The Pelican Sign: Case Series Demonstrating A Unique Description of an Anteriorly Flipped Bucket-Handle Meniscal Tear of the Knee

Abstract Introduction  Bucket-handle tears (BHTs) of the menisci are not uncommon and can occur in isolation or in conjunction with other injuries. The torn fragment can be displaced within the intercondylar notch or flipped anteriorly. In case of anterior flipped fragment, appearances of such tears on magnetic resonance imaging (MRI) scan have been described as various signs in literature (for example double posterior cruciate ligament sign, double delta sign) but mostly in the sagittal or coronal planes. Purpose  The aim of this study was to describe a unique ancillary sign that helps to identify this injury on the axial MRI plane where the anterior flipped BHT figuratively resembles a “pelican bird.” Materials and Methods  A retrospective review of MRI sequences of 10 consecutive patients over a 3-month period referred following a traumatic knee injury with anterior flipped meniscal tears was performed. Demographic details, clinical indication, and other associated features on the MRI were correlated following the observation of characteristic MRI appearance of a BHT. Results  All 10 patients (M:F = 7:3) with a mean age of 24.7 (17–38 years) presented following a twisting injury. 6 out of 10 patients had associated soft-tissue injuries in the knee visualized on the MRI. All patients demonstrated the distinctive “pelican bird” sign on the axial sequences of anterior flipped BHT of either menisci. This was not present with BHTs with displaced fragment within the intercondylar notch. Conclusion  We conclude that the “pelican sign” on an axial sequence when present correlates well with a BHT and its anterior displaced/flipped meniscal fragment. This ancillary sign can complement other previously described signs on different MRI sequences used to confirm a displaced BHT.