Indications of MRI

 Occult fracture
 Marrow abnormality
 Ligament pathology
 Tendon pathology
 Muscular injury
 Infection
 Bone and soft tissue tumor
Meniscal Tear
MRI APPEARANCE
■ ANTERIOR & POSTERIOR HORNS
– Best demonstrated on sagittal view
■ BODY of meniscus
– Best seen on coronal images
Meniscal Tear
Imaging Criteria:
1. Presence of linear signal intensity weather reaching superior or inferior
articular surface or not
2. Abnormal meniscal morphology
3. Complete absence of any meniscal structure.
Meniscal Tear
Grade:
 Grade 1- Globular signal within the meniscus
 Grade 2- Linear signal within the meniscus not reaching the articular surface
 Grade 3- Linear signal within the meniscus reaching the articular surface
Grade I
Grade II
Grade III
Radial tear- Tear perpendicular to free edge of meniscus
Longitudinal tear
 Bucket Handle Tear

 Longitudinal tear along the

length of the meniscus and the
inner rim flips into the
intercondylar notch while
remaining attached to the
anterior and posterior horns.
 Bucket-handle tears
■ There are four traditional findings for bucket-handle tears:
1- Fragment in the intercondylar notch
2- Flipped meniscus sign
3- Double posterior cruciate ligament sign
4- Absent bow tie sign
Fragment in the intercondylar notch
Anterior flipped horn
Flipped meniscus sign
Double posterior cruciate ligament sign

■ Double-PCL sign -The flipped

fragment lies inferior and
anterior to the PCL
Absent bow tie sign
Bucket handle tear lat.M
Meniscal cyst
■ Joint fluid is expressed into adjacent soft
tissue through the tear.
■ Mostly occur in medial compartment.
■ Most common associated tear is horizontal
cleavage tear.
Meniscal cyst
Discoid Meniscus
■ A discoid meniscus refers to a meniscus, almost always the lateral one, that is not C-
shaped but disk like.
■ it covers most of the tibia plateau to varying degrees rather than just its periphery.
■ is usually seen in children and adolescents, in whom it may be asymptomatic and noted
incidentally.
■ It is prone to tearing.
■ The prevalence of discoid lateral meniscus (1.5%-15.5%) is greater than that of discoid
medial meniscus
■ High-resolution coronal images allow better depiction of this enlarged meniscus.
Normal lateral meniscus Discoid lateral meniscus
Complete discoid meniscus
Menisco capsular separation
■ Fluid signal between posterior
portion of medial meniscus and
joint capsule
Meniscal ossicle
 Anterior Cruciate Ligament

■ ACL extends from its semicircular attachment at

the lateral femoral condyle to the anterior
intercondylar region of the tibia.
■ The tibia attachment is larger than the femoral
and fanlike in shape.
■ Straight, parallel to Blumensaat΄s line
■ Linear striated appearance with intermediate
signal intensity on T2 weighed image.
 MRI Appearance
■ ACL is best seen on sagittal
oblique images with slices
parallel to the cortex of the
lateral femoral condyle.
■ ACL may appear as a solid low-
signal-intensity band.
Coronal image

■ ACL as a fanlike structure

adjacent to the horizontal
segment of the PCL near the
medial surface of the lateral
femoral condyle.
■ Proximally, the signal intensity
is uniformly low, whereas
distally it may be slightly
increased.
 ACL Tear
 Acute-
 Replacement of normal striated appearance by cloud like high signal intensity
 Discontinuity of ligament and fibers don’t go parallel to intercondylar roof
 Chronic-
 Non visualization of ligament or Angulation of ligament because of scarring
 Shallow orientation not parallel to intercondylar roof
Normal Acute tear
Discontinuous fibers non visible fibers
Chronic tear
 Empty notch sign

Seen in complete ACL tear

ACL cystic mucoid degeneration
 Ligaments appear thickened and ill
defined with a "celery stalk" appearance
 MRI- Increased signal on all sequences
 Mimic ACL tear
Deep lateral femoral notch sign

 Indicator of chronic ACL insufficiency but

may also be seen in acute tear
Associated injuries with ACL

 O'Donoghue triad-
 ACL rupture
 MCL injury
 Medial meniscal tear
O'Donoghue triad
Segond Fracture
 Other bony injuries with ACL tear
 Bruise in weight bearing portion of
lateral femoral condyle and posterior
aspect of lateral tibia plateau due to
internal rotation of tibia and valgus
angulation of knee
Uncovered Meniscus sign
Uncovered Meniscus sign
Posterior Cruciate Ligament
■ The PCL arises at the lateral surface of the medial femoral condyle and extends to the
posterior surface of the intercondylar region below the level of articular surface of tibia.
■ It is wider and thicker than the ACL.
■ Sagittal images best show the PCL; it appears as a uniformly low-signal-intensity
structure and arcuate in shape in routine MR imaging
Posterior Cruciate Ligament

 Normal:
Uniform low signal intensity on all
MR sequences
Axial section Sagittal section
MRI Findings of PCL tear
■ Increased signal due to hemorrhage and edema
■ Diffuse enlargement of PCL
■ Tear:
Generalized thickening of ligament
with intermediate signal intensity on
T1 weighed sequence and
heterogeneous high signal intensity
on T2 weighed sequence
Medial Collateral Ligament

■ Proton density coronal image shows the

normal medial collateral ligament as a thin,
taut, well-defined, low-signal structure
extending from the medial femoral
epicondyle to the medial tibial metaphysis.
Medial Collateral Ligament injury
 Grade I- Mild partial interstitial tear ,appears as edema along superficial aspect
 Grade II- Extensive interstitial partial tear ,appears as thickening of ligament with internal
signal abnormality or frank thinning due to extensive partial tear
 Grade III- Complete rupture of ligament
Collateral ligaments
■ Grading system
– Grade I : microscopic tear
– Grade II :partial tear
– Grade III : complete tear
MCL injury
■ Grade I : Edema & hemorrhage superficial to ligament.
■ Grade II : Displacement of ligament fibers from bone.
■ Grade III : Complete ligament discontinuity.
■ Grade I medial collateral ligament
tear with surrounding edema
(straight arrows) on a T2WI
■ Note the normal thickness and signal
of the medial collateral ligament and
continued close apposition to the
femoral and tibial cortices.
Grade I Grade II Grade III
Lateral Collateral Ligament tear