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Imaging Features of Avulsion Injuries¹

¹ From the Department of Radiology, Musculoskeletal Division, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242. Recipient of a Certificate of Merit award for a scientific exhibit at the 1997 RSNA scientific assembly. Received April 13, 1998; revision requested June 1 and final revision received October 5; accepted October 6. Address reprint requests to G.Y.E.

View larger version (24K): [in a new window]   Figure 1.  Diagram shows characteristic sites of avulsion injury in the pelvis. AIIS = anterior inferior iliac spine, ASIS = anterior superior iliac spine. (Modified and reprinted, with permission, from reference 6.)

View larger version (114K): [in a new window]   Figure 2a.  Acute avulsion of the ischial tuberosity in a young football player who experienced sudden onset of pain in the right gluteal region. (a) Anteroposterior radiograph shows an acute avulsion of the ischial tuberosity (arrows). The bone fragment is sharply defined and displaced inferiorly. (b) Coronal T1-weighted MR image reveals a hematoma at the site of the avulsion (arrows).

View larger version (126K): [in a new window]   Figure 2b.  Acute avulsion of the ischial tuberosity in a young football player who experienced sudden onset of pain in the right gluteal region. (a) Anteroposterior radiograph shows an acute avulsion of the ischial tuberosity (arrows). The bone fragment is sharply defined and displaced inferiorly. (b) Coronal T1-weighted MR image reveals a hematoma at the site of the avulsion (arrows).

View larger version (119K): [in a new window]   Figure 3a.  Chronic avulsion of the ischial tuberosity in a college football player who had experienced pain in each gluteal fold region on separate occasions several months earlier. (a) Low anteroposterior radiograph of the pelvis shows bilateral chronic avulsions of the ischial tuberosity. Protuberant bone (solid arrows) and a large, smooth fragment (open arrows) are seen. (b) Sagittal proton-density–weighted MR image shows irregularity and bony protuberance of the left side of the ischial tuberosity (arrows), findings that are consistent with the chronic nature of the injury.

View larger version (165K): [in a new window]   Figure 3b.  Chronic avulsion of the ischial tuberosity in a college football player who had experienced pain in each gluteal fold region on separate occasions several months earlier. (a) Low anteroposterior radiograph of the pelvis shows bilateral chronic avulsions of the ischial tuberosity. Protuberant bone (solid arrows) and a large, smooth fragment (open arrows) are seen. (b) Sagittal proton-density–weighted MR image shows irregularity and bony protuberance of the left side of the ischial tuberosity (arrows), findings that are consistent with the chronic nature of the injury.

View larger version (121K): [in a new window]   Figure 4.  Avulsion of the anterior superior iliac spine in a 16-year-old sprinter who had experienced sudden onset of pain above the right hip. Anteroposterior radiograph shows an acute avulsion of the anterior superior iliac spine (arrow). The sharp, distinct margins of the fracture indicate the acute nature of the injury.

View larger version (111K): [in a new window]   Figure 5. Figures 5, 6. (5) Avulsion of the anterior inferior iliac spine in a 16-year-old football player who had experienced sudden onset of pain above the right hip 3 months earlier. Anteroposterior radiograph of the pelvis shows a chronic avulsion of the anterior inferior iliac spine (arrow), the site of attachment for the rectus femoris. The smooth margins and bony protuberance indicate the chronic nature of the injury. (6) Avulsion of the left anterior inferior iliac spine and ischial tuberosity in a 17-year-old track star who presented with a 3-week history of hip pain. Anteroposterior radiograph of the left hip shows a subacute avulsion of the left anterior inferior iliac spine (open arrow) and ischial tuberosity (solid arrows). The margins are somewhat ill-defined, but protuberant bone is lacking. These findings suggest a subacute injury in the healing phase but may be mistaken for a more aggressive process.

