L’importanza della radiologia tradizionale nello studio dell’instabilità carpale

Le lesioni ligamentose del polso sono molto più frequenti di quanto si pensi. Spesso non sono diagnosticate in acuto e restano misconosciute, quindi più insidiose. Nel paziente politraumatizzato ad esempio, la lesione del polso passa in secondo piano rispetto a problematiche in quel momento più urgenti così come un trauma minore come la distorsione del polso può nascondere una seria lesione ligamentosa che viene però, al momento, sottovalutata.
La mancata diagnosi comporta quantomeno un ritardo importante nella diagnosi e nel trattamento di queste importanti lesioni con risultati che a lungo termine possono comportare gravi deficit funzionali.
L’instabilità carpale è una alterazione biomeccanica a patotogenesi multipla che, se non identificata e trattata nel tempo, porta alla graduale degenerazione articolare. Come detto le cause possono essere diverse: i traumatismi sono sicuramente una delle cause principali di instabilità carpale, mentre i depositi di microcristalli causati da malattia metabolica (condrocalcinosi e gotta) o forme congenite (variante ulna minus) sono meno frequentemente coinvolti nella patogenesi. In forme secondarie a traumatismo, il trauma causa lesioni ligamentose che portano a disallineamenti delle superfici articolari così come nei casi di fratture con cattiva guarigione avremo conseguenti incongruenze articolari (instabilità adattive). In entrambe le situazioni, si è generata una modifica della cinematica carpale. Se la normale biomeccanica carpale non viene ripristinata questa alterazione porta, nel corso del tempo, alterazioni degenerative della cartilagine, seguita da erosioni condrali con esposizione del tessuto osseo.
Lo studio radiografico delle instabilità carpali deve evidenziare i segni caratteristici di questa patologia: i disallineamenti delle ossa del carpo sul piano frontale e sagittale.Le I.C. sono difficilmente classificabili. Molti sono i modelli proposti tra cui:Dobyns (1), partendo dalla considerazione che il complesso articolare è formato dal radio, dal semilunare e dal capitato con il semilunare come elemento intermedio (intercalated), sostiene che proprio dal semilunare originano le più frequenti instabilità. Queste si evidenziano radiologicamente osservando la deviazione del semilunare nella proiezione laterale: quando il semilunare si sposta dorsalmente si parla di instabilità dorsale del segmento intermedio o DISI (Dorsal Intercalated Segment Instability) così come lo spostamento volare si definisce VISI (Ventral Intercalated Segment Instability).Secondo Taleisnick (2) le instabilità carpali si dividono anche in I.C. statiche evidenziabili nelle radiografie standard e I.C. dinamiche che sono radiologicamente dimostrabili solo con radiografie sotto stress o con cinefluorografia. Nelle I.C. statiche si ha generalmente la rottura completa dei legamenti interossei, in particolare del legamentoVi sono poi ulteriori metodi di classificazione in rapporto a gravità, cronicità, eziologia, posizione, ….La forma più frequente di I.C. è la dissociazione scafo-lunata (DSL) per lesione del legamento interosseo. Questo tipo di lesione, molto frequente nelle fratture dello scafoide rientra nelle DISI e presenta quadri radiografici classici e abbastanza univoci già nelle proiezioni standard Postero Anteriore e Laterale.
– In PA uno dei segni di DSL è la diastasi scafo lunare (Segno di Terry-Thomas). Un aumento del normale spazio articolare (2 mm) rispetto al controlaterale deve far pensare a una DSL. Questo segno è peraltro meglio evidenziabile e valutabile nella incidenza PA con deviazione ulnare
– Il segno dell’anello di Bell (o segno dell’anello con castone): la rottura del legamento scafo-lunato comporta la flessione e parziale rotazione dello scafoide; polo prossimale e tubercolo si sovrappongono dando luogo a questo caratteristico segno che non è normalmente presente se l’osso è sul suo asse normale (Fig. 1). Questo aspetto resta spesso visibile anche nella proiezione con deviazione ulnare mentre nella incidenza in deviazione radiale è normale apprezzarlo anche in soggetti sani.
Fig. 1: Proiezione PA dei polsi. in Fig A Signet Ring Sign (Anello di Bell) tipico di lassità o rottura del legamento scafo lunato dovuto alla flessione e rotazione dello scafoide. 
– Molti Autori apprezzano anche, come segno di DSL, la forma e la posizione del semilunare in posizione neutra (normalmente trapezioidale); un aspetto triangolare fa sospettare una lussazione del lunare stesso (Fig. 2).
Fig. 2: Stesso caso di Fig. 1. Proiezione PA dei polsi. In Fig A il semilunare assume aspetto triangolare rafforzando il quadro radiografico di Instabilità carpale da lesione del legamento scafo lunare. In fig B il polso sano con il normale aspetto trapezoidale del semilunare
 
