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Meniscal Tears

knee pain acute trauma el paso tx.

 

  • Acute or chronic. Imaged with MRI (95% sensitivity & 81% specificity)
  • Menisci are formed by a composition of radial and circumferential collagen fibers (97% type 1) mixed with cartilage, proteoglycans, etc. 65-75% H2O
  • Aging can lead to meniscal attrition
  • Acute tears are d/t rotational and compressive forces, ACL deficient knees show greater chances of meniscal tears
  • Posterior horn of medial meniscus is m/c torn except in acute ACL tears when the lateral meniscus is m/c torn
  • The meniscus is well vascularized in children. In adults, 3-zones exist: inner, middle and outer (above bottom image)
  • Injury of the inner zone has no chance of healing
  • Injury of the outer zone (25% in total) has some healing/repair

Clinical Presentation

  • Pain, locking, swelling
  • Most sensitive physical sign: pain on palpation at the joint line
  • Tests: McMurry, Thessaly, Apply compression in prone
  • Management: conservative vs. operative depends on location, stability, patient’s age, and DJD and the type of tear
  • Partial meniscectomy is performed. 80% proper functions on follow up. Less favorable if >40-y.o and DJD
  • Total meniscectomy is not performed and only viewed historically. 70% OA 3-years after surgery 100% OA after 20 years post surgery.

Axial MR

knee pain acute trauma el paso tx.

 

  • Appearance the medial (blue) and the lateral meniscus (red)

Menisci Play Significant Role

knee pain acute trauma el paso tx.

 

Types Location & Stability

knee pain acute trauma el paso tx.

 

  • Types, location, and stability of tears are v. important during MRI Dx
  • Vertical/longitudinal tears especially occur in acute ACL tears. Some longitudinal tears found at the periphery or “red zone” may heal
  • Bucket handle tear: longitudinal tear in the inner edge that is deep and vertical extending through the long axis and may displace into a notch
  • Oblique/flap/parrot-beak are complex tears
  • Radial tear at 90-degree to plateau

Axial T2

knee pain acute trauma el paso tx.

 

  • Axial T2 WI fat-sat and coronal STIR slices of the posterior horn of the medial meniscus.
  • Note a radial tear of the posterior horn of the medial meniscus near the meniscal root. This is potentially an unstable lesion requiring operative care
  • The meniscus, in this case, is unable to provide a “hoop-stress mechanism.”

MRI Slices Coronal & Sagittal

knee pain acute trauma el paso tx.

 

  • Fat-sat coronal and sagittal proton density MRI slices revealing horizontal (cleavage) tear that is more typical in the aged meniscus
  • In some cases, when this tear does not contain a radial component, it may partially heal obviating the need for operative care

T2 w GRE Sagittal MRI Slice

knee pain acute trauma el paso tx.

 

  • Complex tear with a horizontal oblique and radial component.
  • This type of tear is very unstable and in most cases may need operative care

Bucket Handle Tear

knee pain acute trauma el paso tx.

 

  • Bucket handle tear are m/c in the medial meniscus esp. with acute ACL and MCL tear
  • MRI signs; double PCL sign on sagittal slices
  • Absent “bow-tie” sign and others
  • Most cases require operative care

DDx From Meniscal Degeneration

knee pain acute trauma el paso tx.

 

  • Occasionally meniscal tears need to be DDx from meniscal degeneration which may also appear bright (high signal) on fluid-sensitive MRI
  • The simplest rule is that if there is a true meniscal tear aka Grade 3 lesion, it always reaches/extends to the tibial plateau surface

The Role of MSK Ultrasound (US) in Knee Examination

  • MSK US of the knee permits high resolution and dynamic imaging of primarily superficial anatomy (tendons, bursae, capsular ligaments)
  • MSK US cannot adequately evaluate cruciate ligaments and the menisci in their entirety
  • Thus MR imaging remains modality of choice

Potential Pathologies Successfully Evaluated by MSK US

  • Patellar tendionosis/patellar tendon rupture
  • Quadriceps tendon tear
  • Prepatellar bursitis
  • Infrapatellar bursitis
  • Pes Anserine bursitis
  • Popliteal cyst (Baker cyst)
  • Inflammation/joint effusion with synovial thickening and hyperemia can be imaged with US (e.g., RA) especially with the addition of color power Doppler

Patient Presented With Atraumatic Knee Pain & Swelling

knee pain acute trauma el paso tx.

 

  • Radiography revealed sizeable soft tissue density within the superficial pre-patella region along with mild-to-moderate OA
  • MSK US demonstrated large septated heterogeneous fluid collection with mild positive Doppler activity on the periphery indicating inflammation d/t Dx of Superficial pre-patella bursitis

Long Axis US Images

knee pain acute trauma el paso tx.

 

  • Note normal lateral meniscus and fibers of LCL (above bottom image) compared to
  • Horizontal degenerative cleavage tear along with protrusion of lateral meniscus and LCL bulging (above top image)
  • Major limitation: unable to visualize the entire meniscus and the ACL/PCL
  • MRI referral is suggested

Rupture of Distal Tendon of Quadriceps

knee pain acute trauma el paso tx.

 

  • Note rupture of distal tendon of the Quadriceps muscle presented as fiber separation and fluid (hypo to anechoic) fluid collection within the substance of the tendon
  • Advantages of MSK US over MRI to evaluate superficial structures:
  • Dynamic imaging
  • Availability
  • Cost-effective
  • Patient’s preparation
  • Disadvantages: limited depth of structures, inability to evaluated bone and cartilage, etc.

Osteochondral Knee Injuries (OI)

  • osteochondral knee injuries can occur in children 10-15 y.o presented as Osteochondritis Dissecance (OCD) and in mature skeleton m/c following hyperextension and rotation trauma, particularly in ACL tear.
  • OCD-typically develops from repeated forces in immature bone and affects m/c postero-lateral portion of the medial femoral condyle.
  • OI in mature bone occurs m/c during ACL tears mainly affecting so-called terminal sulcus of the lateral femoral condyle at the junction of the weight-bearing portion opposed to tibial plateau and the part articulating with the patella
  • Osteochondral injuries may potentially damage the articular cartilage causing secondary OA. Thus need to be evaluated surgically
  • Imaging plays an important role and should begin with radiography often followed by MR imaging and orthopedic referral.

OCD Knee

knee pain acute trauma el paso tx.

 

  • 95% associated with some trauma. Other etiology: ischemic bone necrosis especially in adults
  • Other common location for osteochondral injuries: elbow (capitellum), talus
  • 1st step: radiography may detect osteochondral fragment potentially attached or detached
  • Location: a posterior-lateral aspect of the medial femoral condyle. Tunnel (intercondylar notch) view is crucial
  • MRI: modality of choice >90% specificity and sensitivity. Crucial for further management. T1-low signal demarcating line with T2 high signal demarcating line that signifies detachment and unlikely healing. Refer to orthopedic surgeon
  • Management: stable lesion esp. in younger children>off weight-bearing-heals in 50-75%
  • Unstable lesion and older child or impending physeal closure>operative fixation.
knee pain acute trauma el paso tx.

 

Knee Trauma

 

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Dr. Alex Jimenez DC, MSACP, CCST, IFMCP*, CIFM*, ATN*

email: coach@elpasofunctionalmedicine.com

Licensed in: Texas & New Mexico*