View larger version (105K): [in a new window]   Figure 6. Figures 5, 6. (5) Avulsion of the anterior inferior iliac spine in a 16-year-old football player who had experienced sudden onset of pain above the right hip 3 months earlier. Anteroposterior radiograph of the pelvis shows a chronic avulsion of the anterior inferior iliac spine (arrow), the site of attachment for the rectus femoris. The smooth margins and bony protuberance indicate the chronic nature of the injury. (6) Avulsion of the left anterior inferior iliac spine and ischial tuberosity in a 17-year-old track star who presented with a 3-week history of hip pain. Anteroposterior radiograph of the left hip shows a subacute avulsion of the left anterior inferior iliac spine (open arrow) and ischial tuberosity (solid arrows). The margins are somewhat ill-defined, but protuberant bone is lacking. These findings suggest a subacute injury in the healing phase but may be mistaken for a more aggressive process.

View larger version (107K): [in a new window]   Figure 7.  Chronic avulsion in an athlete with a long history of groin pain but no specific injury or time of onset. Anteroposterior radiograph reveals a chronic avulsion at the insertion of the adductor muscle group to the left symphysis pubis (arrows).

View larger version (170K): [in a new window]   Figure 8.  Chronic avulsion at the pubis in a male athlete with a long history of groin pain. Findings on an anteroposterior radiograph (not shown) were consistent with chronic avulsion of the right symphysis pubis. Coronal T2-weighted MR image shows edema in the marrow and reactive change in the surrounding soft tissues (arrows) caused by chronic repetitive microtrauma. Patient history, radiography, and follow-up are generally all that are required to determine the traumatic pathogenesis. In this case, however, MR imaging was performed because of persistent clinical suspicion for a tumor. The patient was treated with rest, and later at follow-up his pain had resolved.

View larger version (121K): [in a new window]   Figure 9.  Avulsion fracture of the lesser trochanter in a 65-year-old patient who experienced a sudden pop and pain in the left side of the groin. Anteroposterior radiograph shows a lesser trochanter avulsion fracture (solid arrow). A lytic defect is seen at the femur attachment site (open arrow). This case proved to be metastatic squamous cell carcinoma at histologic analysis.

View larger version (111K): [in a new window]   Figure 10a.  Avulsion fracture of the greater trochanter in an 80-year-old man who had twisted his hip. (a) Anteroposterior radiograph shows an avulsion fracture of the greater trochanter with minimal displacement (arrow). (b) Coronal T1-weighted MR image shows the greater trochanter fracture to better advantage (arrows).

View larger version (181K): [in a new window]   Figure 10b.  Avulsion fracture of the greater trochanter in an 80-year-old man who had twisted his hip. (a) Anteroposterior radiograph shows an avulsion fracture of the greater trochanter with minimal displacement (arrow). (b) Coronal T1-weighted MR image shows the greater trochanter fracture to better advantage (arrows).

View larger version (22K): [in a new window]   Figure 11a.  Diagrams show common avulsion sites in the knee as seen from an anteroposterior (a) and lateral (b) perspective. ACL = anterior cruciate ligament, LCL = lateral collateral ligament, PCL = posterior cruciate ligament.

View larger version (19K): [in a new window]   Figure 11b.  Diagrams show common avulsion sites in the knee as seen from an anteroposterior (a) and lateral (b) perspective. ACL = anterior cruciate ligament, LCL = lateral collateral ligament, PCL = posterior cruciate ligament.

View larger version (137K): [in a new window]   Figure 12a.  Segond fracture in a patient who had sustained rotational injury to the knee. (a) Anteroposterior radiograph shows a piece of bone adjacent to the lateral cortex of the tibia (arrows). (b) Coronal T1-weighted MR image shows the avulsed bone fragment (arrow) attached to the medial aspect of the lateral capsular ligament.

View larger version (165K): [in a new window]   Figure 12b.  Segond fracture in a patient who had sustained rotational injury to the knee. (a) Anteroposterior radiograph shows a piece of bone adjacent to the lateral cortex of the tibia (arrows). (b) Coronal T1-weighted MR image shows the avulsed bone fragment (arrow) attached to the medial aspect of the lateral capsular ligament.

