Knee - Meniscal pathology

by 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

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

LEFT: normal medial meniscal root immediately anterior to the

posterior cruciate ligament.
RIGHT: missing posterior root due to meniscal root tear.

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 and a second
portion that travels from medial to lateral to connect to the
anterior horn of the 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.

The lateral meniscus posteriorly comes up higher 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 intensityon
PD-images unequivocally contacting the surface .

High signal intensity not unequivocally contacting surface. Small

black line on inferior margin of the meniscus. At arthroscopy the
meniscus was normal.

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 make the diagnosis of a tear.
If there is doubt whether the high signal touches the surface,
look at all the adjacent images and if there still is doubt than
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.

Longitudinal, horizontal and radial tears
Longitudinal tears
Longitudinal tears parallel the long axis of the meniscus
dividing the meniscus in an inner and outer part.
So 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) than 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

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 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 flippes over onto the anterior horn.

Flipped meniscus: posterior horn is missing because it is flipped over

and located on top of the anterior horn.

Horizontal tear with a meniscal cyst

Horizontal tears
Horizontal tears divide the meniscus in a top and bottom part
(pitta 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 through the horizontal tear and
accumulates periferally to the meniscus.
The connection with the joint space is often 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 bright on T2.
3. Flat lining against the outside margin 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.
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 meniscal parts.

LEFT: Absent or empty meniscus on sagittal image.

RIGHT: Axial image shows complete radial tear leading to a defect in
the meniscus.

Meniscal root tear: on sagittal images there is an absent or empty

meniscus-sign adjacent to the posteior cruciate ligament where the
meniscal root should be. On coronal images a meniscal root tear is
confirmed.

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 considerable posterior horn
of the meniscus on that image or the image adjacent to it.
If this is not the case it is an absent or empty meniscus-sign
indicating a radial tear.

Post-operative Menisci
Post-operative Menisci are harder to evaluate because the
two most important criteria, i.e. abnormal signal and
abnormal shape, do not work any more.
Abnormal signal is not anymore 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).
However if there is also high signal on T2-weighted images
than you can make the diagnosis of a tear as as this is the
result of synovial fluid leaking into a 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 you can compare with prior postoperative images,
you can say if an abnormal shape is a new finding indicative
of a new tear.
Sometimes differation between normal post-op findings and
a re-tear is not possible on conventional MR-images.
In these cases MR-arthrography with 40cc diluted
Gadolineum helps to make the distinction because even
small amounts of Gadolineum that leak into a tear are readily
visible on fat saturated T1 images.

PD and T2W images. Prior partial meniscectomy and suture repair.

At arthroscopy no tear.

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 and a suture
repair.
On the basis of these imaging findings it's impossible to tell if
this is a tear or normal postoperative finding.
This patient had another operation for ACL reconstruction.
They also 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 impossible to determine if the old tear had
healed.
However a new tear is seen, so this case ia easy.

LEFT: Old MR exam with tear. Patient had a suture repair.

RIGHT: On new exam there is a new tear (yellow arrow). Not
possible to tell if old tear has healed.
On a 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.

PD and MR-arthrogram after suture repair for meniscal tear: healed

tear.

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 meniscus (seen on
the original films, but not clearly seen on the compressed
image on the left.
On this image it is not possible to tell if the tear has healed.
So a MR-arthrogram was performed which showed that the
tear has healed.