Meniscal Injuries in Children and Adolescents

R. Baxter Willis, MD, FRCSC

Meniscal injuries in children and adolescents are more common than previously appreci-
ated. Meniscal preservation is the hallmark of treatment in this age group based on the
vascular supply of the peripheral meniscus and its ability to heal. Meniscectomy is to be
avoided if at all possible because of the long-term consequences of degenerative osteo-
arthritis of the knee joint.
Oper Tech Sports Med 14:197-202 © 2006 Elsevier Inc. All rights reserved.

KEYWORDS meniscal injury, meniscal preservation, meniscal suturing

M eniscal injuries in children are distinctly uncommon.

However, the incidence of isolated meniscal injuries or
those seen in conjunction with anterior cruciate ligament
certain excursion during flexion and extension with the
lateral meniscus having more translational excursion than
the medial.9
tears in the adolescent is common.1-6 The exact incidence and
prevalence of meniscal tears in children and adolescents are
unknown but is estimated to comprise 5% of all meniscus Development
tears.7 Injury to the meniscus in the adolescent is usually the At 8 weeks of embryonic development, the menisci are
result of a twisting injury during sports. shaped like the adult version and, at birth, they have an
extensive if not anatomically complete blood supply.10 By 9
months of age, vascular regression of the inner one third has
Anatomy of the Meniscus occurred and, by 10 years of age, the blood supply is mature.10
The menisci are C-shaped or semicircular specialized forms Arnoczky and Warren in a landmark study found that only the
of fibro cartilage with bony attachments situated anteriorly outer 10% to 25% of the lateral meniscus and 10% to 30% of
and posteriorly to the tibial plateau. The medial meniscus is the medial meniscus is vascular.11,12 The blood supply is a
C-shaped with a wider posterior horn than anterior horn. It is rich perimeniscal plexus of capillaries, which arise from
firmly attached anteriorly in most cases to the tibial plateau superior and inferior branches of the medial and lateral
and then to the joint capsule and tibia via coronary ligaments. genicular arteries (Fig. 2). Neural elements are found in
The posterior attachment of the meniscus is anterior to the the outer third of the meniscus, but the inner two thirds
posterior cruciate ligament. are relatively free of neural endings.
The lateral meniscus has a larger footprint than the medial
meniscus and is semicircular in shape. The incidence of dis-
coid lateral menisci is as high as 3.5% to 5%.8 The anterior Microanatomy
horn attachment is adjacent to the origin of the anterior cru- The meniscus is not just an amorphous collection of collagen
ciate ligament and the posterior horn inserting just behind but with specialized collagen fibers that are mostly arranged
the intercondylar eminence anterior to the posterior horn of in a circumferential pattern with some radial fibers at the
the medial meniscus. The attachments of the lateral meniscus surface and within the substance of the meniscus.13-15 The
are not as well developed as its medial counterpart with the circumferential fibers are arranged to allow compressive
popliteal hiatus posterior and lateral to the meniscus an loads to be dispersed throughout the meniscus. The radial
area of decreased stability (Fig. 1). The menisci have a fibers resist longitudinal tearing (Fig. 3).

Division of Pediatric Orthopaedics, Children’s Hospital of Eastern Ontario, Clinical Evaluation

Ottawa, Ontario, Canada.
Address reprint requests to R. Baxter Willis, MD, FRCSC, Division of Pedi- It is often difficult to diagnose meniscal injuries in chil-
atric Orthopaedics, Children’s Hospital of Eastern Ontario, 401 Smyth dren because of the difficulty in obtaining an accurate
Road, Ottawa, ON K1H 8L1, Canada. E-mail: [email protected] history and in carrying out an adequate physical examina-

1060-1872/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. 197
doi:10.1053/j.otsm.2006.06.003
198 R.B. Willis

Figure 1 Anatomy of menisci. Cadaveric left knee showing medial and Figure 3 Histologic characteristics of menisci. Diagram of meniscus
lateral menisci and their attachments. Lateral meniscus is larger than with cutaway to demonstrate variable collagen fiber network including
medial. Menisci attach to joint capsule and tibia by coronary ligaments. circumferential fibers, radial fibers, and mesh network fibers.
(Color version of figure is available online.)

