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


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