meniscal injuries
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MENISCAL INJURIES
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ANATOMY•Medial and lateral menisci are two semilunar plates of fibrocartilage that are placed on the condylar surface of the tibia•They are tibial extension that creates conformity b/w the relatively flat tibial surface and round femoral condyles•Made up of type 1 collagen with some type 2 and some elastin fibers•Arranged in circumferential hoops and radial
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Medial meniscus•Medial menisci is three fifth of a ring; semicircular•Asymmetrically larger posteriorly than anteriorly and fixed to tibia and femur thru the coronary ligaments•Bld supply : medial superior and inferior geniculate arteries•Nerve innervation accompanies peripheral vascularity•Less mobile•Antr horn attached to tibial intercondylar eminence (infront of ACL)•Postr horn attached to intercondylar area (in front of PCL)
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Lateral meniscus•More circular,makes four fifth of a ring with symmetrical antr and postr horns•It has got a hypovascular zone in the area of popliteus tendon hiatus.•In this area it has no peripheral/capsular attachments•Hence greater mobility to lateral meniscus•Antr horn attached to intercondylar eminence of tibia lateral to ACL•Posterior horn attached to intercondylar eminence
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L
M
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Vascular supply good in the most peripheral 20% of the fibersSupplied by the geniculate
arteriesInner 1/3 of the ring is
avascularRelatively thinNourished through synovial
fluidMiddle 1/3 of the ring is
combination
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Functions • joint stabilization•Tibio-femoral stress reduction•Joint nutrition•Wt transmission –abt 40-70 % across the knee joint•As a shock absorber•Increase the tibiofemoral contact area by 40 %•Helps knee in locking mechanism•Prevents impingement of synovial membrane,capsule etc•Assists and control gliding and rolling motion of knee
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Medial meniscus is more commonly injured than lateral meniscus and is usually associated with other ligament injuriesSeen in abt 71 % of cases,and 5% its bilateralLateral meiscus is less injured because:oSmaller in diameteroThicker in peripheryoWideoMore mobileoAttached to both cruciate ligoStabilised postiorly to the femoral condyle by popliteus
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Mechanism of injury•Rotational force when a flexed knee extends•Twisting strain when knee is flexed ;young active athlets are more prone•In middle aged: fibrosis decreases the mobility and hence tear occurs with less force
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An acute twisting injury from impact during a sportUsually the foot stays fixed on the ground and
the rest of body rotates.Rotational force while jt is partially flexed
Getting up from a squatting or crouching Position.
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Associated injuriesIn acute knee injuries with ACL intact, medial
meniscal injury is 5 times more likely than lateral
In acute knee injuries with ACL ruptured, lateral meniscus more likely to be involved
If ACL is previously disrupted, lateral meniscal injury is more likely than medial
In repetitive deep squatting, medial meniscus most likely to be injured
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symptomsNot all meniscal tears are symptomatic
SwellingPain along the joint line (tenderness)Pain when squatting, kneeling or pivotingLocking of the kneeGiving way snaps, clicks, catches in knee.Atrophy of quadricepsInstability of joint
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Signs: Locking positive : Restriction of the last few terminal
degrees of extension of the knee Mc murray’s test positive Hip and knee flexed at 90 degree,with
examiner’s hand over the knee internal and external rotation of knee is done for lateral and medial menisci resp.positive test requires both pain and click to be felt by the examiner
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Joint line tenderness positive medial joint line tenderness is elicited
when knee flexed to 60 degrees and leg externally rotated.positive in 74 % cases of medial meniscal injuries
Quadriceps atrophy positive Steinmanns sign Meniscal pathology may be suspected
if medial pain is elicited on lateral rotation And lateral pain on medial tibial rotation
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Apley’s compression test positive Pt in prone position,fixing the thigh against
the table,the examiner presses the foot and leg downward while rotating the tibia,pain implies meniscal lesion.pain on lateral rotation indicates a medial meniscal tear
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Apley’s Distraction TestHere the examiner pulls the foot and leg
upward to distract the joint while again rotating the tibia.pain noted during axial distraction of joint implies a ligamentous lesion
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Classification Based on appearance on
arthroscopy :
1. Radial/parrot beak tears2. Flap tears3. Degenerative tears4. Bucket handle tears(vertical)5. Horizontal tears
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L R H
B P S
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Investigations:Initial plain xray : To R/O ass. #,ligamentous avulsion, or arthritic change,soft tissue swelling
MRI cuts usually proceed from medial to lateral lateral meniscus is symmetrical in sagital view and has appearance of a bowtie
Arthroscopy
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On MRI meniscal tears are graded 1 to 4o Grade 1 tear has an increased signal in the
meniscal substanceo Grade 2 change involves a more pronounced
and frequently linear signal that does not break the surface of the meniscus.
