P e r p e t u a l S u c c o u r H o s p i t a l

Meniscal Injury

October
13
08
Fall
Kimberly Chu
Fatima Rose Diloy
Adrian Emmanuel Teves
Meniscal Tear
Anatomy
Meniscus otherwise called semilunar cartilages, are two asymmetric fibrocartilagenous joint
disks. The medial meniscus is a semicircle, while the lateral meniscus is four fifths of a ring.
Both menisci are open toward the intercondylar area, thick peripherally and thin centrally,
forming concavities into which the respective femoral condyles can sit. The wedge shaped
menisci increase the radius of curvature of the tibial condyles and therefore joint congruence.
By increasing the congruence or articular contact, the menisci also play an important role on
distributing weight bearing forces and in reducing friction between the joint segments.
The medial meniscus is more firmly attached than the lateral meniscus. Its lack of
mobility may be one of several reasons why the medial meniscus is torn more frequently than
the lateral meniscus.
The menisci are well established in the 8-week old embryo. Initially well vascularized,
the vascularity of the menisci gradually recedes centrally outward, reaching adult form at 10 or
11 years of age. The adult meniscus is vascularized only at the periphery by capillaries from the
joint capsule and synovial membrane. The pattern of vascularity may account for the low
incidence of meniscal injuries in young children whose menisci have ample blood supply and
the ability of the menisci to regenerate only in the vascularized peripheral region.
Etiology
1. Traumatic Injury
2. Degenerative causes prolonged hyperflexion of the knee particularly kneeling
Mechanism of Injury
The medial meniscus acts as a pivot during axial rotation. Meniscal injuries usually occur
as a result of sudden rotation of the fixed tibia when the knee is in flexion. The mechanism of
injury or a meniscal tear is a combination of torsion and impact stress placed on the joint with
secondary tearing of the cartilage substance. The medial meniscus is more commonly torn than
the lateral meniscus. This is because the medial meniscus is less mobile due to its more rigid
attachment, and thus when the knee is subjected to rotational forces; it will not move
accordingly with the moving structures, and what results is a meniscus that is torn.
Medial meniscus injury usually occurs when the foot is fixed on the ground and the
femur is rotated internally, while lateral meniscal injury commonly occurs when the femur is
rotated externally on a fixed tibia. An ACL injury often accompanies a medial meniscus tear.



Classification
Vertical tears
Longitudinal tear
o Tear along the longitudinal axis of the meniscus
Radial tear
o Tear transverse to the circumferential fibers of the meniscus
Bucket handle tear
o Complete longitudinal tear that results in a peripheral and inner fragment
Horizontal tears
Transverse tear
o Tear in the horizontal axis of the meniscus
Cleavage tear
o Complete transverse tear that separates meniscus into superior and inferior
fragments
Parrots beak tear
Combined, incomplete radial and longitudinal tear, with a displaceable component that
resembles a parrots beak
Root tear
Tear in the ant or post meniscal roots where the meniscus attaches to the central tibial
plateau
Degenerative tear
Occur as a result of traumatic or degenerative arthritis

Clinical Manifestations:
Locking of knee
o Unable to fully extend
o Springy end feel
Pain along joint line
Unable to bear weight
Unexpected giving way of knee during amb
Joint swelling
o Slight LOM of flexion/extension
Quadriceps atrophy
Complications
Non-operative treatment
o Knee instability
o Chronic pain
o OA
o Tear extension
Surgical
o Intraoperative damage to neurovascular bundle
Medial meniscus repair saphenous nerve
Lateral meniscus peroneal
o Flexion contracture
o Extensor lag
o Risk of failure of repair
Joint loading
Knee flexion beyond 45
Greatest during first few mos. post-op
Differential Diagnosis
Condition S/Sx Mechanism of Injury Special Test
Cruciate Ligament
Injuries
ACL
PCL
Pain
LOM
Area of
affectation

Hyperextension or
from a valgus force
to the knee
Posterior force to a
bent knee

(+) Anterior drawer
test
(+) Posterior drawer
test
(+) Lachman test

Runners Knee Pain
LOM

Abnormal lateral
tracking of patella

(+) Clarkes test

Meniscal Injury Locking
Pain
LOM
Swelling
Atrophy

Slightly flexed
knee with foot
planted on ground
with sudden
twisting of femur

(+) Mcmurrays Test
(+) Apleys Test
(+) Bounce Home
Test


Diagnosis
Hx
o Occur from excessive loads on normal meniscus
Rot force as a flexed knee comes into extension
o Also from normal forces acting on a degenerative meniscus
PE
Special Tests
o Mcmurray test
Px supine, knee acutely & forcibly flex
PT checks the med men by palpating posteromed margin of jt w/ 1 hand
while grasping foot w/ other hand
ER knee as far as possib., then slowly extend
(+)if A painful click/pop felt/ heard
As femur passes over tear in the men
Lat men is checked by
Palpating the posterolat margin of the jt
IR as far as possib. & slowly extend the knee while listen/feel for click
(-) McMurray test does not r/o tear
o Bounce Home Test
Pt Supine
Knee fully flexed then passively extend
(+) incomplete extension, rubbery endfeel
o Apley grinding test
Prone knee flexed 90
Ant thigh fixed against the table
Foot & leg are then pulled upward to distract jt & rot to place rot strain on
ligs
When ligs torn
Pain on this part of the test
w/ knee in same posn
Press downward & rot foot & leg as jt is slowly flex & extend
When men torn
(+) popping & pain localized to jt line noted

MRI diagnostic imaging of choice
MRI acc. in detection of men tear is 95%
Grade 0 - N men
Grade I - Stellate intrameniscal tear signal that does not extend to a free articular
surface
Grade II - Linear intrameniscal tear that does not extend to the articular surface
Grade III - Sig change in the meniscus that does not extend to the articular
surface represents a torn meniscus
Arthroscopy yields information of greatest diagnostic value
X-ray to rule out fracture, loose bodies, arthritis

Medical Surgical Management
Partial Menisectomy
Indications:
Symptomatic, displaced tear by older and inactive individuals
Tear extending into central less vascular third
Tear localized to inner avascular third

Meniscal Repair
Indications:
Lesions in the vascular one third
Tear extending into the central avascular third of a young (less than 40 50) or
physically active older (greater than 50)
Contraindications
Tear localized to the inner avascular third
Considerable tissue fragmentation
Tear that cant be reopposed

Allograft transplantationis a type of surgery in which a meniscus is placed into your knees.
The new meniscus is taken from a cadaver.

Aspiration to remove excess fluid in the acute stage