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Subchondral Fracture, Knee
Kirkland W. Davis, MD, FACR; Andrew Sonin, MD, FACR; Donna G. Blankenbaker, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Synonyms

                • Subchondral insufficiency fracture (SIF) of knee, insufficiency fracture, stress fracture of knee, Ahlbäck disease
              • Definitions

                • Incomplete atraumatic medullary fracture of subchondral bone of distal femur or proximal tibia
                • Not optimal term for traumatic small nondisplaced fracture: probably better termed "subcortical fracture" or "nondisplaced osteochondral fracture"
                • Spontaneous osteonecrosis of knee (SONK): former term used for end-stage collapse of SIF
                  • Term was created when there was no understanding of MR findings, underlying pathology, or cause
                  • This concept has been abandoned
                  • "SONK" should not be used in radiology reports
                  • True osteonecrosis (ON) does occur in femoral condyles; resembles that of femoral head

              IMAGING

              • General Features

                • Radiographic Findings

                  • CT Findings

                    • MR Findings

                      • Nuclear Medicine Findings

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Gross Pathologic & Surgical Features

                                CLINICAL ISSUES

                                • Presentation

                                  • Demographics

                                    • Natural History & Prognosis

                                      • Treatment

                                        DIAGNOSTIC CHECKLIST

                                        • Consider

                                          • Image Interpretation Pearls

                                            • Reporting Tips

                                              Selected References

                                              1. Gorbachova T et al: Osteochondral lesions of the knee: differentiating the most common entities at MRI. Radiographics. 38(5):1478-95, 2018
                                              2. Matcuk GR Jr et al: Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 23(4):365-75, 2016
                                              3. Viana SL et al: MRI of subchondral fractures: a review. Skeletal Radiol. 43(11):1515-27, 2014
                                              4. Cetik O et al: Risk of osteonecrosis of the femoral condyle after arthroscopic chondroplasty using radiofrequency: a prospective clinical series. Knee Surg Sports Traumatol Arthrosc. 17(1):24-9, 2009
                                              5. Fotiadou A et al: Acute nontraumatic adult knee pain: the role of MR imaging. Radiol Med. 114(3):437-47, 2009
                                              6. Roemer FW et al: MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis. Osteoarthritis Cartilage. 17(9):1115-31, 2009
                                              7. Kattapuram TM et al: Spontaneous osteonecrosis of the knee. Eur J Radiol. 67(1):42-8, 2008
                                              8. MacDessi SJ et al: Subchondral fracture following arthroscopic knee surgery. A series of eight cases. J Bone Joint Surg Am. 90(5):1007-12, 2008
                                              9. Takeda M et al: Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases. J Bone Joint Surg Br. 90(3):324-9, 2008
                                              10. Pape D et al: Postarthroscopic osteonecrosis of the knee. Arthroscopy. 23(4):428-38, 2007
                                              11. Yates PJ et al: Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee. 14(2):112-6, 2007
                                              12. Muscolo DL et al: Medial meniscal tears and spontaneous osteonecrosis of the knee. Arthroscopy. 22(4):457-60, 2006
                                              13. Kidwai AS et al: Radiologic case study. Spontaneous osteonecrosis of the knee reclassified as insufficiency fracture. Orthopedics. 28(3):236, 333-6, 2005
                                              14. Lecouvet FE et al: MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies. Radiol Clin North Am. 43(4):655-72, vii-viii, 2005
                                              15. Ramnath RR et al: MR appearance of SONK-like subchondral abnormalities in the adult knee: SONK redefined. Skeletal Radiol. 33(10):575-81, 2004
                                              16. Yamamoto T et al: Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am. 82(6):858-66, 2000
                                              17. Yamamoto T et al: Subchondral insufficiency fracture of the femoral head and medial femoral condyle. Skeletal Radiol. 29(1):40-4, 2000
                                              18. Ecker ML et al: Spontaneous osteonecrosis of the knee. J Am Acad Orthop Surg. 2(3):173-8, 1994
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        • Diagnostic Checklist

                                                          TERMINOLOGY

                                                          • Synonyms

                                                            • Subchondral insufficiency fracture (SIF) of knee, insufficiency fracture, stress fracture of knee, Ahlbäck disease
                                                          • Definitions

