We describe a case of a patient who presented with pain of the right knee after traumatic incident. Imaging features suggested a diagnosis of meniscal bucket-handle tear.
A 24-year-old male presented with pain of the right knee and lack of full extension. Past history: traumatic incident with sprain of the knee 2 months ago. MR was performed. The MR imaging
examination was performed at our institution with a 0.2T imager (ESAOTE). Axial, coronal, and sagittal T1, T2, PD, STIR weighted sequences have been used.
Bucket-handle tear is usually a vertical or oblique longitudinal tear with an attached fragment displaced away from the periphery of the meniscus. Most tears begin at or near the posterior insertion of the meniscus onto the tibia and extend beyond the junction of the middle and anterior third, allowing the displacement of the inner segment beyond the equator of the femoral condyle and into the intercondylar notch. A clinical history of recurrent pain, locking or lack of full extension is common, as in our case. MR is considered to be the best imaging technique for the diagnosis of meniscal tears and the only imaging tool used to predict the reparability of these tears. Double-posterior cruciate ligament, fragment in the intercondylar notch, absent bow-tie, double-anterior horn, flipped meniscus, and disproportional posterior horn signs are well known and widely used. The double PCL sign consists of an intercondylar meniscal fragment of low-signal intensity located in the same sagittal plane as the PCL, with the meniscal fragment lying inferior and parallel to the PCL. The parallel low-intensity bands can also be appreciated on coronal images but are correspondingly smaller since they are imaged end-on in their transverse diameter. A meniscal fragment within the intercondylar notch was defined as a bandlike area of low signal intensity within the notch but not appearing on the same slice as the PCL on sagittal images. Absent bow tie sign implies the occurrence of only one or no meniscal body segment in consecutive peripheral sagittal MR images. Double-anterior horn sign is proposed to represent the situation when the displaced meniscal fragment and intact anterior horn are not vertically juxtaposed but are located next to one another in the same horizontal plane, whereas flipped meniscus sign denotes an abnormally large anterior horn due to the vertical juxtaposition of the displaced meniscal fragment to the ipsilateral anterior horn. The original description of the flipped meniscus sign is only that of an abnormally large anterior horn ( =6 mm in height), and many authors suggested the double-anterior horn sign to represent an anteriorly displaced meniscal fragment not fully covered by the description of the flipped meniscus sign. Disproportional posterior horn sign denotes the presence of a larger meniscal posterior horn in the central sections than that in the peripheral sections on sagittal image, and is considered to indicate a postero-centrally displaced meniscal fragment. The presence of three or more of the six MR imaging signs of meniscal bucket-handle tears, as in our case, should be regarded as highly suggestive for such a condition. Arthroscopy confirmed the MRI diagnosis.
Bucket-handle meniscal lesion
1. MRI reveals a tear-shaped signal abnormality in the meniscal region of the right knee joint, particularly from the posterior horn to the mid-anterior portion, consistent with a typical longitudinal or oblique longitudinal tear.
2. Certain sequences (sagittal, coronal) show findings similar to the “double PCL sign” and the “disappearing bow tie sign,” suggesting that the torn fragment is displaced into the central or anterior part of the knee joint.
3. A band-like low signal is visible in the central joint space (intercondylar notch), consistent with inward displacement of the bucket-handle tear fragment.
4. No obvious bony fracture is observed around the articular surface. Mild cartilage wear signals are noted, but the main changes involve the torn and displaced meniscus.
5. A small amount of joint effusion is present, which may result from trauma and synovial inflammation.
1. Bucket-Handle Meniscal Tear: Based on the patient’s history of trauma and MRI signs (e.g., “double PCL sign” and “disappearing bow tie sign”), this is the most common diagnosis matching the clinical presentation (knee pain, possible locking/clicking).
2. Conventional Longitudinal Meniscal Tear: If the displaced meniscal fragment has not migrated significantly, similar clinical symptoms may appear. However, evident displacement on imaging suggests a bucket-handle tear.
3. Other Meniscal Lesions (e.g., horizontal or oblique tears): These may cause clinical symptoms, but typically do not exhibit the characteristic “bucket-handle” displacement on imaging, making them less likely here.
Considering the patient’s age (24), history of trauma, clinical symptoms (knee pain, possible locking or limited motion), as well as MRI findings and arthroscopic examination results, the most likely diagnosis is a bucket-handle meniscal tear.
1. Treatment Strategy
- Arthroscopic Surgical Treatment: For a bucket-handle tear, if the tear site has adequate blood supply (outer zone, red zone), meniscal repair may be considered to preserve meniscal function. If the fragment cannot be repaired or the tear is in a poorly vascularized area, partial meniscectomy might be required.
- Postoperative Rehabilitation and Brace Immobilization: The use of a brace and the initiation of weight-bearing exercises depend on the surgical approach (repair or meniscectomy) and the surgeon’s preference. Longer protection is needed after a repair to ensure healing at the suture site.
- Medication and Adjuvant Therapy: Anti-inflammatory and analgesic drugs can be used as needed, along with physical therapy modalities (e.g., cold therapy, ultrasound, low-frequency electrical stimulation) to reduce pain, swelling, and promote tissue repair.
2. Rehabilitation/Exercise Prescription (FITT-VP Principle)
- Initial Phase (0–4 weeks postoperatively):
• Frequency: 1–2 sessions per day of gentle muscle activation exercises.
• Intensity: Avoid significant pain or swelling. Typically includes quadriceps isometric contractions and ankle pump exercises while wearing a brace.
• Time: About 10–15 minutes per session, monitoring knee response.
• Type: Primarily non-weight-bearing or partial weight-bearing range of motion exercises, quadriceps isometric contractions, and straight-leg raises (if permitted by your physician).
• Progression: Gradually increase the number of sessions based on pain and swelling.
- Intermediate Phase (4–8 weeks postoperatively):
• Frequency: 3–5 sessions per week, gradually increasing joint mobility and introducing controlled weight-bearing exercises.
• Intensity: Progressively increase knee flexion/extension range and resistance; if appropriate, partial weight-bearing walking may be done with a brace.
• Time: 20–30 minutes per session, focusing on proper knee response and avoiding excessive fatigue.
• Type: Active range of motion exercises, lower limb strengthening (avoid high loads in deep knee flexion), and balance training.
• Progression: As knee stability and pain allow, approach normal range of motion and carefully increase weight-bearing capacity.
- Late Phase (8 weeks postoperatively and beyond):
• Frequency: 3–4 comprehensive sessions per week, transitioning toward functional recovery and return to sports.
• Intensity: Provided there is no pain and good knee stability, gradually increase strength and endurance training, potentially adding external resistance or equipment.
• Time: Sessions of 30 minutes or more, with short breaks tailored to the exercises.
• Type: Strengthening exercises for quadriceps, hamstrings, and other lower limb muscle groups, balance and coordination drills, and the gradual introduction of running or jumping (with medical clearance).
• Progression: The final goal is to restore daily and sports functions. Should significant discomfort or recurrent swelling occur, reduce or pause training and seek medical advice.
Disclaimer: The above report is a comprehensive reference analysis based on current imaging and clinical information and does not replace an in-person clinical diagnosis and professional treatment by a physician. If you have further questions or if symptoms worsen, please seek medical attention promptly.
Bucket-handle meniscal lesion
