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Maladia de Quervain

Rotaru Marina
Tenosinovita stenozant
1895 Fritz de Quervain
n tendinita de Quervain intervin trei elemente anatomice
Primul compartiment dorsal al minii
Muchiul abductor lung al policelui
Muchiul extensor scurt al policelui
Epidemiologia i incidena
Prevalena n rndul populaiei feminine 1,3%, masculina 0,5%.
Incidena 2.8 cazuri 1,000 p/an pentru femei i 0.6 cazuri 1,000 p/an
brbai.
Implic cu predilecie caregoria de vrst 40-50 ani.
S-a determinat o inciden crescut a maladiei la femeile nsrcinate
i perioada post-partum.
Se dezvolt la anumite categorii profesionale: dactilografi, pianiti,
croitori, agricultori etc.
Practicarea sporturilor precum: volei, golf, caiac-canoe etc.
Incidena 10-20% la bolnavii de diabet.
Etiologie
Microtraumatisme repetitive a I canal
extensorian si a tendoanelor.
Practicarea activitailor ce implic
suprasolicitarea muchilor APL i
EPB.Micri de flexie-extensie a policelui
si minii.
Variaiile n fondul hormonal.
Traumatism la nivelul stiloidei radiale i
bazei I metacarpian.
Variaii anatomice
1. Tendoanele celor 2 muchi sunt
localizate ntr-un canal osteo-fibros.
2. Tendoanele celor 2 muchi sunt
localizate n canale osteo-fibroase separate
de un sept.
3. n primul canal extensorian sunt
localizate mai multe tendoane ale acestor
muchi.
4. Tendoanele supranumerare (unul sau
cteva) sunt localizate ntr-un canal osteo-
fibros separat localizat de regul mai
dorsal n raport cu canalul principal.
Patofiziologie
Stratul superficial

Rol nutriional
esut conjunctiv lax i vase sanguine i terminaiuni nervoase

Stratul intermediar

Rezisten mecanic
Fibroblaste, fibre de colagen dispuse paralel, hialinoza
colagenului,depunere de mucoopolizaharide, receptori hormonali

Stratul profund

Alunecare
Endoteliu, fibroblaste, celule care produc acid hialuronic. Metaplazie
condroida.
Examenul clinic
Durere la nivelul stiloidei radiale la
mobilizarea policelui, pumnului.
Durerea poate iradia proximal pin la
cot i chiar gt i distal pina la vrful
policelui.
Prezena unei tumefieri la nivelul
stiloidei radiale.
Tabachiera anatomic sensibil la
palpare i percuie.
Manevrele Finkelstein i Brunelli
pozitive.
Ultrasonografia
Edemul tendonului cu ngroarea lui la
nivelul SR (se poate estima comparativ cu
mina snatoas).
Creterea cantitii de lichid la nivelul I
compartiment.
Ingroarea retinaculului i a tecii sinoviale
adiacente.
Semnul haloului hipoecogenic, dat de
edemul peritendinos i subcutanat.
Hiperemia subcutanat i peritendinoas
vizibila la Doppler.
Vizualizarea septului ce separa
tendoanele, valoros n gidajul infiltrrilor
cu CS.
Clasificarea sonografic
Tipul I
ngroarea global a
ligamentului ce nglobeaz
ambele tendoane APL, EPB.
Tipul II
Prezena septului ce separ
tendoanele n 2 canale
osteo-fibroase.
Stenoza i presiunea fiind
execrcitat doar asupra
EPB(CE).
Radiografia

Demonsteaz semne non-specifice.


ngoarea esuturilor moi adiacente SR
Modificri focare la nivelul SR :eroziuni
corticale, scleroz sau reacie periostal.
Este concludent pentru excluderea alor
cauze a durerii la nivelul stiloidei radiale:
fracturi, artroz, osteomielit.
Informativ n cazul etiologiei post-
traumatice.
RMN
Semne specifice tenosinovitei
Cantitatea crescut de lichid n teaca tendonului
(crescut T2, scazut-mediu T1).
Retinaculum edemaiat i ngroat.
Detrit n teac.
Edem peritendinos i subcutanat.
Captarea contrastului subcutanat i peritendinos.
Tendinoz
Extinderea maxim a tendonului la nivelul SR, mai mare
dect n poriunea medial.
Creterea semnalului intratendinos n T1-T2 n
comparaie cu alte tendoane.
Aspectul striat al tendoanelor.
Ruptura longitudinal a tendonului.
.

Tratament

Therapeutic Hierarchy:
1 IN (Instructions plus NSAIDs)
2 IS (Instructions plus splinting)
INS (Instructions combined
3
with NSAIDs and splinting)
IC (Instructions plus a
4
corticosteroid injection)
ICS (Instructions combined
5 with a corticosteroid injection
and splinting)
IO (Instructions plus operative
6
treatment/surgery)
Imobilizarea
Kind of Splints Used in Clinical Practice for
de Quervain Disease:
1 Short hand-based (wrist free) splint
including the interphalangeal (IP) joint of
the thumb (S-IPin)
2 Short hand-based splint excluding the
IP joint of the thumb (S-IPex)
3 Long lower arm-based (wrist
immobilized) splint including the IP joint of
the thumb (L-IPin)
4 Long lower arm based splint excluding
the IP joint of the thumb (L-IPex)
Infiltraiile cu cortizon
Lidocain de 0,5ml-1% i 0,5 ml cortizon cu
aciune prolongat.
Poate fi injectat simultan sau secvenial
O injecie amelioreaz simptomele la 50%
pacieni.
A doua injecie realizat peste o lun d
rezultate la alii 40-45%.
Adugarea de acid hialuronic contribuie la
reducerea ratei de recuren.
Realizarea a 4 infiltraii are rezultate bune.
Reacii averse- depigmentarea pielii, atrofia
esutului adipos.
Complicaii- sindromul Wartenberg, eecul 20-
25% .
Tratament chirurgical
Incizia
Longitudinal-neuropatia ramurei senzitive a n.radial.
Oblic-la necesitatea unei expuneri mai bune a
poriunii distale.
Transversal-risc pentru leziunea n.radial.
Decompresia primului comartiment dorsal
Vizualizarea i incizia longitudinal a ligamentului 2 cm
cu eliberarea tendoanelor.
Determinarea variaiilor anatomice:
o Lipsa EPB 5%
o Prezena septului ce separ tendoanele .
o Prezena tendoanelor supranumerare max. 5 pentru
APL i 2 pentru EPB .
Determinarea instabilitii
Realizarea micrilor de flexie-extensie pentru a
exclude tendina spre subluxaie.
Complicaii
Leziunea ramurei superficiale a n.radial.
Formarea neurinomului Wartenberg- hipoestezie i semnul Tinel
pozitiv.
Instabilitatea tendoanelor.
Aderarea tendoanelor.
Eecul decompresiei cu recuren.
Infectarea plgii.
Caz clinic
Pacienta XY, 53 ani or.Criuleni.
Acuze -dureri la nivelul stiloidei
radiale la mobilizarea policelui i
minii pe dreapta, care iradiaz
pin la vrful policelui.
Istoricul bolii- pacienta sufer de
patologia dat de 5 luni, a
administrat AINS.
Examen clinic-Tabachiera anatomic
sensibil la palpare i percuie.
Manevrele Finkelstein i Brunelli
pozitive.
Examen paraclinic-radiografia,
ultrasonografia.
Etapele interveniei chirurgicale
Concluzii
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