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Meniscus Injury

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Meniscus Injury Introduction Role of menisci • Medial meniscus lesions are more common than 01 lateral meniscus because it is attached to the improving articular capsule that make it less mobile thus it cannot congruency and increasing easily to accommodate the abnormal stresses. the stability of the knee • In increasing age – gradual degeneration and change in the material properties of the menisci Meniscus controlling the complex thus splits and tears are more likely that usually associated with osteoarthritic articular damage or rolling and gliding actions of chondrocalcinosis. Injury the joint • In younger people - meniscal tears are usually the result of trauma, with a specific injury identified in distributing load during the history. movement Tear of Meniscus Pathology Pathology • Usually, meniscus more likely to tear along its Vertical tear Horizontal tear length than across its width because the Bucket-handle tear usually ‘degenerative’ or due to repetitive minor trauma meniscus consists mainly of circumferential the separated fragment remains attached front complex with the tear pattern lying in many collagen fibres held by a few radial strands. and back planes The torn portion can sometimes displace towards may be displaced or likely to displace • The meniscus is usually torn by a twisting the centre of the joint and becomes jammed If the loose piece of meniscus can be displaced, it between femur and tibia acts as a mechanical irritant, giving rise to force with the knee bent and taking weight. This causes a block to movement with the patient recurrent synovial effusion and mechanical describing a ‘locked knee’ symptoms • In middle life, tears can occur with relatively posterior or anterior horn tears Some are associated with meniscal cysts little force when fibrotic change has the very back or front of the meniscus is It is also suggested that synovial cells infiltrate into the vascular area between meniscus and restricted mobility of the meniscus. damaged parrot beak tears capsule and multiply there oblique tear pattern creates a flap of meniscus The lateral meniscus is affected much more that may be stable (unlikely to displace) or frequently than the medial unstable (displaced or likely to displace). Clinical Features Physical Examination . Mechanism of injury - twisting force . Knee joint slightly flexed with the knee bent and taking weight. Presence of effusion . Severe pain – avoid further activities . Wasting of quadricep muscle . Locking of knee in partial flexion . Localized tenderness of joint line (suggest bucket-handle tear) . Swelling of knee after hours . ROM- may have full flexion but . Symptoms alleviate with rest and slightly limited extension aggravate after trivial twist or strains . McMurray’s test, Apley’s grinding . Intermittent knee instability followed test, Thessaly test may be by pain and swelling positive Investigation Treatment Treatment OPERATIVE TREATMENT Plain X-rays DEALING WITH THE LOCKED KNEE - Should be normal in young patients with an acute . Indication meniscal injury . Usually unlock spontaneously - if the joint cannot be unlocked - Meniscal calcifications may be seen in crystalline . If not, do gentle passive flexion and rotation - if mechanical symptoms (locking or catching) are arthropathy (ex. CPPD) . Rest the knee for few days and may well unlock itself recurrent and non-operative treatment has failed MRI . If the knee does not unlock, or if attempts to unlock it cause severe . Tears close to the periphery, which have the capacity to heal, can reliable method of confirming the clinical diagnosis pain, arthroscopy is indicated. be sutured; at least one edge of the tear should be red (i.e. linear high signal that extends to either superior or . If symptoms are not marked, it may be better to wait a week or vascularized) inferior surface of the meniscus indicative of a tear two and let the synovitis settle down . Tears other than those in the peripheral third are dealt with by parameniscal cyst indicates the presence of a meniscal . If the tear is confirmed, the offending fragment is removed or excising the torn portion (or the bucket handle) tear repaired if possible . Total meniscectomy is thought to cause more instability and so bucket handle meniscal tears indicated by “double PCL” predispose to late secondary osteoarthritis sign or “double anterior horn” sign CONSERVATIVE TREATMENT . Partial meniscectomy has lesser morbidity but no obvious a horizontal cleavage in the medial meniscus – the advantage characteristic ‘degenerative’ lesion – or detachment of . If a peripheral tear has been identified and the lesion may be . Arthroscopic meniscectomy has distinct advantages over open the anterior or