Dr Arun Gupta Director imaging DepttDr Rakhee Gupta Dr Nitu Narula Dr Ritesh MahajanDr R K Gandhi

Contact :Web site : www.spiralctmricentre.comText references for this presentations : •Musculosketetal MRI ( Kaplan, Helms, Dussault,Anderson,Major) •MRI in orthopaedics and sports medicine ( David W . Stoller)

BUCKET HANDLE TEAR

Usually traumaticOccurs in young patient’s after significant trauma Usually in medial rarely in lateral meniscus Longitudinal vertical tear of the meniscus with unstable displaced inner fragment

( BUCKET HANDLE TEAR OF MEDIAL MENISCUS )

Detached fragment resembles handle of the bucket and remaining intact part of the meniscus resembles a bucket .

Vertical longitudinal tear is the commonest bucket handle tear ( 10 %).

Normal width of the body of the meniscus is 9mm .

Sagittal images from the body of the meniscus shows bow tie appearance in at least two consecutive images .

The bowtie appearance is absent in the bucket handle tear ( ABSENT BOWTIE SIGN ): (very sensitive for assessment of bucket handle tears )

The anterior / posterior horn are Truncated Hypoplastic With or without internal

signal change

The posterior horn of the medial meniscus is normally greater in height than anterior horn ….. Foreshortening of the posterior horn with no h/o partial menisectomy is associated with bucket handle morphology .

The detached fragment form the body of the medial meniscus can place itself anterior to anterior horn of the medial meniscus ( Anterior flipped meniscus sign ) .

The detached fragment can place itself in the intercondylar notch ( ventral to PCL ) and this position of the PCL gives double PCL appearance ( DOUBLE PCL SIGN )

Common tear in young patients

Associated with significant trauma

Associated with ACL injury . Unstable meniscal fragment

locks into the intercondylar notch and involves atleast two third of the meniscal circumference .

Diagnosis of a bucket handle tear requires identification of displaced meniscal tissue from posterior to relative anterior coronal position .

Double delta sign and / or double PCL sign are sagittal MR findings of a displaced bucket handle tear .

Double delta sign : Flipped inner meniscal fragments adjacent ( posterior ) to the anterior horn of the donor site.

Displaced posterior horn or body flap tear may mimic a bucket handle tear hence true bucket handle tear is : when third structure ( separate from ACL / PCL) is documented with in intercondylar notch on more than single cross-sectional image .

Types of vertical longitudinal tears : Single vertical longitudinal tear Double / triple vertical longitudinal

tear . Broken bucket handle tears Displaced bucket handle tear .

YOUNG MALE PATIENT1.FOOTBALL PLAYER2.RECENT TRAUMA3.PAIN RIGHT KNEE

DOUBLE PCL SIGN / DOUBLE DELTA SIGN

( BUCKET HANDLE TEAR OF MEDIAL MENISCUS )

DOUBLE PCL SIGN

The detached fragment can place itself in the intercondylar notch ( ventral to PCL ) and this position of the PCL gives double PCL appearance ( DOUBLE PCL SIGN)

DOUBLE PCL SIGN

DOUBLE DELTA SIGN

Flipped inner meniscal fragment adjacent

( posterior ) to the anterior horn of the donor site.

DOUBLE DELTA SIGN

ABSENT BOWTIE SIGN

Normal width of the body of the meniscus is 9mm . Sagittal images from the body of the meniscus shows bowtie appearance in at least two consecutive images . The bowtie appearance is absent in the bucket handle tear ( ABSENT BOWTIE SIGN ) (very sensitive for assessment of bucket handle tears )

ABSENT BOWTIE SIGN

NORMAL BOWTIE APPEARANCE OF

THE LATERAL MENISCUS

ABSENT BOWTIE APPEARANCE OF

THE MEDIAL MENISCUS

SAGITTAL STIR IMAGE : ( ABSENT BOWTIE SIGN)

APPRECIATE LOSS OF NORMAL BOWTIE APPEARANCE OF THE BODY OF THE MEDIAL

MENISCUS WITH FLUID INSUINATING IN THE REGION OF BODY OF MEDIAL MENISCUS

CORONAL T1W SEQUENCE APPRECIATE DETACHED FRAGMENT OF THE MEDIAL MENISCUS DISPLACED TO

THE INTERCONDYLAR NOTCH

CONSEQUENT CORONAL IMAGES ( PRIMARILY POSTERIOR ONES) DEPICTING THE DISPLACED

MENISCAL FRAGMENT

Diagnosis of a bucket

handle tear requires

identification of displaced

meniscal tissue from posterior to

relative anterior coronal

position .

AXIAL IMAGE IN BUCKET HANDLE

TEAR.

DONOR SITE MEDIAL MENISCUS BODY

DISPLACED MENISCAL FIBROCARTILAGEIN THE INTERCONDYLAR REGION.

Look for the donor site of tear . Look for unstable detached meniscal fibro-cartilage

fragment. Attempt to define meniscal Rim size ( 5mm or

more will need surgery) . Look for signs of chronicity ( deformed twisted

morphology) Double PCL / Double Delta / absent bowtie signs

are to be looked for . Truncation / hypoplasia / foreshortening of the

horns should be commented upon. Multiple posterior coronal images should display

the unstable / displaced meniscal fibrocartilage fragment to define bucket handle tear morphology and differentiate it from other kind of flap tears.