Documente Academic
Documente Profesional
Documente Cultură
6 III/2001
29
Rezumat
Abstract
The carpal capsulo-ligamentar injuries are still insufficiently classified and their inappropriate framing results in
a number of distinct injuries which, in the acute phase, are
labeled with various general diagnoses. As a result, instabilities, avascular necrosis or arthrosis of the carp may
occur. Our own experience as well as the specialized literature made us elaborate a classification which includes all
subtypes of capsulo-ligamentar injuries together with
their associations.
Introducere
Introduction
Principii de clasificare
Complexitatea capsulo-ligamentar i arhitectonic a
articulaiei pumnului suscit discuii i interpretri diferite
ncepnd de la abordarea cinematicii, la ncadrarea, clasificarea i nomina leziunilor de la acest nivel.
n cele ce urmeaz vom expune abordarea noastr
asupra clasificrii leziunilor capsulo-ligamentare ale articulaiei pumnului punctnd considerentele i criteriile care
stau la baza clasificrii.
A. Implicarea unei biomecanici complexe
Unii autori1 consider c teoria cinematic primeaz fa de celelalte teorii i sunt menionate conceptele de instabilitate ale aspectelor radial, central i ulnar ale carpului.
Mai mult, instabilitile carpului sunt interpretate ca rezultatul leziunilor ligamentare i osoase ale acestor coloane.
Classification principles
The capsulo-ligamentar architectural complexity of the
wrist joint determine various discussions and interpretations from the cinematic approach to the classification and
to the name of the injuries at this level.
The following article presents our approach on the
classification of capsulo-ligamentar injuries of the wrist
joint, emphasizing the reasons and the criteria on which
this classification is based.
A. Implication of complex biomechanics
Some authors consider the cinematic theory as being
more important than other theories. They mention the
instability concepts of the radial, central, and ulnar of the
carp1. Moreover, carpal instabilities are interpreted as the
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Teoria coloanelor carpului este prezentat n diferite versiuni, Navrro, Taleisnik, sau Weber fiind autorii care s-au
impus cu modele ce explic fiecare n parte cinematica
pumnului2. Aceast mprire a leziunilor pe coloane nu
ine seama de rezistena variabil de-a lungul coloanelor (mai
ales neuniformitatea structural a coloanei centrale) i de
strnsele legturi existente spre extremitatea distal a
coloanelor.
Elementul central, osul cheie al instabilitilor carpului este descris de toi autorii ca fiind semilunarul. La
aceasta adugm ca i articulaie cheie, articulaia mediocarpian.
Articulaia mediocarpian are o tendin la mobilitate
maxim central prin prezena unei caviti glenoide format de osul scafoid i semilunar n care ptrunde capul
capitatului, i de o zon stabilizatoare extern datorit
articulaiei dintre scafoid cu trapez i trapezoid unde se
formeaz o articulaie plan sau selar3. Din punct de vedere biomecanic, considerm ca un prim element al patternului lezional interdependena ntre dou articulaii cu
grade diferite de mobilitate i tendina de distribuire a forelor
destabilizatoare spre centrul zonei de maxim mobilitate, unde
vom ntlni principalele efracii capsulo-ligamentare. La
aceasta se adaug ca element favorizant prezena zonei
centrale de slbiciune dintre braele ligamentului radiat al
carpului, care permite realizarea unei bree capsulare palmare i vduvete de o aciune frenatoare un impuls spre
dorsal al semilunarului. Ligamentul dorsal al carpului contribuie insuficient i inconstant la stabilizarea carpului.
Dou fascicule fine, unul unind semilunarul i scafoidul,
cellalt semilunarul i piramidalul, sunt ataate la suprafaa proximal a acestora, parte a suprafeei convexe radiocarpiene, formnd un ax de rotaie la acest nivel3. Fr a
intra n amnuntele mobilitii primului rnd carpian,
vom preciza tendinele principale ale poziiilor extreme.
Aceste poziii devin puncte de plecare ale instabilitilor n
cazul aplicrii unor fore nocive fiind legate de geometria
variabil a rndului carpian proximal1.
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Concluzii
n concluzie, formulm urmtoarea clasificare:
ENTORSA SIMPL (ENTORSA STABIL)
ENTORSA GRAV (INSTABIL)
1. Entors grav cu instabilitate n articulaia radio-triangularo-carpian.
2. Entors grav cu instabilitate n articulaia mediocarpian.
La aceste categorii se pot aduga cte dou subtipuri, i
anume:
a) Instabilitate sagital (sertar anterior/posterior).
b) Instabilitate lateral (radial/cubital).
INSTABILITATE CARPIAN DISOCIATIV
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Conclusions
As a conclusion, we formulate the following classification:
THE SIMPLE SPRAIN (STABLE SPRAIN)
THE UNSTABLE SPRAIN:
1. sprain with instability in the carpal-triangular radial
joint
2. sprain with instability in the middle carpal joint.
To each of these categories two more subtypes may be
added, as it follows:
a) Sagital instability (anterior/posterior drawer)
b) Lateral instability (radial/cubital).
DISSOCIATIVE INSTABILITY OF THE CARP
We associate in this category the instabilities due to
subluxation, diastasis and unstable fractures.
A. Instability due to diastasis:
1. Scapho-lunate diastasis
2. Capitate-hamate diastasis ( the extension of the
diastasis between metacarpals 3 and 4)
3. Other diastasis.
B. Instability of the lunate:
1. Dorsal intercalated segmental instability (DISI)
2. Volar intercalated segmental instability (VISI).
C. The horizontal scaphoid (Watson Jones), as a consequence of reducing a perilunate dislocation.
D. Unstable fractures:
The instability occurs after mal-union or non-union of
fractures.
1. Radial triangular carpal instability.
They are consequent injuries that appear as a result of
articular fractures with displacement of the distal epiphyses the radius and ulna (the last one appears with the malposition of the triangular complex).
a. radial instability
b. ulnar instability
c. associations.
2. Isolated fractures of the scaphoid.
3. Scapho-capitate syndrome is an association of the
scaphoid and the proximal pole of the big bone fractures
with a secondary instability of the carp.
DISLOCATIONS OF THE WRIST JOINT.
We associate in this category the fracture-dislocations
as well:
TYPE I:
Dislocations in the proximal carpal row:
A. Dorsal dislocations of the carp, with the subtypes:
1. perilunate
2. trans-scapho perilunate
3. periscapho perilunate
4. trans-styloradial perilunate
5. trans-triquetral perilunate (peritriquetral perilunate)
6. periscaphoid.
B. Volar dislocations of the carp, with same subtypes.
C. Volar dislocations of the carpal bone or associations
(associated fractures).
D. Dorsal dislocations of the carpal bone or associations (associated fractures).
E. Expulsion of the lunate.
TYPE II:
Middle carpal dislocations:
A. Volar middle carpal dislocation, with the subtypes:
1. Trans-scaphoidal which we described as proximal
middle carpal fracture-dislocation. The association of
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Bibliografie / References
Coresponden / Correspondence to
RADU NECULA
Orthopaedic Department II.
Braov County Hospital
Calea Bucuretilor nr. 2527
2200 Braov, Romania