Meniscus Tear

Clinical Presentation

History

• Often a challenging diagnosis with variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables symptoms
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are often able to continue to participate in the initial activity.
• Assess mechanism of injury: 
  • Twisting
  • Cutting
  • Squatting
  • Direct trauma Direct Trauma Toddler’s Fractures
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship often report hearing a pop at the time of injury followed by localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
• Mechanical symptoms are common:
  • Catching
  • Locking
  • Buckling
  • Sensation of giving way
• Severity of symptoms often related to type of meniscal tear:
  • A bucket-handle tear may cause significant locking and associated pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
  • A small vertical tear may cause only intermittent vague symptoms.
• Joint effusion Joint Effusion Septic Arthritis may develop over a few hours (more quickly with other associated injuries).

Physical examination

• Inspection Inspection Dermatologic Examination: 
  • Antalgic gait Antalgic Gait Legg-Calvé-Perthes Disease
  • Inability to squat
  • Effusion (occurs more rapidly with peripheral tears; may take up to 24 hours to demonstrate an effusion)
• Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination: 
  • Joint line tenderness
  • Evaluate for effusion: fluid shift Fluid Shift Translocation of body fluids from one compartment to another, such as from the vascular to the interstitial compartments. Fluid shifts are associated with profound changes in vascular permeability and water-electrolyte imbalance. The shift can also be from the lower body to the upper body as in conditions of weightlessness. Volume Depletion and Dehydration test
• Range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs (ROM): Does the patient have full flexion Flexion Examination of the Upper Limbs and extension Extension Examination of the Upper Limbs?
• Ligamentous stability:
  • Cruciate ligaments: 
    • Anterior/posterior drawer
    • Lachman test Lachman Test Knee Ligament Injuries
  • Collateral ligaments:
    • Varus stress test Varus Stress Test Knee Ligament Injuries
    • Valgus stress test
• Meniscal tests: Multiple tests have been described, with variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables sensitivity and specificity Sensitivity and Specificity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition. Epidemiological Values of Diagnostic Tests:
  • Thessaly test: 
    • The patient is weight-bearing (flat-footed) on 1 leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy flexed at 20 degrees and asked to initiate internal and external rotation External Rotation Examination of the Upper Limbs.
    • A positive test is joint line discomfort or complaints of locking or catching.
  • McMurray test: 
    • The patient is supine, and the knee is taken through its ROM with an associated varus or valgus force with internal and external rotation External Rotation Examination of the Upper Limbs of the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy.
    • A positive test includes popping or clicking of the knee with associated pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
  • Bounce home test: 
    • The patient is supine, and their heel is supported while the examiner passively flexes the knee. The knee is then passively allowed to extend under the influence of gravity.
    • The knee should normally extend fully, or “bounce home,” with a sharp end feel.
    • Positive if incomplete extension Extension Examination of the Upper Limbs of the knee or has a rubbery end feel 
  • Childress test: 
    • The patient squats and duckwalks. 
    • The test is positive if there is incomplete flexion Flexion Examination of the Upper Limbs limited by pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or clicking is heard.
  • Apley compression Compression Blunt Chest Trauma and distraction test: 
    • The patient is prone, with the knee flexed to 90 degrees.
    • The examiner internally and externally rotates the tibia Tibia The second longest bone of the skeleton. It is located on the medial side of the lower leg, articulating with the fibula laterally, the talus distally, and the femur proximally. Knee Joint: Anatomy while applying compression Compression Blunt Chest Trauma then distraction.
    • Positive for ligament injury if rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays plus distraction is more painful or increased rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays compared to normal side
    • Positive for meniscal injury if rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays plus compression Compression Blunt Chest Trauma is more painful or decreased rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays compared to normal side

Diagnosis

Diagnosis is usually suspected with a thorough history and physical examination, and often confirmed with diagnostic imaging (e.g., MRI) or by direct visualization (e.g., arthroscopy Arthroscopy Endoscopic examination, therapy and surgery of the joint. Knee Ligament Injuries).

Laboratory studies

• Only indicated if evaluating for other possible diagnoses:
  • Infection
  • Rheumatological disease
• Arthrocentesis Arthrocentesis Puncture and aspiration of fluid (e.g., synovial fluid) from a joint cavity. It is used sometimes to irrigate or administer drugs into a joint cavity. Septic Arthritis generally not indicated: 
  • May be indicated in the evaluation for other diagnoses
  • May provide symptomatic relief when there is a large effusion

Imaging

X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests:

• Indicated to evaluate for associated acute bony injury or underlying OA OA Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis changes
• Anteroposterior (AP), lateral, oblique, sunrise, and weight-bearing projections of the knee are ideal.

Ultrasound:

• Safe and inexpensive
• Able to visualize peripheral meniscus tears
• Limited ability to visualize deep structures of the knee

MRI:

• Imaging modality of choice for diagnosis and characterization of meniscal tears
• Accuracy greater than 90%
• Not always indicated prior to arthroscopy Arthroscopy Endoscopic examination, therapy and surgery of the joint. Knee Ligament Injuries: may give additional information regarding injuries to associated ligaments and cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology

Arthroscopy Arthroscopy Endoscopic examination, therapy and surgery of the joint. Knee Ligament Injuries:

• Gold standard for diagnosis of a meniscal tear
• Provides direct visualization of the meniscus and other associated tissues
• A diagnostic arthroscopy Arthroscopy Endoscopic examination, therapy and surgery of the joint. Knee Ligament Injuries can be converted to therapeutic arthroscopy Arthroscopy Endoscopic examination, therapy and surgery of the joint. Knee Ligament Injuries if pathologic findings are present.