– La rottura delle linee di Gilula (3): la perdita delle normali relazioni tra le ossa del carpo dovuta a lesione ligamentosa è evidente nella interruzione di almeno uno dei tre archi paralleli descritti da Gilula (Fig 3).
   Fig. 3
Linee di Gilula
La frattura di una delle linee è solitamente un chiaro segno di instabilità carpale

88 Comments

  1. I all the time used to read article in news
    papers but now as I am a user of web thus from now I
    am using net for articles or reviews, thanks to web.

    Look into my webpage Hermine

  2. I was wondering if you ever considered changing the page layout of your website?
    Its very well written; I love what youve got to say. But maybe you could a little more
    in the way of content so people could connect with it better.
    Youve got an awful lot of text for only having one or two images.
    Maybe you could space it out better?

    Feel free to visit my blog :: download joker123 apk android (https://918kiss-m.com/joker888)

  3. Its like you learn my thoughts! You appear to know so much approximately this,
    like you wrote the e-book in it or something.

    I believe that you simply could do with some percent to pressure the message home
    a little bit, but other than that, this is great blog. An excellent read.
    I’ll certainly be back.

    Take a look at my blog … download 918kaya android

  4. I’m really loving the theme/design of your site.
    Do you ever run into any web browser compatibility issues?
    A few of my blog readers have complained about my website not operating correctly
    in Explorer but looks great in Chrome. Do you have any solutions to help fix this problem?

    Here is my webpage Epicwin id test

  5. I was wondering if you ever thought of changing the structure of
    your blog? Its very well written; I love what youve got to say.

    But maybe you could a little more in the way of content so people could connect with it
    better. Youve got an awful lot of text for only having
    one or two images. Maybe you could space it out better?

    Feel free to surf to my web site – xe888 online

  6. Hello! Do you know if they make any plugins to assist with
    Search Engine Optimization? I’m trying to get my blog to rank
    for some targeted keywords but I’m not seeing very good results.
    If you know of any please share. Many thanks!

    Check out my site: demo calibet

  7. Aw, this was an extremely good post. Finding the time and actual
    effort to produce a top notch article… but what can I
    say… I put things off a lot and don’t seem to get anything done.

    Also visit my webpage; Game 3win8 – https://918kiss-m.Com

  8. I’m no longer certain the place you are getting your info, but great topic.

    I must spend some time studying more or figuring out more.

    Thanks for great info I used to be looking for this
    information for my mission.

    my webpage – download mega888 android

  9. I absolutely love your website.. Pleasant colors & theme.
    Did you build this web site yourself? Please reply back as I’m wanting to
    create my own site and would like to learn where you got this
    from or what the theme is named. Appreciate it!

    Feel free to visit my site livechat live22; https://918kiss-m.com/live22/,

  10. You are so cool! I do not think I’ve read anything like this before.
    So nice to find someone with some unique thoughts on this subject
    matter. Really.. thanks for starting this up. This website is something that is
    needed on the internet, someone with a bit of originality!

    Also visit my web-site: Pussy888 Apk

  11. Eхceptional post however I was wanting to know if you coսld
    write a litte morе on this topic? I’d be vеry
    grateful if you could elaborate a little bit more.
    Appreciate it!

    Also visit myy web page; Home

  12. Hi my friend! I wish to say that this post is awesome,
    great written and include almost all important infos.
    I would like to peer extra posts like this.

    Also visit my website: satbh-dz.com

  13. I’m impressed, I must say. Seldom do I encounter a blog that’s both
    equally educative and amusing, and let me tell
    you, you have hit the nail on the head. The problem is an issue that
    not enough folks are speaking intelligently about.
    I am very happy that I found this during my search for something
    concerning this.

    Here is my web blog situs judi slot online

  14. An impressive share! I’ve just forwarded this onto a coworker who had been doing a little research on this.
    And he in fact bought me breakfast simply because
    I discovered it for him… lol. So let me reword this….
    Thank YOU for the meal!! But yeah, thanks for spending some time to
    talk about this matter here on your site.

