need crutches or other types of walking aids. Early use of a knee brace can aid in supporting the knee before considering surgery.
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Surgical Intervention: In contrast to the segond fracture itself, underlying injuries are the focus of surgical intervention. Segond fractures do not need to be treated, according to the evidence. Additionally, research suggests that the existence of a segond fracture does not increase the chance of ACL reconstruction failure. Although segond fractures suggested higher instability associated with ligamentous knee injuries before surgery, the post-operative comparison indicates no change in evaluated stability once the ligamentous injury is resolved. The anterolateral ligament can be repaired directly to treat segond fractures, which may help the knee regain rotational stability. Depending on the size and nature of the fracture, segond fractures can be treated using direct suture techniques, suture anchor techniques, or screw fixation. Segond fracture surgical treatment has produced positive outcomes with few side effects; however, no control group was used to compare these outcomes.
With informed permission and a process of shared decision-making with the patient, all surgical operations should be performed. The patient's comorbidities, activity level, expectations, and the chance of a positive outcome are frequently major factors in the choice to continue with surgery.
All patients require some sort of rehabilitation from an interprofessional team approach, regardless of whether a patient chooses surgery or non-operative therapy. Patients must visit a therapist for therapy, and bracing could help stabilize and ease the knee.
What Are the Complications of Segond Fractures?
A segond fracture's most frequent short-term consequences are persistent pain and stiffness. There are significant short- to medium-term risks linked with the surgical process if the patient has an ACL reconstruction. ACL reconstruction is generally thought to be a safe procedure, with a 0.75 percent chance of a wound complication. Although it is believed that thromboprophylaxis (a measure taken to prevent the formation of blood clots) is not necessary for ACL reconstruction, one publication reported rates of pulmonary embolism (blockage of lung arteries by a blood clot) and deep vein thrombosis at 0.18 and 0.30, respectively. The issue of thromboprophylaxis following ligamentous repair of the knee is debatable, and the surgeon should decide whether to administer anticoagulants (medication to prevent blood clots) postoperatively based on the unique medical conditions of each patient.
Conclusion
A segond fracture itself has a decent prognosis. As was previously mentioned, there has not been any evidence that treating this fracture would be advantageous. Segond fractures also do not seem to increase the likelihood that revision surgery will be necessary. The prognosis is primarily affected by how well the knee's accompanying ligamentous injuries are treated. Patients typically have a positive outcome if their issues are properly handled. Any modification to the knee's mechanics frequently raises the risk of osteoarthritis (OA, - joint disease). It is generally known that a significant percentage of people who experience an ACL rupture develop OA. Although it has been demonstrated that ACL reconstruction lowers the prevalence of OA, it has not been demonstrated to totally lower the chance of getting it.
