Bucket-handle Tears of the Medial and Lateral Menisci of the Knee: Value of MR Imaging in Detecting Displaced Fragments

Objective: A bucket-handle tear of a meniscus is a longitudinal tear with an attached fragment displaced away from the meniscus. Several MR findings of bucket-handle tears have been reported previously. However, the sensitivity of MR for detecting the displaced fragment is unknown. We determined the sensitivity of MR for detecting a displaced bucket-handle tear and determined how the sensitivity varied with tears of different sizes. We also evaluated whether the three findings of a displaced fragment differed in frequency between medial and lateral tears.

Materials And Methods: We retrospectively evaluated the MR examinations of 39 patients with arthroscopically proven bucket-handle tears for signs of a displaced meniscal fragment. Thirty-two patients had medial meniscal bucket-handle tears, and seven had lateral tears. Two observers evaluated each examination independently, with discrepancies resolved by consensus of a third reader. Each observer evaluated for three findings of a bucket-handle tear: a double posterior cruciate ligament sign, a flipped meniscus sign, or a fragment in the intercondylar notch. A double posterior cruciate ligament sign is present when the meniscal fragment is displaced anterior to the posterior cruciate ligament, resembling two ligaments. A flipped meniscus sign occurs when the fragment is flipped anteriorly so the anterior horn of the meniscus appears to be enlarged. We tested for differences between menisci in the sensitivity for each sign using Pearson's chi-squared test or Fisher's exact test. We compared the sensitivity of MR for identifying fragments when the tear involved one third, two thirds, or the entire meniscus using Spearman's rank correlation.

Results: Overall sensitivity for a displaced fragment was only 0.64. When the bucket-handle tear involved the entire meniscus, the displaced fragment could be seen in 84% of the menisci. The double posterior cruciate ligament sign was seen in 53% of the medial and none of the lateral bucket-handle tears (p = .01). The flipped meniscus sign was noted in 44% of medial and 29% of lateral menisci (p = .68), and a fragment was identified in the intercondylar notch in 66% of medial and 43% of lateral menisci (p = .40).

Conclusion: MR is sensitive for detecting meniscal fragments in large bucket-handle tears, but is less so in small tears. The flipped meniscus sign and presence of a fragment in the notch were comparably useful findings of a displaced fragment in both medial and lateral menisci. The double posterior cruciate ligament sign was noted only in medial bucket-handle tears.