View larger version (48K): [in a new window]   Figure 13.  Diagram shows major posterolateral stabilizers of the knee. The site of bone avulsion is usually the fibular head, which is the anchor for many of these ligaments and tendons. (Modified and reprinted, with permission, from reference 22.)

View larger version (98K): [in a new window]   Figure 14. Figures 14, 15. (14) Avulsion fracture of the fibular head in a woman who twisted her knee while running. Anteroposterior radiograph shows a displaced avulsion fracture of the fibular head (arrow). This finding indicates injury of the arcuate complex and posterolateral instability. (15) Knee injury and posterolateral instability. Coronal T1-weighted MR image demonstrates an avulsion of the fibular head (arrow).

View larger version (169K): [in a new window]   Figure 15. Figures 14, 15. (14) Avulsion fracture of the fibular head in a woman who twisted her knee while running. Anteroposterior radiograph shows a displaced avulsion fracture of the fibular head (arrow). This finding indicates injury of the arcuate complex and posterolateral instability. (15) Knee injury and posterolateral instability. Coronal T1-weighted MR image demonstrates an avulsion of the fibular head (arrow).

View larger version (22K): [in a new window]   Figure 16.  Diagrams show the various types of tibial spine avulsions.

View larger version (113K): [in a new window]   Figure 17. Figures 17–19. (17) Avulsion of the tibial eminence in a young patient who presented with acute pain and anterior instability. Anteroposterior radiograph of the right knee shows avulsion of the tibial eminence (arrow) at the attachment site for the anterior cruciate ligament. This injury has the same functional features as any other tear of this ligament. (18) Avulsion of the tibial eminence in a young athlete with anterior instability. Coronal T2-weighted MR image shows edema of the tibial eminence (arrows), which on sagittal T2- and proton-density–weighted MR images (not shown) proved to be a nondisplaced avulsion. (19) Avulsion of the tibial eminence in a patient who had sustained a knee injury about 2 weeks earlier. Coronal T1-weighted MR image shows an avulsion of the tibial eminence (large arrow) with contusion of the medial tibial plateau (small arrow). T1 lengthening (edema) of the tibial eminence is relatively limited, suggestive of a subacute injury.

View larger version (185K): [in a new window]   Figure 18. Figures 17–19. (17) Avulsion of the tibial eminence in a young patient who presented with acute pain and anterior instability. Anteroposterior radiograph of the right knee shows avulsion of the tibial eminence (arrow) at the attachment site for the anterior cruciate ligament. This injury has the same functional features as any other tear of this ligament. (18) Avulsion of the tibial eminence in a young athlete with anterior instability. Coronal T2-weighted MR image shows edema of the tibial eminence (arrows), which on sagittal T2- and proton-density–weighted MR images (not shown) proved to be a nondisplaced avulsion. (19) Avulsion of the tibial eminence in a patient who had sustained a knee injury about 2 weeks earlier. Coronal T1-weighted MR image shows an avulsion of the tibial eminence (large arrow) with contusion of the medial tibial plateau (small arrow). T1 lengthening (edema) of the tibial eminence is relatively limited, suggestive of a subacute injury.

View larger version (148K): [in a new window]   Figure 19. Figures 17–19. (17) Avulsion of the tibial eminence in a young patient who presented with acute pain and anterior instability. Anteroposterior radiograph of the right knee shows avulsion of the tibial eminence (arrow) at the attachment site for the anterior cruciate ligament. This injury has the same functional features as any other tear of this ligament. (18) Avulsion of the tibial eminence in a young athlete with anterior instability. Coronal T2-weighted MR image shows edema of the tibial eminence (arrows), which on sagittal T2- and proton-density–weighted MR images (not shown) proved to be a nondisplaced avulsion. (19) Avulsion of the tibial eminence in a patient who had sustained a knee injury about 2 weeks earlier. Coronal T1-weighted MR image shows an avulsion of the tibial eminence (large arrow) with contusion of the medial tibial plateau (small arrow). T1 lengthening (edema) of the tibial eminence is relatively limited, suggestive of a subacute injury.

