Meniscal injury
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A DETAILED DESCRIPTION OF MENISCIAL INJURY , MENISCUS ANATOMY & BLOOD SUPPLY HAS BEEN EXPLAINED
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Meniscal injury
- 2. OSSEOUS STRUCTURES 3 components: patella, distal femoral condyles, & the proximal tibial plateaus, or condyles.
- 3. Medial & lateral menisci & anterior & posterior cruciate lig. FUNCTION -distribution of joint fluid, nutrition, shock absorption, deepening of jt, stabilization of jt, & wt-bearing fn. Cruciate ligaments function as stabilizers of jt & axes around which rotary motion, both normal & abnormal, occurs. They restrict the backward & fwd motion of tibia on femur & assist in control of both MR & LR of tibia on femur. ER of tibia produces an unwinding of the lig., & IR produces a winding up of cruciate lig. INTRAARTICULAR STRUCTURES
- 4. Posterior view Anterior view Superior view Right knee joint ACL PCL LM FCL MM TCL Patellar ligament FCL
- 8. Superior view of tibial condyles after removal of femur MENISCI POPLITEAL TENDON Anterior meniscofemoral lig PMFL PCL MM LM
- 9. Posterior view of knee after removal of femur. Prevent capsular & synovial impingement during flexion- extension movts. - joint lubrication fn, helping to distribute synovial fluid throughout the joint & aiding nutrition of articular cartilage -contribute to stability in all planes but are especially important rotary stabilizers Menisci PCL Post.Horn of lm popliteus
- 10. Pattern of collagen fibres within meniscus Radial Circumferential
- 12. MENISCAL TEAR • Mech - Rotation as the flexed knee moves toward an extended position. • Medial meniscus, being far less mobile on the tibia, can become impaled b/n the condyles, & injury can result. • M/C location for injury - posterior horn of meniscus • M/C type of injury - longitudinal tears. • Length, depth & position of tear depends on posterior horn position in relation to femoral & tibial condyles at the T.O.I.
- 13. Classification - based on the type of tear found at surgery. (1) longitudinal tears, (2) transverse and oblique tears, (3) a combination of longitudinal and transverse tears, (4) tears associated with cystic menisci, and (5) tears associated with discoid menisci.
- 14. Meniscial cyst are freq. asso. with tears & are 9 times more common on lateral than on medial side. Discoid menisci are abnormal, & because of hypermobility & the bulk of tissue b/n the articular surfaces, they are vulnerable to compression & rotary stresses. Degeneration within the discoid meniscus, as well as tears, may develop.
- 15. DIAGNOSIS • Menisci tears can be divided into two groups: those in which there is locking and the diagnosis is clear, and those in which locking is absent and the diagnosis is more difficult. • Locking usually occurs only with longitudinal tears and is much more common with bucket-handle tears, usually of the medial meniscus.
- 16. • If a patient does not have locking, the diagnosis of a torn meniscus is more difficult. • history of several episodes of trouble referable to the knee, often resulting in effusion and a brief period of disability but no definite locking. • A sensation of “giving way” or snaps, clicks, catches, or jerks in the knee may be described, or the history may be even more indefinite, with recurrent episodes of pain and mild effusion in the knee and tenderness in the anterior joint space after excessive activity. • a sensation of giving way, effusion, atrophy of the quadriceps, tenderness over the joint line (or the meniscus), and reproduction of a click by manipulative maneuvers during the physical examination.
- 17. Diagnostic test • McMurray test • supine • knee acutely & forcibly flexed • medial meniscus - palpating posteromedial margin of jt one hand while grasping the foot with other hand. • Keeping knee completely flexed, leg is ERknee is slowly extended. • As the femur passes over a tear in the meniscus, a click may be heard or felt. lateral meniscus - P/L jt margin, IR leg as far as possible, & slowly extending knee while listening and feeling for a click. A click produced by the McMurray test usually is caused by a posterior peripheral tear of the meniscus and occurs between complete flexion of the knee and 90 degrees. Popping, which occurs with greater degrees of extension when it is definitely localized to the joint line, suggests a tear of the middle and anterior portions of the meniscus. The position of the knee when the click occurs thus may help locate the lesion. • Apley s grinding test
- 18. Thessaly test Karachalios et al. described a test for early detection of meniscal tears Reported diagnostic accuracy rates of 94% in medial meniscus tear & 96% lateral meniscus tear. Examiner – holds pt outstretched hands while pt stands flatfooted on floor. Pt rotates knee & body, internally & externally, 3 times with knee in slight flexion (5 degrees). The same procedure is carried out with the knee flexed 20 degrees. Patients with suspected meniscal tears experience medial or lateral joint-line discomfort and may have a sense of locking or catching. Test - normal knee first to teach the patient how to keep the knee in 5 and 20 degrees of flexion and how to recognize a possible positive result in the symptomatic knee. Thessaly test at 20 degrees of knee flexion was suggested to be effective as a first- line clinical screening test for meniscal tears.
- 19. IMAGING STUDIES • RADIOGRAPHY • AP, lateral, and intercondylar notch views with a tangential view of the inferior surface of the patella should be routine. • Ordinary radiographs will not confirm the diagnosis of a torn meniscus but are essential to exclude osteocartilaginous loose bodies, osteochondritis dissecans, and other pathological processes that can mimic a torn meniscus.