    Have a look at my web blog argonautsofwi.com

  15. I do not even understand how I finished up right here,
    however I believed this post was great. I do
    not realize who you might be however definitely you’re going to a well-known blogger if you happen to are
    not already. Cheers!

    Feel free to visit my site https://diecast.org/

  16. You actually make it seem really easy along with your presentation but I in finding this matter to be really one
    thing which I believe I’d by no means understand. It kind of feels too complex and extremely
    extensive for me. I am taking a look forward in your subsequent post, I’ll attempt to
    get the hang of it!

    My blog: Juliane

  17. Great goods from you, man. I’ve consider your stuff prior to and you
    are just too excellent. I actually like what you’ve acquired here, really like what you’re stating and the
    way wherein you say it. You’re making it enjoyable and you still
    take care of to stay it sensible. I can not wait
    to read much more from you. This is really a wonderful website.

    Also visit my web-site; freeholmes.com

  18. Thank you so much regarding giving us an update on this matter on your site.
    Please realise that if a fresh post appears or if perhaps any alterations occur with the current posting,
    I would be thinking about reading more and knowing how to make good utilization of those approaches you
    share. Thanks for your efforts and consideration of other people by making this web site available.

    Also visit my page http://payfirstsolutions.com/UserProfile/tabid/57/userId/377720/Default.aspx

  19. What i don’t realize is in fact how you’re no longer actually
    a lot more smartly-appreciated than you may be now.
    You are very intelligent. You realize therefore considerably in terms of this matter, made me for
    my part believe it from numerous varied angles. Its like men and women are
    not involved until it is one thing to accomplish
    with Girl gaga! Your individual stuffs nice.
    All the time maintain it up!

    My web blog :: http://anapa-alrosa.com.ru/modules.php?name=Your_Account&op=userinfo&username=MarsdenJacinto

  20. Excellent beat ! I wish to apprentice whilst you amend your site, how can i subscribe for a weblog site?
    The account aided me a appropriate deal.
    I have been tiny bit acquainted of this your broadcast offered vibrant
    clear idea

    Feel free to surf to my web blog – ztgsd.cn

  21. hello there and thank you for your info ? I?ve definitely picked up something new from right here.
    I did however expertise some technical issues using this website, as
    I experienced to reload the site many times previous to I could get it to load correctly.
    I had been wondering if your web hosting is OK?
    Not that I’m complaining, but sluggish loading instances times will often affect your placement in google and could damage your quality score if ads and
    marketing with Adwords. Anyway I?m adding this RSS to my e-mail
    and could look out for much more of your respective fascinating content.
    Make sure you update this again soon..

    My web page … freeholmes.com

  22. Pretty nice post. I just stumbled upon your blog and wished to
    say that I have truly enjoyed browsing your
    blog posts. After all I’ll be subscribing to your feed and I hope you write again soon!

    Here is my blog khoquet.com

  23. Thanks for ones marvelous posting! I truly enjoyed reading it, you will be a great
    author. I will be sure to bookmark your blog and may come back later on.
    I want to encourage one to continue your great posts, have a nice evening!

    Here is my web site … Ila

  24. Simply desire to say your article is as surprising. The clarity in your post is simply great and i could assume you’re an expert on this
    subject. Well with your permission let me to grab your feed
    to keep updated with forthcoming post. Thanks a million and please carry on the
    rewarding work.

    Also visit my web site – 2xueche.com

  25. I have been exploring for a bit for any high quality articles or blog posts in this sort of house .
    Exploring in Yahoo I at last stumbled upon this web
    site. Studying this info So i am happy to express that I have a very good uncanny feeling I found out just what I needed.
    I most indubitably will make certain to don?t forget this
    web site and give it a look regularly.

    Here is my homepage http://www.ptfang.com

  26. Wow, amazing blog layout! How long have you been blogging for?
    you made blogging look easy. The overall look of your web site is wonderful,
    let alone the content!

    Check out my site – discuz.e70w.com

  27. I cherished as much as you’ll obtain carried out proper here.
    The comic strip is attractive, your authored material stylish.
    however, you command get got an impatience over that you want be turning in the following.
    unwell indubitably come more before again as precisely the same nearly very ceaselessly inside of case you protect this increase.

    Feel free to surf to my web site; bbs.ranmao.com

  28. I do not leave a response, however I read a few of the remarks here L’importanza della radiologia tradizionale nello
    studio dell’instabilità carpale – Dottor Sergio De Bac.
    I do have a few questions for you if it’s okay. Is it just me or does it look as if like a few of these comments
    look like they are left by brain dead folks? 😛 And, if you are posting on other social sites, I
    would like to follow you. Could you post a list of
    the complete urls of all your public pages like your Facebook page, twitter feed, or linkedin profile?