View larger version (137K): [in a new window]   Figure 20. Figures 20–22. Avulsion fracture of the posterior cruciate ligament due to hyperextension of the knee. (20) Lateral radiograph shows an avulsed bone fragment at the site of attachment of the posterior cruciate ligament (arrow). (21) Axial CT scan demonstrates an avulsion fracture with minimal displacement of the avulsed fragment (arrows). (22) Sagittal proton-density–weighted MR image demonstrates an avulsion fracture with displacement of the avulsed fragment (arrow).

View larger version (134K): [in a new window]   Figure 21. Figures 20–22. Avulsion fracture of the posterior cruciate ligament due to hyperextension of the knee. (20) Lateral radiograph shows an avulsed bone fragment at the site of attachment of the posterior cruciate ligament (arrow). (21) Axial CT scan demonstrates an avulsion fracture with minimal displacement of the avulsed fragment (arrows). (22) Sagittal proton-density–weighted MR image demonstrates an avulsion fracture with displacement of the avulsed fragment (arrow).

View larger version (179K): [in a new window]   Figure 22. Figures 20–22. Avulsion fracture of the posterior cruciate ligament due to hyperextension of the knee. (20) Lateral radiograph shows an avulsed bone fragment at the site of attachment of the posterior cruciate ligament (arrow). (21) Axial CT scan demonstrates an avulsion fracture with minimal displacement of the avulsed fragment (arrows). (22) Sagittal proton-density–weighted MR image demonstrates an avulsion fracture with displacement of the avulsed fragment (arrow).

View larger version (18K): [in a new window]   Figure 23.  Diagrams show the various types of tibial tuberosity avulsions. (Modified and reprinted, with permission, from reference 26.)

View larger version (83K): [in a new window]   Figure 24. Figures 24, 25. (24) Avulsion fracture of the tibial tuberosity in a basketball player who experienced acute, intense pain on landing after a jump. Lateral radiograph of the knee shows a type 1 tibial tuberosity avulsion fracture that involves the center of ossification (arrows) without injury to the tibial epiphysis. (25) Avulsion fracture of the tibial tuberosity in a young male athlete. The patient had sustained a knee injury while pole vaulting. Lateral radiograph shows a type 3 tibial tuberosity avulsion fracture with displacement of the proximal base of the epiphysis and extension into the joint (arrows).

View larger version (101K): [in a new window]   Figure 25. Figures 24, 25. (24) Avulsion fracture of the tibial tuberosity in a basketball player who experienced acute, intense pain on landing after a jump. Lateral radiograph of the knee shows a type 1 tibial tuberosity avulsion fracture that involves the center of ossification (arrows) without injury to the tibial epiphysis. (25) Avulsion fracture of the tibial tuberosity in a young male athlete. The patient had sustained a knee injury while pole vaulting. Lateral radiograph shows a type 3 tibial tuberosity avulsion fracture with displacement of the proximal base of the epiphysis and extension into the joint (arrows).

View larger version (87K): [in a new window]   Figure 26. Figures 26, 27. (26) Osgood-Schlatter disease in a young basketball player known for his jumping ability who presented with chronic knee pain. Lateral radiograph shows protuberant bone tissue of the inferior pole of the patella, "jumper's knee" (arrowhead), and irregularity of the tibial tuberosity (arrow). (27) Chronic unresolved Osgood-Schlatter disease in a 28-year-old male athlete who presented with pain in the tibial tuberosity. The disease had been diagnosed when the patient was an adolescent. Sagittal T2-weighted MR image shows several bone fragments adjacent to the tibial tuberosity (solid arrows) and proximate to edema in the tibia (open arrow). These findings, together with the patient's history, were consistent with Osgood-Schlatter disease.

