1- Meniscal lesion:
The medial meniscus is involved in over 70% of cases. Originally essentially traumatic. Median time: 36 years.Vascularization meniscus decreases from the periphery to the center. The medial meniscus is C-shaped, essential during flexion-extension (with the ACL prevents the anterior tibial translation of), it is not mobile (meniscus ext. Is mobile).
A- Mechanism:
differing constraints on the posterior segment of the medial meniscus to the tablet by the liver and femoral condyle brought forward by its capsular insertion. 2 mechanisms:
– The occasional occurrence of a lesion of the medial meniscus is the external tibial rotation on a slightly bent knee, foot fixed to the ground in support monopod.
– The other mechanism is hyperflexion followed by a sharp increase (tile)
* Result: longitudinal slot (vertical) of the posterior part of the internal mis-nisque which can be extended before performing the bucket handle. This bucket handle can dislocate in the intercondylar notch and cause joint fusion.
B- Clinic:
* Pain: almost constant; horizontal on the joint line commences
* Hydrarthrosis: Inaugural then can be recurrent mechanical type
* Blocking: the extension of limitation; but not limited flexion (genu flexion analgesic). The release is followed by a snap or jump.
* Instability sensation: and dérobement
* Shock patellar -> hydarthrosis
* Cry meniscal: exquisite tenderness of the joint space and the progressive extension of the knee (sign Oudard)
* Projection of the internal meniscus associated with pain during the transition from flexion to extension and stress leg external rotation (MacMurray maneuver)
* The “grinding test”: pain caused by compression and external rotation of the leg, knee flexed to 90 ° and patient in the prone position (Apley maneuver)
* Test Généty: ventral decubitus patient, the knee projecting from the table. The leg on the affected side down so low (flexion) than the other.
* A complete ligament examination is always associated with the review of the menisci
C- Imaging:
* Arthrography: not systematic, it is done remotely trauma
* Magnetic resonance imaging (it has the same reliability as arthrography graphy with false positives)
* NB: arthroscopy is not part of the diagnostic tests but can confirm the injuries and especially to have a therapeutic role
D Differential Diagnosis
Blocking foreign bodies; chondropathies patellar (instability rotu-lian); plicae synovial; synovitis villonoculaire; cysts of the lateral meniscus; discoid lateral meniscus.
E- Evolution:
– Peripheral lesions have a greater healing potential (especially for highly mobile lateral meniscus)
– The isolated meniscal resection or particularly associated with ligament injuries of the central pivot generates osteoarthritis of the knee in the long term (the term evolutionary any meniscectomy).
F- Treatment:
– Lesions minimal if they are tolerated can benefit only from a functional treatment: rest, NSAIDS, analgesics.
– Partial Meniscectomy arthroscopic meniscal rupture at
– Irreducible dislocation of the bucket handle -> meniscectomy in semiurgence.
– At very peripheral vascular lesions located in zone meniscal sutures can be achieved if the knee does not present ligament instability associated.
Meniscal lesion external –
It is most commonly achieved at trauma, but the healing potential which is more important that it is rarely clinically translated. The lesion is often horizontal or cross. The lateral meniscus is presented morphological abnormalities (discoid meniscus, hypermobile meniscus). The presence of meniscal cyst (horizontal injury) may oriented external diagnosis (swelling that appears on the extension and flexion disappears)
* Degenerative the medial meniscus (miniscose)
This is worships older (> 40 years) whose morphology is often in knee varus. The beginning is more progressive. The internal pain relief predominates with complained of inflammatory (night pain). OA is most commonly found.Impressions of evasions or instability are common. Genu flexion deformity is rarely found, complete flexion can be painful. There is often a hydarthrosis. The direction finding lower limbs (radiography) allows found the varus deformity.Arthroscopic meniscectomy treatment or valgus osteotomy (if there is an important internal tibiofemoral pinch associated with a varus).
2- Ligament injuries:
– The central pivot is composed of prior and posterior cruciate ligaments. A ruptured ligament does not heal (still tense).
– Device Training: medial collateral ligament, lateral collateral ligament and the posterolateral corner and postérointerne points.
– Moderately serious sprain -> rupture of peripheral structures (LLI)
– Severe sprain: involvement of the central pivot
– Segond fracture: fracture of the anterior edge of the external tibial plateau confirming the ruptured anterior cruciate ligament.
A- lesional mechanisms:
* Valgus or varus pure: begins to injure the lateral ligaments
* Pure Rotation: external rotation damages the peripheral elements while the inner rotation damages the central pivot starting with the anterior cruciate ligament.
* Hyperextension (shoot into space) first broke the anterior cruciate ligament
* Posterior drawer (by direct trauma to the anterior surface of the anterior tibial extrem-ity) -> posterior cruciate ligament (it’s the classic accident “dashboard”)
* External valgus-flexion-rotation: (ski) lese first the internal lateral ligament and the anterior cruciate ligament. The medial meniscus is often injured (anteromedial triad). When more violent trauma -> pentad by reaching the posterior cruciate ligament
* Internal Varus-flexion-rotation (fall motorcycle jump receipt) reached the anterior cruciate ligament and the external ligament.
Involvement of the lateral meniscus is common. reaching the posterior cruciate ligament is possible if more violent trauma.
B- Clinic:
* The presence of a haemarthrosis fears the rupture of anterior cruciate ligament (70%) -> patellar shock
* Movement disorders in a frontal plane:
* The varus and valgus forced at 30 ° of flexion explore the lateral ligaments. Frank laxity indicates a ligament rupture.If laxity persists when the knee is extended, it must fear an extended break peripheral structures (joint capsule).
* Abnormal movements in a sagittal plane:
* Anterior drawer increased to 20 ° of flexion (sign Lachman) is the most suggestive evidence of rupture of the anterior cruciate ligament
* Posterior drawer 90 -> posterior cruciate ligament rupture
* A recurvatum -> is a serious sign that testifies to achieve at least a cruciate ligament and a corner point.
* Abnormal movements in a horizontal plane
* The internal rotation jump (shift pivot McIntosh or Lemaire) is pathognomonic of a torn anterior cruciate ligament. The projection corresponds to the reduction of the anterior subluxation of the tibial plateau at 30 ° of flexion of the knee in varus and forced internal rotation. The Jerk-test proceeds from flexion to extension.
* The jump in external rotation can be found on normal knee
C- Treatment:
* The TRT premium ligament rupture on that of Menis-wedge injury
* Severe sprain of the MCL -> cast immobilization for 6 weeks
* Lesion isolated ACL -> according to the age. sports topic: surgery (ligament). In all cases, rehabilitation is fundamental and must often be extended up to 6 months to 1 year.
* In case of infringement associated (ACL + MCL) -> articulated knee; if the knee remains unstable -> secondary ligamentoplstie
* Achievement of the posterolateral corner point -> surgery urgently. This is the only case where the surgery is essential.
NB -> a neglected severe sprain always causes laxity that leads to chronic instability in the medium term and knee OA may occur in the long term.