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Case Study: Medial Meniscal Tear
Mary Ellen is a 38-year-old patient who lifts weights, and she has done so in the last ten years. On the 10th of October 2017, she presented with persistent pain on the posteromedial right knee. There were occasional effusions from the joint though the patient did not characterize the discharges. Upon doing a magnetic resonance imaging, the client had a tear of the medial meniscus on the affected limb. This paper will review her condition, diagnosis, and possible treatment options.
Anatomy of the Meniscus
Menisci are pads of fibrocartilage located both medially and laterally in the knee joint, and they play a role in musculoskeletal morbidity. Their function is to absorb shock hence protecting the knee from injury during falls, and they help maintain stability in case of a rotation (Khalifa et al., 2020). The meniscus has four parts: the anterior, posterior horns, the anterior and posterior root attachments. These horns provide attachment of the menisci to the subchondral tibial bone. The medial meniscus occupies about 60% of the articulation area hence more stable, and its posterior horn is larger than the anterior one (Burgess & de Cicco, 2020). There are anterior and posterior cruciate ligaments which prevent the knee from sliding forward and backward respectively. When injured, there is swelling, pain, loss of stability, and mobility is affected.
Etiology
Meniscus tears are common injuries which affect people who participate in contact sports. It can also be caused by wear and tear due to strenuous activities which exert pressure on the knee joint. These wounds are due to a shearing force exerted between the tibia and femur bones. Tearing occurs mainly on the meniscis inner parts because of reduced thickness and lack of vascularization (Garvick & Reich, 2020). Pathophysiology of the illness is different in young patients compared to adults. In the former, the twisting energy acts on the flexed knee, which carries weight, and it results in vertical or oblique tears which extend from the posterior to the meniscuss anterior horn. It is mainly due to degeneration in adults, and the tears are directed horizontally.
Clinical Signs
The tearing of the meniscus presents with several clinical signs. The patient experiences severe ache, difficulties in bending the knee, there is swelling around the joint, and the leg is locked in a partial flexion position (Burgess & de Cicco, 2020). The aching is experienced as a sharp stab which lasts for some minutes, and a dull twinge then follows it for some hours. Locking can be either pseudo or true locking, depending on the prevailing conditions. The former is caused by swelling of the joints due to effusions or attempts to avoid pain because of the femoral condyles torn meniscuss compression. The latter is not common, and it happens in bucket-handle tears. The occasional effusions seen occur when chronic reactive synovitis has set in (Garvick & Reich, 2020). However, tears in the vascular supply can result in immediate discharges.
Diagnosis
Meniscal tears can be diagnosed using radiography, magnetic resonance imaging techniques, or the McMurray test. Though plain radiographs do not show injury to the cartilage, they help determine if there is arthritis in the joints. The former tool is the most efficient one as it gives a definitive finding and indicates if surgery is necessary. MRI provides images of the meniscus in axial, sagittal, and coronal planes, and it can pinpoint the exact location of the injury.
In the McMurray test, the patient gets undressed to their underwear then lies flat on a table. The knee is then held on one hand and the sole on the other. The technician then bends the knee fully and then pulls it outwards in a position called knock-need. This step is repeated, but the pull is done in a bow-legged position. The doctor then rotates the foot externally as they extend the knee. If clicks are heard or pain is felt, then the test is positive for a meniscal tear.
Treatment Plan
An initial form of acute knee trauma treatment involves conservative measures such as protection, rest, ice, compression, and elevation. Nonsteroidal anti-inflammatory drugs (NSAIDs) help in easing pain and swelling, but they do not treat the condition. Non-operative management should be done for three to six months if the mechanical symptoms are not severe (Doral, 2018). If this technique fails and symptoms persist, surgical options are then sought.
Arthrocentesis refers to a process where a needle and syringe are used to draw fluid from a joint capsule. The patient is injected with a local anesthetic first, and then the contents are drawn. This helps to reduce the swelling in the joint and allows for some degree of mobility. This procedure can also be used in diagnosis as the fluid is taken to a laboratory for analysis.
There are three main surgical treatment options: meniscal repair, meniscal reconstruction, and meniscectomy. The latter entails partial or complete incision of the meniscus to alleviate the pain. According to Burgess and De Cicco (2020), this procedure is done on old patients whose meniscal tears are related to degeneration. Moreover, the technique is ideal for people with concurrent osteoarthritis. Partial meniscectomy has no benefits and causes meniscal extrusion and increased body mass index in females (Doral, 2018). Therefore, this technique should only be a last resort for the patient.
Meniscal repairs are preferred in acute and traumatic tears located in a peripherally well-vascularized zone. This practice effectively manages medial meniscus tears on the posterior root with little or no complications, such as degenerative joint disease (Daggett et al., 2020). Since the patient is active in sports, this technique will be helpful as it will allow her to start lifting weights again.
References
Burgess, C. J., & De Cicco, F. L. (2020). Meniscectomy. StatPearls. Web.
Daggett, M., Tucker, T., Monaco, E., Redler, A., Pettegrew, J., Bruni, G., & Saithna, A. (2020). Partial medial meniscectomy using needle arthroscopy and a standardized local anesthetic protocol. Arthroscopy Techniques, 9(5), 593-598. Web.
Doral, M. N., Bilge, O., Huri, G., Turhan, E., & Verdonk, R. (2018). Modern treatment of meniscal tears. EFORT Open Reviews, 3(5), 260-268. Web.
Garvick, S. J., & Reich, S. (2020). Meniscal tears. Journal of the American Academy of PAs, 33(1), 45-46. Web.
Khalifa, A. A., Mohamed, R. A. E., Abo-Zeid, A. R., & Abd-Elaal, A. M. (2020). Rehabilitation options for patients with an isolated meniscal tear, a narrative review. Sports Orthopaedics and Traumatology, 36(4), 364-369. Web.
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