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Conduite à tenir devant un genou douloureux non traumatique (306c)
Professeur Philippe GAUDIN - Juillet 2005

Résumé :

La démarche diagnostique devant un genou douloureux est d’abord clinique. La ponction articulaire si elle est possible est une étape importante.
La radiographie est l’imagerie de première intention qui oriente très vite alors sur les techniques d’imagerie complémentaire avec au premier plan l’IRM. On distingue

Les étiologies mécaniques avec radiographies anormales
  • les radiographies anormales avec interligne pincé (gonarthrose fémoro-tibiale ou fémoro-patellaire)
  • les radiographies anormales avec interligne normal (algodystrophie, maladie de Paget osseuse, ostéochondrite et ostéonécrose aseptique, maladie d’Osgood Schlatter, ostéoarthropathie pneumique hypertrophiante, fracture de fatigue, hyperostose, ostéoarthropathie neurogène)

  • Les étiologies mécaniques avec radiographies normales
  • avant 40 ans distinguer les pathologies ligamentaires, méniscales ou secondiares à une coagulopathie)
  • après 40 ans orientation vers l’algodystrophie ou l’ostéonécrose aseptique débutantes

  • Les étiologies à sémiologie inflammatoire (le contexte clinique est primordial)
  • maladie inflammatoire systémique (PR, lupus, rhumatisme psoriasique, spondylarthropathie, maladie de Still, goutte, CCA…)
  • étiologie infectieuse (arthrite septique ou ostéo-arthrite : germe banal ou BK, gonocoque…)
  • étiologie plus rare comme l’ostéo-chondromatose, la synovite villo-nodulaire, une tumeur synoviale maligne, une tumeur osseuse de voisinage…




  • 1. Introduction

    Devant un genou douloureux non traumatique, l’interrogatoire et l’examen clinique orientent en général sur le caractère mécanique ou inflammatoire de l’affection.
    La ponction articulaire si possible confirme l’orientation.
    La suite de la démarche diagnostique est fonction du contexte et de l’imagerie.
    La démarche diagnostique peut être résumée sous la forme d’arbres décisionnels.



    Schéma : arbre décisionnel devant un genou douloureux non traumatique
    (Ph. Gaudin)


    2.2. Genou douloureux non traumatique avec radiographie anormale mais interligne normal



    Photo : radio genou, AGD, algodystrophie
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)



    Photo : radio genou (profil) et scintigraphie osseuse, maladie de Paget osseuse
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)



    Photo : radio et IRM genou, ostéonécrose aseptique
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)



    Photo : radio genou (face), ostéochondrite
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)



    Photo : radio genou, Osgood Schlatter
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)



    Photo : radio genou (face), scintigraphie osseuse, radio pulmonaire
    Ostéoarthropathie pneumique
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)



    Photo : radio genou (face et profil), fracture de fatigue
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)

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    Photo : IRM genou, fracture de fatigue
    (Ph. Gaudin, F. Brun, L. Pittet-Barbier)

    Version complèteDroits