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Instabilité Scapulo humérale de l'enfant

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Instabilité Scapulo humérale de l'enfant

  1. 1. *LL’’iinnssttaabbiilliittee ggllèènnoo-- hhuumméérraallee cchheezz ll’’eennffaanntt RR..EEllbbaauumm** ,FF..MMoouunnggoonnddoo**** ** CCHHIIRREECC OORRTTHHOOPPEEDDIICC GGRROOUUPP CClliinniiqquuee EEddiitthh CCaavveellll ****SSeerrvviiccee dd’’OOrrtthhooppééddiiee HHôôppiittaall UUnniivveerrssiittaaiirree EErraassmmee
  2. 2. *jf 10A *Chute de cheval 04/2013 *Impotence fonctionnelle MSD *1er Bilan RX aux urgences: « L'examen ne démontre pas de lésion à caractère traumatique.»
  3. 3. * 3 mois post trauma:amyotrophie deltoidienne+++(3 chefs) + Hypoesthésie territoire n.axillaire * EMG: singne compatible avec une atteinte du n.circonflexe D (étirement sévère) * 2ème bilan RX +CT: avulsion rebord inférieur glène (Bony Bankart) * Traitement fonctionnel ++ * 12M post trauma :récupération complète * pas de récidive actuelle
  4. 4. * Pathologie inhabituelle chez l’enfant et l’adolescent à physes ouvertes Rockwood 1984 (8 cas) Wagner & Lyne 1983 (9 cas) Hovelius 1987(102 cases <22y) Marans 1992 (21 cas) Elbaum et coll 1993(9 cas) Lawton et all 2002 (70 cas) *Généralement, il s’agira de fracture métaphysaire ou de décollement épiphysaire (Salter 2)
  5. 5. •Rares : 0,01% de toutes les lésions a cette période •Solidité des structures ligamentaires  fracture de l’humérus proximal plus fréquentes (0,4%) •plus grande proportion de collagène de type 3 (élastique) au niveau capsulo-ligamentaire chez les jeunes •Facteurs favorisants (laxité constitutionnelle, collagènose, dysplasie glénoidienne,facteurs familiaux) Luxation scapula-humérale traumatique chez l’enfant et l’adolescent. A propos de 9 patients Elbaum R, Parent H, Zeller R, Seringe R. Acta Orthop Belg. 1994;60(2):204-9. Arthroscopic treatment of post-traumatic shoulder instability in children and adolescents. Kraus R, Pavlidis T, Heiss C, Kilian O, Schnettler R. Knee Surg Sports Traumatol Arthrosc. 2010 Dec;18(12):1738-41.
  6. 6. •Augmentation du niveau des compétitions à des âges de plus en plus bas •Lésions d’hyper sollicitations (sports de lancé) •Lésions traumatiques (Sports avec collisions)
  7. 7. • une chute sur la paume de la main, membre en rétro-pulsion rotation externe, • une abduction rotation externe forcée • une traction sur le membre en abduction rotation externe • choc direct sur le moignon de l'épaule.
  8. 8. *9900%% aanntt iinntt ((rraarrtt ppoosstt oouu eerreeccttaa)) *MM ssuupp FF *EEttiioollooggiiee ttrraauummaattiiqquuee 8855%% *LLééssiioonnss oosssseeuusseess ffrrééqquueenntteess ((HHiillll-- SSaacchhss,, BBoonnyy BBaannkkaarrtt,,aavvuullssiioonn ttrroocchhiitteerr)) *IImmmmoobbiilliissaattiioonn ppeeuu eeffffiiccaaccee *PPTT ++ CChhiirruurrggiiee pplluuss eeffffiiccaaccee
  9. 9. *Taux de récidive éélleevvéé:: 6600--110000%% !!!!!! lliiéé àà uunn ddééffaauutt ddee cciiccaattrriissaattiioonn ddee ll’’aavvuullssiioonn llaabbrraallee AAII ((GGLLAADD lleessiioonn)) eett àà llaa llaaxxiittéé ccaappssuullaaiirree ((HHeerrrriinngg 22000088)) *RRiissqquuee ddee llééssiioonn nneeuurroovvaassccuullaaiirree ((nn..aaxxiillllaaiirree)) *NNééccrroossee ééppiipphhyyssaaiirree hhuumméérraallee (( GGrreeeennssppaann 22000044))
  10. 10. • Réduction : Toujours sous AG ou MEOPA !!! • Immobilisation : ??? • En cas de chirurgie systématique après un premier épisode, 20% serait faite inutilement Surgical versus nonsurgical treatment in first traumatic anterior dislocation of the shoulder in athletes. Arliani GG, Astur DD, Cohen C, Ejnisman B, Andreoli CV, Pochini AC, Cohen M. Open Access J Sports Med. 2011 Mar 15;2:19-24.
  11. 11. *Wagner et coll: récidive significative malgré 6 sem d’immobilisation *Hovelius: récidive significative malgré 3-4 sem d’immobilisation *Notre série: pas de corrélation entre la durée de l’immobilisation, le programme de rééducation et le risque de récidive *…
  12. 12. • Apparait typiquement lorsqu’une force est exercée sur un humérus en position abduction, extension et rotation externe.(bras armé) • Symptomatologie variable (soit luxation franche,soit sensation d’instabilité soit gène ou appréhension) • 20-90% chez les ado après 1er épisode • 100% chez les patients jeunes Shoulder injuries in young athletes.May MM, Bishop JY.Pediatr Radiol. 2013 Mar;43 Suppl 1:S135-40.
  13. 13. P R E M I E R E P I S O D E R E C I D I V A N T E V O L O N T A I R E F a c t e u r p s y I N V O L O N T A I R E L é s i o n B a n k a r t T R A U M A T I Q U E V O L O N T A I R E f a c t e u r s p s y e m o t i o n n e l l e s I N V O L O N T A I R E C o l l a g é n o s e e . g . E h l e r s - D a n l o s D I V E R S C o n g é n i t a le n e u r o . .. A T R A U M A T I Q U E I N S T A B I L I T E S H
  14. 14. *R LLawton and coll Journal of Pediatic Orthopedics 2002
  15. 15. • Instabilité liée à une lésion de Bankart dans 40 à 100% des cas • 5% de récidive après réparation de la lésion de Bankart • Facteurs morphologiques et tissulaires
  16. 16. • Conservateur : 71-92% de récidive chez l’enfant jeune et actif • Programme strict de réeducation active et de renforcement du deltoide,des rotateurs int et ext (Rockwood 1984) • Bankart arthro = Bankart open => faible taux de récidive même dans les sports de contact • Bristow preocedure, Latarjet,Putti Platt… Mazzocca AD, Brown FM Jr, Carreira DS et al (2005) Arthro-scopic anterior shoulder stabilization of collision and contact ath- letes. Am J Sports Med 33:52 – 60 Ide J, Maeda S, Takagi K (2004) Arthroscopic Bankart repair using suture anchors in athletes: patient selection and postoperative sports activity. Am J Sports Med 32:1899 – 1905
  17. 17. *Surtout postérieur ou multidirectionnelle *par le simple jeu de la contraction musculaire, l'enfant est capable de sub-luxer son épaule qui se réduit par le simple relâchement musculaire, sans nécessiter la mise en position luxante du bras. *Facteur Psy !!! *Traitement difficile (psy) *Surtout éviter la chirurgie
  18. 18. *Pathologie rare *Risque de récidive plus important que chez l’adulte *Facteurs tissulaires à prendre en compte *Chirurgie stabilisatrice précoce en cas de récidive (arthro ou mini-open)

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