La fracture de fatigue du col fémoral chez le sportif d’endurance : l’importance d’un diagnostic précoce

Stress fractures of the femoral neck are rare traumatic events but they are far from being exceptional within the high level sportsmen community and even less rare within the military. The authors report the case of a 19 years old young man enlisted in the French Foreign Legion. He came up with a right femoral neck stress fracture as a result of intense physical exercices. Although painful prodromic signs had been evolving for 15 days, the right diagnosis wasn’t made until the fracture moved to Garden III. The surgical treatment consisted in a reduction with a triple screwing of the femoral neck. One year later, the fracture was set to anatomic position, the hip function was normal and the femoral head showed no signs of osteonecrosis. The patient was then lost for further follow-up. When there has been no slipping, these fractures develop favourably with an ad integrum hip restoration. On the other hand, a secondary slipping leads to a pathology that has to be taken care of in a quite different way, with an often catastrophic outcome at the functional level. Nearly constant prodromic signs come in usefully for an early diagnosis. Secondary slipping of the femoral neck stress fractures should happen less frequently by an appropriate awareness campaign aimed at all the health professionals including sports trainers.     

Hernie musculaire postérieure de la cuisse réparée par plaque non résorbable. À propos d’un cas et revue de la littérature

Muscle hernias in the hamstring (semitendinosus, semimembranosus and biceps femoris) area of the thigh are rarely described in the literature. We report a case of an athletic patient, an avid cyclist, who presented a daily discomfort in the posterior region of the left thigh with irradiation to the knee and it became intensive in one year. A soft reducible non-painful superficial mass could be palpated. Ultrasonography reveals the herniation of fatty tissue through the superior superficial fascia of the thigh at the base of the posterior cutaneous nerve. Since primary repair of the fascial dehiscence was not possible, the surgery was performed by implanting a non-degradable surgical mesh, routinely used to treat inguinal hernias. The results after 24 months of follow-up are highly satisfactory: the patient has been able to return to all his daily and sports activities without discomfort or recurrence of the hernia.     

Rupture post-traumatique négligée du retinaculum extensorum à la cheville. À propos d’un cas et revue de la littérature

Post-traumatic ruptures of the retinaculum extensorum (RE) to the ankle is rare and behind a tendinous luxation, of a rope effect, tiredness and weakening or loss of strength. We report the observation of a patient aged 35 practicing full contact for 20 years, victim of a sports accident two years before upon a foot kick in the kicking bag during a training session bringing about a rupture of the RE at the ankle. Imagery (echography and MRI) made sure the clinical exam and to call for the diagnosis of the rupture of the lower band of the retinaculum with subluxation of the tendons of the tibialis anterior and of the extensor hellucis longus. The take in charge consisted of a local plasty of the RE. On the relapse (6 months), the patient is satisfied with the outcome and taking back to his initial sports activity. Through our observation and a review of the literature, we attempt to review the anatomy of the RE to the ankle and to analyze the causes and the consequences of its rupture as well as the usefulness of the imagery in analyzing its anatomic structure. The rupture of the RE is a rare affection mainly affecting sports persons. They can be unseen and may compromise the sports career of athletes. A meticulous clinical exam and targeting imagery as well as an adequate take in charge allow avoiding this unwanted evolution.     

Reconstruction du LCA chez le sportif de compétition. Évaluation, à court terme,après reprise du sport

Background

Most studies have observed satisfactory outcome after anterior cruciate ligament (ACL) reconstruction. The best series report 80 to 90% success, irrespective of the type of operation. The purpose of this work was to investigate resumption of sports activities after ACL reconstruction. We studied the impact of the conditions of sports activity after the operation, gender, type of sport, presence of an extra-articular reinforcement and time since surgery.

Material and method

In order to search for significant differences between the postoperative and follow-up scores, a questionnaire with a subjective IKDC grid was addressed 12 months after their hospitalization to all athletes who had undergone ACL reconstruction at the CERS from 1^st January, 2003 through 31^st October, 2004.