tion. The primary complaint is usually pain, but often the

precise location is difficult to ascertain. In addition to
Physical Examination
pain, complaints consist of swelling or effusion, a snap- The most accurate finding in juvenile meniscal tears is usu-
ping sensation, giving way, intermittent locking and a ally joint line tenderness. The tenderness is often exacerbated
locked knee (Table 1).16,17 by rotating stress applied to the knee by rotating the tibia.
Internal rotating stress and varus stress often increase the
tenderness in a medial meniscus tear. Lateral meniscus tears
are exacerbated with external rotation and a valgus stress.17
McMurray’s test is classically indicative of a posterior horn
tear. In children, the majority of tears are peripheral in loca-
tion and longitudinal in nature rendering McMurray’s test
ineffective. There is a significant association of anterior cru-
ciate ligament tears with meniscal injuries. Careful evaluation
of ligamentous stability of the knee is a definite part of the
physical examination.5,7,15,17-19 With chronic tears, quadri-
ceps atrophy is usually noted in comparison to the normal
knee.

Imaging Studies
Routine radiographs, AP, lateral, skyline and tunnel views
should be done at the time of the initial examination to rule
out osteochondral fractures, tibial eminence fractures, osteo-

Table 1 Symptoms17 of Meniscectomies in Children

Complaint Incidence (%)
Pain 95
Effusion 71
Snapping sensation 66
Figure 2 Blood supply of meniscus. Outer 10% to 30% of medial
“Giving way” 63
meniscus and outer 10% to 25% of lateral meniscus have a rich
Intermittent locking 54
perimeniscal plexus of vessels arising from the medial and lateral
Locked knee 7
genicular arteries.
Meniscal injuries in children and adolescents 199

blood supply of the meniscus.11 Their vascular injection

studies showed a rich complex of vessels at the meniscosy-
novial junction capable of allowing peripheral meniscal tears
to heal if they were within 3 mm of the meniscosynovial
junction.11,12,32
Their work has led to the concept of 4 zones within the
meniscus. Zone 0 is the rich vascular meniscal synovial junc-
tion, Zone 1 represents the vascular “red-red zone” with
blood supply on either side, Zone 2 is the transitional red-
white zone with vessels on the outside margin but little blood
supply on the inner meniscal side, Zone 3 is the “white-
white” avascular zone with little or no blood supply, and
Zone 4 is the inner free margin of the meniscus.
Treatment of meniscal injury is based on the patient’s age,
duration of symptoms, pattern of the meniscal injury, and
presence or absence of concomitant injuries.5,7,15,17,33,34
Fortunately, most meniscal tears in children occur in the
peripheral vascular “red-red” zone and are amenable to repair
and/or healing. If the knee is stable but meniscal injury is
suspected, arthroscopic examination and possible repair is
recommended. In the situation of a small tear which is stable
and in Zone 0 or 1, healing of the meniscus will usually occur
without the need for meniscal repair. The edges of the tear are
rasped to promote vascular ingrowth and the knee is either
immobilized in a cylinder cast or controlled motion knee
brace (Fig. 5).5,7,15,17,35
Figure 4 MRI of knee showing meniscal tear. MRI of knee (sagittal
view) showing vertical tear in posterior horn of medial meniscus.
This tear represents a Zone 2 tear with blood supply on the outer
portion of the tear and lack of blood supply on the inner portion.

chondritis dissecans, tumors, and ligament avulsion frac-

tures. Magnetic resonance imaging (MRI) has become the
study of choice to evaluate intra-articular pathology. It is
nonevasive, painless and, in most cases, requires no sedation
in children. However, it should not be used as a screening test
in the child with a knee injury. Significant false-positive find-
ings of meniscal tear are noted in several series of asymptom-
atic knees in children (Fig. 4).3,4,6,20-25
Studies correlating MRI findings of anterior cruciate liga-
ment disruption and meniscal injury with arthroscopic find-
ings have noted high false-positive rates for meniscal injury
both medial and lateral.4,24 Despite these shortcomings, MRI
provides useful information about meniscal integrity and
possible ligamentous injury. It should not replace a careful
physical examination as a screening tool for internal derange-
ment of the knee.

