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Okay.

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So today,

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we're going to start out with bucket handle tears.

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We're into the menisci once more,

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and I would encourage you to go back and look at

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our first two forays into the meniscai to

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learn a little bit more about anatomy.

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But we're going to drill a little bit deeper today

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into the concept of bucket handle tears.

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So let me draw my meniscus,

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and I will try,

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do my best to make it somewhat three dimensional.

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And we've said in the past that bucket handle

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tears usually begin as vertical,

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longitudinal tears. They're often in the middle,

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and usually these vertical,

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longitudinal tears in the middle don't persist

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as simply vertical tears. They do progress.

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And I've had innumerable instances,

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especially of professional athletes,

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that chronically complain of pain and kind

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of a vague sensation of clicking the.

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Mr. Is absolutely normal.

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And then when you go back in retrospect,

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you can see a quarter of a millimeter line through

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the center of the meniscus that was barely

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visible. That, even in retrospect, is hard to see.

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And that was the initiation of what eventually

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became a meniscus that split into two parts,

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a so called bucket handle tear.

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So there's kind of a pre bucket type

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pain syndrome that may occur.

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Now,

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these vertical tears will start to widen and gap,

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and they'll get a little bigger and a

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little bigger and a little wider,

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such that this portion of the meniscus starts to

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migrate inwards in the typical

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classic bucket handle tear.

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So you get something that looks

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a little bit like this

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with a big hole in the center.

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Now,

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if you were to perform a coronal slice through

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here such as this, what might you see?

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You would see a truncated portion of the meniscus

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that looks like it's chopped right there,

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and it's going to have a specific

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rim to it or width to it.

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And that's important because they're

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going to have to sew one piece,

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namely this inside piece right here,

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which looks something like this,

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back to it.

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So if you have a very thin rim out here,

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it's nice to know what you're sewing to.

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You also want to know if this rim has a

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horizontal tear in it, which it may,

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which decreases the likelihood that you can

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sew Humpty Dumpty back together again.

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Now, what's going to be in here?

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Blood, inflammatory tissue, a little bit of fluid,

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but this configuration is going to persist

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slice after slice after slice.

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You're going to see it here,

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you're going to see it here.

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You're going to see it here,

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and then all of a sudden it's going to go away.

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The meniscus is going to come back together again

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unless the bucket handle tear goes

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all the way out the front.

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So the bucket handle tear could do this,

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and even this piece can start to sort

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of migrate in. Let's erase.

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Let's get our eraser up here a little bit.

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Erase that piece. And now you've got this big,

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huge fragment all the way in the front,

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but not quite all the way to the back.

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So the separation will persist all the way in the

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front and continue on as you go back with a series

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of coronal slices until you get

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all the way into the back.

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Now,

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there could be what we call

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the free fragment bucket.

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I've just illustrated for you one that extends all

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the way anterior, the so called anterior bucket.

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I showed you initially the classic bucket,

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the one in the center.

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But let's take the situation where

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we have the free fragment bucket.

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So here we've got the outer rim,

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and then here we've got a piece right here,

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and they're not attached to each other anymore.

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They're kind of squished down

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by the femur and the tibia.

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So then you're going to get something where

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you have a truncated meniscus in the back.

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Let's change colors, actually,

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a truncated meniscus in the back because

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this was attached back here,

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maybe another area of truncation.

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And then continued separation of two fragments

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all the way from front to back,

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so you never see these two fragments

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join ever again.

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And it's even possible for this piece,

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which I will use my little

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light blue drawing here.

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It's even possible for this piece to go all the

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way back and for you to have two pieces in the

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coronal plane like this on every single Slice.

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That's what I call a coast to coast,

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or a complete anterior to posterior bucket

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handle tear with a free fragment.

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All right,

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so now let's erase and start with a clean slate

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and show you a few other configurations

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of buckets.

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So let's assume we have a bucket handle tear with

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a big hole. It started out as a vertical tear.

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Here's our hole.

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And now this piece,

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which is still attached by a little

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twig here in the back,

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kind of migrates forward and it can dip

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right underneath the anterior horn,

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in which case, when you perform a sagittal view,

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it may look like you have a piece of meniscus here

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and a piece of meniscus right behind it.

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In fact, it may bolster up right underneath it.

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So you have these two meniscoid looking

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structures. You do a sagittal,

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and you've got a double meniscus sign.

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Or this could happen.

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You could have the same thing,

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a big hole in the middle, pardon my squeaking,

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a huge tear. And then this time,

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our piece kind of wanders in

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front of the anterior horn

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and looks something like this.

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Again, another double meniscus sign.

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If we do a sagittal,

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you'll see two meniscal looking structures.

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And to make matters more complex,

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you might have a transverse ligament

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lurking here anteriorly.

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So you might have a little round structure and

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a triangulated structure or some deformed

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triangulated structure and

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another one behind that.

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And then you might even have another little

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rim before you run into this hole.

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So it can get rather complex.

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You can have two, three,

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and even four areas of hypointensity

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in the anterior aspect of the knee.

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Now, do buckets ever do the opposite?

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Do they ever go backwards posteriorly?

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Not very commonly.

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Most of the time they do migrate anteriorly,

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but they can twist.

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So if this thing's pretty narrow,

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you can get a pedicle.

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And the bucket handle tear can

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actually turn on itself,

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which makes things rather complex.

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Now, this piece of the bucket right here,

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which I've colored in green,

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that's the part that you're going to see on a sag.

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Let's make our sagittal view nice and blue.

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Our sagittal slice goes through it.

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And you're going to see a bow tie looking or

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rectangular structure in one

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of these central slices.

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And that structure may sit right underneath

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the arcing posterior cruciate ligament.

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That's going right over top of it,

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creating the double pcl sign

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of a bucket handle tear.