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Syndrome d'ischemie musculaire d'effort ou syndrome de loge

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Syndrome d'ischemie musculaire d'effort ou syndrome de loge

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Syndrome d'ischemie musculaire d'effort ou syndrome de loge

  1. 1. Syndrome d’Ischémie Musculaire d’Effort (S.I.M.E.) ou Syndrome de loge
  2. 2. 1. Données épidémiologiques du syndrome de loge chronique d’effort de jambe - a. La prédominance masculine est très nette, allant jusqu’à 90% - b. Il y a autant d’hommes que de femmes concernés - c. L’âge moyen est de l’ordre de 25 ans - d. La loge antéro-externe de jambe représente 2/3 des cas - e. Les enfants de moins de 14 ans ne semblent jamais atteints
  3. 3. 2. Les sports en causes dans les syndromes de loge chronique d’effort - a. Au niveau des jambes : course à pied et marche forcée sont les plus fréquentes - b. Au niveau des loges antérieures de l’avant bras, motocyclisme et planche à voile arrivent en tête - c. Le cyclisme ne semble jamais provoquer de syndrome de loge - d. L’endofibrose iliaque primitive du cycliste est une cause de syndrome de loge - e. Les sports de combats en raison des chocs sur les tibias sont la cause principale de syndrome de loge de jambe
  4. 4. 3. Le syndrome de loge - a. peut être chronique et évoluer vers le mode aigu - b. peut être aigu et évoluer vers le mode chronique - c. peut être traité médicalement - d. est bilatéral dans 50 à 60% des cas au niveau des jambes - e. existe aux cuisses, bras, mains, pieds et même en paravertébral
  5. 5. 4. Quelle que soit la localisation, la physiopathologie est toujours identique : - a. L’inadéquation entre la perfusion musculaire et le retour veineux - b. L’inadaptation entre le contenant (loge) et le contenu (muscle) - c. L’augmentation de la pression tissulaire intracompartimentale - d. L’anomalie des valvules veineuses - e. L’augmentation du gradient de pression entre la pression capillaire et la pression interstitielle
  6. 6. 5. La douleur du syndrome de loge chronique - a. est souvent bilatérale avec un côté prédominant - b. est reproductible pour un même type d’effort (durée, intensité) - c. est diffuse sur la loge concernée, à type de crampe ou de serrement - d. disparaît en moins de deux minutes à l’arrêt de l’effort comme toutes douleurs de claudication d’effort - e. est absente entre les efforts
  7. 7. 6. L’examen clinique de repos - a. est normal dans la plupart des syndromes de loge chronique - b. peut retrouver une discrète asymétrie des pouls périphériques - c. retrouve parfois une ou plusieurs hernie(s) musculaire(s) - d. sa normalité est un des éléments importants du diagnostic positif et différentiel - e. retrouve parfois un territoire veineux dilaté
  8. 8. 7. L’examen clinique post effort déclenchant retrouve : - a. une tension douloureuse de la loge concernée à la palpation - b. l’apparition de varices - c. parfois des troubles sensitifs - d. aucune modification des pouls distaux - e. parfois un steppage
  9. 9. 8. Le syndrome de loge aigu - a. est une urgence chirurgicale - b. présente une douleur qui ne disparaît pas après l’effort déclenchant - c. peut être responsable de dégâts neuro-musculaires irréversibles - d. se traduit par une douleur irréductible d’évolution inéluctable - e. peut être dramatique en moins de 6 heures après son début
  10. 10. 9. Les diagnostics différentiels - a. sont nombreux - b. concernent aussi bien la pathologie ostéo-articulaire, musculo-tendineuse, que vasculaire, neurologique ou générale - c. doivent rechercher en priorité la périostite, la fracture de fatigue et l’artère poplité piégée - d. doivent être évoqués dès que la prise de pression intramusculaire post effort est négative - e. n’existent pas
  11. 11. 10. Examens complémentaires - a. seul le doppler artériel et veineux est justifié - b. en dehors de la prise de pression intracompartimentale, ils ont peu d’intérêt - c. l’électromyogramme permet de confirmer le syndrome évoqué par la prise de pression tissulaire - d. l’IRM devient l’examen de choix - e. la biologie (dosage des enzymes musculaires) est indispensable
