Bucket-Handle Meniscus Tear and the Locked Knee

What is a bucket-handle tear?

The meniscus is a C-shaped cushion of cartilage between the thigh bone and the shin bone. In a bucket-handle tear, a split runs along the length of the meniscus. The inner piece stays attached at both ends but swings into the centre of the joint, like the handle of a bucket lifting away from the rim.

In that position the fragment can jam between the bones and block movement. It is one of the more serious meniscal tear patterns, because the displaced piece is large and is under strain for as long as it stays out of place.

Symptoms, in patients' own words

• "My knee is stuck bent and I can't straighten it"
• "Something is in the way when I try to extend my leg"
• Pain on the inner or outer side of the knee after a twist
• Swelling over the first day or two
• Walking with a limp or on tiptoe because the heel will not go down flat
• The knee locking and then suddenly unlocking with a clunk

Some people have repeated episodes of catching before the knee finally locks.

Causes and who gets it

Bucket-handle tears usually follow a twisting injury with the foot planted, the classic movement in football, padel, basketball and martial arts. They are most common in young, active men and very often occur together with an ACL tear, especially when an unstable knee has given way several times. In manual workers, a forceful twist while squatting or rising under load can cause the same tear.

Diagnosis

A knee surgeon suspects a bucket-handle tear when the knee has a springy block to full straightening after a twisting injury. An MRI scan confirms it: the displaced fragment often lies next to the posterior cruciate ligament, a picture described as the double PCL sign. The MRI also checks the ACL, the other meniscus and the cartilage, which helps plan surgery.

X-rays are taken to exclude a fracture or a loose fragment of bone.

Treatment

Most displaced bucket-handle tears need arthroscopic surgery. The fragment is put back in place and, wherever its quality and blood supply allow, it is stitched with meniscus repair techniques so it can heal. Saving the meniscus matters, because losing a large part of it raises the long-term risk of osteoarthritis.

When the torn piece is badly damaged or cannot heal, the unstable part is removed and as much healthy meniscus as possible is kept. If the ACL is also torn, Dr. Gelber often reconstructs it in the same operation, since a stable knee protects the repair.

Non-surgical treatment is rarely suitable for a knee that is truly locked, although a small, non-displaced longitudinal tear may sometimes be watched.

Recovery

After repair, the knee is protected while the meniscus heals. Crutches and a brace are commonly used for around four to six weeks, with deep bending limited. Physiotherapy starts early to recover straightening and thigh strength.

Office work is often possible within one to two weeks, and driving once you can control the car safely. Return to running is usually around three to four months, and to pivoting sports such as football and padel around four to six months, or longer when the ACL was reconstructed at the same time. Sujood and sitting on the floor are usually avoided for several months.

When to see a knee specialist in Doha

• The knee is locked and will not fully straighten
• It keeps catching or giving way after a twisting injury
• Swelling appeared soon after the injury
• You cannot walk with the heel flat on the ground

A locked knee is not usually a hospital emergency, but it should be assessed within days rather than weeks, because the chance of repairing the meniscus is generally higher when surgery is early. Dr. Gelber sees these injuries at Aman Hospital in Doha.