J R Army Med Corps 158(4): 335-337 335 Introduction A bucket handle meniscal tear is a longitudinal tear of the meniscus whereby the inner fragment is displaced towards the intercondylar notch, whilst the peripheral fragment remains in place. eir frequency is estimated at approximately 10% in most large series [1] with a higher proportion involving the medial meniscus [2]. ey are often associated with anterior cruciate ligament (ACL) injuries either in the acute or chronic setting. e presence of a bucket handle tear in both the medial and lateral meniscus is a phenomenon that is rarely reported in the literature. ose that are [3-12], have tended to occur in young adults following an acute traumatic event, with subsequent instability or mechanical symptoms in cases that are not immediately treated. In general, treatment has involved a single stage procedure with repair or resection of the torn meniscal fragments and concurrent reconstruction of the ACL. We report a case of locked medial and lateral bucket handle meniscal tears, with associated ACL rupture, whereby the meniscal tears appeared to have occurred following two separate injuries. To our knowledge, no previous reports demonstrate a clear dissociation of timing between the two tears in this type of injury. A discussion ensues of the presentation and management of this injury, as compared to previous cases published in the literature. Case Report An 18-year-old male seen in our clinic described a two-year history of his knee giving way, with subsequent pain and swelling for a few days on each occurrence. He had aspirations to join the military as an officer, and wished to address the functional deficit associated with his unstable knee. He recalled an initial injury playing football, whereby he ‘jump-kicked’ the ball and landed twisting his knee. is resulted in a large effusion, which settled over two weeks, however no further investigation ensued. Over the two years his knee gave way every few weeks whilst playing football, or during other twisting activities. Often he would kneel on the affected knee to ‘click’ it back into normal position. Mild pain and swelling would persist for a few days. He presented to our clinic following a second severe twist-injury to his knee whilst pivoting to kick the football, resulting in a large effusion and reduced ability to weight bear on the affected side. Examination of his knee demonstrated a moderate effusion, a range of movement of 10 – 100° and a fixed flexion deformity of 10°. He also had lateral joint line tenderness, with positive Lachman’s, anterior drawer, and pivot shift tests. An MRI showed a lateral meniscus bucket handle tear with the flap lying in the anterior joint compartment, a flap tear of the medial meniscus posterior horn, and interstitial injury to the ACL. It also demonstrated the characteristic ‘quadruple cruciate sign’ whereby the ACL, PCL (posterior cruciate ligament) and the displaced medial and lateral meniscus fragments are visible within the intercondylar notch, as previously described by Bugnone et al [3]. ere was no evidence of further intra-articular pathology or injury to the posterolateral corner. Subsequent arthroscopy was performed six weeks following the presenting injury, confirming full bucket handle tears of both lateral and medial menisci and a full rupture of the ACL. e PCL was intact. e medial meniscus injury appeared to be chronic, with rounded off edges and a yellow coloured appearance (Figure 1). It was non-reducible hence a subtotal meniscectomy was performed. e lateral meniscus tear appeared acute (Figure 2) and was reducible, therefore it was repaired with three sutures (DePuy Mitek, Johnson & Johnson, MA, USA) using the inside- inside technique. e lateral drive through sign was negative in correlation with the MRI findings. Corresponding Author: Miss J Shepherd, Department of Trauma and Orthopaedics, Queen Elizabeth Hospital, Stadium Road, Woolwich, London, SE18 4QH Tel: 020 88366000 E-mail: shepherd.jo@gmail.com Locked Bucket Handle Tears of the Medial and Lateral Menisci with Associated Chronic ACL Deficiency J Shepherd 1 , HB Abdul-Jabar 2 , A Kumar 3 1 Core Trainee in Surgery, Queen Elizabeth Hospital, Woolwich London; 2 Specialist Registrar in Trauma and Orthopaedics, Queen Elizabeth Hospital, Woolwich, London; 3 Consutant Orthopaedic and Knee Surgeon, Queen Elizabeth Hospital, Woolwich, London. Abstract Bucket handle meniscal tears involving both the medial and lateral menisci are very rarely reported in the literature. ose that are, have generally been managed using a one-stage procedure, with concurrent reconstruction of the anterior cruciate ligament (ACL) in ACL-deficient cases. We report a case of an 18-year old male who presented with bi-compartmental bucket handle meniscal tears with an associated ACL deficiency, whereby the medial and lateral tears appear to have clearly occurred on separate occasions. A staged approach to management was adopted. We discuss the presentation and management of our case in comparison to previously reported cases. CASE REPORT group.bmj.com on June 24, 2013 - Published by jramc.bmj.com Downloaded from