Thank you for the detailed presentation on bucket handle tears of the medial meniscus. A thorough MRI evaluation is important to accurately identify and characterize this type of meniscal tear.

1. Dr Arun Gupta
Director imaging
Deptt
Dr Rakhee Gupta Contact :
Dr Nitu Narula Web site : www.spiralctmricentre.com
Dr Ritesh Mahajan Text references for this presentations :
Dr R K Gandhi •Musculosketetal MRI ( Kaplan, Helms,
Dussault,Anderson,Major)
•MRI in orthopaedics and sports medicine
( David W . Stoller)

2. ( BUCKET HANDLE TEAR OF
MEDIAL MENISCUS )
BUCKET
HANDLE TEAR
Usually traumatic
Occurs in young
patient’s after
significant trauma
Usually in medial
rarely in lateral
meniscus
Longitudinal
vertical tear of the Detached fragment resembles
meniscus with handle of the bucket and
unstable displaced remaining
inner fragment intact part of the meniscus
resembles a bucket .

3.  The posterior horn of the medial
 Vertical longitudinal tear is the meniscus is normally greater in
commonest bucket handle tear ( 10 height than anterior horn …..
%).
Foreshortening of the posterior horn
 Normal width of the body of the
meniscus is 9mm . with no h/o partial menisectomy is
 Sagittal images from the body of the associated with bucket handle
meniscus shows bow tie appearance morphology .
in at least two consecutive images .  The detached fragment form the
 The bowtie appearance is absent in body of the medial meniscus can
the bucket handle tear ( ABSENT place itself anterior to anterior horn
BOWTIE SIGN ): (very sensitive for of the medial meniscus ( Anterior
assessment of bucket handle tears ) flipped meniscus sign ) .
 The anterior / posterior horn are  The detached fragment can place
 Truncated
itself in the intercondylar notch
 Hypoplastic
( ventral to PCL ) and this position of
 With or without internal signal change
the PCL gives double PCL
appearance ( DOUBLE PCL SIGN )

4.  Common tear in young patients  Double delta sign : Flipped inner
 Associated with significant meniscal fragments adjacent
trauma ( posterior ) to the anterior
 Associated with ACL injury . horn of the donor site.
 Unstable meniscal fragment  Displaced posterior horn or body
locks into the intercondylar flap tear may mimic a bucket
notch and involves atleast two handle tear hence true bucket
third of the meniscal handle tear is : when third
circumference . structure ( separate from ACL /
 Diagnosis of a bucket handle PCL) is documented with in
tear requires identification of intercondylar notch on more than
displaced meniscal tissue from single cross-sectional image .
posterior to relative anterior  Types of vertical longitudinal tears :
coronal position .  Single vertical longitudinal tear
 Double delta sign and / or  Double / triple vertical longitudinal
double PCL sign are sagittal MR tear .
 Broken bucket handle tears
findings of a displaced bucket  Displaced bucket handle tear .
handle tear .

5. DOUBLE PCL SIGN / DOUBLE DELTA SIGN
( BUCKET HANDLE TEAR OF MEDIAL
MENISCUS )
YOUNG MALE
PATIENT
1.FOOTBALL
PLAYER
2.RECENT TRAUMA
3.PAIN RIGHT KNEE

6. DOUBLE PCL SIGN
DOUBLE PCL
SIGN
The detached
fragment can place
itself in the
intercondylar notch
( ventral to
PCL ) and this
position of the PCL
gives double PCL
appearance
( DOUBLE PCL
SIGN)

7. DOUBLE DELTA SIGN
DOUBLE DELTA
SIGN
Flipped inner
meniscal fragment
adjacent ( posterior )
to the anterior horn
of the donor site.

8. ABSENT BOWTIE SIGN
ABSENT
BOWTIE SIGN
Normal width of the body
of the meniscus is 9mm .
Sagittal images from the
body of the meniscus
shows bowtie appearance
in at least two consecutive NORMAL BOWTIE
images .
APPEARANCE OF
The bowtie appearance is
absent in the bucket THE LATERAL MENISCUS
handle tear
( ABSENT BOWTIE
SIGN ) (very sensitive ABSENT BOWTIE
for assessment of APPEARANCE OF
bucket handle tears ) THE MEDIAL MENISCUS

9. SAGITTAL STIR IMAGE :
( ABSENT BOWTIE SIGN)
APPRECIATE LOSS OF NORMAL
BOWTIE APPEARANCE OF THE BODY OF
THE MEDIAL MENISCUS WITH FLUID
INSUINATING IN THE REGION OF BODY
OF MEDIAL MENISCUS

10. CORONAL T1W SEQUENCE
APPRECIATE DETACHED FRAGMENT OF
THE MEDIAL MENISCUS DISPLACED TO
THE INTERCONDYLAR NOTCH

11. CONSEQUENT CORONAL IMAGES
( PRIMARILY POSTERIOR ONES)
DEPICTING THE DISPLACED
MENISCAL FRAGMENT
Diagnosis of
a bucket
handle tear
requires
identification
of displaced
meniscal
tissue from
posterior to
relative
anterior
coronal
position .

12. AXIAL IMAGE
IN BUCKET HANDLE TEAR.
DONOR SITE
MEDIAL
MENISCUS BODY
DISPLACED
MENISCAL
FIBROCARTILAGE
IN THE
INTERCONDYLAR
REGION.

13.  Look for the donor site of tear .
 Look for unstable detached meniscal fibro-cartilage fragment.
 Attempt to define meniscal Rim size ( 5mm or more will need
surgery) .
 Look for signs of chronicity ( deformed twisted morphology)
 Double PCL / Double Delta / absent bowtie signs are to be
looked for .
 Truncation / hypoplasia / foreshortening of the horns should
be commented upon.
 Multiple posterior coronal images should display the
unstable / displaced meniscal fibrocartilage fragment to
define bucket handle tear morphology and differentiate it
from other kind of flap tears.