 Good morning, everyone, and welcome to today's radiology journal, brought to you by Indian radiologists. We've had several journal clubs so far. We started with new imaging, and since then, we've had several sessions on cardiac imaging, oncoimaging, pediatric neuro radiology, breast and body imaging, and musculoskeletal imaging. Today, we have with us Dr. Rajan Mehmetah. We'll be taking another journal club in musculoskeletal radiology. Last month, we had with us Dr. Nikhil Kamath and Dr. Saritha Nader who took sessions and contrast media complications. I'm extremely thankful to the entire team at Indian radiologist Dr. Chalindra Singh, Dr. Jignesh Chakkar, Dr. Manisa, Dr. Parker, so providing us this platform and coming up with such an excellent idea. I'd like to thank my colleagues, Dr. Mitusha Verma, Mamta Ma'am, and Dr. Mehmetah Dakar. A big thank you to our educational partners, Bayer, for their continued support throughout our various activities. Before moving on, quick info about the upcoming academic events. We have the 21st MRI teaching course, which is to be held in August. It's a hybrid event. 13th and 14th will be the on-site sessions and 6th, 7th, 12th and the 21st of August will be online sessions. We have some interesting offers going on currently for registrations. Please make the most of it. Also, do send us your paper and poster submissions. The last date is on 31st of July. The other events are the Sonobahs 2023, which is to be held in Jan and CTBahs in October on the 29th and 30th. We will be sharing the links for registration in the chat box. Details are also available on the Indian radiologist's website. Next month, we have the Fatal Eco Masterclass on the 17th of July. It's a Fatal Eco Cardiography workshop on basic skills and clinical applications. Please do register for the same. For those who are new, the Radiology Journal Club was started with the idea of staying updated. We have discussions on articles which are centered around current advances and research topics, which is usually followed by interesting case discussions. Today, for Musculoskeletal Imaging Journal Club, we have with us Dr. Chinmay Mehta. Dr. Chinmay is working as an interventional radiologist in Musculoskeletal Imaging at PULS, team of diagnostic centers, Mumbai, and Newtick Imaging Center, Kalyan. He's done several fellowships in interventional MSK Radiology from Newfield Orthopaedic Institute, Oxford, UK, and Innovation Imaging and Sports Med Institute, Mumbai. He's been a guest faculty in more than 30 radiology conferences and webinars. He's a co-founder of Café Rangin Education Forum. He's worked in several other hospitals including Hinduja Healthcare and Pokhila Ben Derbhai Ambani Hospital in Mumbai. He's published several articles in various index journals. It's a pleasure to have you with us, Dr. Chinmay, and over to you. Thanks, Dr. Gowri, for this kind introduction. At the outset, I would like to thank the entire team of Indian radiologists for having me over this Sunday morning. And I must, MSS, clap for the wonderful work that IR Indian radiologist is doing for education activities. Coming to today's session, it's going to be the Journal Club on Miniscal Ramp Lesions. The article that I'm going to discuss is by Dr. Atul Taneja. There's also a parallel article by Dialen and Grief in the Skeletal Radiology Journal as well. So we'll be discussing these articles simultaneously as we go through the next 45 minutes or so. Coming to an overview of what we are going to talk about is first we'll look at the miniscal anatomy. Then we'll see what a ramp lesion is. What are the signs to identify it on MR? What's the classification that is being currently used? And what is the significance of these that we are spending almost an hour discussing these single miniscal type of miniscal tests? And what are the mimics of ramp lesions? So let's look at this first few examples to see where we stand. This is a quiz question. Please look at it carefully and then answer the poll question that follows. The answer for this will be revealed at the end of the session. So that's the first case. You have to tell me whether there is a miniscal tear in which of the four cases. So that's the first image. First case. This is the second case. And this is the third case and the fourth patient. So which of these four has a ramp lesion? So if you could just launch the poll and let us see the results that we get before beginning the session and we'll come back to it at the end of the session. So which of these four cases has a miniscal tear or a ramp lesion? I'll just scroll through the cases once again. This is case four, case three, case two, and the case one. Yeah, so we can end the poll and share results. Lovely. So we'll get back to what the answer for this question is at the end of the session and understand what the difference the session has made to the knowledge of ramp lesions. So let's move to the anatomy section. So we'll see what is the ramp anatomy or the posterior medial miniscal anatomy first. Now this is the posterior horn of medial meniscus. This is the superior menisco-capsular ligament. The inferior band which attaches the meniscus to tibia is the menisco-tibial