La RM nelle lesioni legamentose della mano

Body:

Le lesioni alle dita sono abbastanza comuni, poiché è stato stimato che il 20% delle visite al pronto soccorso sono dovute a lesioni traumatiche alle dita.  Molte di queste lesioni riguardano i legamenti collaterali, il più noto dei quali è la rottura ulnare del legamento collaterale del pollice .

Anatomia e fisiologia

I legamenti collaterali delle dita variano in larghezza da 4-8 mm e misurano 12-14 mm in lunghezza. Sono presenti legamenti collaterali  propri ed accessori.  I legamenti collaterali propri verranno indicati per semplicità come legamenti collaterali. I legamenti collaterali accessori sorgono alla stessa depressione dei legamenti collaterali propri ma in una posizione più palmare. Queste strutture si estendono in una direzione palmare per attaccarsi saldamente alla piastra plantare.

Aspetto normale della risonanza magnetica:

Il punto anatomico chiave nella valutazione dei legamenti collaterali sulla risonanza magnetica è il riconoscimento del decorso obliquo del legamento quando le dita si trovano nella loro normale posizione estesa per la risonanza magnetica. Theumann et al. ha descritto un nuovo approccio MR in cui si ottengono scansioni in flessione dell’MCP, nel qual caso i legamenti collaterali possono essere visualizzati su una singola fetta assiale ortogonale (figura in basso a sinistra). Sebbene sia una tecnica elegante, questo approccio non è pratico per l’imaging di routine poiché altre strutture anatomiche diventano più difficili da valutare. Pertanto, nella pratica clinica di routine, si ottengono immagini con le dita in estensione e l’interprete della risonanza magnetica (figura in basso a destra) deve riconoscere che il legamento deve essere seguito da prossimale a distale quando si passa da dorsale a palmare sul piano coronale.

Dovrebbe essere pertanto ricostruita un immagine RM (fig in basso a destra)  su un piano di scansione obliquo (figura in basso a sinistra).

IMAGING RM di lesioni legamentose

L’indice  e le dita piccole  sono più comunemente colpiti, presumibilmente perché non sono sostenuti su entrambi i lati da dita adiacenti. Le lesioni del legamento collaterale ulnare sono più comuni al dito indice in quanto sono suscettibili a deviazione radiale non supportata. Nota in basso a destra la lesione inserzionale della testa metacarpale nella sua sede  anatomica dorsale.

ma le lesioni del legamento collaterale ulnare di alto grado del dito indice  sono funzionalmente più importanti da riconoscere perchè se non  trattate adeguatamente hanno maggiori probabilità di provocare un significativo deterioramento funzionale con perdita di pizzico e forza di presa. La freccia rossa indica la lesione prossimale di alto grado del legamento collaterale radiale (fig in basso a sinistra) con perdita della stabilità sul piano sagittale (fig in basso a destra) testimoniata dalla sublussazione dorsale della testa metacarpale; la freccia indica l’alterazione infiammatoria della testa metacarpale dovuta a  microfrattura per ipertrazione legamentosa.

LESIONE DEL LEGAMENTO COLLATERALE ULNARE DELLA MECACARPO FALANGEA DEL POLLICE (POLLICE DELLO SCIATORE).

La lesione distrattiva legamentosa può in teressare l’inserzione prossimale metacarpale come nell’immagine sottostante (freccia rossa).

Ma la lesione clinicamente e funzionalmente più importante è quella  di Stener cnella quale si determina la completa lesione con avulsione e retrazione del capo inserzionale distale del legamento collaterale ulnare della I articolazione: la lesione non può riparare per cicatrizzazione in quanto il legamento retratto viene separato della sua inserzione ossea dall’aponeurosi dell’adduttore del pollice, come riportato nello schema sottostante. La freccia rossa indica il moncone distale del legamento collaterale ulnare che si posiziona al di sopra dell’aponeurosi dell’adduttore del pollice (asterisco).

In alcuni casi l’avulsione legamentosa porta con sé la bratta ossea inserzionale: questa evenienza viene ben dimostrata dall’esame radiografico. L’ecografia specie con le nuove sonde lineari  dedicate allo studio delle dita consente di individuare la lesione

ma il planning chirurgico richiede sempre la RM la quale permette l’esatta documentazione della complessita dell’avulsione legamentosa. (fig sottostante). L’immagine in basso a sinistra è anatomica mentre le altre due rappresentano in caso di lesione lispessimento e la retrazione del leg  collaterale radiale (puntini rossi) al di fuori del piano dell’adduttore del pollice (puntini blu).

LESIONE SIMIL STENER DEL MIGNOLO.  In alcuni casi di lacerazioni del legamento collaterale radiale dell’articolazione MCP, il tessuto legamentoso può essere interposto tra il suo sito di attacco e la fascia sagittale o il cappuccio estensore, con il risultato di una “lesione simile a quella di Stener” (fig in basso a sinistra). Nell’immagine rm coronale (in basso al centro) la freccia indica l’avulsione distale e la retrazione del legamento collaterale radiale della V articolazione metacarpo falangea. Nell’immagine assiale (in basso a destra) la freccia indica il legamento retratto e consensualmente ispessito e le punte di freccia mostrano la fascia sagittale che è in posizione più profonda, Questo reperto suggerisce l’indicazione chirurgica.

La maggior parte dei chirurghi raccomanda un trattamento conservativo come lo splinting e il buddy buddy per rotture parziali del legamento collaterale parziale e per lesioni con fratture da avulsione composte o minimamente scomposte.  Le indicazioni tipiche di intervento chirurgico comprendono la presenza di fratture intra-articolari, grandi frammenti di avulsione e lesioni simili a Stener. Tuttavia, per la riparazione chirurgica si deve considerare qualsiasi strappo del legamento collaterale di alto grado con instabilità articolare, poiché esiste un rischio ben noto di instabilità cronica e osteoartrite secondaria in pazienti con tali lacrime che vengono trattati in modo conservativo (Figura in basso). La freccia indica ispessimento cicatriziale della porzione prossimale del legamento collaterale radiale che ha causato nel tempo, per verosimile instabilità, sofferenza osteocondrale della testa metacarpale (immagine sagittale in basso a destra).

I legamenti lasciati guarire in modo conservativo spesso appaiono più spessi a causa di cicatrici e collagene disorganizzato, ma queste strutture più spesse mancano della forza di un normale legamento collaterale. Gli individui altamente attivi come gli atleti o le persone il cui lavoro richiede una presa attiva sono candidati all’intervento operativo, così come i pazienti con lacrime croniche che hanno fallito la terapia conservativa.

a cura di Sergio De Bac

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