Orthopedic Knee Injuries Meniscus tear Injury

1. Meniscus Injury
Presented By Siti Nur Rifhan Kamarudin

2. ANATOMY
• Meniscus is a cushion structure made of
cartilage which fits within the knee joint
between tibia and femur.
• Each Menisci has
- Two ends
- Two borders
- Two surfaces

4. MEDIAL MENISCUS
• C- Shaped structure and
lateral meniscus is more
circular.
• Anterior horn : Attached to
the tibia anterior to the
intercondylar eminence to
the ACL.
• Posterior horn : Anchored
immediately in front of the
attachment of PCL posterior
to the intercondylar
eminence.

5. Medial Meniscus
• Peripheral border
attached to the
medial capsule
through the coronary
ligament to the upper
border of tibia.
• Most of the weight
borne on the
posterior portion of
meniscus

6. LATERAL MENISCUS
• Circular shaped
• The anterior and posterior
horns are closer to each
other & near insertion of ACL
• Anterior Horn : Attached to
the tibia in front of the
intercondylar eminence.
• Posterior Horn : Attached to
the posterior aspect of the
intercondylar eminence in
front of posterior attachment
of medial meniscus.

7. Lateral Meniscus
• The lateral meniscus is mobile and medical
meniscus is more fixed -> causing more tears to
occurs in medical meniscus
• Lateral meniscus is associated with discoid
meniscus and meniscal cysts
• Lateral meniscus is also assoc. with acute injury
to ACL
Medial Meniscus
• Tears of medical meniscus occurs more with
degenerative tears
• Associated with a baker’s cyst.

8. BLOOD SUPPLY
• The blood supply of meniscus
decides the healing potential of the
meniscus
• The outer one-third of meniscus is
vascular. It will heal if repaired
• The inner one-third is not vascular
and is nourished by synovial fluid.
• The middle third is red/white and it
is avascular.
• The blood supply of meniscus
originates from medial and lateral
genicular arteries

9. FUNCTIONS OF MENISCUS
• Shock Absorber: Provides load
sharing across knee by increasing
the contact area and decreasing
the contact stress.
• Act as joint filler : Compensates
for the gross incongruity
between tibial and femoral
articulating surfaces.
• Joint Lubrication: help to
distribute Synovial fluid through
the joint and aiding the nutrition
of articular cartilage.

10. OVERVIEW of MENISCAL INJURY
• Epidemiology:
- Most common indication for knee surgery
• Location:
 Medial Tears
- More common
- Degenerative tears in older patients usually
occur in posterior horn of medial meniscus.
 Lateral Tears
- More common in acute ACL tears

11. CLINICAL FEATURES
• Pt is usually a young person who sustain
twisting injury to the knee
• Knee pain (often severe)
• Swelling of the knee within 48hours
• “Locking” : Sudden inability to extend the knee
fully – suggest a ‘bucket-handle tear’.
• Popping or clicking within the knee.
• Limited motion of knee joint.
• Tenderness when pressing on the meniscus
(Knee joint line)

12. CLASSIFICATION OF MENISCAL TEAR
• Based on Location
 Red Zone: Outer third, vascularized
 Red-White Zone : Middle Third
 White Zone : Inner third, Vascularized

13. Based On Pattern
• Vertical/Longitudinal
- Common, esp. with
ACL tears
• Bucket Handle
- Vertical tear which
may displace into
notch
• Horizontal
- More common in
older population
- May be associated
with meniscal cysts

14. PHYSICAL EXAMINATION
• The joint may be held slightly flexed and there
is often an effusion.
• In late presentations, the quadriceps will be
wasted.
• Tenderness is localized to the joint line,
particularly the medial line.
• Flexion is usually full but extension is often
limited.

15. SPECIAL TESTS
1) Thessaly Test
• Standing at 20 degrees of knee flexion on
affected limb
• Patient twists with knee external and internal
rotation.
• Positive Test: Clicking, pain or discomfort on
joint line.

17. 2) McMurrays Test
• Principle: To trap the meniscus
between the tibia and femur.
• Pt needs to be relaxed.
• One hand on knee joint line.
Other hand holds the foot &
ankle.
• Flex the knee as far as possible
(Hyperflexion)
• Externally rotate(Medial Me.) or
internally rotate (Lateral Me.) the
tibia and then extend the knee.
• Positive McMurray’s : Clicking or
popping felt associated with
pain.

19. 2) Apley’s Grinding test
• Patient is in prone
position
• Knee flexed to 90 degrees
• The leg is rotated from
side to side
• Compression force
applied
• A painful response
signifies a torn or
degenerate meniscus.

21. IMAGING
Radiographs
• Should be normal in young patient with acute
meniscal injury
MRI
• Most sensitive diagnostic test
• Findings
- MRI Grade III signal is indicative of a tear
- Parameniscal cyst indicates presence of meniscal
tear
- May see ‘Double PCL” sign that indicates bucket-
handle meniscal tear.

23. MANAGEMENT
NON-OPERATIVE TREATMENT
Indication: First line of treatment for degenerative
tears
: Acute episode without locking but with
acute synovitis
• Immediate abstinence from weight bearing
• Rest
• Ice pack application
• Compression dressing
• NSAIDS
• Rehabilitation exercises

24. SURGICAL MANAGEMENT
1)Meniscectomy
2)Meniscal Repair
3)Meniscal Transplantation

25. OPERATIVE TREATMENT
1) Partial Meniscectomy
• Indication: Tears not amenable to repair (complex,
degenerative, radial tear patterns)
: Repair failure > 2 times
• Objective: Remove the torn meniscal fragment and
contour the peripheral rim, leaving a balanced, stable rim
of meniscal tissue.
• Outcomes
- >80% satisfactory function
• Partial is preferred over total meniscectomy
- Shorter operating time, Faster recovery, better
post-op function.

26. Anthroscopic Meniscal Repair
3 important steps:
- Appropriate patient selection : should have
documented tear that is able to heal
- Tear debridement and local synovial, meniscal
and capsular ablation to stimulate a
proliferative fibroblastic response
- Suture placement to reduce and stabilize the
meniscus

27. Meniscal Repair
Risks:
– Saphenous Nerve and Vein damage
– Peroneal Nerve
– Popliteal Vessels

28. 3) Meniscal Transplantation
• Attempts at meniscal replacement with
- Allograft meniscus
- Autograft fascial material
- Synthetic meniscus

29. REFERENCES
• Apley and Solomon’s Concise System of
Orthopedic and Trauma, 4th Edition