band. And this is the, and this green tissue is the posterior menisco junction capsule. So this is the posterior capsule. This red band which attaches the meniscus to the femur is the menisco, superior menisco-capsular ligament. The inferior band which attaches the meniscus to the tibia is the menisco-tibial ligament. This yellow bit is the fat that is interspersed between these capsular ligaments. This is the tibial articular cartilage and this is the tibial plateau, medial tibial plateau. So this is how it looks on MRI. The posterior horn of medial meniscus, medial tibial plateau, the articular cartilage. The band that attaches meniscus to the femur is the superior menisco-capsular ligament. We can see this black structure over here. The band that attaches meniscus to the underlying tibia, this is the menisco-tibial ligament. And the hypointense structure which is attaching the meniscus to the capsule is the menisco-capsular or the posterior menisco-capsular over here. And the white structure, white substance between these menisco-capsular ligaments is the fat. Now this is a PD non-fats at image, the sagittal sections. On the fat suppressor, the fluid sensitive sequences, we can appreciate the menisco-capsular ligament over here. This is the menisco-tibial ligament attaching the meniscus to the underlying tibia. The posterior capsule is hypointense on all sequences and the fat is suppressed between the meniscus and the capsule. The articular cartilage and the posterior menisco-tibial plateau. So that's the anatomy of posterior menisco-medial menisco-capsular junction. Why is this called as a ramp? Because ramp is a slope which connects two surfaces at different levels. And the periphery of the posterior meniscus is thicker than the central edge. And this menisco-capsular ligaments attach it to the femur and menisco-tibial ligament and therefore they kind of form a ramp. Ramp is not an abnormality or a tear, ramp is an anatomical nomenclature. And tears in this location are called as ramp lesions because it's the ramp that forms between the meniscus and the capsule. And any tear that affects this meniscus as well as the capsule is called as a ramp lesion because it's the location of ramp where the tears occur. Now what's the definition of ramp lesions? When do we call it as a ramp meniscal tear? First of all it involves only the meniscus. It's called for the meniscus, posterior meniscus. So they're defined as longitudinal, vertical and or oblique. So they could be longitudinal or oblique. They have to be peripheral. Peripheral means it involves the peripheral red-red zone 1. That's the vascular zone of meniscus. And it should be within 3 millimeters of the menisco-capsular junction as measured on the sagittal sections. It affects the posterior home of meniscus and the medial lateral distance should be less than 2 centimeters. We'll look at these, we can look at the examples for better understanding. So the criteria is it has to be longitudinal or oblique involving the peripheral that is the red-red zone 1. Affecting the posterior home of meniscus with a medial lateral extent of less than 2 centimeters or 2.5 centimeters. Different articles record a different range. So 2 to 2.5 centimeters, which leads to menisco-capsular and menisco-tibial disruption. As per the current understanding and literature, these are called only when there is an ACL tear. If there is no ACL tear, then you do not label it as a ramp lesion. So what are the signs on MRI that helps us identify the ramp menisco tears? The first and foremost is the longitudinal tear with fluid signal intensity between the red-red zone 1 of the posterior home of meniscus and the posterior medial capsule. Either reaching the superior or inferior or both these articulate surfaces. So let's look at this clip to understand how it looks on MRI. So these are the sagittal fat suppress sequence. This is the axial corroborate for the same. And what we see here is the fluid section between the posterior home of meniscus and the capsule. And this fluid signal over here, which traverses between the meniscus and the adjoining capsule that is fluid in intensity is what we call as a ramp tear. This complete disruption of the menisco-capsular interface and this reaching both superior as well as inferior articulate surfaces. It can reach either of the one that is also sufficient to call it as a ramp lesion. So as you see on this video, we are scrolling from medial to lateral. And you can see this discrete cleft between the menisco-capsular junction, which is fluid filled and there is no contiguity between the meniscus and the adjoining capsule. So that's the sign. That's the first sign of identifying a ramp lesion on MRI. Let's look at the next sign. We'll look at the video again. So there's an ACL tear. That means this qualifies for a ramp tear if there's a tear. So on this section, we are at the actual section over here. And on this section, we can see there is irregularity and step off at the superior menisco-capsular interface. If you can appreciate this irregularity and the step off, reaching the superior articulate surface. For a menisco tear, there has to be extension of the tear to either of the