What is a bucket handle tear of the meniscus?

What is a Bucket Handle Tear?

A bucket handle tear is a specific type of vertical longitudinal meniscal tear where a displaced fragment of the meniscus flips centrally into the intercondylar notch of the knee, resembling the handle of a bucket, and typically causes mechanical locking that requires urgent surgical intervention. 1, 2

Anatomical Description

• The tear pattern is vertical, longitudinal, or oblique in direction with an attached fragment that becomes displaced from the parent meniscus body 1
• The displaced fragment typically flips into the intercondylar notch between the femoral condyles, creating the characteristic "bucket handle" appearance 1, 2
• These tears occur in either the medial meniscus (more common) or lateral meniscus, with medial tears being approximately three times more frequent 3
• The tear usually occurs in the white-white zone or red-white zone of the meniscus 1

Clinical Presentation

• Patients experience intermittent or persistent mechanical locking of the knee as the displaced fragment blocks normal joint motion 4, 2
• Pain, perceived instability, and inability to fully extend the knee are hallmark symptoms 2
• Most cases result from traumatic injury rather than degenerative processes 2, 3
• Bucket handle tears are frequently associated with ACL injuries, particularly acute ACL tears for lateral meniscus and chronic ACL deficiency for medial meniscus 3

Diagnostic Imaging Features

MRI reveals several characteristic signs that help identify bucket handle tears: 1, 2

• "Fragment within the intercondylar notch sign" - the displaced fragment visible in the notch
• "Flipped meniscus sign" - the fragment appears flipped over
• "Double anterior horn sign" - two meniscal structures visible anteriorly
• "Absence of the bow tie sign" - missing normal meniscal body on consecutive sagittal images
• "Double PCL sign" or "triple PCL sign" - the displaced fragment mimics additional cruciate ligaments
• "Quadruple cruciate sign" or "Jack and Jill lesion" - when both medial and lateral bucket handle fragments are displaced alongside intact ACL and PCL 2

CT can also diagnose bucket handle tears in trauma settings when MRI is unavailable, though MRI remains the gold standard 5

Critical Management Distinction

This injury pattern requires fundamentally different management than degenerative meniscal tears: 6, 7, 8

• Bucket handle tears causing true mechanical locking (objective inability to fully extend the knee) require urgent arthroscopic surgery with repair or partial menisectomy 6, 8
• The Journal of the American Academy of Orthopaedic Surgeons recommends admission for surgery with arthroscopy and repair for locked knee/bucket handle meniscal tears 6
• This is the ONE clear exception to the general recommendation against arthroscopy for degenerative meniscal pathology 8
• Conservative management is generally not recommended as first-line treatment for bucket handle tears in young patients 7, 8

Common Pitfall

Do not confuse bucket handle tears with degenerative meniscal tears - the BMJ guidelines strongly recommending against arthroscopy for degenerative knee disease explicitly do NOT apply to traumatic bucket handle tears causing mechanical obstruction 7, 8. The presence of clicking or catching alone does not indicate a bucket handle tear; true mechanical locking with objective inability to extend the knee is the defining feature requiring surgery 8.

Rare Considerations

While spontaneous healing of bucket handle tears has been described in rare cases (primarily young patients), this is exceptional and should not delay surgical evaluation when mechanical locking is present 4.