0:00

The history was a 12 year old with

0:05

pain and swelling.

0:07

So I'll do this one a little bit different 'cause we have two sags and a

0:12

single Corona on this one. So we'll do it this way.

0:15

So here we have an ACL of essentially a high grade,

0:19

if not complete tear of its proximal to mid portion. Okay.

0:24

No real, uh, translation of the, uh,

0:26

or maybe a little bit of anterior translation of the, of the, uh,

0:30

tibial with respect to the femur.

0:32

And I like to look at it on the lateral side and,

0:34

and maybe arguably a little bit of a small bone contusion right here.

0:38

And the other, uh,

0:39

pertinent finding for this case is that we have a longitudinal,

0:44

vertically oriented tear at the posterior horn of the medial meniscus. Okay?

0:49

And because it is, uh,

0:51

about three se three millimeters within Okay.

0:55

The meniscal capsular junction, which is right here, okay?

1:00

This is what's called a, uh, ramp lesion. Okay?

1:03

If you look at this under a scope, this, uh, up sloping, okay.

1:07

It looks like a ramp to arthroscopists,

1:10

and that's why it's called a ramp lesion. Okay?

1:13

And just to highlight some of the anatomy, okay? Uh,

1:19

let me try to do this. Okay. There's,

1:21

just to go over a little bit of normal anatomy, okay? There's, there's, uh,

1:26

back here at the meniscal capsular junction,

1:29

we have this meniscal tibial ligament,

1:32

which I've sort of tried to highlight in red here. Okay?

1:36

And then there's a

1:41

meniscocapsular ligament, okay? Which is typically in this area,

1:45

which I'm trying to show in green. Okay? And finally,

1:50

there's a posterior joint capsule,

1:53

which is typically right arounds here,

1:56

which is I've highlighted in yellow. Okay? Now, um,

2:01

there's an author, uh, by the name of au, and I apologize,

2:06

I if I misspell his or mispronounce and misspell his, his or her name,

2:10

but is T-H-A-N-A-U-T-I believe it is.

2:14

Okay. But, uh, they came up with a classification system for these ramp le,

2:19

for these ramp lesions. But the important thing, uh, is to be aware of this,

2:24

okay? Um, if you read the literature, and depending on who you read, uh,

2:28

about 50% of these ramp,

2:31

so-called ramp lesions or peripheral tears, uh, are, are missed, um,

2:37

by, uh, MRI. Okay? And, but basically you want to pay attention to this,

2:42

uh, peripheral aspect or this peripheral zone of the, uh, uh,

2:47

medial, uh, medial meniscus. Now,

2:49

the posterior horn of the medial meniscus typically measures about 11 or 12

2:54

millimeters in central peripheral or anterior posterior thickness. Okay?

2:58

And this is the thickest part, okay. Of the, uh,

3:02

menisci this posterior horn. Okay? And why is,

3:07

why are these zones important? It's important because at the peripheral third,

3:12

okay, it's called the red zone because it's, it's, uh, fed,

3:17

uh, the meniscus is fed, um,

3:20

from a peripheral to central dem, uh, uh,

3:24

from a peripheral to central fashion. Okay?

3:27

So there's more vascularity in the periphery. So what does that mean for, for,

3:32

uh, management? It means that, uh,

3:36

these peripheral tears are gonna be, um,

3:38

amenable to repair versus the white zone tears,

3:43

which the white zone is the inner two-thirds,

3:46

or the central two-thirds. Those tears are gonna be, uh,

3:50

typically debrided. Okay? Because it's avascular,

3:53

these typically are not going to heal as well.

3:57

So some surgeons will go in, uh, ready to debride instead.

4:02

So it's, uh,

4:05

arguably important to describe where these tears occur, especially, um,

4:10

with bucket handle tears per se. And,

4:13

and that's what we have our trainees do at UCSD. Um,

4:18

we try to describe where the tears occur so that, uh,

4:22

our surgeons are prepared, um,

4:25

with their surgical tray to either go in, uh, ex uh, and,

4:29

and also discuss with the patient what the plan for, uh,

4:34

during surgery is, whether to go in and debride or potentially repair,

4:39

um, you know, a red tear, sorry, a white tear or a red tear,

4:43

red zone tear respectively. Okay? So, um, that's, uh,

4:48

probably the, that's that, those are the two main findings, uh, for this case,

4:53

the ACL tear, along with, uh, this, so-called ramp lesion.

4:59

Now, Theo, uh, going back to Theo, there's four or five, uh,

5:03

classes or types or grades of injuries. But basically, um,

5:09

the type one and two, if I remember correctly, are going to be involving the,

5:14

uh, superior half, uh, of the, uh, ramp or, and,

5:18

or the meniscal capsular ligament. Okay? While the, uh,

5:24

the ramp, uh,

5:27

the type three A and three B lesions are gonna

5:31

involve the, um,

5:34

posterior inferior aspect of the, uh,

5:37

posterior of the meniscus and the, uh, meniscal tibial ligament.

5:42

Now, there's, I believe, a type four and five,

5:45

and that's where you basically have a through and through vertical tear.

5:49

And then the higher grade injury, you basically, I,

5:52

I think it's a type five and you can double check me by, uh, reviewing those,

5:56

uh, that

5:57

Literature. But it's basically a double vertical tear at the, uh, uh, at the,

6:01

uh, meniscal capsular junction here. Okay? So that's, uh,

6:06

that's the, uh, um, the summary of, uh, ramp lesions.

6:11

So try not to miss these because there's,

6:13

because there's so peripherally and they involve the red zone, they're gonna,

6:17

um, they're gonna be amenable to, um, meniscal repair. Um,

6:23

and, and rather than, uh, uh, treating these with debridement, okay?

6:28

So you guys could feel free to, to take a snapshot of this, but this is a, a,

6:33

a nice recent, uh, review article in the, uh,

6:36

MSK radiology literature Scale rad, um,

6:40

over going through the various ramp lesions that may help. But it basically,

6:45

uh, summarizes really nicely. Uh, and this is, I believe, a group from, uh,

6:50

Brazil or, or, uh, yeah, Florida and, and,

6:55

and, um, uh,

6:57

but this basically really nicely summarizes what,

7:01

what I was trying to go over in that, in this last case. But again,

7:05

it, it starts out with the, all the anatomy and then, and then, uh,

7:10

it goes through the various different, different types Okay. Of,

7:14

of these ramp lesions. So feel free to try to look at this, but again,

7:19

too, if, if you're not sure how to best categorize, uh,

7:24

these ramp lesions, then it's okay to just describe them,

7:29

you know, longitudinal vertical tear and,

7:32

and where it's situated from the meniscal capsular junction,

7:35

if you want to get that specific. And whether involves the, uh,

7:38

meniscal tibial ligament. And as I mentioned, or hopefully I mentioned earlier,

7:42

you don't, we don't all,

7:43

or I at least I don't always see that meniscal capsular ligament. I,

7:47

I feel that that's more flimsy and, um, attenuated in appearance, um,

7:53

even in, in normal cases. Um,

7:56

so it can be difficult to pick out. But this is, uh, definitely a,

8:00

an article to, uh, check out.