articulate surfaces or the free margin. And this qualifies to be a ramp tear because there is peripheral longitudinal tear reaching the superior articulate surface with irregularity and step off over here. So this is also a ramp or a medial meniscus posterior longitudinal tear affecting the zone one with an associated ACL tear with extent of mediolateral. So this is the mediolateral extent of the tear, which is less than 2 to 2.5 centimeters. So this also qualifies as a medial meniscus ramp tear involving the posterior. And that's the clipping. We could scroll across, pull the body section and back and forth. And we can really well appreciate the meniscus tear reaching the superior articulate surface with irregularity at the margins and a step off. So that's the second sign which helps us. And then the rest of the signs for a ramp tear are similar to what we see in an ACL tear like a posterior medial tibial contusion has a high probability to see an underlying meniscus ramp lesion. So whenever what are the signs of ACL tear will apply for a ramp lesion as well. Now, when we have identified that there is a ramp tear, we need to classify that's what all doctors love classifications and classifications. So how do we classify ramp tears and the management is also deferred to some extent on this classification. So Thaunat and grief have given two classifications to classifications to us. The grief classification is more of a modification of the Thaunat one. We can follow it's almost similar. So let's go through each of these subtypes. Let's look at the subtype one first. In this subtype, there is just the menisco-captular ligament tear at the superior margin. So menisco-captular ligament is the one that attaches the posterior of medial meniscus to the underlying femur. And there is just the posterior superior ligament tear without involvement of the meniscus substance as such. So as we scroll through this video, there's an ACL tear. Therefore this qualifies to be called as a ramp tear. That's the first criteria. Then this one over here, as you can trace the menisco-captular ligament, this is the menisco-captular ligament. And as we trace in the subsequent sections, we will be able to see that there is fluid signal and disruption at the menisco-captular junction. So this is what classifies as a ramp tear. Type one. Because there is just the menisco-captular ligament tear at its insertion onto the superior aspect of the posterior horn of medial meniscus. So just the ligament tear is what is called as the type one ramp tear. We could also see it on the actual sections. This is where the tear extends. It is less than 2 to 2.5 centimeters and it is involving, it is reaching the superior articular surface. There is an ACL tear. It's a longitudinal type of tear and it involves just the attachment of the menisco-captular ligament onto the posterior horn of medial meniscus. So that's the first type of the type one ramp tear. That's menisco-captular ligament separation. So let's look at the next type. In type two, the superior, that's a menisco-captular ligament, it rips off a part of the meniscal tissue as well. So that is when we call it as a type two tear. If you see this graphic, the menisco-captular ligament is attached to the small piece of menisco tissue of the posterior horn, which is ripped off and the tear reaches the superior articular surface. So when you see such a kind of a tear, it is called as a type two ramp tear in which there is a partial superior posterior part of the medial meniscus that is ripped off along with the ligament. So let's look at this example. So as we scroll through the sagittal sections, we can appreciate that there is a discrete fluid signal at the interface between the capsule and the meniscus. And this small chunk of meniscal tissue is ripped off from the adjoining meniscus as well. So you can see in this section, there is this meniscal tissue contrary to the previous type in which there is a capsular tear. In this, there is a part of meniscus that comes along with the capsule and then this qualifies as a ramp type two tear because it has pulled out a part of the meniscus as well along with the menisco-captular ligament. So the strength or the force magnitude is higher, which kind of helps in pulling out the meniscal tissue as well along with the menisco-captular ligament. This reaches only the superior articular surface and not the inferior articular surface, which is pristine and normal. So this is a type two ramp tear. We can correlate on the actual sections as well over here. On the actual sections, this is where the tear is and it extends for less than 2 to 2.5 centimeters in this medial lateral dimension. So this qualifies to be a classical ramp type two tear. We can see a part of the meniscal tissue that's pulled along with the superior menisco-captular ligament. So the first type is just tearing of the menisco-captular ligament. Type two is when there is a part of meniscus that is attached to the menisco-captular ligament. Then let's look at the third type. In the third type, we move to the inferior aspect now. So in the third type, the inferior aspect wherein there is attachment of the menisco-tibial ligament. So