posterior horn without an obvious tear repairable, then arthroscopy and suture repair of the meniscus can meniscectomy: shorter hospital stay, lower costs and more rapid Diagnostic knee arthroscopy be employed return to function but still have complication Infrequently performed due to increased use of MRI . Non-operative care should be instigated . Postoperative pain and stiffness are reduced by prophylactic non- scanning steroidal anti-inflammatory drugs Introduction Pathology A small, well-demarcated, avascular 02 The lower, lateral surface of the medial femoral condyle is usually affected fragment of bone and overlying An area of subchondral bone becomes avascular cartilage sometimes separates from Articular and within this area an ovoid osteocartilaginous one of the femoral condyles and segment is demarcated from the surrounding appears as a loose body in the joint bone. Defects – At first the overlying cartilage is intact and the Causes - trauma, either a single fragment is stable impact with the edge of the patella or Osteochondritis over a period of months the fragment separates repeated microtrauma from contact but remains in position Dissecans finally the fragment breaks free to become a loose with an adjacent tibial ridge. body in the joint The small crater is slowly filled with fibrocartilage, leaving a depression on the articular surface. Clinical Features Investigation Management Plain X-Rays usually between 15 and 20 years of age ‘stage’ the lesion - a line of demarcation around a lesion in situ, Do MRI or arthroscopy intermittent pain or swelling usually in the lateral part of the medial femoral In the earliest stage, when the cartilage is intact and the lesion is attacks of knee instability condyle ‘stable’, no treatment is needed but activities are curtailed for 6– ‘locking’ sometimes occurs - Once the fragment has become detached, the 12 months. Small lesions often heal spontaneously. empty hollow may be seen – and possibly a loose If the fragment is ‘unstable’ (i.e. surrounded by a clear boundary The quadriceps muscle is wasted body elsewhere in the joint with radiographic ‘sclerosis’ of the underlying bone), or showing MRI features of separation, treatment will depend on the size of may be a small effusion MRI the lesion and the age of the patient. tenderness localized to one femoral condyle - Most effective imaging technique to define the A small fragment should be removed by arthroscopy and the base soon after attack (diagnostic) site, size and activity of an OCD lesion drilled, the bed will eventually be covered by fibrocartilage, Wilson’s sign: if the knee is flexed to 90 degrees, - An OCD lesion will typically demonstrate an area leaving only a small defect of low signal intensity in the T1-weighted images, A large fragment (more than 1 cm in diameter) should be fixed in rotated medially and then gradually with adjacent bone also appearing abnormal, situ with pins or Herbert screws, or in the younger patient with straightened, pain is felt; repeating the test with probably due to oedema open growth plates. the knee rotated laterally is painless (diagnostic) Arthroscopy In older patients, removal of the unstable fragment and cartilage repair techniques (e.g. microfracture or autologous cartilage - To determine if an OCD lesion is stable or implantation (ACI) can be carried out. unstable, prior to fixation or removal Introduction Pathology Chronic disorder of synovial joints, in which 02 articular cartilage breakdown starts in an area of there is progressive softening and disintegration excessive loading of articular cartilage accompanied by new can affect all of the soft tissues around the knee growth of cartilage and bone at the joint margins Disease localized to the medial compartment is (osteophyte), cyst formation and sclerosis in Articular the commonest pattern occurring, producing subchondral bone, mild synovitis and capsular varus deformity to normal limb alignment fibrosis. Other intra-articular characteristic features The knee is the commonest of the large joints to Defects – found include peripheral osteophyte formation, be affected by osteoarthritis bone loss, degenerative change to the menisci Often bilateral and in these cases there is a Osteoarthritis and anterior cruciate ligament (ACL) destruction strong association with Heberden’s nodes and Concurrent chondrocalcinosis is relatively generalized osteoarthritis. common Clinical Features Investigation Treatment Patients are usually over 50 years old and are often Standard X-Ray of Knee NON-OPERATIVE TREATMENT overweight. - tibiofemoral joint space is diminished Pain that worsen after used or walking up stairs Educate on good information about the disease, exercise and Joint stiffness after rest - subchondral sclerosis weight-loss if
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