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Young and Idiot

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LESIONS LIGAMENTAIRES ET MENISCALES AIGUES DU GENOU

RAPPELS ANATOMIQUES :
L’articulation du genou est entre tibia (plateaux tibiaux et épine tibiales) et fémur (echanchure inter condylienne du fémur)
Membrane synoviale qui tapisse l’ensemble de l’articulation.
L’espace fémoro patellaire communique avec espace fémoro tibial : cet espace remonte jusqu’au cul de sac quadricipital

Pivot central ou ligaments croisés : assure la stabilité antéro postérieur et rotatoire du genou : * Ligament croisé antéro externe : face interne du condyle externe * Ligament croisé postéro interne : face externe du condyle interne
Ils sont dans le fer à cheval ouvert en arrière de la capsule : ils sont extra capsulaire et extra articulaire
Le LCAE est collé à la capsule. En cas de rupture, ce ligament va déchirer avec lui les structures capsulaires auquel il adhère : provoque un saignement dans l’articulation (hémarthrose) et rend positif le choc rotulien. il est richement vascularisé.
Les ligaments collatéraux
Ils sont extra articulaires et extra capsulaires
Ils ne collent pas a la capsule et peuvent déchirés sans rompre la capsule : il peut tout de même y avoir des ecchymoses mais jamais d’hémarthrose lorsqu’ils rompent seuls.
Fractures articulaires : * Fracture de la patella * Fracture des plateaux tibiaux * Fracture des condyles fémoraux * Fracture de l’échancrure * Fracture de l’épine : va provoquer une hémarthrose
Absence d’hémarthrose ne veut pas dire qu’il y a une rupture du LCAE

CIRCONSTANCES ET MECANISME :
LESIONS DU LCAE : * Chute dans les escaliers * Chute d’un lieu élevé * Chute en ski * Football, tennis, basket * Chute au travail
Lors d’un shoot : hyper extension du genou avec contraction contrariée : provoque une avancée du tibia en avant : tiroir antérieur positif.
Flexion rotation externe et valgus ou flexion rotation interne et varus.
Lors d’une flexion rotation externe valgus
Le premier ligaments sollicité sera le LLi . Puis le ménisque interne puis LCAE et le LCPI * Triade : lésion LLI, ménisque interne, LCAE, LCPI. * Pintade : LLI ménisque interne LCAE LCPI (+ point d’angle postéro interne : nappe fibreuse entourée par la capsule, la corne postérieure du ménisque interne et le tendon du semi membraneux )
Lors d’une flexion rotation interne valgus
LLE puis ménisque externe puis LCAE puis LCPI * Triade : lésion LLE, ménisque externe, LCAE, LCPI * Pintade : lésion LLE, ménisque externe, LCAE, LCPI(+ point d’angle postéro externe : nappe fibreuse profonde, au contact de l’articulation, entourée par la capsule, la corne postérieure du ménisque externe, le biceps fémoral, les extensions du muscles poplité)

EXAMENS COMPLEMENTAIRES :
A LA RADIO :
Si ottawa positif : radio profil et face
Si patella : radio avec incidence fémoro patellaire
LLI et LLE : on peut trouver des arrachements osseux au niveau condyles fémoraux et tête de la fibula
LCAE et LCPI : arrachement osseux de l’épine tibiale : lésion grave
Hémarthrose apparait comme un comblement gris

A l’IRM
Injection d’un produit opaque dans l’articulation : dessin en négatif des ménisques : montre une rupture capsulaire par la fuite du produit
Lésions ligamentaires, méniscales, et osseuse (hyper signal)
Lorsque le LCAE rompt, il tombe, se couche
TRAITEMENTS :
Ponction de l’hémarthrose au niveau de l’angle supéro externe de la patella. Souvent 60 à 100 cc de sang : soulage le patient.
Le patient repart avec une orthèse, atèle de Zimmer posé a titre antalgique pendant 8 jours.
Puis rééducation : libération du genou
KINESITHERAPIE : on va renforcer les muscles voisins : principalement les ischios jambier pour ne pas accentuer le tiroir antérieur
CHIRURGIE :
Kenneth Jones : LCAE rompu, il n’est pas suturable : on va le remplacer par le milieu du tendon patellaire avec ses insertions osseuses. On le fixe à l’emplacement habituel du LCA : épine tibiale et face interne du condyle externe.
Cette méthode est la plus rependue et donne le moins de récidive (1 à 2%). Elle sera suivit par une rééducation.
INDICATIONS : * Jeunes sportifs de haut niveau * sportif de 40 ans * récidive : instabilité résiduel * Sinon kiné
COMPLICATIONS : * Instabilité : * Arthrose : lésion du cartilage et des ménisques

Lésion du LCPI :
Choc du tableau de bord. TABLEAUX CLINIQUES : * Choc rotulien positif témoignant de la présence d’une hémarthrose : dans 95% des cas lésions LCAE avec capsule * Douleur et réaction inflammatoire * Test de Lachmann (15 20 de flexion) ou du tiroir positif
Attention aux faux positifs provoqués par la rupture du LCPI et aux faux négatifs provoqué par les contractures musculaires et des épanchements articulaires * Ressaut rotatoire positif : peut être faiblement présent * Douleur, pression dans le genou * Sensation de dérobement du genou plusieurs semaines après : instabilité
TRAITEMENT
LESIONS DU LCPI :
Lésions rares contrairement au LCAE
C’est la dernière barrière : il faut un mouvement très violent. Mais il peut être touché dans le syndrome du tableau de bord.