View larger version (177K): [in a new window]   Figure 27. Figures 26, 27. (26) Osgood-Schlatter disease in a young basketball player known for his jumping ability who presented with chronic knee pain. Lateral radiograph shows protuberant bone tissue of the inferior pole of the patella, "jumper's knee" (arrowhead), and irregularity of the tibial tuberosity (arrow). (27) Chronic unresolved Osgood-Schlatter disease in a 28-year-old male athlete who presented with pain in the tibial tuberosity. The disease had been diagnosed when the patient was an adolescent. Sagittal T2-weighted MR image shows several bone fragments adjacent to the tibial tuberosity (solid arrows) and proximate to edema in the tibia (open arrow). These findings, together with the patient's history, were consistent with Osgood-Schlatter disease.

View larger version (146K): [in a new window]   Figure 28.  Jumper's knee in a volleyball player who presented with anterior knee pain. Sagittal proton-density–weighted MR image shows a thickened patellar tendon with abnormally increased signal intensity, especially at insertion sites on the tibial tuberosity and patella, findings that are consistent with patellar tendinitis (arrows). The high signal intensity persisted on T2-weighted images.

View larger version (115K): [in a new window]   Figure 29.  Patellar sleeve fracture associated with hyperextension injury in an 11-year-old boy. Lateral radiograph shows an area of hyperlucency in the inferior patellar pole (arrows).

View larger version (127K): [in a new window]   Figure 30.  Calcaneal insufficiency avulsion fracture in a 52-year-old patient with diabetes. Lateral radiograph shows a calcaneal insufficiency avulsion fracture (arrow), probably due to osteopenia and neuropathic changes because such a fracture occurs almost exclusively in diabetic patients.

View larger version (104K): [in a new window]   Figure 31.  Posterior capsular avulsion of the ankle in a woman who had sustained an injury 5 weeks earlier. Lateral radiograph shows curvilinear calcification adjacent to the posterior tibial margin (arrow). This finding is consistent with posterior capsular avulsion but is not often seen; clinically, the injury amounts to a sprained ankle and there is no need for follow-up imaging. The patient usually recovers fully with conservative treatment.

View larger version (100K): [in a new window]   Figure 32.  Anterior capsular avulsion in a basketball player with chronic pain in the proximal anterior foot. Lateral radiograph shows protuberance of the anterior talus where the joint capsule is inserted, which indicates chronic avulsion (arrow). As with posterior capsular avulsion, this type of injury usually goes unrecognized because radiographic follow-up is not required (cf Fig 31).

View larger version (38K): [in a new window]   Figure 33.  Diagram shows the major fracture regions of the fifth metatarsal bone.

View larger version (136K): [in a new window]   Figure 34a.  Avulsion fracture of the greater tuberosity in a patient who had fallen from a horse onto her outstretched arm. (a) Anteroposterior radiograph shows a nondisplaced avulsion fracture of the greater tuberosity (arrows). (b) Coronal oblique T1-weighted MR image shows the fracture to greater advantage (arrow). The rotator cuff was intact.

View larger version (150K): [in a new window]   Figure 34b.  Avulsion fracture of the greater tuberosity in a patient who had fallen from a horse onto her outstretched arm. (a) Anteroposterior radiograph shows a nondisplaced avulsion fracture of the greater tuberosity (arrows). (b) Coronal oblique T1-weighted MR image shows the fracture to greater advantage (arrow). The rotator cuff was intact.

View larger version (128K): [in a new window]   Figure 35.  Avulsion fracture of the lesser tuberosity secondary to seizure. Anteroposterior radiograph shows an avulsion fracture of the lesser tuberosity (arrows).

View larger version (152K): [in a new window]   Figure 36.  Medial epicondylar avulsion in an 8-year-old boy who had fallen onto his outstretched arm. Anteroposterior radiograph shows a displaced, avulsed medial epicondylar apophysis between the ulna and the as yet unossified trochlear epiphysis (arrow), which could be mistaken for the trochlear ossification center. The avulsed fragment was reduced and surgically affixed to its site of origin at the medial epicondyle.