3/13/2019 The Radiology Assistant : Knee - Meniscus basics

Knee - Meniscus basics

David Rubin and Robin Smithuis
Radiology department of the Washington University School of Medicine, St. Louis, USA and the
Rijnland hospital in Leiderdorp, the Netherlands

Publicationdate July 20, 2005

This article is based on a presentation by David

Rubin and adapted for the Radiology Assistant
by Robin Smithuis.
Interactive cases are presented in the menu bar
to test your knowledge.

by David Rubin and Robin Smithuis

Normal Meniscal Anatomy

Medial meniscus

Both horns are triangular in shape and have

very sharp points.
The posterior horn is always larger than the
anterior horn (figure).
Medial meniscus: The posterior horn is always larger If this is not the case, then the shape is
than the anterior horn. abnormal, which can be a sign of a meniscal
tear or a partial meniscectomy.

The posterior root is immediately anterior to the

posterior cruciate ligament.
If it is missing on the sagittal images, then
there is a meniscal root tear (figure).
The anterior horn has an insertion on the tibia
LEFT: normal medial meniscal root immediately and a second portion that travels from medial
anterior to the posterior cruciate ligament. RIGHT: to lateral to connect to the anterior horn of the
missing posterior root due to meniscal root tear. lateral meniscus (intermeniscal or transverse
ligament).

Lateral meniscus

On sagittal images the posterior horn is higher

in position than the anterior horn.
Both horns are about the same size.

Lateral meniscus. Both horns are about the same

size.

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The lateral meniscus posteriorly comes up high

over the tibial spine to insert near the posterior
cruciate ligament.
This upward position of the posterior horn may
be the reason for the higher signal intensity of
the posterior horn in all planes due to magic
angle effect.

Lateral meniscus: posterior horn and posterior

meniscal root.

Meniscal tears
Criteria for tears

The two most important criteria for meniscal

tears are an abnormal shape of the meniscus
and high signal intensity unequivocally
contacting the surface on PD images.

It is a misunderstanding that menisci should be

homogeneously low in signal intensity on
proton-density images.
The meniscus does not have to be black.
Only when the high signal unequivocally
reaches the surface of the meniscus you can
High signal intensity not unequivocally contacting make the diagnosis of a tear.
surface. Small black line on inferior margin of the If there is doubt whether the high signal
meniscus. At arthroscopy the meniscus was normal. touches the surface, look at all the adjacent
images.
If there is still doubt, then do not diagnose a
tear.
If you have a questionmark in your head, say
"meniscus is normal". (figure)

Nomenclature of Meniscal Tears

Shapes. There are 3 basic shapes of meniscal

tears: longitudinal, horizontal and radial.
Complex tears are a combination of these basic
shapes.

Basic shapes: Longitudinal, Horizontal and Radial.

Displaced Tears
Bucket-handle tear = displaced longitudinal
tear.
Flap tear = displaced horizontal tear.
Parrot beak = displaced radial tear.

Bucket handle, Horizontal Flap tear and Parrot beak.

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Longitudinal, horizontal and radial

tears

Longitudinal tears
Longitudinal tears parallel the long axis of the
meniscus dividing the meniscus into an inner
and outer part.
Therefore, the distance between the tear and
the outer margin of the meniscus is always the
same (figure).
The tear never touches the inner margin.

Longitudinal tears follow the collagen bundles

that parallel the contour of the meniscus.
If a longitudinal tear has other components
(horizontal or radial), then it is a complex tear
violating the collagen bundles.
This requires a higher energy trauma.

Three sagittal images of a longitudinal tear

Longitudinal tear (2)

Bucket handle tear

is a displaced longitudinal tear.

LEFT: abnormal shape of posterior horn. A piece is

missing. RIGHT: displaced fragment in the
intercondylar fossa.

On coronal images bucket handle tears are

easier to recognize.
Normally there are only two structures in the
intercondylar fossa: the anterior and posterior
cruciate ligament.
Any other structure in the intercondylar fossa is
abnormal and a displaced meniscal fragment is
the most likely possibility.
LEFT: meniscus is abnormal in shape and there is a
displaced fragment. RIGHT: Three structures in the More on Bucket handle tears
intercondylar fossa: post cruciate lig (1), ant cruciate
lig (2) and displaced fragment (3).

Longitudinal tear (3)

Flipped meniscus is a form of bucket handle

tear.
There is a capsular detachment or peripheral
tear of the meniscus, usually the posterior horn.
The posterior horn flips over onto the anterior
horn.
Flipped meniscus: posterior horn is missing because
it is flipped over and located on top of the anterior More on Flipped meniscus
horn.

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Horizontal tears
Horizontal tears divide the meniscus in a top
and bottom part (pita bread).
If horizontal tears go all the way from the apex
to the outer margin of the meniscus, they may
result in the formation of a meniscal cyst.
The synovial fluid runs peripherally through the
horizontal tear and accumulates within the
meniscus and finally result in a cyst.
The connection with the joint space is often
Horizontal tear with a meniscal cyst lost, so they will not fill with contrast on MR-
arthrography.
The synovial fluid is absorbed and is replaced
by a gelatinous substance.