Results

For the period considered, 2248 athletes were hospitalized at the CERS for ACL reconstruction. The response rate was 43% (969 responses at 12 months). There was no significant difference between the hospitalized population and the responders in terms of type of sports activity or type of graft. There was however a significant female predominance among responders (p = 0.01). Mean follow-up was 13.9 ± 2.9 months. Reconstruction methods were: hamstring graft 54%, free patellar graft 43%, MacIntosh fascia lata 2%, MacIntosh quadriceps 1%. The main activity was a pivot sport for 74% of the athletes. Male gender predominated: 77%. There was no difference regarding postoperative training, but competition level was achieved more readily by males (65% versus 54%, p = 0.0038), since more females stated resumption of competition was not an objective. It was also noted that resumption of training occurred earlier for gliding sports than for pivot–contact sports (7.32 ± 2.09 months versus 8.23 ± 2.66 months, p = 0.021). The presence of a lateral reinforcement did not have a significant impact on resumption of sports activities which was more frequent in the hamstring group than the patellar group (16% versus 7%, p < 0.0001) and more frequent in the pivot–contact sports (p = 0.0039). Regarding the role of the surgical technique, resumption of training and competition was better after hamstring plasty compared with patellar tendon plasty for follow-up less than or equal to 12 months (p = 0.0009 and 0.0001 respectively). The subjective IKDC score was also significantly better in the hamstring group for the period considered (p = 0.0006). The differences observed early in the follow-up resolved over time and no significant difference was observed at 18 and 22 months. Regarding the MacIntosh fascia lata plasty, resumption of competition was significantly earlier (7.67 ± 1.87 months) compared with hamstring plasty (9.69 ± 2.58 months) and patellar tendon plasty (9.65 ± 3 months). Resumption of training (90%) and competition (76%) was also better with the MacIntosh fascia lata plasty compared with the two other techniques but the difference was not significant. These differences, in favor of the MacIntosh fascia lata plasty, might have been due to a recruitment bias since the level of the sports activities was significantly higher in the MacIntosh population than in the populations of the other two methods.

Conclusion

This study is of particular interest because of the size of the homogeneous study population resulting from the highly selective recruitment of athletes at the CERS. This study is generally in agreement with prior data in the literature, particularly concerning the rate of resumed training one year after surgery. This study shows that the patellar tendon plasty reaches maturity more slowly than the hamstring plasty although the two techniques yielded comparable results at 18 months for all criteria studied.     

Traitement des luxations récentes du coude : à propos de 30 cas

Elbow dislocations are encountered in contact sports and other extreme sports. This retrospective study included 30 cases of elbow dislocations, treated between 2007 and 2012. The average age of our patients was 36 years, all male and victims of violent trauma in local equestrian competitions. The dislocation was posterolateral in 23 cases and direct posterior in the other seven. This involvement was associated to a fracture of the radial head in six cases and a medial epicondyle tear in a patient. All subjects had a reduction under sedation or general anesthesia. Fractures of the radial head were treated by screwing in four cases and resection in two cases. We also made screwing for the epicondyle fracture. The treatment was completed by analgesic immobilization for about 10 days followed by active mobilization in 22 patients, in whom the elbow was considered perfectly stable. In eight patients, mobilization in the area of stability, protected by an articulated orthosis, was established for a minimum of 45 days. After a mean follow-up of 22 months, a range of motion for flexion-extension greater than 100° was achieved in 80% of patients and only two cases have kept a severe stiffness. The overall results, as assessed using the Mayo Elbow Performance Score, were good to very good in 25 patients, fair in three patients and poor in only two cases. The sport recovery was gradual and the return to competition was not allowed before the sixth month.     