a part of the meniscal tissue is attached to the menisco-tibial ligament and it kind of pulls away that meniscus part or the inferior meniscal segment. And this is what is called as a type three meniscal tear, type three ramp tear. So let's look at this example. And in this section, we can clearly see that there is a discrete longitudinal tear reaching the inferior articular surface, not reaching the superior articular surface at the attachment of the menisco-tibial ligament. This tear is within three millimeters of the menisco-captular junction and it extends mediolaterally for less than 2.5 or 2.5 centimeters. So that qualifies as a ramp tear with an ACL injury as well. So this is a classical example where there is just the inferior section, the tear reaches as the inferior articular surface. There is this medial meniscal contusion as well. And this is a classical example of a ramp type three tear where it reaches just the inferior articular surface where the menisco-tibial ligament is attached. So this is essentially a longitudinal tear involving the peripheral red zone one extending for a less than 2.5 centimeter of medial lateral length and within the three centimeters criteria as well. Reaching only the inferior articular surface doesn't communicate with the superior articular surface and you can see the menisco-captular ligament appears intact over here. Whereas the menisco-tibial ligament is attached to this ribbed off peripheral meniscal fragment. So this is a type three ramp tear where in the menisco-tibial ligament attachment is where the tear lies. That's type three. Let's look at type four now. So in type four tear, the tear extends along the entire extent of the meniscal tissue. That's superior as well as inferior. It could be involving a part of the meniscus or just at the menisco-captular junction irrespective of which part it is when it reaches the superior as well as the inferior articular surface. That is it involves the entire thickness of the posterior horn of medial meniscus in the zone one. Then it is called as a ramp type four tear. Let's look at this example. In this, we can see that there is a continuous fluid signal. That is what is necessary for the tear reaching both the superior as well as inferior articular surfaces. That's the superior articular surface. This is the inferior articular surface. It involves the zone one and the zone zero. That's the menisco-captular zone traverses for less than 2.5 centimeters within three millimeters of the menisco-captular surface and reaching both the superior as well as the inferior articular surfaces. Reaching both the superior as well as inferior articular surfaces. This is a classical example of a ramp type four tear wherein we see a full thickness. That's the entire thickness of the meniscal tissue in the posterior horn segment is involved with the tear. It reaches both the superior as well as the inferior articular surfaces and there is a through and through like a longitudinal transaction involving the zone one or the zone zero. That's type four tear. This is how it looks on the actual sections and we can correlate for the extent on the actual section as well. So that's type four menial ramp tear. Let's look at the next example. That's the ramp type five tear in which there is longitudinal tear which has two ramifications like there are double longitudinal tears involving the zone one. So within three millimeters of the menisco-captular junction there are two discrete longitudinal tears reaching both superior and inferior articular surfaces. So there is like a double longitudinal tear. The tear is your and the tear extends in the posterior section as well. So let's look at this example and understand how does that type five ram tear look like. So this is a PD non-FATSAT sequence on the sagittal sections. What we appreciate over here on these sections is there is a discrete double longitudinal tear traversing the peripheral zone one that is the first longitudinal tear going through the entire thickness of the meniscus. And this is the second longitudinal tear which again traverses the entire thickness of the posterior horn of meniscus. So when it reaches the superior and inferior articular surfaces with two parallel longitudinal tears within three millimeters of the menisco-captular junction and extends for less than 2.5 or two centimeters on the medial lateral scale, then we call it as a ramp type five tear. Of course it has to be accompanied with an ACL injury and we can appreciate this double longitudinal appearance on the actual sections as well. So this is a classical example of a ramp type five tear wherein we see two discrete longitudinal tears. As we saw on this video clip, there are two discrete longitudinal tears traversing the entire thickness of the posterior horn of middle meniscus within three millimeters and involving less than 2.5 centimeters on the medial lateral aspect. So that's a classical example of a ramp type five tear. Summarizing the five tears, first tear type one in which we saw just the superior menisco-captular junction injury, menisco-captular injury, then there was a menisco-captular injury with a part of the medial meniscus. The type three