TABLEAUX CLINIQUES : * Comblement du creux poplité * Pas forcément d’hémarthrose * Sensation de gros genou mais choc rotulien négatif * Recul de la TTA en arrière : tiroir postérieur spontané * Flexion limitée * Possibilité d’un faux positif du tiroir antérieur car tiroir postérieur spontané * Pas d’instabilité réelle.
Lorsque LCP associés a d’autres lésions : souvent très grave

Si rompu avec le LCA, c’est le LCA qui primera
Si il rompt rompt seul : renfort quadriceps

LESION DU LIGAMENT COLATERAL TIBIAL OU LLI Ligament large : fasiceau fémoro tibio, fémoro méniscaux et méniscaux tibiaux
Entorses isolées très fréquentes.

MECANISME : * Valgus * Flexion valgus rotation externe
CLINIQUE : * Douleur face interne du genou * Douleur a la palpation * Etiré : entorse bénigne * Rompu : entorse sévère * Réaction inflammatoire post traumatique * Ottawa genou pour être sûr qu’il n’y a pas de fracture * 4 pas sans aide : fracture articulaire * Palpation de la tête de la fibula, patella * Flexion du genou active : si ne dépasse pas 90°, ottawa positif * Lésion isolée LLI ottawa négatif * Pas d’hémarthrose car extra articulaire

Test dynamique lorsqu’il n’y a pas de fracture

TRAITEMENT :
Traitement orthopédique : 3 semaines pour une entorse bénigne et 6 semaines pour une entorse grave
On peut éviter les mouvements latéraux mais ne pas empêcher une flexion extension : pas d’enraidissement.

COMPLICATIONS : * Syndrome de Pelligrini: souffre encore plusieurs semaines, plusieurs mois après et limitations du mouvement qui deviennent algiques. Calcification du LLI, flou, irrégulière
A traiter comme une tendinopathie calcifiante. * Infiltrations locale de corticoides * Ains et antalgiques * Ultrasonothérapie * Pas de place pour le traitement orthopédique * Syndrome de Palm : cicatrisation raccourcisant le LLI et l’épaississant. Douleur et limitation de mouvement.
Traitement : cf pelligrini * Instabilité

Lésions du LLE :

Fréquence du mécanisme
Varus seul ou varus RI
Lésé souvent dans un complexe de triade ou pintade et rarement seul

CLINIQUES * Douleur face externe genou * Pas d’hémarthrose car extra capsulaire * Réaction inflammatoire post traumatique * Ottawa négatif

TRAITEMENT :
Traitement orthopédique : 3 semaines pour une entorse bénigne et 6 semaines pour une entorse grave
On peut éviter les mouvements latéraux mais ne pas empêcher une flexion extension : pas d’enraidissement.

LESIONS MENISCALES :

Fibro cartilage permettant d’augmenter la congruence articulaire
La partie latérale adhère quasiment a la capsule externe surtout
Ils amortissent les chocs violents entre les deux os surtout lors des mouvements de flexions rotations.
Lésions fréquentes surtout le ménisque interne, genou droit, corne postérieure.
Les ménisques sont peu vascularisés

MECANISME ET CIRCONSTANCES * Position accroupie chez les personnes de forte corpulence * Football
Fissure longitudinale (plus fréquente) et fissure transversale * La partie fissurée peut agir comme un corps étranger et bloqué l’articulation en hyper extension. * Genou qui se dérobe * Hydarthrose : liquide réactionnel, épanchement dans le genou provoqué par la synoviale * Douleur comme un éclair *
Anse de seau : les deux cornes restent attachées et il y a une fissure entre les deux

CLINIQUES : * Hyper extension impossible * Douleur peut être derrière comme devant * Cri méniscal : palpation de l’interligne en fonction du ménisque lésé * Signe de Mc Murrey : provoque une pression au niveau du ménisque :le praticien empaume le pied et effectue un mouvement rotatoire et une valgisation du genou en passant de l’extension à la flexion : a ne pas faire si Ottawa positif

Si épanchement réactionne l : on ponctionne
Si blocage : on le dégage : ménisque interne : valgisation
Si anse de seau : traitement chirurgical a ciel ouvert ou sous arthroscopie * Réinsérer la languette méniscale avec le ménisque principal * Exciser cette languette méniscale
Pour opérer un ménisque

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