Fracture-avulsion de l’épine iliaque antéro-inférieure et du petit trochanter chez un jeune adolescent

The avulsion fractures of the anterior-inferior iliac spine and lesser trochanter are rare. They occur most often in adolescents during sports activities. The forms in adults are rare. We report a case in a young 15-year-old teenager. He had consulted for pelvic trauma with groin pain and functional impotence of the right lower limb occurred during a recent game in triple jump. Physical examination revealed pain in the mobilization of the right hip in extension. Standard radiography of the pelvis has highlighted an avulsion fracture of the anterior-inferior iliac spine avulsion of the right with small trochanter, which has been confirmed by computed tomography. The patient has been treated orthopedically by rest and landfilling lower limb trauma, evolution was marked the disappearance of pain a few weeks later and resumption of the sporting activity in order to 6 months.     

L’ostéome ostéoïde du col fémoral du sportif : intérêt de la résection percutanée scanno-guidée (À propos de 11 cas avec revue de la littérature)

Introduction

Treatment of the osteoid osteoma was based a long time on the surgical resection, but with a considerable frequency of complications. The percutaneous resection tomography-guided belongs to therapeutic progress of these last years, it became the method of choice for the treatment of osteoid osteoma in our institution. The purpose of our study is to evaluate effectiveness of this technic by analyzing the clinical evolution, the duration of convalescence and resumption of sports activities.

Patients and methods

It is a retrospective study concerning 11 observations of osteoid osteoma of the femoral neck, treated and followed to the service of Traumatology-Orthopedy II of the military hospital of the CHU Rabat between January 2004 and October 2009. Our series was composed of three professional athletes, two footballers exercising in national shampionship and six soldiers subjected to a constant and regular drive.

Results

This intervention was done in the day's hospital, all the patients left the hospital the same day with resumption of the total support in the 24 hours following operation. Nine patients (80%) observed a total disappearance of the pain a few hours after the intervention. With a minimal retreat one year, no case of complication was raised. And finally on the subjective level all the patients were satisfied and took again their sports activities on the same former level.

Discussion

The treatment for osteoid osteoma must be simple, precise, effective and the least expensive possible. In the light of our results and those brought back in the literature, the percutaneous resection tomography-guided is proven effective, sure, not very invasive and is associated with a reduction in the health expenditure. It can be recommended like the treatment of choice of osteoid osteoma as well for the femoral neck as for the other localisations. More aggressive and more expensive treatments are difficult to justify, in particular in sportsmen, thus allowing them a fast convalescence and an early recovery their sports activities.     

Les ruptures du tendon du muscle tibial antérieur

In sports medicine, tears of the tibialis anterior are exceptional. We describe our experience with one case. Two types of injury can be observed: true tears involving the main body of the muscle under the pulley or the more distal portion at the insertion and fissurations. These injuries usually occur in a context of longstanding tenosynovitis or tendinopathy and are generally observed in runners. The mechanism requires stretching with the foot in forced plantar flexion and external rotation (fall backward with forefoot blocked). The diagnosis is clinical. Complementary explorations, excepting plain X-rays to search for a distal detachment from the bone, are not indispensable. In sports medicine, surgical treatment is required for full thickness tears. A plasty is usually performed with the third toe extensor. Recovery is long and progressive. In our experience, corticosteroid injections do not provoke these tears but can be useful for more rapid recovery in the athlete. After an injection, we immobilize the ankle for three weeks in a walking cast in order to “limit” the motivated athlete.     

Calcification post-traumatique du muscle ilio-psoas. À propos d’un cas et revue de la littérature

Post-traumatic iliopsoas calcifications are extremely rare affections. We report the case of a patient who presented a right hip discomfort after a wakeboard accident. A thick calcification of the right iliopsoas was visible on standard X-rays. Surgery was performed by the removal of the calcification associated to a non-steroidal anti-inflammatory treatment. The result after six months was excellent. The patient has resumed his sports activities at the same level without discomfort and no recurrence of the ossification.     