was involving the inferior aspect. Type four is single longitudinal tear through the entire thickness of the medial meniscus. And type five is when there are two longitudinal tears involving the peripheral red-red zone one. So these are types that's the classification that we use in daily practice. The arthroscopis also follow this classification for the surgical management. Now, coming to what's the significance of these tears and why are we breaking our head on this is what we have to look at. Because it's a single longitudinal type of tear that we're spending almost an hour on it. And why is this significant? Because they are under-diagnosed. And if not repaired, then it can lead to consequences. That's graft failure and meniscal tear. Now, this is important because these tears are not visualized during routine arthroscopies because they use the antrometal and the antrolateral portal. Whereas these tears are located in the posterior medial section. So unless they use specific portals in the posterior medial compartment or they do specific maneuvers, there are high chances that these might be missed when they do a routine arthroscopy for an ACL tear. So that is why we need to pre-operatively give them a clue that there could be a ram tear. You go ahead and do a posterior portal or do specific maneuvers to check arthroscopically whether there is a tear or not. Nowadays, most senior arthroscopists perform certain maneuvers to make sure that these are not missed. But we have to give them a clue that there are chances of a ram collision on the MRI, looking at the MRI. The incidence of ram tears is almost close to 40% of all ACL injuries and the MRI sensitivity is close to 50% by routine radiologist. By musculoskeletal experience radiologist reaches 60 to 70%, but still we are missing out on 30% of the cases. If the arthroscopist doesn't pick up or even we miss on MRI and he also doesn't look at it, then it may lead to ACL graft failure or meniscal repair failure. And if this proceeds or progresses, then it leads to cartilage damage and like an accelerated osteoarthrosis in the medial compartment. So that is why we are spending almost an hour today, Sunday morning, discussing ramp lesions because they are crucial. They are difficult to pick up and not only for us, but also for the arthroscopic surgeons. So it's important if we can give them a clue beforehand. Now, what are the mimics or what are the meniscal lesions that we often confuse with a ram lesion? Like how do we differentiate a ram tear from a routine longitudinal signal in the peripheral zone 1 or menisocarpital junction? So let's look at a few of these mimics. We'll use the pole function also over here to see how much we have understood in the past in the last 30 minutes or so. So I'll play the first clip and if Gauri can launch the pole after that, it would be great. So this is the first case. That's the video clip. Please tell me if you think there is a ram lesion or not. Is this a ram medial meniscus tear or no? Now there are just two options. Is this one or two? Please don't answer number four. So is this a ram tear or not? Okay, we can end the poll. I'm glad that almost close to 60% have got this, right? And that's the sensitivity of MRI for ram lesions. So this is not a ram lesion because the first criteria that the ACL should be done is not met. That is the most basic. That's the fundamental reason or the fundamental thing that we need to understand before we call it as a ram lesion. The ACL is intact in this case. Therefore this cannot be a ram lesion. The second thing is there is no tear. The ligaments are intact and there is no fluid cleft that traverses through the ligaments. What we see here are the medial meniscus, sorry. What we see here are the medial meniscus reces superiorly and the inferiorly, which are sometimes fluid filled whenever there is joint effusion and extensive distension of the joint cavity. So these recesses can mimic a ram lesion. We can exclude them when we see an intact ACL. And the second thing is if there's an ACL tear, then we would be able to see the continuity of the meniscocapsular and the menisco tibial ligaments. So these ligaments are pretty much intact. So this fluid intensity is actually a recess or a pocket, which we often see in this location. So do not call these as ram tears. Even if there's an ACL tear, these are recesses. So you need to identify the ligaments, the superior and the inferior, that's a menisco tibial and the meniscocapsular ligaments. There is no tear of these ligaments. And these fluid recesses are sometimes can very closely mimic a ram lesion. So even if this is an ACL is intact, so that's not a question, but even if the ACL is torn, be careful when you see fluid in this recesses. Let's move to the second case. Again, if you can launch the poll, I'll play the video. Oh, no, there's no video for this. There's just two images. That's image one, the same patient. Image one, that's a fluid sensitive sagittal and the coronal sequence. Is this a ram lesion or no? Okay, we'll end the poll here. And a few of them got this correct, contrary to the previous one. So why this is again not an ACL, not a ram lesion is because there is