                                                            • Incomplete atraumatic medullary fracture of subchondral bone of distal femur or proximal tibia
                                                            • Not optimal term for traumatic small nondisplaced fracture: probably better termed "subcortical fracture" or "nondisplaced osteochondral fracture"
                                                            • Spontaneous osteonecrosis of knee (SONK): former term used for end-stage collapse of SIF
                                                              • Term was created when there was no understanding of MR findings, underlying pathology, or cause
                                                              • This concept has been abandoned
                                                              • "SONK" should not be used in radiology reports
                                                              • True osteonecrosis (ON) does occur in femoral condyles; resembles that of femoral head

                                                          IMAGING

                                                          • General Features

                                                            • Radiographic Findings

                                                              • CT Findings

                                                                • MR Findings

                                                                  • Nuclear Medicine Findings

                                                                    • Imaging Recommendations

                                                                      DIFFERENTIAL DIAGNOSIS

                                                                        PATHOLOGY

                                                                        • General Features

                                                                          • Gross Pathologic & Surgical Features

                                                                            CLINICAL ISSUES

                                                                            • Presentation

                                                                              • Demographics

                                                                                • Natural History & Prognosis

                                                                                  • Treatment

                                                                                    DIAGNOSTIC CHECKLIST

                                                                                    • Consider

                                                                                      • Image Interpretation Pearls

                                                                                        • Reporting Tips

                                                                                          Selected References

                                                                                          1. Gorbachova T et al: Osteochondral lesions of the knee: differentiating the most common entities at MRI. Radiographics. 38(5):1478-95, 2018
                                                                                          2. Matcuk GR Jr et al: Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 23(4):365-75, 2016
                                                                                          3. Viana SL et al: MRI of subchondral fractures: a review. Skeletal Radiol. 43(11):1515-27, 2014
                                                                                          4. Cetik O et al: Risk of osteonecrosis of the femoral condyle after arthroscopic chondroplasty using radiofrequency: a prospective clinical series. Knee Surg Sports Traumatol Arthrosc. 17(1):24-9, 2009
                                                                                          5. Fotiadou A et al: Acute nontraumatic adult knee pain: the role of MR imaging. Radiol Med. 114(3):437-47, 2009
                                                                                          6. Roemer FW et al: MRI-detected subchondral bone marrow signal alterations of the knee joint: terminology, imaging appearance, relevance and radiological differential diagnosis. Osteoarthritis Cartilage. 17(9):1115-31, 2009
                                                                                          7. Kattapuram TM et al: Spontaneous osteonecrosis of the knee. Eur J Radiol. 67(1):42-8, 2008
                                                                                          8. MacDessi SJ et al: Subchondral fracture following arthroscopic knee surgery. A series of eight cases. J Bone Joint Surg Am. 90(5):1007-12, 2008
                                                                                          9. Takeda M et al: Spontaneous osteonecrosis of the knee: histopathological differences between early and progressive cases. J Bone Joint Surg Br. 90(3):324-9, 2008
                                                                                          10. Pape D et al: Postarthroscopic osteonecrosis of the knee. Arthroscopy. 23(4):428-38, 2007
                                                                                          11. Yates PJ et al: Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee. 14(2):112-6, 2007
                                                                                          12. Muscolo DL et al: Medial meniscal tears and spontaneous osteonecrosis of the knee. Arthroscopy. 22(4):457-60, 2006
                                                                                          13. Kidwai AS et al: Radiologic case study. Spontaneous osteonecrosis of the knee reclassified as insufficiency fracture. Orthopedics. 28(3):236, 333-6, 2005
                                                                                          14. Lecouvet FE et al: MR imaging of epiphyseal lesions of the knee: current concepts, challenges, and controversies. Radiol Clin North Am. 43(4):655-72, vii-viii, 2005
                                                                                          15. Ramnath RR et al: MR appearance of SONK-like subchondral abnormalities in the adult knee: SONK redefined. Skeletal Radiol. 33(10):575-81, 2004
                                                                                          16. Yamamoto T et al: Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am. 82(6):858-66, 2000
                                                                                          17. Yamamoto T et al: Subchondral insufficiency fracture of the femoral head and medial femoral condyle. Skeletal Radiol. 29(1):40-4, 2000
                                                                                          18. Ecker ML et al: Spontaneous osteonecrosis of the knee. J Am Acad Orthop Surg. 2(3):173-8, 1994