Treatment
Fairbank’s classic article on the deleterious long-term conse-
quences of total menisectomy has led to the concept of me-
niscal preservation in the hope of maintaining normal joint
biomechanics and preventing the inevitable degenerative
changes seen with menisectomy especially in younger pa-
tients.12,19,26-31 Figure 5 Rasp- and zone-specific cannulas. The rasp is used to de-
The concept of meniscal healing is based on the work of bride relatively avascular granulation tissue back to bleeding tissue
Arnoczky and Warren, who did pioneering work on the and promote vascular ingrowth once the meniscus is repaired.
200 R.B. Willis

Figure 6 Medial meniscal tear. Arthroscopic image of longitudinal,

peripheral tear of medial meniscus in Zone 2 or red–white zone.
(Color version of figure is available online.)
Figure 8 Arthroscopic image of repair of peripheral separation of
medial meniscus. View shows the cannula in place to allow suture to
be passed through meniscus and capsule. Image shows one suture
It would seem that a period of immobilization would pro- in place. (Color version of figure is available online.)
mote healing, but work by Dowdy et al36 have shown that
more collagen is produced at surgically created mensical
tears in nonimmobilized animals than in immobilized ones. freshened up with a rasp and the meniscus stabilized by any
Therefore, immobilization may not be required in small pe- of several techniques. Bioabsorbable devices have been em-
ripheral tears. ployed for specific meniscal tears in the hope of avoiding the
In larger tears in Zones 0 to Zone 2, meniscal repair is potential problems of meniscal suturing especially neurovas-
recommended (Figs. 6 and 7). The margin of the tear is cular injury. These devices are placed across a meniscal tear
arthroscopically as an all-inside device. They are most often
employed for small longitudinal tears especially if the tear is
located in the posterior horn. Although they have been em-
ployed in children and adolescents, they are not recom-
mended routinely for meniscal tears in this age group.35,37
The most common method of meniscal repair is the inside-
out technique, which uses zone-specific cannulas that allow
precise suture placement. A vertical mattress suture is used
and strategically placed skin incisions to avoid neurovas-
cular injury when the sutures are tied outside the capsule
(Fig. 8).5,7,15,18,27,33,34
On the lateral side, sutures in the posterolateral quadrant
are at risk of injuring the common peroneal nerve. An inci-
sion of 2 to 3 cm is made and dissection carried down to
identify the nerve. The sutures exiting the capsule are iden-
tified within the incision and the sutures tied to the capsule
with the nerve carefully protected.
On the medial side, the saphenous nerve is at risk. A 2-cm
longitudinal incision is made and the nerve identified. Again
the sutures are tied down to the capsule carefully protecting
the nerve or any blood vessels medially and posteriorly
(Fig 9).
Figure 7 Arthroscopic view of bucket handle tear of meniscus. In In addition to suturing, the addition of a fibrin clot may
children and adolescents, the displaced portion of the meniscus increase the likelihood of healing in meniscal tears in chil-
should be reduced and a repair of the tear performed if possible. dren. This technique has been used with success in adults,
Meniscal injuries in children and adolescents 201

and it makes sense that it would be successful in younger

patients.23 The edges of the meniscal tear need to be rasped to
promote bleeding and vascular ingrowth before the place-
ment of the sutures.
The outside-in approach requires that spinal needles be
placed through the capsule and the meniscus. A suture is
passed through the needle and brought outside the knee,
where a knot is fashioned and the knot itself used to reduce
the meniscus and stabilize it (Fig. 10).5,6,15,33
Finally, if the tear is in Zone 3 or 4, meniscal repair uni-
versally fails, and meniscal trimming back to the stable por-
tion of the meniscus is recommended. As much of the intact
meniscus as possible should be retained. Some authors be-
lieve an attempt at repair is warranted in the younger patient
with a longitudinal tear in Zone 3 or 4 with an expectation of
healing in approximately 75% of patients.38
It is important to assess and evaluate the child’s knee for
concomitant ligamentous instability. Meniscal repair in the
face of ligamentous instability usually will fail.18,39 Meniscal
repair and ligamentous reconstruction of the anterior cruci-
ate ligament are recommended when the 2 lesions are seen
simultaneously. Approximately 50% of meniscal injuries in
children are associated with anterior cruciate ligament tear
and instability.7,15,18,21 Figure 10 Diagram showing technique of outside-in repair method.
The results of meniscal repair in children are very encour- Spinal needles are passed through the capsule from outside into the
aging. For repairs in Zones 0 and 1, Mintzer and colleagues joint through the meniscus and a suture passed through the needle.
An incision is made to protect the neurovascular structures and a
had a 100% success rate, even with concomitant anterior
knot tied to reduce and stabilize the meniscal tear.
cruciate ligament reconstruction.5 For tears in zones 2 and 3,