Une estimation des décès traumatiques liés à la pratique sportive en France métropolitaine,en 2010

Introduction

Physical exercise presents numerous health benefits but it can also lead to accidents, of varying degrees of severity, some of which can result in death. The purpose of this study was to estimate, for the year 2010 in metropolitan France, the number of injury-related deaths linked to sporting practices.

Method

The study consisted in counting the injury-related deaths that occurred in 2010 in metropolitan France following a sporting practice, regardless of the context (professional, leisure or travel). Deaths linked to cycling, deaths in airplanes and deaths by drowning were not considered as sporting practices and so were not included in the study. The figures were collected from documentation compiled by government institutions or available in on-line media and the websites of associations and government organizations involved with sport.

Results

In 2010, 246 people died as a result of a sporting activity in metropolitan France. Mountain sports were the most dangerous (99 deaths), followed by water sports (50), hunting (27), aviation sports (23, of which 22 in ultralight/microlight aircraft), mechanical sports (23) and free flight sports (20, of which 10 were linked to paragliding and five to hang gliding). Seven times more men died than women. The most dangerous periods were summer and winter.

Discussion

Our study missed some cases, which led to an overly low figure for certain sports (horse riding and fishing, etc.), and missed those people who did not die immediately following their accident. This simple study, which remains to be completed, has provided an initial estimate of the number of injury-related deaths linked to sporting activities in metropolitan France.     

La rupture du tendon calcanéen : à propos de 53 cas

The Achilles tendon is the most resistant of the tendons of the human body; its rupture is increasingly frequent in the world and our country because of the considerable development of the sporting activities. This retrospective study relates to 53 observations listed in the service of traumatology and orthopedics of the Hospital Avicenne of Rabat over a period of 5 years between 2005 and 2009. Each patient underwent monitoring protocolisé. Criteria for Comis were used for clinical evaluation. All patients received open surgery. The middle age was of 37 years. The clinical examination was sufficient to pose the diagnosis. All the patients profited from an open surgery. Three patients presented pain after surgery. Infection local skin was noted in two patients. One patient presented a rerupture and 88.6% of the patients have very good performances. The rupture of the Achilles tendon is much more frequent in men; this is explained by the frequency of sports activity in men. Three patients had a history of tendinitis. Clinical examination was easy enough for diagnosis. Open surgical treatment remains the method most widely and most used. In the classic controversy between the effectiveness of surgical and orthopedic treatment in the rupture of the Achilles tendon, the emergence and development of percutaneous techniques still currently did not make it possible to conclude to the superiority of treatment over another.     

Lésions musculo-aponévrotiques et tendineuses. Classification–explorations radiologiques

The aim of this paper is to remind the classifications of sport-related myofascial and myotendinous lesions and to discuss the place of medical imaging (MRI and sonography). Muscular lesions are divided in extrinsic and intrinsic ones, whether they result from a direct impact or a brutal contraction or extension. O'Donoghue classification evaluates injury severity. Myofascial lesions may be peri-muscular, inter-muscular or intra-muscular. In tendinous lesions, we distinguish tendinosis, longitudinal intra-tendinous tears, partial and full-thickness tears. They occur from several origins: overuse tendinopathy, brutal pulling, direct impact, paratendinopathy by repetitive frictions or snapping. Medical imaging provides differential and positive diagnosis as well as injury severity, allowing evaluation of sports intermission. It allows evaluation of healing (doppler sonography and post-Gadolinium MR imaging). Doppler sonography performed by musculoskeletal radiologists has become more and more efficient and sufficient in a lot of cases. MR imaging is used in first or second intent, especially in professional sports and in serious conditions. It remains more accurate in small acute lesions, and in complex lesions, which are not rare in sport-related injuries.     

