0:00

The history on this case was hit in the knee playing

0:05

football one week ago, pain and swelling. Okay, so here,

0:11

uh, going just straight to the pertinent findings again,

0:13

we also see obviously another fibro,

0:17

but here just another complete tear of the proximal to mid portion of the anter

0:22

cruciate ligament.

0:22

As we can see the increased signal and abnormal or wavy morphology,

0:27

we see the, uh,

0:29

bone contusions and also the injuries of the medial supporting structures,

0:34

uh, including the deep medial meniscal femoral ligament.

0:38

Underneath all that, that third layer we see,

0:42

we start to see the other main finding, which is that peripheral, uh, the,

0:46

uh, peripheral vertical or vertical tear of the body, okay?

0:51

Of the, uh, medial meniscus here.

0:54

But the other important finding, okay,

0:58

is this tear, okay? At the posterior horn of the lateral meniscus.

1:03

And let me just blow this up, okay.

1:06

And this is what's called a wrist berg rip, okay? Or,

1:11

uh, uh, a Ziploc tear or zipper tear. Uh,

1:15

I've heard some authors call, okay? And the importance of this,

1:20

or the differential of this, uh,

1:22

finding is going to be a normal insertion of the meniscal femoral

1:27

ligaments. Okay? So let's, uh, do a, uh, a quick tangent. Okay?

1:32

There are actually, uh,

1:34

two meniscal femoral ligaments that arise or insert, depending on how,

1:39

on your point of view, uh,

1:42

at the posterior horn of the lateral meniscus and run to attach

1:46

either okay,

1:48

on the PCL or the lateral aspect,

1:52

or the inner aspect of the medial femoral condyle. Okay? There's,

1:57

there can be two ligaments. One,

2:00

the one that runs anteriorly is gonna be Humphrey's ligament.

2:04

The one posteriorly is going to be called berg li ligament.

2:09

These ligaments are variably present, okay? Not, uh,

2:14

in, uh, patient's knees. And depending on who you read,

2:17

these ligaments are seen about, uh, I don't know,

2:20

about three quarters of patients. So not always seen, okay? Now,

2:25

the importance of this is, um, this wrist berg ligament,

2:30

okay? Comes as, as we can see here,

2:33

attaches upon the posterior horn of the lateral meniscus. Okay?

2:37

So the next question here is, uh, when is it abnormal? Okay?

2:42

And there's a skeletal radiology article,

2:44

and I don't remember the name of the author or the group off the top of my

2:49

head, but what they showed was, okay, uh,

2:54

if you look at, uh, a normal knee

2:59

With a wrist berg ligament, okay?

3:03

If you have a cleft of fluid, okay,

3:07

that measures about 14 millimeters in

3:12

medial lateral distance from the edge of the posterior

3:17

cruciate ligament, okay? Anything beyond that 14 millimeters,

3:22

you wanna consider that a positive for a wrist

3:27

berg rip or a lateral meniscal tear, okay? But what I do is,

3:32

uh, in my practice, okay,

3:35

what I do is I just scroll to look for the PCLI go one

3:40

slice, or just to the edge of the PCL and most, uh,

3:45

or at least, uh, most images or, or, um,

3:50

um, studies at, at our institution, the,

3:54

the slice thickness is typically about three millimeters.

3:58

Assuming you are not doing three D isotropic and getting thinner slices, okay?

4:03

But if you measure out,

4:05

assuming your slice is about three millimeters in thickness, okay,

4:08

so I just measure, I just go to the PCL and I click over

4:13

1, 2, 3,

4:16

and anything beyond three or four slices as in this case, so here,

4:20

as you can see,

4:21

we're already on our fifth click or fifth slice over from the PCL,

4:25

you still see a tear, or sorry, you still see a klepto fluid.

4:29

So you gotta call this a, a wrist berg rip or a positive, uh,

4:33

lateral meniscal tear. So that's how you're, that's how you can, uh,

4:38

parse out whether you have a normal insertion of a meniscal femoral

4:43

ligament, uh, the wrist berg or Humphrey's ligament, or a true,

4:48

uh, um, tear of the posterior horn or so-called, uh,

4:52

wrist berg rip. Okay? So just to do that again, right?

4:56

So ECL we see glimpses of it here.

4:59

So 1, 2, 3, 4,

5:04

right? So in theory, this, this, if you do the math,

5:07

you probably at about 12 millimeters, uh, lateral. So,

5:12

you know, add another, so here about, you know, 15 millimeters, right?

5:16

And then here, a few more clicks out.

5:18

We're about almost two centimeters away from, um, the posterior,

5:23

uh, posterior cru ligament. So we're far, pretty far lateral here. So,

5:28

you know, we should be calling this a, uh, positive for a lateral meniscal tear.

5:34

Okay? So that along with the, uh, you know,

5:38

the ACL, uh, tear, um, um,

5:43

that I believe, uh,

5:45

and some other injuries to the medial supporting structures that about completes

5:49

that case. And, uh, with that,

5:54

I believe those were all the pertinent findings to discuss with

5:59

this case.