Orthopaedics

1. MENISCAL INJURIES
NUR IZZATUL NAJWA BINTI
SHARUPUDDIN 036

2. STRUCTURE OF MENISCUS
• It is a fibrocartilage disc interposed
in femorotibial joints between
femoral condyles and tibial plateaus
• Have a triangular cross section –
thickest at periphery, tapering to a
thin edge
• Histologically made up of collagen,
fibrochondrocytes, proteoglycans,
glycoprotein and elastin

3. STRUCTURE OF MENISCUS
• Vascular supply from
inferior medial and lateral
geniculate arteries
• The central part, 2/3 of
menisci is avascular and
receive nutrition from the
synovial fluid – ONCE
TORN, DOES NOT HEAL
ILG
IMG

4. MEDIAL MENISCUS
• C-shaped
• Less mobile – get torn more
often
• Firmly attached to tibia (via
coronary ligaments) and
capsule (via deep MCL)
LATERAL MENISCUS
• Circular
• More mobile
• Loose peripheral
attachment
• No attachment at popliteal
hiatus (where popliteus
tendon enters joint

6. FUNCTION
• Load transmission and shock
absorption
– 50% in extension, 85% in flexion
• Joint congruity and stability
– Between curved condyles and flat
plateus, as stabilizers
• Joint lubrication
– Distribute synovial fluid across
articular surface
• Joint nutrition
– Absorb and release to cartilage
• Proprioception
– Nerve ending provide sensory
feedback for joint position

7. MECHANISM OF INJURY
• Commonly in sports activity such as in rugby and getting up
from squatting or crouching position
Sustained injury when standing on semi-flexed
knee, twist his body to one side
During the movement, meniscus is sucked in
and nipped as rotation occurs between condyles
of femur and tibia
Longitudinal tear of the meniscus

8. MECHANISM
• A degenerated meniscus in the elderly may get torn by
minimal or no injury

9. TYPES OF MENISCAL TEAR
• Bucket handle tear is the
commonest
• Others : radial, anterior horn
and posterior horn tear
• Underlying pathological
changes that make it prone to
tear :
– Discoid meniscus
(shape like a disc)
– Degenerated
– (in osteorthirits)
– Meniscal cyst

12. CLINICAL FEATURES
• Young male, active in sports or old
age
• Recurrent episodes of pain
• Locking of knee
• ‘Jhatka’, a sudden jerk while walking
or flicking over inside the joint
• Swelling (due to synovial reaction) –
after few hrs, lasting few days
• Every successive episode of locking be either spontaneously
corrected or may need manipulation
• H/o of sudden locking and unlocking, with a click located in one or
other joint compartment is diagnostic of meniscal tear

13. EXAMINATION
• Swollen knee
• Locked knee
• Tenderness on region of joint line
• Gentle attempt to force full extension produce
sensation of elastic resistance and pain
• Wasting of quadriceps

14. SPECIAL TEST
McMurray’s Test
The basic premise of the McMurray test is that
meniscus tears are trapped during certain knee
movements, with resultant pain and clunking.
• Full flexion of knee + external rotation + varus
force (adduction force)
• Gradually extended
• Pain or click felt over medial aspect of joint line at
certain angle
• Finding : tear of medial meniscus
• Similarly for lateral meniscus : flexion + internal
rotation + valgus force (abduction force)

15. SPECIAL TEST
Apley’s Test
• The concept behind the Apley test is that
ligaments usually are painful when stressed in
distraction, whereas pain involving the
meniscus is felt with compression.
• Prone position, the knee flexed 90°, and the
femur stabilized with one hand,
• Distraction is applied with the other hand by
pulling upward on the ankle while rotating
medially and laterally. A varus and valgus
force may also be applied to further delineate
whether the MCL or the LCL might be the
source of pain (Apley distraction test).
• Compression is applied to alternately grind
the medial and lateral meniscus between the
tibia and femur, with gentle varus and valgus
force applied, while internally and externally
rotating and compressing the ankle
downward (Apley grinding test)

16. SPECIAL TEST
• Duck walk test (Childress sign). The squatting position places
great stress on the posterior horns of both menisci and is
painful if the posterior horn is torn. The patient is asked to
squat and “walk like a duck.” Pain in combination with a clunk
suggests a posterior horn meniscus tear

17. INVESTIGATION
• X-ray – to rule out other pathology
• MRI – very sensitive

19. TREATMENT
• Acute meniscal tear
– If knee locked,
manipulated under general
anaesthesia
– Knee immobilised for 2-3
weeks
– Physiotherapy

20. TREATMENT
• Chronic meniscal tear
– To excise the displaced
fragment of the meniscus
– Repair by arthroscopic
surgery
– Excise the tear by fine
cutting instruments
– Arthroscopic meniscus
suturing

21. • Left knee, lateral meniscus (LM), viewing portal anterolateral (A, B, and D) and anteromedial (C). A
suture passing device is shown with a vertical suture passing through both the inferior and superior
tissue planes with the suture exiting superiorly, marked by the circle (A). Two sutures cinch the
superior and inferior tissue planes of the horizontal tear (B). The third suture is placed through the
posterior aspect of the horizontal tear (C), finalizing the repair construct and creating the shape of a
normal meniscus (D).

22. SUMMARY

23. REFERENCE