the success rate decreases to approximately 75% but should

still be attempted with the child with open physes in an
attempt to prevent the inevitable degenerative changes which
will occur with meniscectomy.5,38
Complications of meniscal repair are rare but include su-
perficial and deep infection, retear of the meniscus, nerve
injuries, popliteal artery injury, and joint stiffness (arthrofi-
brosis).37 Neural injury is probably the most common com-
plication.
In summary, the incidence of meniscal injury in the skel-
etally immature athlete is probably more common than orig-
inally appreciated. Careful clinical examination followed by
an MRI examination will lead to the diagnosis. Every attempt
should be made to preserve the meniscus by any one of
several meniscal repair techniques. Instability of the knee,
especially of the anterior cruciate ligament, should be dealt
with as well to prevent lack of meniscal healing or re-rupture.

Acknowledgment
Figures 1, 4, 5, 6, 7, 8, 9, and 10 are reproduced with special
permission of Donald Johnson, MD, Division of Orthopaedic
Surgery, University of Ottawa, Ottawa, Ontario, Canada.
Figure 9 Arthroscopic image of medial meniscus after inside-out
repair. The peripheral tear was freshened with a rasp and stabilized References
with sutures placed strategically to oppose the 2 sides of the tear. A 1. De Haven KE, Linter DM: Athletic injuries: comparison by age, sport,
small incision is made to identify the saphenous nerve and protect it and gender. Am J Sports Med 14:218-224, 1986
while the sutures are tied to the capsule. (Color version of figure is 2. Harvell JC Jr, Fu FH, Stanitski CL: Diagnostic arthroscopy of the knee
available online.) in children and adolescents. Orthopaedics 12:1555-1560, 1989
202 R.B. Willis