the horizontal tear. If you can see on the sagittal and the coronal images, this is not a longitudinal tear. This is not an oblique tear. There's a discrete horizontal tear. And therefore we would not call this as a ram lesion. If you remember the definition, of course, the ACL tear is the first criteria. But the second is longitudinal tears involving the zone one and reaching either of the articulate surfaces and extending medial at least for less than 2 or 2.5 centimeters. This is not a longitudinal tear. This is a very well made out horizontal tear. And therefore you would not call this as a ram lesion. With an ACL tear, any middle meniscus tear is not a ram lesion. It has to be fit into that criteria that I mentioned earlier. And this is a discrete horizontal tear which doesn't have a longitudinal ramification going through the peripheral zone one. So this is again not a ram tear and a close mimic of it. Let's look at the third case. This has a video clip. Can we have the poll once the clip is played? So these are sagittal fluid sensitive sequence. That's the actual sections as we scroll through it. And is this a ram lesion or no? Can we launch the poll please? Yes, we'll end the poll in like 5 seconds. Great. So close to 70% have got this right. This is not a ram lesion. And the reason is that there is a longitudinal tear. There is an ACL tear, but still it is not a ram lesion because it traverses the red-white zone 2 and not the zone 1. So as per definition I would reiterate it has to be longitudinal tear with an ACL injury going through the zone 1 and extending for 2.5 centimeters. So this involves the zone 2. This distance is almost close to 7 millimeters. And therefore this again doesn't qualify to be called as a ram lesion. And it's again a mimic because this is a longitudinal tear and not a horizontal one. That is an ACL injury. But because it doesn't go through the peripheral zone 1, this will not call it as a ram lesion. And the reason being this is not a highly vascular zone and the potential for healing after repair is limited as compared to when the tear is in the peripheral zone 1. And therefore there is the significance of why we give importance to ram lesions whereas these zone 2 tears or zone 3 tears have poor healing even post repair. So let's look at the next case. Is this again a ram lesion or no? Can we launch the poll please? So let's go to the case. We can end the poll here. So this was a tricky one. I agree that a larger percent of them have got it wrong. And the reason is that this is a longitudinal tear with an ACL injury through the peripheral zone 1 as well. However, why this is not a ram tear is because this medialateral extent is for more than 2.5 centimeters. Now, if you go to the static image, this is a bucket handle tear. There's a big flap over here. And the tear extends from the body, almost from the mid body or the anterior as anterior body junction till the posterior hand root junction posteriorly. So the extent of the longitudinal tear is close to 4.4 centimeters. And as per the definition, it is 2 or 2.5 centimeters is the limit. And why this is so? Because the ram zone or the ram region, that's the miniscule capsular zone or the junction is only for 2 centimeters or 2.5 centimeters. And when the tear extends beyond it, we do not classify it as a ram tear. So that's the fourth criteria where we need to agree to or there should be these four criteria for it to classify as a ram region or which of these type of ram region it is. But unless these four criteria are met, we cannot label the miniscule tear as a ram tear. So in this, the tear extends for close to 4 centimeters. The medialateral dimension is more than 2.5 centimeters. And therefore, this does not again classify as a ram tear. It's a bucket-handled tear with a large flap in the internal condom and notch. And the longitudinal tear has traversed almost the anterior body, the body and the posterior as well as the posterior root junction. So this again doesn't qualify or signify to be a ram tear. So that's the summary of the mimics that when can we label a medial miniscule longitudinal tear or medial miniscule tear as a ram region. First, ACL tear should be present. There should be longitudinal tears and not a horizontal tear. It could be oblique or longitudinal. That's a vertical tear. It should extend through the zone 0 or and zone 1. And that's within 3 millimeters of the miniscule absolute junction, that is zone 1. The medial lateral extent of the tear should be less than 2 to 2.5 centimeters. So this is what I've emphasized repeatedly in the last 45 minutes that when these four criteria are met, that is when we call it as a ram region, then we can offer the state whether it is type 1, type 2, type 3, type 4, type 5. That's secondary first and foremost we need to classify whether this is a ram or not. Once we have done that, then we can subclassify into whichever type it fits into. So let's look at a few more examples. This is a fifth case. If you can launch the poll now after the video is over, whether this is a ram region or not. Is this a ram tear or not a ram tear? Great. So we can end the poll here. I'm glad that now we are reaching close to 80 percent sensitivity. 