Traumatologie oculaire liée à la pratique du rugby

Although the risk of rugby-associated contact injuries is high, eye injuries are rarely severe. The orbit and eyelids are frequently injured, whereas traumatic lesions of the eyeball itself are rare and exceptionally carry a poor visual prognosis. The most frequent ocular lesions may be traumatic keratitis and intraocular hemorrhage which usually heal without sequellae. The most severe ones are often caused by intentional injuries including "gouging" with fingers, kicks, or blows from fists, elbows and knees. Prevention of these injuries rely on better education of players and establishment of rules that provide even more protection of the players. This paper is an overview of rugby-associated ocular injuries.     

Le kyste méniscal médial intra-articulaire : à propos de cinq cas

The intraarticular medial meniscal cyst is a rare pathology, very little described in the medical literature. This pathology is often discovered fortuitously by the development of the imagery in particular by magnetic resonance. Its physiopathology is not still perfectly known. The authors report five observations of intra articular medial meniscal cyst treated by arthroscopy allowing the meniscal resection with evacuation of the contents of the cyst. The evolution was considered good in all the cases with a complete functional recovery.     

Les kystes du ligament croisé antérieur : à propos de 24 cas

The purpose of this study is to present clinical and magnetic resonance imaging (MRI) features of ganglion cysts of the anterior cruciate ligament (ACL). Such cysts are rare and often unsuspected. We reviewed a series of 24 ganglion cysts of the ACL (7 females, 17 males) between 1998 and 2004. The mean age was 45 years old (25–74). All patients presented with knee pain. The mean follow-up was 25 months (6–48). All patients had a preoperative MRI, which confirmed the diagnosis. Seventeen patients had an arthroscopic treatment and 7 were treated with percutaneous aspiration and steroid injection under. Fourteen patients were evaluated with the International knee Documentation Committee (IKDC) subjective score. Computed tomography or ultrasound guidance. MRI demonstrated 16 mucoid degenerative cysts of the ACL and 8 well circumscribed ganglion cysts with a fluid collection. The surgical pathology confirmed 13 mucoid cysts and 4 ganglion cysts; 2 recurrences were observed after surgical treatment. After percutaneous aspiration, we observed 3 recurrences, 2 failures and one vascular complication. We observed two types of ACL cysts, which could be differentiated on the MRI. Percutaneous treatment was less reliable than surgical treatment. The percutaneous aspiration should be reserved to the ganglion cysts with fluid collection, while arthroscopy is indicated for the failure cases. We recommend resection for the mucoid cysts. An aggressive resection of the ACL may compromise the knee stability so that the patient must be informed preoperatively. In theses cases, aspiration was often inefficient.     

Place du traitement médicamenteux et des infiltrations dans la prise en charge médicale des lésions de la coiffe des rotateurs

One of the main objectives of medical treatment of rotator cuff lesions is to attenuate or totally relieve pain and allow the patient to access the next phase of functional rehabilitation. Relative rest is desirable. Harmful sports movement should be avoided. Strict immobilization is never indicated. The question is raised as to whether wider use of analgesics would be warranted. The inflammatory nature of rotator cuff tendiopathies remains to be clearly demonstrated and the efficacy of analgesics in this indication would be related more to their intrinsic pain killer action. Analgesics should thus be prescribed prudently and limited to a few days, particularly because of the potential adverse effects. Theoretically, steroidal anti-inflammatory drugs should not be used for tendonitis. Myorelaxing agents could be used in the event of associated muscle contracture. If the patient requires further relief, corticosteroid injections could be considered, taking care to avoid contraindications for intra-articular injections and avoiding any risk of contamination while keeping in mind the possible adverse effects.     

Rupture traumatique du tendon du grand pectoral chez le rugbyman

Humeral avulsion of pectoralis major tendon is not so rare in rugby practice even if it is less frequent than for fifty years old bodybuilder. Clinical diagnosis is generally evident but can be confirmed by a RMI. In case of total avulsion, surgical reattachment has to be performed to recover plain function and expect a return to competition. Procedure consists in a humeral reattachment using suture anchors. Usually, specific rugby training begins after three months.     

Réglage du niveau de pression expiratoire positive au cours du syndrome de détresse respiratoire aiguë : un faux problème…

Whereas tidal volume reduction is now largely accepted as a prerequisite to protect the lungs in mechanically ventilated ARDS patients, a debate persists concerning the best PEEP to avoid excessive loss of functional residual capacity. This discussion should take into account the effect of PEEP application on pulmonary circulation, and not only on lung aeration, improvement in the latter usually being obtained at the expense of the former. An appropriate balance should thus be respected to obtain a functional, and not only anatomical, improvement.     

Laxité chronique antérieure du genou chez le sportif. À propos de 118 cas

The chronic anterior laxity of the knee is an evolutive disease owing to a rupture of the anterior crossed ligament which engages the functional prognosis of the lower member and compromise sportive activity. Many techniques of ligamentous plasty were described. Our study is about 118 sportsmen suffering from chronic anterior laxity treated by the modified Kenneth-Jones procedure between 1998 and 2002. After a main following-up of 25 months, we tried to value our results and determine the real place of ligamentous plasty using patellar tendon in the treatment of sportsmen chronic anterior laxity.     

