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Acute traumatic medial meniscal tear — MSRA MCQ

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HardKnee InjuriesAcute traumatic medial meniscal tearMSRA

A 19-year-old man attends general practice 3 days after twisting his right knee while rising from a deep squat during weight training. He felt a pop at the medial joint line and stopped exercising. Swelling developed gradually over the subsequent evening. He can weight-bear with a limp but reports recurrent painful catching when turning. Examination shows a small effusion, focal medial joint-line tenderness, and pain with external rotation of the tibia at 90 degrees of knee flexion. He has full active and passive extension and flexion to 125 degrees. Lachman, posterior drawer, and collateral ligament testing are normal. He can perform a straight-leg raise. There is no bony tenderness, deformity, neurovascular deficit, fever, or erythema. Plain knee radiographs are normal. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Arrange urgent referral to an orthopaedic knee service

Explanation lettering: C = shown as A · E = shown as B · A = shown as C · B = shown as E

This presentation is highly suggestive of an acute traumatic medial meniscal tear: a twisting mechanism, delayed effusion, focal joint-line pain, and rotational provocation of pain. He does not have a true locked knee: he has full extension and flexion beyond 90 degrees, with intermittent catching rather than a continuous mechanical block. Therefore, same-day emergency assessment for urgent arthroscopy is not indicated. However, he is under 30 years old and has a convincing acute traumatic meniscal history. UK orthopaedic referral guidance recommends urgent referral in this group because a recent peripheral or bucket-handle tear may be amenable to timely meniscal repair. This differs from an unstable flap tear with mechanical symptoms in an older patient, or a degenerative tear, where an initial period of conservative management is generally appropriate. A is therefore inappropriate because it risks delaying assessment of a potentially repairable tear. C is plausible because MRI may be useful in suspected meniscal injury, but referral should not be delayed for primary-care MRI when urgent assessment is indicated in a young patient with an acute traumatic tear. D would become appropriate with true locking, defined by a persistent loss of extension and inability to flex to 90 degrees. E has no role in the initial management of this acute potentially repairable injury.

Reference: NHS Tayside RefGuide: Meniscal Problems (Next review date: 02/07/2027) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/knee/meniscal-problems/?organization=nhs-tayside&useNavigation=true NHS Tayside RefGuide: MRI Criteria (Next review date: 02/07/2027) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/knee/mri-criteria/?UNLID=&useNavigation=true