Salsabeel Matalqah
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Menisci Tears
*Common among young active adults.
*Common in Football players: flexion of knee joint in addition to
twisting.
*Little force is needed in middle aged, because fibrosis restricts
mobility of meniscus.
*After age 50, tears are more commonly due to arthritis than
trauma.
*Medial Menisci: more prone to injury because of its restricted
anatomy due to attachment to the joint capsule and to the tibial
collateral ligament make it less mobile.
Meniscus Tears
 Classification according to
 Mechanism ( traumatic Vs
degenerative)
 Pattern of tear ( bucket
handle Vs horizontal…. ).
Menisci Tears
Patterns of tears:
*Bucket-Handle Tears:
The split is vertical, along the circumference of
the meniscus
leaving anterior and posterior segments
attached loosely.
Sometimes the torn part displaces towards the
center, causing “locking” (extension block).
Menisci Tears
Horizontal tears:
*Usually degenerative in origin or due to repetitive
minor trauma, or with association with meniscal cysts.
*Generally speaking, most of the meniscus is avascular,
except the outer third-from capsule-, due to this
spontaneous repair doesn’t occur.
*The loose part act as a mechanical irritant causing
recurrent synovial effusion, and in severe cases
secondary osteoarthritis.
Menisci Tears
Clinical Features:
• Patients may complain of pain at the joint line area, locking,
clicking, giving way, and swelling with activity.
• In ptn >40yrs the main complaint is recurrent giving way or
locking.
Physical exam:
•Joint line tenderness (Mostly medial).
•Joint held slightly flexed.
•Joint effusion may be present.
•In late cases quadriceps are wasted.
•Flexion is full , extension limited.
_ Joint line tenderness:
the most imp and specific test
_ Apley’s grind test:
• Isolates meniscii
• Prone with knee flexed,axial load
and rotation.
- McMurray’s test
• Flex/ext with varus/valgus and
int/ext rotation.
• Goal is to get torn piece to pop
in and out of place.
• Positive if pop or reproduction of pain.
Menisci Tears
Imaging
X-ray – Normal
MRI – most useful may reveal tears missed by arthroscopy
Arthroscopy : Diagnostic and therapeutic.
You have to be certain that the lesion you can see is the one causing the
patient’s symptoms.
Treatment
Most meniscal tears do not heal without intervention. If conservative
treatment does not allow the patient to resume desired activities,
occupation, or sport, surgical treatment is considered. Surgical treatment of
symptomatic meniscal tears is recommended because untreated tears may
increase in size and may abrade articular cartilage, resulting in arthritis.
Menisci Tears
Treatment
 Conservative treatment of meniscal injuries begins
with RICE (Rest, Ice, Compression, and Elevation).
 Arthroscopy is the preferred method.
 peripheral tears – surgery.
 The displaced portion should be excised.
 Postoperative physiotherapy.
Recurrent patellar dislocation
 Anatomy of patella
Soft tissue elements affecting
the patella are the stabilizing
capsular and ligamentous
structures within which the
patella lies. Some ligaments of
the knee are continuous with the
fibrous capsule surrounding the
patella.
When injuries occur, all structures
are simultaneously affected.
These ligaments hold the patella
in place during static and
dynamic phases.
Recurrent patellar dislocation
 The knee is normally in slight valgus so



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there is a natural tendency for the patella
to pulled to the lateral side when the
quadriceps muscle is contracted
Traumatic dislocation is due to sudden
sever contraction of the quadriceps muscle
while the knee is stretched in valgus and
external rotation.
The patella dislocates laterally and the
medial retinacular fibers may be torn
15-20. % of patient with patellar dislocation
will have recurrent episodes.
It may develop without initial trauma
Recurrent patellar dislocation
 The predisposing factors are :
1- generalized ligamentous laxity .
2- under development of lateral femoral condyle and
flattening of the intercondyler groove.
3- maldevelopment of the patella;too high or to small .
4- valgus deformity of the knee.
5- primary muscle defect.
Clinical features
 Females > males .
 Often bilateral
 c/o:
-acute pain :tearing sensation
- knee is stuck in flexion and the patient
may fall. Often the patella is repositioned
spontaneouslly
- if the patella remain unreduced
Medial mass because the uncovered
medial femoral condoyle stand out
prominently- NOT THE PATELLA-.
no active or passive movement is
possible
On exam :
- Tenderness on the medial side of the joint.
- Swelling .
- Aspiration may reveled a blood stained
effusion .
- positive Apprehension test.
Clinical features CONT.