Lésions méniscales isolées chez le sportif. À propos de 120 cas

Meniscal lesion is a frequent affection in sport practice and which can affect – in mid and long terms – the fonctionnal prognosis of the knee and thus the sport career of the patient. Hence the importance of precocious diagnosis and adequate take-in-charge. We report a series of 120 cases of isolate meniscal lesions (76% internal meniscal lesions and 24% external meniscal lesions) in a sports population treated under arthroscopy and rechecked after a mean relapse of four years. Our results were good to excellent in 82.5% of the cases with retake of sport activity in 90% of our patients of which 60% in the preoperative level. 54% of the cases underwent standard radio control in their last visit. This control was normal in 46% of them, showed a pinching in the internal compartment in 22% of the cases and external in 32% of the cases. As for its reliability, its simplicity and relative innocuteness, the treatment of meniscal lesions under arthroscopy fulfills the requirements imposed by sport population's tasks.     

Étude épidémiologique prospective des pathologies dans le XV de France féminin de rugby de juillet 2006 à septembre 2010

The objective of this prospective study is to determine the rate of injury on the population of the French women's rugby team. It was conducted over 50 months from July 2006 to September 2010. The medical staff of the French team collected data during training and match exposure. One of the main results of the study is the significant difference in the incidence of injury leading to a sports interruption greater than 8 days between female and male (5.99/1000 hours vs. 42,1/1000 hours). Lower limb injuries represent half of the injuries observed in our study but the articular lesions represent 80.43% of the injuries leading to an interruption superior to 8 days with an incidence of 4.62/1000 hours of exposure per position. This confirms the data found in the medical literature. The ruptures of the anterior cruciate ligament, following a tackle, are the most severe lesions of our study. The forwards had a higher rate of injury than backs. The three positions most exposed to injuries are the nos. 8, 9 and 14. The players are most vulnerable when they are being tackled, during the runs and during the rucks. The study described significant differences concerning a much higher number of severe articular lesions, a more significant vulnerability of women in sustained tackles in a match situation and a different exposure of certain position, particularly the scrum-half and the right-wing.     

L’ostéochondrite disséquante du genou chez l’enfant et l’adolescent. Notre expérience à propos de 32 cas

Osteochondritis dissecans (OCD) rarely involves the femoral condyle and affects especially the athletes. Etiology of OCD remains enigmatic. This retrospective study analyzed 32 cases (28 children) stemming from a paediatric series. All the concerned children exercised a sports activity. OCD can be grave on the functional plan and burden the sports future of the child. The clinical symptomatology was poor. The circumstances of discovery were essentially represented by an atypical pain of the knee. The diagnosis was confirmed by a standard radiography revealing a specific hurt of variable aspect, being able to go of a simple suspect line to a big loss of substance at the level of the femoral condyles. The used classifications were the ones of Bedouelle, Cahill, as well as Harding one. Mostly, the pathology was diagnosed at a premature stage I and II of Bedouelle. The examinations of imaging (Magnetic Resonance Imaging [MRI], CT scan) were individually decided to explore the lesion or for a choice of the therapeutics. The stake in simple discharge with a strict stop of the sport gave satisfactory results so clinical as radiological in our study. The surgery was exceptional. The forecast is usually good at the child's subject to an adapted coverage by not allowing passing the hour of the surgery. The sport practised in an excessive, intense way (competitive sport) is recognized as a major risk factor.     

Le traitement des fractures comminutives de l’extrémité distale du radius par fixateur externe : à propos de 18 cas

Comminuted fractures of the distal radius are common. A retrospective study was conducted in the department of orthopaedic trauma-A of university hospital Hassan II of Fez on a six-year period between January 2005 and December 2010 involving 18 cases of comminuted fractures of the distal radius treated with distraction external fixator. The average age of our patients was 28 years old, all male, all of our patients had a wrist injury during a sports accident. The right side was affected in 88 % of cases. X-rays have objectified an articular fractures and/or comminuted without opening the skin, we adopted the Castaing classification stadifier for fractures of the distal radius. The treatment consisted of a bipolar distraction external fixator combined with a plug-in three patients, ablation of osteosynthesis material was carried out in 6 weeks, then physical therapy was started. After falling 21 months, our results were very satisfactory with good recovery of mobility of wrist and back of any sport.     