There are 3 criteria for the diagnosis of a

meniscal cyst:

1. Horizontal tear.
2. Fluid accumulation with bright signal on
T2.
3. Flat lining against the periphery of the
meniscus.

The diagnosis of a meniscal cyst is important to

the surgeon because it takes one operation on
the outside of the knee to remove the cyst and
another operation on the inside for the
meniscus.

Radial tears
Radial tears are perpendicular to the long axis
of the meniscus.
They violate the collagen bundles that parallel
the long axis of the meniscus.
These are high energy tears. They start at the
inner margin and go either partial or all the way
through the meniscus dividing the meniscus
into a front and a back piece.
Radial tears are difficult to recognize. You have
to combine the findings on sagittal and coronal
images to make the diagnosis.

The following combination of findings is

diagnostic:
In one plane: triangle missing the tip and in the
other plane: a disrupted bow tie.

LEFT: triangle missing the tip.RIGHT: disrupted bow

tie.

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Small radial tears are difficult to diagnose.

Sometimes the only sign is a disrupted bow tie.

Disrupted bow tie indicating a small radial tear.

If you image a complete radial tear directly

along the length of the tear you will see an
absent or empty meniscus.
These complete radial tears open up and give
the impression that there is a part missing.
However you will not find a displaced meniscal
fragment. It is simply separation of the
LEFT: Absent or empty meniscus on sagittal meniscal parts.
image.RIGHT: Axial image shows complete radial
tear leading to a defect in the meniscus.
More on empty meniscus sign
Meniscal root tear

A meniscal root tear is a radial tear located at

the meniscal root.
Normally when you image the posterior cruciate
ligament on sagittal images you should see a
Meniscal root tear: on sagittal images there is an considerable portion of the posterior horn of the
absent or empty meniscus-sign adjacent to the meniscus on that image or the image adjacent
posterior cruciate ligament where the meniscal root to it.
should be. On coronal images a meniscal root tear is
If this is not the case it is an absent or empty
confirmed.
meniscus-sign, indicating a radial tear.

More on meniscal root tears

Post-operative meniscus

Post-operative menisci are harder to evaluate

because the two most important criteria, i.e.
abnormal signal and abnormal shape, do not
apply.

Abnormal signal is no longer a reliable sign of

a tear, because if there has been a suture
repair, this will heal with scar tissue, which also
has high signal on PD-images (figure).
Although an uncommon finding, if there is also
high signal on T2-weighted images, then you
can make the diagnosis of a tear, as this is the
result of synovial fluid leaking into a meniscal
tear.
This however is an uncommon finding.

Abnormal shape can be the result of partial

meniscectomy.
So you need to know what procedure was
performed during arthroscopy.
Only when comparison is made with prior
postoperative images, can you determine, if an
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abnormal shape is a new finding indicative of a

new tear.

Sometimes differentiation between normal

post-op findings and a re-tear is not possible on
conventional MR-images.
In these cases, MR-arthrography with 40cc
diluted Gadolinium helps to make the distinction
because even small amounts of Gadolinium that
leak into a tear are readily visible on fat
saturated T1 images.

Post-operative Meniscus 1
The case on the left shows a meniscus with an
abnormal shape aswell as abnormal signal
touching the surface on PD but not on T2W-
images.
This patient had a prior partial meniscectomy
PD and T2W images. Prior partial meniscectomy and
and a suture repair.
suture repair. At arthroscopy, there was no tear. On the basis of these imaging findings, it is
impossible to tell if this is a tear or a normal
postoperative finding.
This patient had another operation for ACL
reconstruction.
The surgeon looked at the meniscus and the
meniscus was found to be normal i.e. no tear.

Post-operative Meniscus 2
This patient had a suture repair for meniscal
tear.
There was a new injury.
On the new MR, it is impossible to determine if
the old tear had healed.
LEFT: Old MR exam with tear. Patient had a suture However a new tear is seen, so this case is
repair. RIGHT: On new exam, there is a new tear
(yellow arrow). It is not possible to tell if the old tear
easy.
has healed.

On an MR-arthrogram, there was very high

signal intensity in the new tear comparable with
the synovial fluid, but only moderate signal
intensity at the healed old tear.
So comparison with the old films was diagnostic
for the new tear, while the arthrogram showed
that the old tear has healed.

MR-arthrogram: In the new tear the signal is as

bright as in the synovial fluid (yellow arrows). In the
healed tear the signal is not as bright.

Post-operative Meniscus 3
This patient also had a suture repair for
meniscal tear.
After a new injury, the PD-images show high
signal unequivocally reaching the surface of the
PD and MR-arthrogram after suture repair for meniscus (seen on the original films, but not
meniscal tear: healed tear. clearly seen on the compressed image on the
left).

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1. Rubin DA: Magnetic resonance imaging of On this image, it is not possible to tell if the
chondral and osteochondral injuries. Top Magn tear has healed.
Reson Imaging 1998; 9:348-359 So an MR-arthrogram was performed which
2. Rubin DA, Kettering JM, Towers JD, Britton CA: showed that the tear has healed.
MR imaging of knees having isolated and
combined ligament injuries. AJR, 1998; 170:1207-1213

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