​Kembara Xtra - Medicine - Meniscal Injury

​Kembara Xtra - Medicine - Meniscal Injury 
The fibrocartilaginous menisci, which are located between the femoral condyles and tibial plateaus, aid in stabilizing the knee and distributing forces throughout the joint.
Meniscal tears can result in knee discomfort and impairment and are ultimately a risk factor for the onset of osteoarthritis (OA).
Child Safety Considerations
Meniscal injuries in children under 10 are uncommon. They frequently result from a discoid meniscus rather than trauma in this population.
Meniscal repair is a viable therapeutic option with positive clinical outcomes in the pediatric/adolescent population, yet MRI is still the study of choice because it is more sensitive and specific for identifying meniscal tears in children younger than 12 years old.

Epidemiology 

Young athletes (traumatic) and older patients (degenerative) make up the bimodal age distribution.
Incidence
Injury to the medial meniscus is more prevalent.
Prevalence
Affecting 0.6 to 8 individuals per 1000 each year, it is one of the most frequent musculoskeletal injuries.

Pathophysiology and Etiology 
Traumatic tears have a sharp edge. Degenerative rips are persistent and typically result from the knee twisting while the foot is planted. They typically happen as a result of overuse and little damage.
Genetics
There is no known gene locus in particular.

Risk factors for traumatic tear include: - Heavy physical activity, especially in sports that require cutting;
Degenerative tear: - Increased age (>60 years) - Anterior cruciate ligament (ACL) insufficiency - Underlying meniscal degeneration—can still increase risk of meniscal tear even in traumatic event
- Obesity - Kneeling, crouching, and stair climbing at work
GENERAL PREVENTION Weight management Quadriceps and hamstring muscle strengthening and enhanced flexibility Treatment and rehabilitation of prior knee injuries, especially ACL injuries 

Accompanying Conditions 
Traumatic tear: - In one-third of instances, the ACL is simultaneously torn.
Medial meniscal tears are more frequently associated with degenerative rips such as Baker cysts and osteoarthritis (OA).


History Locking, catching - Limited correlation between self-reported mechanical symptoms and presence of meniscal tear on arthroscopy. History Medial or lateral knee discomfort and swelling—increased with knee flexion, walking down steps


clinical assessment 
Joint line tenderness (medial and/or lateral) Reduced range of motion of the knee - Pain with full flexion (posterior horn tear) or extension (anterior horn tear) Variable accuracy of specialized tests (McMurray, Apley grind test).

Differential diagnosis: Patellofemoral syndrome, osteochondritis dissecans, pathologic plica, loose body or fracture, ACL or collateral ligament injury.

Laboratory Results 
The presence of fractures, loose bodies, or degenerative changes can be seen on plain radiographs.
MRI is the major imaging technique for detecting meniscal tears, while ultrasound may be able to detect them.
Tests in the Future & Special Considerations
It is crucial to correlate history, physical exam, and imaging findings because meniscal tears are frequently seen incidentally on MRI and may not always be the origin of a patient's complaints.
 In 60% of asymptomatic patients with MRIs, incidental rips were discovered. Asymptomatic tears are more prevalent in older adults; if the MRI is inconclusive, diagnostic procedures or further arthroscopy may be required.

Management 

Consider surgery for traumatic rips (with locking feeling, indicating bucket handle tear) because these patients typically recover more quickly than patients with degenerative injuries.
Nonsurgical care is a suitable first-line treatment for symptomatic meniscal tears without mechanical symptoms in degenerative tears. Rest, ice, and activity moderation are a few of them.
Physical treatment (PT), OTC drugs, and intra-articular corticosteroid injections
 Give supportive care a priority initially; there is no added benefit to surgery over physical therapy for patients over 40 with degenerative meniscal tears.
- Over a 5-year period, both conservative and surgical treatment choices result in clinically good outcomes—reduced pain, increased quality of life, and improved knee function. If initial PT is unsuccessful, an arthroscopic partial meniscectomy may be a viable alternative.
- Those who undergo surgery may have a slightly increased rate of total knee replacement.
- From a financial perspective, PT is preferable to surgery because it is more cost-effective.
- In one study, regardless of the course of treatment, 90% of patients with degenerative meniscal tears reported symptom reduction after two years. Increased BMI, increased pain, declining mental health, concomitant OA, and decreased quadriceps/hamstring strength were all indicators of poor recovery.


First Line of Medicine
NSAIDs, such as acetaminophen [Tylenol] or ibuprofen (800 mg PO TID or 500 mg PO BID, respectively)
 Corticosteroid injection (5 mL lidocaine plus 80 mg/mL of Depo-Medrol or an equivalent amount of methylprednisolone acetate)
QUESTIONS FOR REFERENCE
surgical consultation for patients who meet the requirements for surgery or who want a surgical repair

Further Therapies 

Both surgical and nonsurgical patients need rehabilitation.
Weight loss Platelet-rich plasma (PRP) injections could help with degenerative meniscal tears' symptoms.

Surgery Take into account surgery if the following conditions exist: - Young/active patient with acute tear and no underlying OA
- Related injuries, such as an ACL tear
- Mechanical signs, such as "catching" or "locking" of the knee
- Degenerative tear conservative treatment for 3 to 6 months did not result in any symptom relief.
The preferred procedure is meniscal preservation surgery, which involves meniscal repair or replacement.
Meniscectomy removes the damaged area of the meniscus. Articular cartilage deterioration and OA can result from both partial and total meniscectomy.
- Age >40 years, high BMI, and valgus malalignment all increase risk.

Follow-up After meniscal repair, patients can typically resume their normal activities in 3 to 6 months. Return to play requires the athlete to be pain-free, have full range of motion, and full strength.

Patient Education Patients should be informed of the advantages and disadvantages of surgery in comparison to non-surgical treatments.

Prognosis The prognosis is better if surgery is performed within 8 weeks of an acute tear, the patient is under 30, or the tear is lateral or peripheral and less than 2.5 cm.


Complications 
Meniscectomy may eventually result in OA, and 20 years after a meniscectomy, the risk of getting OA increases six-fold.

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