- 20. Normal meniscus sagittal image—the bow-tie appearance
- 21. Normal meniscus coronal. Note the triangular appearance and dark signal
- 22. Tear of the posterior horn of the medial meniscus
- 23. Displaced bucket handle tear with double posterior cruciate ligament sign
- 24. RADIAL TEAR
- 27. • High-resolution CT - sensitivity of 96.5% - specificity of 81.3%, and - accuracy of 91%. - CT for examining the patellofemoral joint because it allows evaluation of normal & abnormal relation of articulation at various degrees of knee flexion, with & without quadriceps contraction.
- 28. Nonsurgical management • groin-to-ankle cylinder cast or knee immobilizer worn - 4 to 6 weeks. • Crutch walking with toe touch wt bearing is permitted when pt gains active control of the extremity in the cast. • To strengthen the quadriceps, hamstrings, and gastrocnemius and soleus muscles around the knee as well as the flexors, abductors, adductors, & extensors around the hip- Progressive isometric exercise program during the time the leg is in the cast
- 29. • At 4 to 6 weeks, immobilization is discontinued & rehabilitative exercise program for the muscles around hip & knee is intensified. • Patient must be informed that any tear in the meniscus may not have healed despite this period of immobilization. • If symptoms recur after a period of nonoperative Rx, surgical repair or removal of damaged meniscus may be necessary, & more specific diagnostic procedures, such as MRI & arthroscopy, are used as indicated.
- 31. Operative Mx • Amt of degenerative change in the articular cartilage is directly proportional to amt of meniscus removed. • If the derangement produces almost daily symptoms, frequent locking, or repeated or chronic effusions, the pathological portion of the meniscus should be removed because problems caused by present disability far outweigh the probability or significance of future degenerative arthritis. • If a significant portion of the peripheral rim can be retained by subtotal meniscal excision, the long-term result is improved.
- 32. • Complete removal of meniscus is justified only when it is irreparably torn, & the meniscal rim should be preserved if at all possible. • Total meniscectomy is no longer considered Rx.O.C in young athletes or other people whose daily activities require vigorous use of the knee.
- 33. • OPEN MENISCAL REPAIR • MENISCAL AUTOGRAFTS AND ALLOGRAFTS
- 34. THANK U • Source - campbell
Notas do Editor
- ACL attaches to tibia anteriorly. PCL attaches to tibia posteriorly. . Extend leg. articular surfaces of femur & tibia are in maximum contact. • Jt is “locked” in its most stable position. • ACL taut & prohibits further extension. Flex leg. less contact b/n articular surfaces of femur & tibia. • Some rotation occurs in knee joint. •PCL prevents the tibia from being pushed posteriorly. • ACL prevents t from being pulled anteriorly
- The principal intraarticular structures of importance are the medial and lateral menisci and the anterior and posterior cruciate ligaments
- ACL – ORIGIN – arises from posteromedial corner of medial aspect of lateral femoral condyle in the intercondylar notch. This femoral attachment is on posterior part of medial surface of lateral condyle well posterior to longitudinal axis of femoral shaft …runs inferiorly , medially & anteriorly Insertion – anterior to intercondylar eminence of tibia,being blended wit ant.horn of mm…. Pcl – medial femoral comdyle ..insert- post.cortical surface of tibia in sagittal midline
- In addition to their synergistic functions, cruciate and collateral ligaments exercise basic antagonistic function during rotation. A, In external rotation, it is collateral ligaments that tighten and inhibit excessive rotation by becoming crossed in space.
- none of the four ligaments is under unusual tension
- Collateral ligaments - more vertical & lax, Cruciate ligaments become coiled around each other & come under strong tension
- joint filler,b/n femoral & tibial articulating surfaces .mm- c shaped, larger diameter, thinner periphery, Post horn wider than ant horn .Ant .horn – attach to tibia ant to iCE. Lm – ant horn – attached to tibia medially in front of ice ..MMPost horn – attach in front of pcl post to iCE. Mm does not attach to either of cruciate lig. LM. post horn – insert in post aspect of ice in front of post attachment of mm Lm- more circular, smal dia, thicker periphery, wider body, more mobile; lm lacks capsular attachment at popliteus hiatus, more mobile than mm Post horn receive anchorage to femur by lig of wrisberg & humbrey[AMFL] & from fascia covering popliteus, arcuate complex at post.lat corner of knee mmis firmly attached to tibial collateral ligament. In contrast, the lm is not attached to the FCL
- Run from post horn of LM to lateral aspect tof medial femoral condyle
- . The arrangement of these collagen fibers determines to some extent the characteristic patterns of meniscal tears
- vascular supply to the medial and lateral menisci originates predominantly from lateral & medial geniculate vessels (both inferior and superior). Branches from these vessels give rise to a perimeniscal capillary plexus within the synovial and capsular tissue Branching radial vessels from perimeniscal capillary plexus (PCP) can be seen penetrating peripheral border of medial meniscus. F, Femur; T, tibia. Three zones of meniscal vascularity are shown: 1 RR, red-red is fully within vascular area; 2 RW, red-white is at border of vascular area; and 3 WW, white-white is within avascular area.
- The most common type of tear is the longitudinal tear, usually involving the posterior segment of either the medial or the lateral meniscus. Before the extensive use of arthroscopy for diagnosis and treatment of meniscal injuries, tears of the medial meniscus in most series were approximately five to seven times more common than those of the lateral meniscus.
- Knee – full extension , femur slightly rotates on tibia to lock the knee jt in place Popliteus –key to unlocking knee as it begins knee flexion by laterally rotating femur on tibia
- Compared with arthroscopy, MRI has been shown to have 98% accuracy for medial meniscal tears and 90% for lateral meniscal tears. Others have reported that MRI had a positive predictive value of 75%, a negative predictive value of 90%, a sensitivity of 83%, and a specificity of 84% for pathological changes in the menisci.