0:00

What I have in my notes was injury a week or two ago,

0:05

felt a pop. So going real quickly on our, uh,

0:10

localizers, okay? Nothing too much, no tumors. Okay.

0:16

Um, marrow looks pretty good. Okay, so rolling right through.

0:21

So right on the first cut,

0:22

we see that we have what's called what's been termed written in the lit as the

0:26

double PCL sign. Okay?

0:29

So what we're gonna look for is that medial meniscal tear, okay?

0:32

And for most of bone radiology, and especially for Mr, what I harp on the,

0:37

my trainings here at UCSD is to call anything torn.

0:42

It's morphology and signal. Okay? And here, obviously the morphology,

0:46

the triangular appearance of not, of, of both the,

0:50

the posterior and to scent,

0:52

the anterior horns of the medial meniscus is abnormal.

0:56

We also have abnormal signal, more so cut, uh,

1:01

involving the superior surface and inner margin of that posterior horn looking,

1:06

pulling up the coronal. Okay? We see a diminish body, okay?

1:11

But we also see that displaced, uh, uh,

1:14

inner rim of meniscal tissue. And that medial, uh,

1:19

or inner rim of displaced meniscal tissue is sort of degenerated and may be

1:24

partially torn as well. Okay? So the teaching points here,

1:29

you should not see three structures within the interocular notch.

1:34

If you see something beyond the ACL and PCL,

1:37

you gotta think of this along with other things such as focal synovitis,

1:42

maybe arthrofibrosis or maybe even a body. Other things,

1:46

rare things to think about. Maybe a prominent, uh, meniscal,

1:50

meniscal ligament. Okay? Either oblique, usually, okay,

1:54

as I mentioned earlier, right? And, uh,

1:57

maybe some crystal deposition disease or something like that.

2:00

But then you're getting, uh, more rare.

2:03

The meniscus is typically okay, depending on who you read. The,

2:07

the medial meniscus typically larger, but typically about, I don't know, uh,

2:12

12 millimeters ish,

2:14

15 millimeters in central peripheral width. Okay?

2:19

Why is that important? If you read the literature, okay,

2:23

and it's been shown in JBJS and other, uh, orthopedic literature,

2:27

the peripheral zone, the peripheral one-third is, uh,

2:32

called the red zone because that's where the capillary, uh, uh,

2:36

network innervates or comes into the meniscus, supplying the meniscus.

2:41

And the inner two-thirds is considered the white zone. Why is this important?

2:45

Because when you have tears in the red zone,

2:47

those are the ones that are gonna be, uh, easier to repair.

2:51

They have vascularity,

2:53

so they usually are going to heal and take better after surgery.

2:57

The white zone tears, that is the inner two thirds,

3:00

those are the ones that are typically gonna be more, uh,

3:03

typically be debrided because don't he, those don't heal as well.

3:08

So what, what we read bucket handle tears, meniscal tears. We tell,

3:13

we try to tell our surgeons, or our surgeons like to know where the failure is,

3:17

whether it's a red white tear, a red red tear,

3:22

or a white white tear. That is,

3:24

so they know what to have on their surgical trade to go in. So they, they,

3:29

they can prognostically or negotiate with the patient

3:34

pre-op to say, Hey, this is what I expect to see,

3:38

and this is what we are gonna be ready to do based on the MRI findings.

3:42

So if it's a red white tear or a red red tear, our surgeons like to know that.

3:47

So then they'll go in with tax, what have you, ready to do, the suturing,

3:52

to put the labrum, or, sorry, not the labrum, the menisci back together,

3:56

what have you. So that's something to be aware of,

3:59

not just to call bucket handle tear.

4:01

Some of your surgeons may want to know where the failure is within the red or

4:06

white zones or there in between. If you're not sure.

4:10

Sometimes it's hard and it's degenerated like this.

4:13

I'll measure what the inner and outer RI of, uh, uh,

4:17

meniscal tissue measures. And from that, the surgeon,

4:20

I let the surgeon decide how to go about that as well. Okay?

4:25

So that's, uh, a nice, um, a nice case. Uh,

4:28

classic case of a bucket handle tear. Now, um, this is considered,

4:33

uh, unstable meniscal lesion or meniscal tear.

