The Triple PCL Sign: Bucket Handle Tears of Both Medial and Lateral Menisci in a Chronically ACL-Deficient Knee

Abstract

Bucket handle tears of both menisci in the setting of acute or chronic anterior cruciate ligament (ACL) tears of the same knee have rarely been reported in the literature. This article presents a case of a bucket handle tear affecting both the medial and lateral menisci in a patient with chronic ACL rupture. Both bucket handle tears were displaced and locked in the intercondylar notch. A new magnetic resonance image (MRI) sign suggested on sagittal view is called the triple PCL sign, comprising the intact posterior cruciate ligament (PCL) and the 2 displaced fragments in the intercondylar notch from the two bucket handle tears. The precise diagnosis of this condition is of obvious importance for optimal operative planning. While finding the displaced fragment from the medial meniscus is expected to cause the double PCL sign, the torn ACL may have made it easier to visualize the bucket handle tear of the lateral meniscus in the same sagittal plane as the PCL. Only 5 other reports mention bimeniscal bucket handle tears of both the medial and lateral menisci in association with an ACL tear. None have shown the suggested triple PCL sign because of lack of overlap between the 2 bucket handle tears in the coronal plane while lying in the intercondylar notch causing them not to fall in the same sagittal plane. Our patient showed some overlap between the 2 meniscal fragments while lying in the notch to create the triple PCL sign on sagittal MRI.

Locked bucket-handle tears of both medial and lateral menisci with simultaneous anterior cruciate and medial collateral ligaments injury

“…Tecklenburg et al 4 reported that the arthrofibrosis in their patient might have resulted by the extensive initial surgery. Information regarding physiotherapy regime, complications and more importantly follow-up evaluation, are not given in the other cases reported 1–3. This kind of injury is a complex one and in our opinion long-term follow-up will only reveal the natural history of such cases.…”

“…Bugnone et al 1 described the quadruple cruciate sign in which four structures are demonstrated in the coronal images: the ACL, posterior cruciate ligament (PCL) and the medial and lateral bucket-handle meniscal fragments. Kakel et al 3 reported the triple PCL sign in which in the sagittal view, the PCL and the two meniscal fragments lying in the notch are seen.…”

Locked Bucket Handle Tears of the Medial and Lateral Menisci with Associated Chronic ACL Deficiency

“…All reported cases are of young adults (16-38 years of age) and have followed a traumatic event occurring at some stage prior to presentation -these included twist injuries sustained during skiing, football, basketball, biking and dance activities, one motorcycle accident, and one fall from a height [3][4][5][6][7][8][9][10][11][12]. Our patient sustained his initial and presenting injuries playing football, in both cases describing a high impact twist mechanism.…”

“…Bi-compartmental bucket handle tears have been described as either an acute injury, where both menisci are injured during a single event [3][4][5][6][7][8][9][10], or as part of a chronic picture with multiple episodes of giving way, clicking and catching episodes [11,12]. In addition, they are described in association with both ACLdeficient [3][4][5][6][7][8]11,12], and ACL-intact knees [9,10].…”

“…The presence of a bucket handle tear in both the medial and lateral meniscus is a phenomenon that is rarely reported in the literature. Those that are [3][4][5][6][7][8][9][10][11][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.…”