  12. 12. 11. La prise de pression intracompartimentale - a. est anormalement élevée dès le repos - b. est inutile en continu - c. est significative de syndrome de loge si supérieure à 30mmhg à l’acmé de l’effort et de la douleur - d. est significative de syndrome de loge si supérieure à 30mmhg 5 mn après l’arrêt de l’effort - e. la précision au mm de hg près est indispensable
  13. 13. 12. Le traitement médical - a. repose sur le port d’orthèse plantaire - b. est inefficace - c. n’est pas curatif, tout au plus symptomatique - d. est toujours préventif - e. repose sur un travail excentrique spécifique des loges concernées
  14. 14. Notions épidémiologiques Fréquence sous estimée Prédominance masculine à 90 % Age moyen de découverte 25 ans Extrêmes de 15 ans à 50 ans Ne semble pas exister chez l’enfant
  15. 15. Notions épidémiologiques Localisation la plus fréquente: 2/3 des cas loge antéro-externe de jambe Course à pied et marche forcée sont les sports les plus fréquemment en cause 60% des cas sont bilatéraux Moto et planche à voile sont les sports en cause pour les membres sup Jamais de cycliste
  16. 16. Notions épidémiologiques Autres localisations possibles: psoas, mains, pieds, paravertébraux… 22% de prévalence sur les douleurs d’effort des jambes incidence moyenne par centre spécialisé: 1997: 3,5/an 2007: 7/an (6 pour les membres sup)
  17. 17. Physiopathologie: Cercle vicieux inadaptation du contenant (loge ) avec le contenu (muscle) Augmentation de la pression tissulaire intracompartimental Ultrafiltration capillaire, extravasation, oedème Augmentation du gradient de pression capillaire/interstitielle Hypoperfusion musculaire…
  18. 18. Physiopathologie: Cercle vicieux Le seuil critique de pression intra-musculaire est de 30 mm Hg drainage de retour diminue augmentation du volume musculaire compression augmente….
  19. 19. Physiopathologie: Cercle vicieux PIM Volume interstitiel Flux capillaire Flux veineux Flux lymphatique Ischémie Oedème Volume musculaire Aponévrose rigide Pas de modification de la pression sur les gros troncs artériels = persistance des pouls périphériques
  20. 20. Physiopathologie: Facteurs favorisants Aponévroses épaisses Hématomes , cals Séquelles de contusion Compression veineuse poplité
  21. 21. Diagnostic repose sur: terrain prédisposant (overuse) douleur type (topographie, évolution) examen clinique normal au repos
  22. 22. La douleur : stéréotypée (crampe, serrement) diffuse au niveau de la loge souvent bilatérale impose souvent l’arrêt de l’effort disparaît en 10 à 30 mn reproductible, aggravation progressive
  23. 23. Examen clinique : normal parfois hernies musculaire sensibilisé par l’effort parfois troubles sensitifs parfois steppage
  24. 24. Diagnostics différentiels : nombreux ostéo-articulaires, musculo-tendineux, vasculaires, neurologiques, iatrogènes…
  25. 25. Trois diagnostics différentiels : Périostite Fracture de fatigue Artère poplitée piégée
  26. 26. Examens complémentaires PIM seule nécessaire Au début (normale) Dès la fin de l’effort (souvent > 30 ) 5 mn après (reste > 30 mmhg)
  27. 27. Traitement traitement médical inefficace non curatif tout au plus symptomatique voir préventif
  28. 28. Traitement chirurgical PIM Volume interstitiel Flux capillaire Flux veineux Flux lymphatique Ischémie Oedème Volume musculaire Aponévrose rigide Pas de modification de la pression sur les gros troncs artériels = persistance des pouls périphériques aponévrotomie
  29. 29. est une urgence chirurgicale présente une douleur qui ne disparaît pas après l’effort déclenchant peut être responsable de dégâts neuro-musculaires irréversibles se traduit par une douleur irréductible d’évolution inéluctable peut être dramatique en moins de 6 heures après son début peut faire suite à un syndrome chronique Le syndrome de loge aigu

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