Meniscal Tears - TeachMe Orthopedics (2022)

Meniscal Tears - TeachMe Orthopedics (1)Basics

Description

  • Menisci are the cartilaginous structures that serve in transmitting tibiofemoral load, shock absorption, lubrication, and passive stabilization of the knee.

  • The peripheral 1/3 zone has a vascular supply, while the central 2/3 zone is avascular.

  • Tears are classified as longitudinal, radial, oblique, horizontal, degenerative, complex, flap, or bucket-handle.

  • Meniscal tears can disrupt knee biomechanics, causing varying degrees of symptoms and predisposing the knee to other short- and long-term sequelae, including quadriceps or hamstring inhibition, patellofemoral pain syndrome, altered gait, and osteoarthritis.

  • Synonym(s): Cartilage tear (common usage by patients for a meniscal tear)

Epidemiology

  • One of the most common knee problems; annual incidence is 60–70 per 100,000 persons (1).

  • Traumatic tears typically occur in 13–40-yr-old individuals with sports-related injuries.

  • Degenerative tears typically develop in patients over 40.

  • Posterior horn of medial meniscus is most commonly affected location.

  • More common in males than females, with ratio between 2.5:1 and 4:1 (1)

Risk Factors

  • Abnormal mechanical axis

  • Ligament deficiency

  • Degenerative joint disease

  • Discoid meniscus

  • Poor quadriceps control

Etiology

A meniscal tear may occur following twisting, shearing, or compressive forces from contact or noncontact mechanisms.

Commonly Associated Conditions

  • ∼1/3 of traumatic meniscal tears associated with anterior cruciate ligament (ACL) injury

  • Tibial plateau and femoral shaft fractures

Meniscal Tears - TeachMe Orthopedics (2)Diagnosis

History

  • With a skilled practitioner, diagnosis can be correctly made in 75% by history alone (2)[B].

  • Traumatic tears in the younger, athletic population are most frequently associated with a significant cutting/twisting injury, whereas degenerative tears in older patients usually lack identifiable trauma.

  • Pain in area of medial or lateral joint line

  • Pain with weight-bearing and twisting/turning of knee or squatting

  • Degree of pain usually such that individual is able to ambulate after acute injury and may be able to continue sports participation

  • May be associated with slow onset of effusion over several hours

  • Catching, locking, or clicking sensation

  • Episodes of giving way

  • Symptoms may wane, but typically recur with resumption of activities.

  • Subsequent intermittent effusions not uncommon

Physical Exam

  • With a skilled history and physical, clinical examination can reach 88–92% accuracy (3)[C].

  • Exam findings suggestive of meniscal tear:

    • Effusion/hemarthrosis may be a sign of meniscal, ligament, or osteochondral injury.

    • Locked knee is suggestive of bucket-handle meniscal tear, ligament tear, or loose body.

    • Valgus/varus instability suggestive of medial collateral ligament (MCL)/lateral collateral ligament sprain, which may have associated meniscal injury.

    • Positive anterior/posterior drawer or Lachman test indicates cruciate ligament injury, which may have associated meniscal injury.

    • Tenderness to palpation isolated over the medial or lateral joint line is the most common finding on physical exam (sensitivity 71–85%, specificity 86–93%) (2)[B].

    • Positive McMurray's test: Palpable click and pain over joint line produced when meniscal fragment catches during test (sensitivity 48–80%, specificity 86–94%) (2)[B]

    • Positive Apley test: Pain over the respective joint line with the patient prone and the knee flexed to 90 degrees, while the leg is internally and externally rotated under an axial load (sensitivity 41%, specificity ranges 80–93%) (2)[B]

    • Positive Thessaly test: Pain over the respective joint line with the patient standing on the affected leg at 5 and 20 degrees of knee flexion, followed by internal and external rotation of the leg and torso (sensitivity 66–92%, specificity 91–97%) (2)[C]

    • Atrophic quadriceps suggestive of chronic inhibition by pain or effusion

    • May have decreased range of motion secondary to pain or effusion

Diagnostic Tests & Interpretation

Imaging

  • Standard weight-bearing anteroposterior/lateral/tunnel/patellar (sunrise, merchant) views to rule out other conditions such as loose body, arthritis, osteochondritis dissecans, or fracture

  • MRI useful to evaluate for concomitant structural damage when the diagnosis is in question or for operative planning

  • Should be performed quickly for locking symptoms or suspicion for substantial injury. Otherwise, is typically reserved for symptoms persisting >4–8 wks in the otherwise healthy knee

  • MRI findings of meniscal tear include meniscal cleavage signal, which extends to the meniscal surface.

