Patient with right knee pain and swelling.

Contributed from the case records of the  Indiana University Department of Radiology

Patient with right knee pain and swelling.

Patient with right knee pain and swelling.

Findings:

Image 1 – Sagittal proton density image of the knee showing the “double delta” sign of a bucket handle meniscal tear.

Image 2 – Sagittal proton density image of the knee showing the displaced bucket handle into the femoral notch.  The displaced meniscus is shown in the sagittal image as the 2 areas of low signal within the joint.  See image panel below for sequence of images moving from lateral to medial.

Findings (continued below):

Image 3 – Sagittal proton density image of the knee showing intact ACL.

Image 4 – Sagittal proton density image of the knee showing intact PCL.

Image 5 – Coronal STIR image of the knee showing an area of low signal along the medial aspect of the lateral condyle where the displaced bucket handle meniscal tear is located

• Lateral meniscus bucket handle
• Chronic ACL rupture
• Medial meniscus free edge tear
• Lateral meniscus free edge tear

Patient with right knee pain and swelling.

Bucket handle meniscal tears: 

• Clinical presentation:
  • Complaints of knee pain after a traumatic event. Event usually involves "twisting" of the knee. Often patient cannot fully extend knee.
• Demographics
  • Bucket handle tears are more common with the medial meniscus.
  • More common in active young patients,
  • M>F 2.5:1. Peak age for males 31-40. Peak age for females 11-20.
• Imaging key points:
  • Bucket handle tear is a vertical peripheral tear of the meniscus with displacement of the mesial portion of the meniscus towards the notch of the knee.
  • A bucket handle tear of the medial meniscus can demonstrate the double PCL sign.
  • A bucket handle tear on either side can demonstrate the double delta sign. This sign results from capturing the non displaced meniscus in its sagittal plane along with the inverted portion in the same plane, resulting in 2 delta like shapes.
  • Coronal images can demonstrate the displaced cartilage in the femoral notch (not seen on this patient)
  • CT imaging may reveal a low density mass seen displaced towards or within the femoral notch
• Treatment is determined by location of the rip. Classification may be done by location.
  • The outer 1/3 of the meniscus is vascular and is termed the "red zone". This zone may heal if meniscus is returned to normal position.
  • The middle 1/3 of the meniscus is the "red-white" zone where the periphery is vascular and may heal but the middle portion is avascular and will not heal.
  • The inner 1/3 of the meniscus near the free edge is avascular and is termed the "white" zone. This portion will not heal if returned to normal position. Tears involving the white zone are debrided.
• Of note, studies have shown gadolinium enhanced imaging not to be effective in determining the vascularity of the meniscal tear.

• A bucket handle tear of the medial meniscus can demonstrate the double PCL sign.
• A bucket handle tear on either side can demonstrate the double delta sign. This sign results from capturing the non displaced meniscus in its sagittal plane along with the inverted portion in the same plane, resulting in 2 delta like shapes.
• Coronal images can demonstrate the displaced cartilage in the femoral notch (not seen on this patient)
• CT imaging may reveal a low density mass seen displaced towards or within the femoral notch

References: 

1. https://my.statdx.com/STATdxMain.jsp?rc=false#dxContent;meniscal_bucket_handle_tear, accessed 8/30/2011.
2. Characterization of the "Red Zone" of Knee Meniscus: MR Imaging and Histologic Correlation, October 2000 Radiology, 217, 193-200.  Also found at http://radiology.rsna.org/content/217/1/193.full.
3. Radiologic evaluation of the acutely painful knee in adults. Modarresi, et al. Uptodate.com  http://www.uptodate.com/contents/radiologic-evaluation-of-the-acutely-painful-knee-in-adults?source=related_link accessed 8/30/2011.
4. Meniscus Injuries, Baker, S. Bradley and Lubowitz James. Emedicine. ttp://emedicine.medscape.com/article/90661-overview#a0106 accessed 8/30/2011.

Patient with right knee pain and swelling.