80 percent of you have got this correct. And this is actually a ram region. And finally, we have given an example of a ram region. Why do we call this as a ram region? Because it fulfills all the criteria. There is an ACL tear here. And as we scroll through, there is a discrete longitudinal tear reaching the superior as well as the inferior articular surfaces. In this section, we can very well appreciate the fluid signal going the superior as well as the inferior articular surface. It involves the zone 0 and the zone 1 within 3 millimeters. And the tear involves less than 2.5 centimeters on the media lateral dimension. So it fulfills all the criteria. This is a ram type 4 tear maybe. But first and foremost, we need to say that whether this is a ram region or not. And this does fulfill all the four criteria that we discussed earlier. And this is actually a ram region. And I'm glad that 80 percent of you got this correct. So that's the tear as shown. It does traverse the peripheral zone 1 and the zone 0. And there's an ACL tear accompanying it. It's a longitudinal tear. So that's a ram type 4 tear. Now let's look at the next example. Again, we'll launch the poll after the video has played. So yes, there is an ACL tear with the limited salary of six sections. I give this to you as an ACL tear. Now, whether this fits into a ram tear or not is what you have to answer. Great. So let's end the poll here. A good number of you have got this. It's more than half of you have got this correct. This is actually a ram region. There's a ram type 3 tear and there is an ACL tear. So that's the first criteria. There is a discrete longitudinal tear that involves the. I'm sorry. So there is a discrete longitudinal tear that involves the peripheral red-red zone 1. It reaches the infill articular surface and is within the 3 millimeter within the 3 millimeter range as well. So that's less than 3 millimeters. I've gone to the next case. So this tear over here is within the 3 millimeter criteria. It extends to the infill articular surface. It is involving the zone 1. It is longitudinal in morphology and there is an ACL tear. So it does fulfill almost all, not almost, it does fulfill all the criteria for a ram pollution. We can then subclassify it into type 3 because it reaches the infill articular surface and not the superior articular surface. A few of them who got it wrong might have thought that this is more than 3 millimeters, but it is just as a brink of 3 millimeter for zone 1 part. So this we would classify it as a ram type 3 tear, reaching the infill articular surface with an ACL injury. Now coming to the quiz question we began with. So which of these 4 cases is an ACL tear, is a ram tear? I'll just scroll through these individual slides again and you can answer or start the poll at the last slide. So which of these 4 cases is a ram tear? That's case 1. This is case 2, case 3 and this is case 4. So which of these 4 is a ram pollution? So which of these 4 is a ram pollution? I'll just go through the cases again as you guys answer it. So that's case 1, the case 2, case 3 and case 4. Yes, that's fantastic. So we can share the results close to 65% have got this correct. And the answer for that was case 4, where in this discrete longitudinal tear, which goes through and through the zone 0 of the posterior bone of middle meniscus with an ACL tear. So it does fulfill all the criteria of a ram tear and this is a classical example of a type 4 ram pollution. The previous ones were the type 3 is a horizontal tear. This case 3 has a horizontal tear. Case 2 has an oblique tear, which is more than 3 millimeters from the menisco capsule junction and case 1 doesn't have an ACL tear at all. So case 1, case 2, case 3 were not ram pollution. Case 4 was a classical example of ram pollution, where in this fluid signal and more than 65% of you got it correct. Of those who answered got it correct. And I'm glad that we have improved the sensitivity of reading ram pollution over the past 45 to 50 minutes. And I hope this replicates in the day-to-day reporting as well. Just summarizing, these are the references. This is the main article, which we discussed today. There's one in skeletal radiology as well, where you can read dialen and griff. And you can read these two as well. I'm happy to answer any questions. I hope this was worth spending your Sunday morning and the understanding of ram pollution has improved after the session. Thank you Dr. Chinmay for taking this topic today. The entire purpose of the journal club is that we take these kinds of topic and we discuss them in details because it's difficult in conferences and lectures to have this much detailed discussion on one single topic, which are really confusing. So thank you once again. There are questions which are there in the Q&A. So one of them is from where should we measure the ram as three millimeters zone as posterior ton of meniscus is posteriorly displaced. Yeah, I'll just share my... Yeah, you are on mute Dr. Chinmay. Yeah, so the measurement is from the menisco-capsular junction that's the zone zero is where we measure the tear from. So for example, let's come to this case. Yes, in this case, this