Meniscal injuries


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Meniscal injuries

  1. 1. •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
  2. 2. •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)
  3. 3. •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
  4. 4. L M
  5. 5.  Vascular supply good in the most peripheral 20% of the fibers  Supplied by the geniculate arteries  Inner 1/3 of the ring is avascular  Relatively thin  Nourished through synovial fluid  Middle 1/3 of the ring is combination
  6. 6. • 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
  7. 7. Medial meniscus is more commonly injured than lateral meniscus and is usually associated with other ligament injuries Seen in abt 71 % of cases,and 5% its bilateral Lateral meiscus is less injured because: oSmaller in diameter oThicker in periphery oWide oMore mobile oAttached to both cruciate lig oStabilised postiorly to the femoral condyle by popliteus
  8. 8. •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
  9. 9.  An acute twisting injury from impact during a sport  Usually 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.
  10. 10. Associated injuries  In 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
  11. 11. symptoms  Not all meniscal tears are symptomatic  Swelling  Pain along the joint line (tenderness)  Pain when squatting, kneeling or pivoting  Locking of the knee  Giving way snaps, clicks, catches in knee.  Atrophy of quadriceps  Instability of joint
  12. 12.  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
  13. 13.  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
  14. 14.  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
  15. 15. Apley’s Distraction Test  Here 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
  16. 16. Based on appearance on arthroscopy : 1. Radial/parrot beak tears 2. Flap tears 3. Degenerative tears 4. Bucket handle tears(vertical) 5. Horizontal tears
  17. 17. L R H B P S
  18. 18. 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
  19. 19. o Grade 1 tear has an increased signal in the meniscal substance o 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
  20. 20.  locked bucket handle tear usually involves medial meniscus and is seen as ‘double PCL sign’ on sagittal images
  21. 21. Depends on age, presence of arthritis, damage or deformity of meniscus, and association of cruciate ligament tear etc Conservative in patient’s soon after injury with no locking and with infrquent attacks of pain and in tears less than 10mm,partial thickness tears Surgery if joint cannot be unlocked and if symptoms are recurrent
  22. 22. 1. Abstinence from weight bearing 2. Rest,ice packs,compressive bandage 3. Buck’s skin traction 4. Joint aspiration 5. Quadriceps exercises 6. If symptoms persists,a cylindrical cast may be considered
  23. 23.  Total meniscectomy  Partial meniscectomy  Meniscal repair  Inside out  Outside in  All inside
  24. 24. Partial Meniscectomy  Done when tear involves interior 70%  May be done when athlete wants to resume activity ASAP  Done with mobile fragments  10-35 minute arthroscopic procedure under regional or general anesthetic  Mobile areas removed  Edges contoured to “prevent further tears”  Immediate partial weight bearing allowed  Crutches for 1-2 days
  25. 25. Total meniscectomy  Irreparably torn meniscus  Not a treatment of choice in young athlets  Steps:  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
  26. 26.  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.
  27. 27. 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
  28. 28. •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
  29. 29.  Post op hemarthrosis  c/c synovitis  Injury to popliteal vessels  Painful neuromas of infra patellar branch of saphenous nerve  Thrombophlebitis
  30. 30. Meniscus Repair  Arthroscopically 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
  31. 31. •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