Ortho Dx: Knee pain following a "pop" during gymnastics - Clinical Advisor

Ortho Dx: Knee pain following a “pop” during gymnastics

Slideshow

  • Sagittal magnetic resonance image showing a large displaced meniscal fragment in the intercondylar notch

    Slide

    Sagittal magnetic resonance image showing a large displaced meniscal fragment in the intercondylar notch

  • Sagittal magnetic resonance image showing intact anterior cruciate and posterior cruciate ligaments in the knee

    Slide

    Sagittal magnetic resonance image showing intact anterior cruciate and posterior cruciate ligaments in the knee

A 16-year-old girl presents with a 2-day history of right knee pain after a gymnastics injury. She admits to feeling a “pop” as she fell awkwardly during a landing, and she has had difficulty with ambulation since the injury. The patient is guarded and difficult to evaluate. During the examination, she is unable to extend her right knee fully. Sagittal magnetic resonance images of the right knee were taken.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.


The patient's magnetic resonance imaging (MRI) findings and inability to extend her knee fully are consistent with a large bucket handle tear of the medial meniscus. Sagittal MRI shows a large displaced meniscal fragment in the intercondylar notch or a...

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The patient’s magnetic resonance imaging (MRI) findings and inability to extend her knee fully are consistent with a large bucket handle tear of the medial meniscus. Sagittal MRI shows a large displaced meniscal fragment in the intercondylar notch or a “double posterior cruciate ligament sign.” The displaced fragment is being impinged and is blocking full extension. Anterior cruciate and posterior cruciate ligaments are intact. 

The treatment of choice for a large bucket handle meniscus tear in a 16-year-old patient is arthroscopic meniscal repair. Meniscal tears that are stable after reduction and occur in the vascular zone or within 3 to 5 mm of the periphery are considered for repair.1 Unstable tears may require partial meniscectomy and may later result in arthritic changes proportional to the amount of meniscus removed.

The significant differences in postoperative limitations between meniscal repair and meniscectomy should be made clear to patients before surgery. Those undergoing meniscectomy may resume weight bearing as tolerated immediately after surgery and may progress to other activities as tolerated. Common postoperative protocols for meniscal repair include avoiding knee flexion during weight bearing for 4 to 6 weeks. Return to sports following repair varies significantly among providers; some advise return as tolerated, whereas others recommend waiting at least 4 months after surgery. Currently, there are no data to support one protocol over the other.2 The overall failure rate of meniscal repair can be as high as 30%, with most failures occurring after 2 years.3 

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

  1. Wheeless CR III. Bucket handle meniscus tear. In: Wheeless CR III, Nunley JA II, Urvaniak JR, eds. Wheeless’ Textbook of Orthopaedics. http://www.wheelessonline.com/ortho/bucket_handle_meniscus_tear. Updated August 31, 2012. Accessed February 1, 2016.
  2. Laible C, Stein DA, Kiridly DN. Meniscal repair. J Am Acad Orthop Surg. 2013;21(4):204-213.
  3. Nepple JJ, Dunn WR, Wright RW. Meniscal repair outcomes at greater than five years: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(24):2222-2227. 
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