Rugby à XV,sport de combat,rachis lombaire et croissance. Réflexion sur croissance,sport précoce de haut niveau et atteintes rachidiennes lombaires précoces

We conducted a retrospective analysis of the lumbar spine in young rugby players. The series included 62 young players enrolled in high-level training programs and 33 players in a training school. The medial files of these players showed a significant number with lumbar spine lesions, 42% and 85% respectively. We propose here an anatomic analysis focusing on temporary mechanical incompetence of the lumbar segment during periods of rapid growth. Based on data in the literature, we show that when practised intensively by young athletes, sports such as rugby implying spinal stress have a traumatic effect on the lumbar vertebro-discal system with subsequent deleterious mid-term effects. In our opinion, this problem should be examined closely for categories aged under 15 years so that the conditions of sports’ practice can be adapted using modern high-performance diagnostic methods to enable harmonious growth and avoid early disc and spine degeneration. The lesions we discovered started earlier to be visible in the current study and will evolve later. All were not symptomatic. This spinal involvement may not have a deleterious effect until a few years later. The risk is to compromise later participation in high-level professional sports. Undeniably, if complementary studies confirm these early findings, sports’ practice in growing youth will have to be adapted.     

Infiltrations articulaires et para-articulaires chez le sportif : intérêts et limites

Few studies have validated the use of corticosteroid joint injections in sports medicine, and many recent studies have questioned their usefulness. The beneficial effect is essentially short lived, enabling the athlete to complete a specific performance. Local complications have been well described but the systemic effects are underestimated, especially during the first week. Corticosteroid joint injections are not on the regulatory list of products requiring an Authorization for Use for Therapeutic Applications (AUTa) for sportive events. Several studies have demonstrated that the corticotrop axis can be inhibited after a single injection, reflected by decreased production of endogenous cortisol for as long as two weeks. This biological adrenal insufficiency can lead to acute renal insufficiency if the athlete resumes competition too early under stressful conditions. Since there is no known way to identify predisposed individuals, the risk appears to be disproportionate compared with the expected benefit. Rest from sports must therefore be prescribed for any individual given a joint injection.     

Adaptation de la force isocinétique des muscles rotateurs de l’épaule à la pratique sportive

Physiological, anatomy and biomechanical adaptations of the shoulder joint to the stresses induced by the throwing gesture, which allow performance, could be the cause of “desadaptation” that can lead to injury by microtrauma. Thus, exploration of any adaptations or changes in internal (IR) and external (ER) muscle strength (and/or agonist/antagonist balance represented by the ratio ER/IR) to solicitations sports is relevant in order to better understand the pathophysiology of shoulder injury. Many studies have focused on identifying patterns of IR and ER muscle strength according to the practice of overhead sports. Despite the methodological limitations, although an increase in the IR strength of the dominant side was reported, it does not seem to exist an “imbalance” in muscle strength between the IR and ER, induced by overhead sports, which could be a “desadaptaion” in the origin of shoulder pathologies. There is no imbalance that could be implicated as a risk factor predisposing to shoulder pathologies.     

Luxation antérieure de l’épaule associée à une fracture de la diaphyse humérale homolatérale (à propos d’un cas)

The association of shoulder dislocation with ipsilateral humeral shaft fracture remains rare. Is presented along with a review of the literature regarding 18 reported cases. The prognosis depends on that of the shoulder. The authors report a case of shoulder dislocation with ipsilateral humeral shaft fracture at a patient of 34 years an accident of sport (cyclocross). After closed reduction of the anterior shoulder dislocation. The treatment was surgical, required open reduction of the humeral fracture with compression plating. At recession of one year, the clinical examination finds amplitudes comparable to the shoulder controlatéral without instability.