Traitement médicamenteux du syndrome de détresse respiratoire aiguë : quelles perspectives ?

There is no pathophysiological medicinal treatment of Acute Respiratory Disease Syndrome (ARDS). In light of the failure of previous therapeutic trials, three questions should be asked before considering a therapeutic trial in ARDS: why (the pathophysiological target, it is often detailed), when (the optimal therapeutic window) and which end-point (the rational of the calculation of the sample size). This latter question is of major importance, since some valuable therapeutics will be abandoned due to a too ambitious mortality end-point. The recent validation of biomarkers of prognostic value in ARDS by the “biological” studies derived from the ARDS Clinical Trials Network should constitute more conformed end-points to phase II trials, which is an indispensable prerequisite for phase III trials with justified calculation of sample size. Three “inadequate” biological processes could constitute interesting pathophysiological targets: 1) the decompartmentalization of the inflammatory response with involvement of the whole lung and systemic spill over, 2) the occurrence of alveolar inflammation in absence of pathophysiological reason/necessity (ARDS due to non pulmonary causes for instance), and 3) the perpetuation or repetition of lung injury while the initial process (pneumonia for instance) seems controlled, as if the resolution of the inflammatory response could not occur.     

Rugby et traumatismes du coude

The elbow is requested brutally during the falls, collisions, tackles, direct impacts and especially during hand-off while pushing a tackler away. All the types of lesions can be observed, from simple torn ligaments of functional treatment to complex fractures dislocations of difficult surgical processing. The clinical diagnosis is done on the ground but it must be supplemented by a systematic radiographic assessment readily refined by 3D CT-scan.     

Intérêt des infiltrations du « mur méniscal » par les corticoïdes dans les douleurs méniscales du genou. À propos de 214 cas

Femorotibial pain is a common manifestation of meniscal injury or microtrauma. In this situation, meniscectomy does not appear to accelerate joint degeneration. Meniscal wall steroid injections have been proposed for consenting patients suffering from degenerative or post-traumatic meniscal pain. The technique consists in injecting corticosteroids into a juxtameniscal zone after identification of the painful area by palpation of the joint space and radiographically. We conducted two non comparative studies: a first retrospective analysis of 178 patients aged 44 years on average and a second prospective series of 36 patients aged 39 years on average who were treated with one to three injections for meniscal pain. The main outcome assessment combined pain relief and return to prior activities at 60/90 days. Results were favorable in the retrospective series: 106 responders versus 46 non-responders (26 lost to follow-up) and also for the prospective series: 28 responders versus six non-responders (two lost to follow-up). Neither series yielded a clinical or radiographic finding predictive of outcome. The pattern of a “good” responder to treatment could not be identified. It was noted, however, that meniscal pain associated with a blocked knee appeared to be a poor indication for corticosteroid injections and that injections of hyaluronic acid should be associated in cases with cartilage damage. Meniscal wall injections thus appear to be a new perspective for the medical treatment of meniscal pain. Comparative studies versus arthroscopy will be needed to determine the role of this method in our therapeutic armamentarium.     

De la trachéotomie à la décanulation : quels sont les problèmes dans une unité de sevrage ?

The purpose of the present review is to discuss the daily practice of tracheostomy management in mechanically ventilated patients from cannulation to decannulation. During mechanical ventilation, tracheotomy difficulties are related to change in cannula or to local complication. Rather than systematic, replacement of cannula should be considered individually according to oro-tracheal requirements. The décannulation process includes weaning of mechanical ventilation, evaluation of swallowing, cough and speech. A multidisciplinary approach, with an exploration of upper-airway, may be necessary in case of difficulties. For this decannulation protocol, tracheostomy tube should be subsequently step by step downsized and obstructed for one to three days before removing cannula from trachea.     

Les lésions articulaires de la main du rugbyman

All the phases of the game can lay the hand of the rugby player to injurys. Joints are in particular often wounded and the triteness of this traumatism must not hide its potential gravity, which can lead to handicap compromising sports future. Rugby expose to high level energy crash leading to serious injuries as palmar thumb metacarpo phalangeal joint or long fingers proximal interphalangeal joint dislocation, usually unknown because uncommon compare with other sport activities. Considering relative bad results of secondary surgery, knowledge of theses particular trauma is mandatory to allow early adapted treatment and optimal functional recovery.     

Instabilité méniscale par subluxation récurrente de la corne postérieure du ménisque latéral

A young football player presented several episodes of locking knee associated with pain of the lateral compartment while MRI was considered normal. The occurrence of an irreducible blocking requires performing arthroscopy with evidence of instability of the posterior horn of the lateral meniscus. After reviewing the literature, it appears that popliteomeniscal fasciculi play an important role in maintaining the stability of the posterior horn of the lateral meniscus. Disruption of these structures, either by default or rupture leads to hypermobility of the lateral meniscus. Clinical examination is not contributory; at most, one finds a pain when tensioning the posterolateral compartment at the “Figure-4 Test” and hypermobility in internal rotation of the knee. The popliteomeniscal fasciculi can be viewed on the “classic” MRI of the knee. We need to know the search during an episode of locking knee without meniscal lesion. The management is surgical with the aim of preserving the meniscus.