Apprehension sign. The knee is
placed at 30° flexion, and lateral
pressure is applied. Medial
instability results in apprehension
.by the patient
Imaging :
X-ray (includes anteroposterior, true lateral, and axial or
sunrise views (
CT scan
MRI
lateral patellar
dislocation (arrows)
Sunrise (skyline) view
Recurrent patellar dislocation
Complications :
-Repeated dislocation damage the contiguous surface of patella and
femoral condyle which lead to further dislocation
-later Secondary OA.
Rx:
If still dislocated :
PUSH IT BACK ( gently) + cylinder plaster or splint is applied for 2-3
weeks
+ quadriceps strengthening exercise for 3 months.
In children :
The patellar mechanism tends to stabilize as the child grows but 15% of
these children will suffer from repeated attacks which will be an
indication for surgery .
Role of surgery in recurrent patellar dislocation :
1- to repair or strengthen the medial patellofemoral ligament .
2- to realign the extensor mechanism.
Ligament injury
Anterior Cruciate Ligament:
 The Anterior Cruciate Ligament (ACL) is the main support
structure of the knee that prevents rotation of the Femur
on the Tibia .The ACL also prevents the Tibia from
translating forward on the Femur. This ligament is injured
in sports more.
 The knee is a hinge joint, comprised
of three bones and four main
ligaments. The joint has one plane
of motion, flexion and extension.
Due to this construction, a slight
amount of rotation does occur, but
the ligaments limit this motion.
The three bones are the Femur,
Tibia and Patella .The four
ligaments in the knee are the ACL,
Posterior Cruciate (PCL), Medial
Collateral (MCL), and Lateral
Collateral (LCL). These ligaments
connect the Tibia and Femur and
provide the structural integrity to
the knee.
 The ACL and PCL were named for their
location. The two ligaments are located in the
middle of the knee and cross one another
(cruciate is Latin for cross). The ACL has its
origin on the front, or anterior, aspect of the
Tibia, while the PCL originates on the back, or
posterior, aspect of the Tibia. The MCL is
located on the inside, or medial, aspect of the
knee and the LCL is located on the outside, or
lateral, aspect of the knee.
Which ligament is affected?
History
 History of hyper-extension and twisting injury, claim
to have heard a “pop” as the tissue snapped (at the
time of injury).
 Immediate swelling
 Knee is painful
 Tenderness is most acute over the torn ligament.
Stressing one or other side of the joint may produce
excruciating pain
 P/E
 Physical exam shows a positive anterior drawer sign at
30 degrees (Lachman test) and at 90 degrees.
 drawer test
Lachman test
 the pivot shift test is also positive.
Investigation
 Stress x-rays may provide evidence of instability
 Plain x-rays may show that the ligament has avulsed a
small piece of bone:-The MCL usually from the femur
-LCL from the fibula
-ACL from the tibial spine
-PCL from the back of the upper tibia
treatment
• Conservative management is indicated
in patients who can accept
modification of activities that produce
instability; instability is
thought to put the menisci at risk of
damage
• Surgical repair is not successful;
reconstruction is an individual
decision based on the patient’s desires
and requirements
• Patients engaging in competitive
athletics generally require reconstruction;
the methods vary but generally use
autograft to replace
the ACL
Sprains and partial tears
 Intact fibers splint the torn ones and so spontaneous
healing will occur
 Adhesions may result, so active exercise is prescribed
 Aspirating the haemarthrosis and applying ice packs
intermittently relieves pain
 Weight-bearing is allowed
 Knee is protected from rotation or angulation strains
by a heavily padded bandage or a functional brace
Complete tears
 Isolated MCL or LCL treated as above
 Isolated tears of ACL may be treated by early operative
reconstruction if the individual is a professional sportsman
 Cast-brace is worn until symptoms subside, thereafter
movement and muscle-strengthening exercise. This is
sufficient in about half of the patients as they regain good
function and need no further treatment.
 Remainder will have varying instability, late assessment
will identify those who will benefit from ligament
reconstruction.
 Isolated tears of the PCL are usually treated conservatively
Combined injuries
 In ACL and collateral ligament injury treatment starts
with joint bracing and physiotherapy to restore a good
range of movements before ACL reconstruction
 Combined injuries involving the PCL the same
approach is used however all damaged structures need
to be repaired
Complications
 Adhesions
If the knee with a partial ligament tear is not actively
exercised, torn fibers will stick to intact fibers and bone.
The knee gives way with catches of pain, localized tenderness
and pain on lateral or medial rotation occur
Confusion with a torn meniscus can be resolved by the
grinding test or arthroscopy
 Instability
The knee continues to give way and tends to get worse
predisposing to osteoarthritis. Reconstruction before
degeneration is wise.
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