is where the zone zero is. This is where the menisco-capsular junction is. So you measure it from this, even if this horn is displaced posteriorly, the menisco-capsular junction will not displace posteriorly because it will be attached to it unless there is a longitudinal tear separating the two. The menisco-capsular junction will also be displaced posteriorly. So you measure it from that junction for three millimeters. It's not a three millimeters like a... You don't measure it with a scale or your measurement tools every time. It's more of eyeballing and it goes on the logic that this posterior horn of meniscus is divided into three equal segments. So on a ballpark figure, on an average, this length is around 11 millimeters. That's the width of the posterior horn of meniscus, which is the widest that the meniscus is. So this is 11 millimeters. And when you divide it into three equal sections, beginning from the menisco-capsular junction, the first outer one is three millimeters, then zone two is three millimeters, and zone three is the rest of two or two three millimeters. So that is how they're divided arbitrarily into zone one, zone two, and zone three. And three millimeters, if it is 3.3 millimeters, then you can obviously call it as a ramp lesion again, because you're not gonna not use that term just because of the 0.3 millimeters that is there. So we can understand how menisculable 0.3 would matter. And at the end of it, why are we labeling this as ramp lesion so that the arthroscopist knows that he has to search for them in the surgery. That's the whole point of labeling these or giving an awareness that there could be a posterior horn meniscus there so that he does probe the meniscus using portal, whichever technique he wants to, and he doesn't miss out on repairing these. That's the whole point of giving these or significance as well. So don't sit with a ruler and tell me that it's 3.3 millimeters, or should I call it as a ramp or shouldn't call it as a ramp? Why we say this is because the vascular zone extends close to the outer one-third of the meniscus. So that outer one-third is then arbitrarily divided or given a figure of three millimeters. So that's what it is. The next question is, if only miniscule T-bill ligament is strong, yes, that's a good question. So the type three is further subclassified as 3a and 3b by the Dylan-Griff classification, which does mention only miniscule T-bill ligament there as 3b and the miniscule inferior fragment, if the stair is like this, then it's a 3a. And if the ligament only is strong, then it's 3b. But it's sometimes difficult to identify the miniscule T-bill ligament well, and it might get confusing. So I didn't further classify as 3a, 3b, 4a, 4b and then 5. If you can, as long as you understand that when the stair is inferior or the miniscule T-bill ligament is strong, that's the inferior section is involved, then it is type three. If it's superior, then it's one or two. If it's through and through, then it's four. And if it's double longitudinal through and through or the entire thickness, then it's type five. The third question is, how to differentiate paraminiscule cyst from peripheral stair in case three? A paraminiscule cyst and a tear would be separate. I mean, cyst is a fluid-filled cystic lesion, whereas a tear is through the miniscule substance. So whatever the extra miniscule part of it is, let me just get to the third case. I think this is the third case. So this is a horizontal tear. So this is a horizontal tear. This is a cyst in the superior miniscule capsular and the posterior miniscule resist, and the tear is over here. So this was not, like a tear is usually either a longitudinal, that's a thin stream, or a horizontal one, which a thin fluid signal. When it gets more bulbous and globose, then it looks like a cyst. So this is not like a tear. This is like a paraminiscule cyst and a horizontal tear over here. Yeah, that's all. Just three questions and I'm happy that either I could make everyone understand or it just went over their heads. That's where the lack of questions. I'll show the references once again and end the session over here. Thank you for taking those questions as well, and I'm sure that people are going to take advantage of this being on the YouTube channel of Indian Radiologists, so that they can revise it as many as time they want to. That usually happens with the Journal Club. So we have almost over 2,000 viewership for these clubs in the YouTube platform rather than live. So that is where we revise everything. Yeah, thanks a lot. And as all YouTubers go, like, share and subscribe, I guess. I've also shared the links for the upcoming masterclass events as well as the teaching courses like MRI teaching course, CT bus, Sonobus in the chat box. Take those links from there and also register for all our upcoming courses. So this was today's Journal Club session on Miniscal Ramp Lesions by Dr. Chinmay Mehta. And with all the details into it, thank you all for joining us today and do visit our YouTube channel to get the details about the upcoming courses as well as this particular Journal Club session. Thank you all and see you all in the next masterclass event.