grade 1 and 2 appears normal on arthroscopic evaluation
o Grade 3 change is a signal that traverses through the meniscal surface and will be noted as tear on arthroscopy in 80% of cases
o There is extension of tear through both the tibial and femoral surfaces of the meniscus
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locked bucket handle tear usually involves medial meniscus and is seen as ‘double PCL sign’ on sagittal images
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Treatment Depends on age, presence of arthritis, damage or deformity of meniscus, and association of cruciate ligament tear etcConservative in patient’s soon after injury with no locking and with infrquent attacks of pain and in tears less than 10mm,partial thickness tearsSurgery if joint cannot be unlocked and if symptoms are recurrent
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Conservative 1. Abstinence from weight bearing2. Rest,ice packs,compressive bandage3. Buck’s skin traction4. Joint aspiration5. Quadriceps exercises6. If symptoms persists,a cylindrical
cast may be considered
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Total meniscectomyPartial meniscectomyMeniscal repair
Inside outOutside inAll inside
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Partial MeniscectomyDone when tear involves interior 70%May be done when athlete wants to resume
activity ASAPDone with mobile fragments10-35 minute arthroscopic procedure under
regional or general anestheticMobile areas removedEdges contoured to “prevent further tears”
Immediate partial weight bearing allowedCrutches for 1-2 days
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Total meniscectomyIrreparably torn meniscusNot a treatment of choice in young athletsSteps: anteromedial incision medial to patella upto
upper tibia.Incise capsule and fascia.Lift the synovium and make a small opening.Extent the opening proximally and distally
and examine the structures of joint
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Palpate the meniscus on both surface entirely with meniscal hook.
Mobilise anterior 1/3 with scalpel.Middle 1/3 by retracting tibial collateral
ligament.Then mobilise posterior 1/3 of menisci.Check the medial and antr stability of knee
joint.
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Consequences of Meniscectomy increased osteophyte formation and femoral
cartilage deterioration in meniscectomized knee
In medial meniscectomy, load bearing surfaces are halved, doubling stress on tibial plateau
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Complications:•Infection•Nerve palsy (saphenous,tibial,peroneal)•Vascular injury•Post op effusion : sign of hyaline cartilage injury. Trt:ice,anti inflammatory agents,chondroprotective agents
•Reflex sympathetic dystrophy –decrease range of motion with pain Trt: aggressive pain control,rehabilitation, sympathetic blocks ,continued limitation of motion,arthroscopy,manipulation and post operatively continuous epidural block can effectively manage RSD
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Post op hemarthrosisc/c synovitisInjury to popliteal vesselsPainful neuromas of infra patellar branch of
saphenous nerveThrombophlebitis
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Meniscus RepairArthroscopically aid repair Used in longitudinal tears,vascularised zone Through posteromedial arthrotomy multiple
interrupted sutures placed vertically through periphery of meniscus and tied outside joint capsule.
Outside in, inside out, and all inside technique
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Rehabilitation:•Patient’s who underwent partial meniscectomies can be allowed immediate wt bearing,range of motion exercises,functional strengthening and quick returns to daily activities•Presence of degenerative changes slows recovery and return to full activity must be individualised
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