Meniscus of Knee

2013.02.18
R1 임경재
Meniscus
 C-shaped fibrocartilaginous tissue
 Attached to condylar surface of tibia
 Mechanical stability for femorotibial gliding

 3 segments: Anterior horn

Body (mid-zone)
Posterior horn
Meniscus
 Medial meniscus
• Half of circle, open C-shaped
• Wide posterior horn
• Firm peripheral & central attachment
• Lesser mobility
 Lateral meniscus
• 3/4 of circle shape
• Relatively symmetric in width
• Post. horn : Humphrey, Wrisberg of PCL
• Loose peripheral & central attachment
 Transverse ligament : both ant. horn
 Height : 3-5mm
 Width : medial ant. – 6mm, post. -12mm
lateral – 10mm

 Vascularity : From geniculate artery

• Except 10~25% peripheral (3mm) : relatively avascular
• Red zone : peripheral vascular
• White zone : central avascular

 Signal intensity on MRI

• Normal : Uniform Dark SI (T1,T2,T2*)
• Abnormal signal intensity
 Intrameniscal SI on short TE image
Normal attachment of MM
 Superior, inferior surface : equal in length
 Anterior root
• Inserts broadly on anterior intercondylar crest
• 15% : attachment at anterior margin of tibia (subluxation)
• Accessory ligament extending to ACL
 Posterior root
• Posterior slope of medial tibial tubercle
• Fissured appearance
 Normal attachment of LM
 Transverse meniscal ligament (geniculate lig.) PD

 Anterior root : inserts on smaller area, lateral to the ACL

• Fissured appearance / Horizontal division
T2
 Posterior root : sup. oblique course (magic angle effect)
 Popliteomeniscal fascicle : to joint capsule
 Meniscofemoral ligament : Humphrey, Wrisberg
 Uncommon meniscal variants
 Discoid meniscus (1.4~15.5%)
• Dysplastic, lost semilunar shape, broad disc-like configuration (LM>MM)
• Complete / Incomplete / Wrisberg ligament type
• 5~13mm / congenital, frequently bilateral, susceptible to tear
• Clinical : pain, clicking, snapping, locking
• MR : diffuse internal SI at articular contact - difficult to diagnosis a tear
Uncommon meniscal variants
 Ring lateral meniscus : DDx. with displaced fragment
 Meniscal ossicle : post. horn of MM
 Oblique meniscomeniscal ligament (1~4%)

0
Meniscal tears
 MR criteria - 1. Intrameniscal signal intensity
2. Abnormal meniscal morphology
 MR grading system (signal distribution)
 Grade 1 : Globular intermediate SI
 Grade 2 : Linear regions of intrameniscal SI
* Grade 1,2 - Not extension to articular surface
 Grade 3 : Regions of intermediate SI
Extension to articular surface
– Grade 3A : Linear signal intensity
– Grade 3B : Intermediate SI in the entire meniscus
(more extensive degenerative change)

 Morphologic : foreshortening of AP diameter, steeper slope,

decreased height, blunted free edge, notch sign
Grade I Grade II Grade III
 Classification of meniscal tears
 Simple, Complex
 Based on MR sagittal sections : Vertical, Horizontal
 Based on circumferential or surface anatomy : Longitudinal, Flap,
Radial
 Horizontal tear
• Usually more than 40 years old – degenerative tears
• Often at posterior horn ~ extend into body and ant. horn
• Restricted to the free edge, asymptomatic
• Sup. Inf. Extension : flap tear – meniscal cyst formation
• Extensive fibrillation on surface : better at T2WI (fluid
sensitive)
F/13 9699530, Discoid meniscus c horizontal tear
 Longitudinal tear
• Young patients, acute traumatic (with ACL tear)
• Vertical peripheral tear, longitudinal axis, begin posterior horn
• DDx : posterolat. structures, transverse meniscal lig.
meniscofemoral lig.
• Near meniscal attachment to capsule : reparable (vascularity
↑)
• Fragment inner displacement : bucket-handle or flap
M/63 9839480, MM vertical longitudinal tear
 Bucket-handle tear
• Displaced longitudinal tear of meniscus
• Common tear in young pt. with trauma, ass. with ACL injury
• Involves at least 2/3 of meniscal circumference
• Displaced tissue is restricted to posterior, DDx. with flap tear
• Medial meniscus > lateral meniscus (larger frag. from post.)
• Double PCL sign, double delta sign, fail to normal bowtie
M/25 10288672, Twisting injury
 Radial or Transverse tear
• Vertical tears perpendicular to the free edge of meniscus
• Classic radial tear : ant. horn-body junction of LM
• Root tear : post. horn of MM, meniscotibial attachment
• Cleft, truncated sign, ghost meniscus sign, marching sign
 Flap tear
• Composite of longitudinal and radial tears (oblique tear)
• Inner 1/3 of meniscus
• Vertical grade 3 intensity / Deficiency of inf. surface meniscus
• Change in the slope of superior surface
• Meniscal extrusion into coronary recess / Displaced meniscus
M/58, 5847001, Radial tear

M/71, 5320310 F/52, 9661512

 Complex tear
• Tear extends in more than one plane, creating separate flaps of
meniscus
• Extensive distortion and multiple SI to the meniscal surface
• Horizontal tear : superior, inferior flap
• Vertical : extension of additional flap
• Radial : free-edged flap, parrot-beak tear
Indirect signs of a meniscal tear
 Subchondral bone marrow edema
 Presence of a parameniscal cyst
• Fluid collections located at the periphery of the meniscus
• Lateral meniscal cyst : horizontal flap tear, horizontal cleavage tear,
complex tear with horizontal and radial components (in 90% case)
Pitfalls of meniscal tear
 Meniscomeniscal ligament / Meniscofemoral ligament
 Medial meniscal flounce Chondrocalcinosis
 Chondrocalcinosis / Meniscal ossicles
 Popliteus tendon / Magic angle
Meniscomeniscal Meniscofemoral

Meniscal ossicle

Meniscal flounce
Reference
 AJR 2012; 199: 481-499
 AJR 2003; 180: 93-97
 AJR 2002; 179: 1115-1122
 Am J Sports Med 2005; 33: 131-148