4:37

Other you could think of, right? Meniscal tears as three main flavors, right?

4:42

The radial tears, which disrupt the hoop strength, the horizontal tear,

4:47

okay? Right? And then the longitudinal vertical tear.

4:52

But each of those flavors is gonna have a stable type and

4:57

an unstable type. And when you have a vertical unstable type,

5:01

that's what's been called these bucket tears.

5:03

If you have a radio tear that's unstable, then that's the,

5:07

so-called parrot beak or the radio oblique tear with mon uh,

5:11

displacement of the flap. And if you have a horizontal tear,

5:15

the upper or that is the superior or inferior hemi

5:20

buckets can displace. So you can have like the superior staying, uh,

5:25

situ you, and then the inferior bucket, if you will, uh,

5:30

of the horizontal component, displaced inwards or, or essentially. And,

5:35

and Dr. Clyde Helms has written about that,

5:38

I believe in Scale Rad a few years back for those that are interested. Okay?

5:42

So that's, that's how I sort of think of, uh,

5:45

meniscal tears and unstable meniscal tears.

5:49

Sadi in terms of, you know, textbooks and, uh, reading up, I know you,

5:53

you're been trained under Dr. Renick, I've read, uh, Dr. STAs,

5:58

uh, books. I guess it's difficult to find a, a good recommendation,

6:02

but what would you think between these two authors?

6:06

I think both are good. Uh, you know, obviously my biases towards Dr.

6:10

Resnick, um, when I first started,

6:13

started studying out bone when I was, um, became interested in Bone,

6:18

I love Dr. Dr. Stoller's book is, is great for all his,

6:23

his schematics. And he has,

6:26

he has a really good checklist method and, and if you notice reading, uh,

6:31

um, his knee sections, um, he does a,

6:36

not if I remember correctly, he does, he does not do a structural approach.

6:40

And if you go to his talks, he does a plain approach.

6:43

So he'll pull up a coronal and make, make all the findings on the coronal,

6:47

then the Sagittals, then the Axials. And, and I've, I've personally, um,

6:53

uh, met him, um, at his workplace and he is, uh,

6:58

using his method and he outlines it in his talks and also I think in

7:03

some of his checklists and in, and some of his toes, in his, uh, in his, uh,

7:08

books. And if you follow that, you, you, you, you'll find yourself, um,

7:12

you know, pretty adept at, at, at Reading Bone. So,

7:15

but obviously my bias towards, um, Dr. Resnick, I find Dr.

7:20

Resnick's books, um, are Dr.

7:24

Resnick believes more in, in my opinion, uh,

7:28

knowing the pathology and knowing it down to a cellular sort of

7:33

histologic level. So if, you know, like knowing the why, um,

7:37

and knowing things on a more histologic level, then I, I would, I would, uh,

7:42

direct you more towards Dr. Resnicks. But if, if you like, uh,

7:47

you know, I, I think, but I think overall both are, are good. Um,

7:51

but for me personally, I tend to read more, uh, around cases.

7:56

And I, I just look for articles and I just,

8:00

I just find myself going around,

8:02

studying around topics until I feel I'm satisfied.

8:05

And then I just try my best to stay up to date around with, with the,

8:10

the latest articles.

8:12

Do you work closely with your surgeons? Uh, they do laparoscopic and, uh,

8:17

you know, correlate your findings with Mr with what they

8:19

Say. Yeah. Yeah, some, so, so, so as I said, mentioned earlier, uh, I am, I,

8:24

I love anatomy. Um, that's why I love bone.

8:27

There's just so many lumps and bumps, colliculi and, and tubercle,

8:31

what have you to, to know and memorize. But these days, uh, um,

8:36

I am more in tuned with, uh, my traumatologist, um,

8:42

ID team and oncologist. 'cause that's, that's,

8:46

that's what I think, uh, as of late, that's what I'm studying more.

8:49

But my sports medicine, I do, we do work on with our,

8:54

directly with our sports medicine, um, physicians and,

8:57

and we take care of a lot of the collegiate and, um,

8:59

professional teams around town and, and in the area. Yeah.

9:03

So we do get a lot of that too.