 Okay, it's your search button and go to sp 127 go a little slower in the beginning My suggestion is you hit either two or three I usually go three up to give me size Give it a little magnification which I will do and my approach to Menisci is that I work off the sagittal if it's a younger person first The coronal if it's an older person first why efficiency You're gonna fish where the fish are and where are the fish when you're 60 in the meniscus body? And where do you see the body best? coronal Where are the fish when you're 20 in the back or the front? So that's why we'll use the sagittal first in a younger person. It's expedient. It's faster. It's efficient It's gonna make you better Next thing I do as I look at the meniscal size I Look at the depth the volume and the position relative to the condyles Is it under the condyle or as it slipped out from under the condyle? So-called partial extrusion or pseudo extrusion In other words, is there good conformity and alignment? The very last thing I do by the way is look at the signal and I analyze the signal For its verticality Horizontality complexity. I look for areas of interruption like this one or Disappearance like this one in the sagittal projection meniscal ghosting the next thing I do is I compare the two menisci For intra meniscal signal the medial meniscus because of weight-bearing and the normal valgus inclination of the knee Always has more signal than the lateral meniscus until you get a bit older and things start to Dry out a little bit and your knee starts to change The conformity of your knee changes the convexity of the condyles change Now if I've identified a meniscus abnormality, I'm going to look at where it is. Is it at the root? Next to the root. Is it in the posterior horn the horn body junction the body the anterior body horn junction or the smaller anterior horn medial or lateral the Position of the tear It's not critical to the to the clinician, but it's nice to have the right location I'm also going to assess in the body whether the tears in the inner third middle third or outer third so called White white zone red white zone and red red zone. We could also see White white zone red white zone white white zone inner third middle third outer third I'm going to give it a length No I don't sit there with my Measurer and measure the tear because that takes me an extra two minutes if I do that ten times a day That's 20 minutes of measuring people that measure things all day long They're boring and they usually not sexually active. So let me show you what I do I know that the meniscus is going to be Approximately Six and a half to seven centimeters long. So if my tear is here, I just break it up into thirds It's in the back. It's about two centimeters two and a half centimeters. I'll say two to two and a half I've got another two centimeters here and another two centimeters here. So I'll give a range So if it goes all the way from stem to stern from root to root It's about a six to six and a half centimeter tear. It's got the whole meniscus So you can guesstimate it by looking at The length of the tear based on the number of slices or if you're comfortable with the anatomy Where you are on the meniscal target now The covering of the meniscus is a bit different in other words How much meniscus you have we'll see a little bit later depends on which side you're on the lateral on the medial side It's about 80 60 in terms of the amount of covering of the articular surface But once you lose the meniscus not good things happen now the Highland cartilage underneath vulnerable the bone underneath vulnerable The shape of the condyle vulnerable So I look at these secondary findings to decide is my meniscus tear relevant because you know what everybody over age 60 has a meniscus tear quite a few of you have an asymptomatic meniscus tear the menisci crack What else do I look at I look at whether that tear is unstable and needs surgery And we're gonna talk about that a little later on. What are those criteria? So this is our introduction to to the meniscus So now that we've identified This tear where is it? It's all the way in the back So if we're getting a series of sagittal slices, what's gonna happen slice slice slice We're gonna go through this hole and that's where we are right here in the hole a meniscus ghost It's gapped. How much is it gapped? We could measure it. You can eyeball it, too Don't like to measure a lot But that's about a seven or eight millimeter gap from side to side which helps determine whether you're gonna operate on it Is it in the inner third middle third or outer third? Well, all three thirds are affected that even though It's not as bad as that that doesn't look like that That's not a nice black triangle, but started on the inside and went to the outside It's a radial type of tear radial tears looking like this. It's also right near the meniscus root So radial tears are like this It's a type of vertical tear and it's pretty straight. So you usually see it on one cut. You're out of it You're in it. So if you scroll sagittally, you'll be out of it and in it very quickly All right, what else is associated with this tear? Well, we said loss of the meniscus makes the Highland cartilage vulnerable it is Blow up your sagittal blow it up really big That's what the cartilage should look like look at the fuzzy ill-defined thin cartilage in the back That is not normal. That is extensive class two to three Conrad Malaysia over the tear no surprise there How about the subconrad bone? Multiple linear hypo intense foci in the sub cortical subconrad bone with osteoedema lots of osteoedema a Sub-cortical insufficiency fracture also known as a SIF It's a 48 year old female. She was running across the street and felt a pop. What do you think popped answer? I don't know but there's only two possibilities Her meniscus popped or her bone popped Yes, a sub cortical insufficiency fracture acute will be associated with a pop So one or both of those things occurred when she was running across the street To complete the exercise We should close the loop Lots of people run across the street and they don't get a meniscus tear and a fracture. She needs a dexa. It's a woman She's got an acute fracture You got to work her up for osteoporosis Calcium phosphorus alkaline phosphatase your real doctors You are imaging clinician specialists You're not radiologists Your clinicians you're helping other clinicians and Your radiologists One last caveat. Where is this thing? Let's blow up our coronal. Let's make it as big as we can get it I'm gonna focus on these structures right here the roots The meniscus roots are ligamentous anchors in the back To the posterior tibia in the front to the tibial spines Some of these anchors sit in very close proximity to the cruciates for instance the anterior Root sits right at the base of the ACL and many people say that they merge There's the ACL. There's the root attachment More commonly because the medial meniscus is more rigid. It is more prone to medial root injuries What do medial root injuries lead to? Partial extrusion of the meniscus Meniscus not there anymore partially extruded what happens? Conrad Malaysia Subcortical insufficiency fracture it all goes together Soon as I see a I know I'm looking for B C D and E. I know before I even see it You can classify these root abnormalities by purely ligamentous There's a classification system out we'll share with you a little bit later But they can purely involve the ligament they can be within three millimeters of the ligament They can be three to six millimeters away from the ligament or greater than six millimeters away from the ligament Or they can completely disrupt the ligament and completely disrupt the meniscus tissue itself So you see you could have true tears of the actual ligament You can have true tears of the meniscus interfacing with the ligament next to the ligament a little further away from the ligament and These posterior lesions near the root are very important to identify and have only come into our stream of consciousness in the last decade so the diagnosis is posterior horn meniscus tear Adjacent to the root attachment within three to five millimeters of the root root attachment with a gap of Seven to eight millimeters trizonal with subjacent class two to three Condro Malaysia and weight-bearing subcortical insufficiency fracture or SIF that is your dictation That is your conclusion and it's going to be tight and brief