3. King SL, Curty HML, Brady O: Magnetic resonance imaging of knee 22. LaPrade RF, Burnett QM II, Veenstra MA, et al: The prevalence of
injuries in children. Pediatr Radiol 26:287-290, 1996 abnormal magnetic resonance imaging findings in asymptomatic
4. McDermott MJ, Bathgate B, Gillingham BL, et al: Correlation of MRI knees. With correlation of magnetic resonance imaging to arthroscopic
and arthroscopic diagnosis of knee pathology in children and adoles- findings in symptomatic knees. Am J Sports Med 22:739-745, 1994
cents. J Pediatr Orthop 18:675-678, 1998 23. Port J, Jackson DW, Lee TQ, et al: Meniscal repair supplemented with
5. Mintzer CM, Richmond JC, Taylor J: Meniscal repair in the young exogenous fibrin clot and autogenous cultured marrow cells in the goat
athlete. Am J Sports Med 26:630-633, 1998 model. Am J Sports Med 24:547-555, 1996
6. Stanitski CL, Harvell JC, Fu F: Observations on acute knee hemarthro- 24. Stanitski CL: Correlation of arthroscopic and clinical examination with
sis in children and adolescents. J Pediatr Orthop 13:506-510, 1993 magnetic resonance imaging findings of injured knees in children and
7. Busch MT: Meniscal injuries in children and adolescents. Clin Sports adolescents. Am J Sports Med 26:2-6, 1998
Med 9:661, 1990 25. Zobel MS, Borrello JA, Siegel NR: Pediatric knee MR imaging: pattern of
8. Vandermeer RD, Cunningham FK: Arthroscopic treatment of the dis- injuries in the immature skeleton. Radiology 190:397-401, 1994
coid lateral meniscus: Results of long-term follow-up. Arthroscopy 26. Baratz ME, Fu FH, Mengato R: Meniscal tears: The effect of menisec-
5:101-109, 1989 tomy and of repair on intraarticular contact areas and stress in the
9. Vedi V, Williams A, Tennat SJ, et al: Meniscal movement. An in-vivo human knee. A preliminary report. Am J Sports Med 14:270-275, 1986
study using dynamic MRI. J Bone Joint Surg Br 81:37-41, 1999 27. DeHaven KE, Arnoczky SP: Meniscus repair: basic science, indications
10. Clark CR, Ogden JA: Development of the menisci of the human knee for repair, and open repair. Instr Course Lect 43:65-76, 1994
joint. Morphological changes and their potential role in childhood 28. Fairbank TC: Knee joint changes after meniscectomy. J Bone Joint Surg
meniscal injury. J B Joint Surg Am 65:538-547, 1983
Br 30B:664, 1948
11. Arnoczky SP, Warren RF: Microvasculature of the human meniscus.
29. Medlar RC, Mandiberg JJ, Lyne ED: Meniscectomies in children: a
Am J Sports Med 10:90-95, 1982
report of long-term results. Am J Sports Med 8:87-92, 1980
12. Arnoczky SP, Warren RF: The microvasculature of the meniscus and its
30. Rangger C, Klesh t, Gloetzer W, et al: Osteoarthritis after arthroscopic
response to injury. An experimental study in the dog. Am J Sports Med
partial meniscectomy. Am J Sports Med 23:230-244, 1995
11:131-141, 1983
31. Wroble RR, Henderson RC, Campion ER, et al: Meniscectomy in chil-
13. Gries PE, Holstrom MC, Burdana DD, et al: Meniscal injury: basic
dren and adolescents: a long-term follow-up study. Clin Orthop 279:
science and evaluation. J Am Acad Orthop Surg 10:168-176, 2002
180-189, 1992
14. Ghosh P, Taylor TK: The knee joint meniscus. A fibrocartilage of some
32. King D: The healing of semilunar cartilages. Clin Orthop 1990:4-7,
distinction. Clin Orthop 224:52-63, 1987
15. Kocher MS, Micheli LJ: The pediatric knee: evaluation and treatment, 1936
in Insall JN, Scott WN (eds): Surgery of the Knee (ed 3). New York, 33. Eggli S: Long-term results of arthroscopic meniscal repair: an analysis
Churchill Livingstone, 2001, pp 1356-1397 of isolated tears. Am J Sports Med 23:715-720, 1995
16. Vahvanen V, Aalto K: Meniscectomy in children. Acta Orthop Scand 34. Johnson MJ, Lucas GL, Dusek JK, et al: Isolated arthroscopic meniscal
50:785, 1979 repair: a long-term outcome study (more than 10 years). Am J Sports
17. Stanitski CL: Meniscal injuries in the skeletally immature patient, in Med 27:44-49, 1999
Delee J (ed): Delee and Drez’s Orthopaedic Sports Medicine (ed 2). 35. Barber FA, Herbert MA: Meniscal repair devices. Arthroscopy 16:613-
Philadelphia, WB Saunders, 2003, pp 1687-1692 618, 2000
18. Andrish JT: Meniscal injuries in children and adolescents: diagnosis 36. Dowdy PA, Miniaci A, Arnoczky SP, et al: The effect of cast immobili-
and management. J Am Acad Orthop Surg 4:231-237, 1996 zation on meniscal healing. An experimental study in the dog. Am J
19. Manzione M, Pizzutillo PD, Peoples AB, et al: Meniscectomy in chil- Sports Med 23:721-728, 1995
dren: a long-term follow-up study. Am J Sports Med 11:111-115, 1983 37. Austin KS, Sherman OH: Complications of arthroscopic meniscal re-
20. Boden SD, Davis DO, Dina TS, et al: A prospective and blinded inves- pair. Am J Sports Med 21:864-868, 1993
tigation of magnetic resonance imaging of the knee. Abnormal findings 38. Rubman MH, Noyes FR, Barber-Westin SD: Arthroscopic repair of
in asymptomatic subjects. Clin Orthop 282:177-185, 1992 meniscal tears that extend into the avascular zone. A review of 198
21. Kocher MS, DiCanzio J, Zurakowski D, et al: Diagnostic performance of single and complex tears. Am J Sports Med 26:87-95, 1998
clinical examination and selective magnetic resonance imaging in the 39. Cannon CR, Vittori JM: The incidence of healing in arthroscopic me-
evaluation of intra-articular knee disorders in children and adolescents. niscal repairs in the anterior cruciate ligament-reconstructed knee ver-
Am J Sports Med 29:292-296, 2001 sus stable knees. Am J Sports Med 20:176-181, 1992