    My web blog: https://mpc-install.com/

  29. You really make it seem so easy together with your presentation but I find this topic to be really one thing which
    I think I might never understand. It kind of feels too complex
    and very extensive for me. I am having a look forward
    for your subsequent post, I’ll try to get the grasp of it!

    My site … https://grazebo.com/

  30. I simply couldn’t go away your web site prior to suggesting that I extremely enjoyed the standard info a person provide to your visitors?

    Is gonna be back steadily in order to inspect new posts

    My web blog; grazebo.com

  31. Good write-up, I’m regular visitor of one’s web site, maintain up the nice operate, and
    It’s going to be a regular visitor for a lengthy time.

    Feel free to visit my blog post; Charlene

  32. Greetings from Colorado! I’m bored at work so I decided to check out your blog on my iphone during lunch break.

    I enjoy the information you present here and can’t wait to take a look when I get home.
    I’m shocked at how quick your blog loaded on my mobile ..
    I’m not even using WIFI, just 3G .. Anyways, good blog!

    Feel free to visit my webpage – memorytoday.com

  33. Hi I am so glad I found your blog, I really found you by mistake, while I was searching
    on Digg for something else, Regardless I am here now and would just like to say many thanks for
    a tremendous post and a all round enjoyable blog (I also love the theme/design), I don’t
    have time to look over it all at the moment but I have bookmarked it
    and also included your RSS feeds, so when I have time I will be back to read more, Please do keep up the superb job.

    Look at my web-site http://www.hotelforrest.ru

  34. Pretty great post. I simply stumbled upon your blog and wanted to mention that I’ve truly enjoyed surfing around your weblog posts.
    In any case I will be subscribing on your rss feed and I’m hoping you write once more very soon!

    My site – https://mpc-install.com/

  35. Today, while I was at work, my sister stole my iPad and tested to see if
    it can survive a 30 foot drop, just so she can be a youtube sensation. My apple
    ipad is now destroyed and she has 83 views.
    I know this is completely off topic but I had to share it with someone!

    My webpage … memorytoday.com

  36. I all the time used to study paragraph in news papers but now
    as I am a user of net so from now I am using net for articles,
    thanks to web.

    Also visit my homepage :: chengdian.cc

  37. Your means of telling the whole thing in this
    article is in fact pleasant, all can easily know it,
    Thanks a lot.

    Also visit my web-site; kebe.top

  38. I wish to show some thanks to this writer just for rescuing
    me from this type of incident. Just after checking throughout the world-wide-web and coming across notions which were not
    helpful, I believed my life was well over. Living minus the approaches
    to the difficulties you’ve sorted out by way of the short article is a critical case, as well as the ones that could have
    badly damaged my entire career if I had not noticed your site.
    Your own expertise and kindness in playing with every part was very helpful.
    I’m not sure what I would have done if I hadn’t come across such a point like this.

    I am able to at this point relish my future. Thanks so much for
    your expert and sensible guide. I won’t think twice to suggest your web site to anyone
    who needs to have guidance about this area.

    Look at my webpage: Myrtle

  39. I’m no longer sure the place you’re getting your information, however good topic.

    I must spend a while studying much more or
    working out more. Thank you for magnificent information I was looking for this info for my
    mission.

    Also visit my blog; haojiafu.net

  40. I know this if off topic but I’m looking into starting my own weblog and was wondering what all
    is required to get setup? I’m assuming having a
    blog like yours would cost a pretty penny? I’m not very internet smart so I’m not 100% certain.
    Any suggestions or advice would be greatly appreciated.
    Thank you

    My web-site – http://epcsoftware.org/

  41. magnificent submit, very informative. I ponder why the opposite
    specialists of this sector don’t understand this. You should proceed your writing.
    I am sure, you’ve a huge readers’ base already!

    Feel free to visit my webpage: frun-test.sakura.ne.jp

  42. Excellent blog here! Also your site quite a bit up fast!
    What host are you the use of? Can I am getting your associate link to
    your host? I wish my web site loaded up as quickly as yours lol.

    my website: virtualchurchcamp.com

  43. This is a great tip particularly to those new to the blogosphere.
    Brief but very accurate information? Appreciate
    your sharing this one. A must read post!

    Here is my blog post – Quad Air Drone

Lascia un commento

Il tuo indirizzo email non sarà pubblicato.