Differential Diagnosis

  • Synovitis

  • Intra-articular loose body

  • Articular cartilage defect

  • Ligamentous injury, particularly ACL and/or MCL

  • Patellar subluxation/dislocation

  • Degenerative joint disease

  • Chondromalacia patellae

  • Tibial plateau fracture

Meniscal Tears - TeachMe Orthopedics (3)Treatment

  • Initial treatment is RICE—rest, ice (20 min several times per day), compression, elevation—and NSAIDs.

  • Immobilization is not recommended unless evaluating for fracture or major ligamentous injury; however, a hinged knee brace may offer support, protection, and symptom relief.

  • While infrequently required, crutches with partial weight-bearing may provide relief.

  • Sports activity should be restricted until symptoms resolve or (if indicated) MRI is performed.

  • Further management decisions are based upon patient's age, symptomatology, type of tear, and co-existing knee conditions.

  • Younger patients with traumatic tears should be thoroughly evaluated and more aggressively treated.

P.385

Additional Treatment

Referral

  • Expedited surgical referrals should be made for:

    • Traumatic longitudinal or radial peripheral tears measuring ≥1 cm (4)[B]

    • Locking symptoms, flap tears, and bucket-handle tears

    • Associated cruciate ligament injury, osteochondral defect, loose bodies, or fracture

  • Nonurgent referrals include tears treated nonoperatively but that continue to cause pain or disability.

  • Individuals with degenerative joint disease will likely have meniscal tears, and the presence of one is not necessarily a cause for a surgical referral.

Additional Therapies

Surgery/Other Procedures

  • Both partial meniscectomy and meniscal repair are outpatient-based procedures.

  • Partial meniscectomy is frequently performed for flap and bucket-handle tears or for tears failing nonoperative treatment.

  • Horizontal tears are typically degenerative tears and have a minimal chance of healng. As they may progress to flap tears, they may be excised.

  • Meniscal repair is attempted most commonly for traumatic longitudinal or radial tears in the periphery (4)[C].

  • Occasionally bucket-handle tears are amenable to repair.

Meniscal Tears - TeachMe Orthopedics (4)Ongoing Care

Prognosis

  • ∼20% of meniscal tears may heal without surgical intervention. These are typically small (<1 cm), traumatic longitudinal or radial tears along the meniscal periphery (4)[B].

  • Younger patients are more likely to spontaneously heal than older patients, and have better outcome with meniscal repair (5)[C].

  • In the carefully chosen patient, meniscal repair is successful in up to 80% (6)[B].

  • Successful repair compared to resection has a lower incidence of degenerative change after 5 yrs (6)[B].

  • Regardless of healing, many meniscal tears become asymptomatic (4)[B].

  • Greatest factor affecting long-term outcome after meniscectomy is presence of articular cartilage damage. 80–90% of patients without articular cartilage damage have good to excellent results with partial meniscectomy within 1st 5 yrs (6)[B].

  • Total meniscectomy in previously normal knees results in significant arthrosis in 2/3 of patients by 15 yrs from surgery.

Complications

  • Injury to peroneal nerve possible with lateral meniscus repair

  • Injury to infrapatellar branch of saphenous nerve possible with medial meniscus repair

  • Repair could fail, resulting in repeat arthroscopy

  • Infection

References

1. Arendt EA, ed. Orthopaedic knowledge update: sports medicine 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999.

2. Karachalios T, Hantes M, Zibis AH, et al. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg Am. 2005;87:955–962.

3. Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. Int Orthop. 2006.

4. DeHaven KE. Meniscus repair. Am J Sports Med. 1999;27:242–250.

5. Stärke C, Kopf S, Petersen W, et al. Meniscal Repair. Arthroscopy. 2009;25:1033–1044.

6. Greis PE, Holmstrom MC, Bardana DD, et al. Meniscal injury: II. Management. J Am Acad Orthop Surg. 2002;10:177–187.

7. Ryzewicz M, Peterson B, Siparsky PN, et al. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res. 2007;455:123–133.

Additional Reading

Andersson-Molina H, Karlsson H, Rockborn P. Arthroscopic partial and total meniscectomy: A long-term follow-up study with matched controls. Arthroscopy. 2002;18:183–189.

Greis PE, Bardana DD, Holmstrom MC, et al. Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg. 2002;10:168–176.

Klimkiewicz JJ, Shaffer B. Meniscal surgery 2002 update: indications and techniques for resection, repair, regeneration, and replacement. Arthroscopy. 2002;18:14–25.

Meniscal Tears - TeachMe Orthopedics (5)Codes

ICD9

  • 836.0 Tear of medial cartilage or meniscus of knee, current

  • 836.1 Tear of lateral cartilage or meniscus of knee, current

  • 836.2 Other tear of cartilage or meniscus of knee, current

Clinical Pearls

Not all patients with meniscal tears require surgery. Clinical evaluation by a skilled examiner identifies patients with surgically amenable meniscus tears with equal or better reliability than MRI (7)[C].

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