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TRS NOMBREUSES
PARTICULARITS
CLINIQUE COMMUNE
Douleur, spontane
Douleur dclenche par le mouvement, augmente par la
flexion contrarie (course concentrique) et l'extension
passive (excentrique)
Douleur la palpation ( emptement)
Diminution de la force
Plus rarement rupture
IMAGERIE NCESSAIRE ?
LE DOIGT RESSAUT ET
DIAGNOSTICS DIFFRENTIELS
EPIDMIOLOGIE
PHYSIOPATHOLOGIE
136
The
A-1 pulley may triple in thickness as
ou
extension
Accrochage en flexioncartilage.
the histologic inner gliding layer of the A-1 pulley
changes from the spindle-shaped fibroblasts and
ovoid cells normally seen to cells with chondrocyte
characteristics.
It has been proposed that tendovaginitis is a more
accurate term to describe the condition than tenosynovitis. This is because the pathologic inflammatory
changes are found in the retinacular sheath and peritendinous tissue rather than in the tenosynovium. The
2 terms continue to be used interchangeably in the
literature.
Conservative Treatment
Activity modification, nonsteroidal anti-inflammatory drugs, splinting, steroid injection, and surgical
release all have been used in the management of
Corticosteroid Injection
Long-acting corticosteroid injection is
in initial management of the symptom
digit. Injection of the involved flexor te
provides long-term relief of symptoms
92% of affected digits with up to 3 inje
tamethasone sodium phosphate is the
choice because it is water soluble, does
residue in the tendon sheath, is not kno
tenosynovitis, and it causes less fat ne
injection is placed in the tissue around
PHYSIOPATHOLOGIE
Friction entre le bord
distal de la poulie et le
tendon lors de la flexion
Mtaplasie cartilagineuse
de la couche interne
Augmentation paisseur
(x 3) de la poulie
Pas dinflammation de la
gaine (mais des tissus
pri-tendineux)
Poulie
Tendon
CLINIQUE
Douleur la base du doigt en
regard de la poulie (plus douloureux
au pouce - Pruzansky, 1990)
Parfois tumfaction douloureuse
(Kyste associ)
Crainte fermer / tendre
compltement le doigt
Ressaut lors de la flexion
Blocage
Hypertrophie de la poulie A1
(flches) avec
hypervascularisation au
doppler et hyperfixation en IRM
On observe en chographie:
hypervascularisation (91%),
synovite liquidienne (55%),
tendinose (48%), tendinose
avec synovite liquidienne (39%)
TRAITEMENT MDICAL ?
INFILTRATION DE CORTICOSTRODES
on the v
joint an
Meilleure prcision
70% dinjection dans la gaine vs 15% si fait laveugle
Pas dinjection intra-tendineuse vs 30% si fait laveugle
Meilleure efficacit pour certains, Mais pas de bnfice
dmontrs le faire sous chographie (Cecen)
Cecen GS, Gulabi D, Saglam F, Tanju NU, Bekler HI. Corticosteroid injection for trigger
finger: blinded or ultrasound-guided injection? Arch Orthop Trauma Surg. 2015 Jan;
135(1):125-31.
Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A
prospective, randomized, controlled double-blinded study. J Bone Joint Surg 2007;89A:2604 2611.
Stepan JG, London DA, Boyer MI, Calfee RP. Blood glucose levels in diabetic patients following
corticosteroid injections into the hand and wrist. J Hand Surg Am. 2014 Apr;39(4):706-12.
Wang AA, Hutchinson DT. The effect of corticosteroid injection for trigger finger on blood glucose level in
diabetic patients. J Hand Surg 2006;31A:979 981
TRAITEMENT CHIRURGICAL
Ryzewicz and Moriatis Wolf / Trigger Digits
137
13
Peterson WW, Manske PR, Bollinger BA, Lesker PA, McCarthy JA. Effect of pulley
excision on flexor tendon biomechanics. J Orthop Res 1986;4:96 101
144
PATHOLOGIES ASSOCIES
Amyloidose: (synovectomie associe)
digits may be the higher incidence of a diffuse inflammatory stenosis of the tendon sheath rather than
a focally nodular process.
Studies have reported poor glucose control in patients for several days after steroid injection for trigger fingers but none have documented the incidence,
extent, or management of such phenomena. Patients
should be advised of the possibility of increased
blood sugar levels after steroid treatment but the
presence of diabetes should not be considered a contraindication for flexor tendon sheath injection.
Diabetic hand complications are believed to be
primarily fibrosing processes related to the same
pathogenic mechanisms that induce other diabetic
complications. Hyperglycemia increases collagen
cross-linking while conferring a resistance to degradation, therefore causing collagen accumulation.
This could explain the predilection toward trigger
fingers in diabetic patients.
Rheumatoid arthritis. In contrast to idiopathic
trigger finger, triggering in rheumatoid patients is
referred to correctly as tenosynovitis. Rheumatoid
arthritis is a systemic disorder that affects the synovial tissues. The digital flexor tendon sheath is lined
with synovium. Inflammation of the tenosynovium
causes a mismatch between the size of the contents of
the sheath and the enclosing fibro-osseous canal,
producing symptoms that may resemble closely those
of idiopathic trigger finger. Such symptoms in a
patient with rheumatoid arthritis, however, require an
entirely different diagnostic and therapeutic approach
than that for idiopathic tendovaginitis.
Flexor tenosynovitis in the rheumatoid patient may
cause finger pain, swelling, triggering, limited motion, or rupture of the flexor tendon. The diagnosis is
characterized by digital triggering or stiffness with
palpable swelling on the volar aspect of the digit.
Passive range of motion in the finger that exceeds the
active range of motion is helpful for distinguishing
flexor tenosynovitis from articular pathology. Fixed
joint stiffness may develop in chronic cases, however, making the diagnosis of restricted flexor tendon
excursion as a consequence of diffuse tenosynovitis
more difficult.
The surgical treatment of rheumatoid flexor tenosynovitis is tenosynovectomy and preservation of the
annular pulleys, with selected cases requiring USSR
or excision of rheumatoid nodules from the tendon.
Although the condition may respond temporarily to
corticosteroid injection, early surgical intervention in
the form of flexor tenosynovectomy with decompression of the carpal tunnel is recommended by many
investigators to prevent flexor tendon rupture and
irreversible damage to the median nerve.26
Figure 7. The tendency toward ulnar drift of the flexor tendons after the A-1 pulley of the middle and ring fingers is
shown.
An A-1 pulley release in rheumatoid flexor tenosynovitis is not recommended. Despite pulley release, motion still may be limited by rheumatoid
nodules or diffuse flexor tenosynovium in the area of
one of the more distal pulleys. The division of the
A-1 pulley will increase the rheumatoid tendency for
digital ulnar drift (Fig. 7), with resultant increase in
the ulnar torque across the MCP joint.
Surgical Technique
Standard Bruner incisions are used to approach the
digital flexor tendon sheath. The more proximal aspect of the sheath is approached in the palm through
transverse incisions in the distal palmar crease. A
standard approach to the carpal tunnel is used to
expose the flexor tendons at this level if necessary.
The tendon sheath is opened proximal to the A-1
pulley and between the A-2 and A-4 pulleys. The
A-1, A-2, and A-4 pulleys all are preserved.
Diseased tenosynovium surrounding the tendon is
removed. Intratendinous nodules are excised care-
Everding NG, Bishop GB, Belyea CM, Soong MC. Risk factors for complications of
open trigger finger release. Hand (N Y). 2015 Jun;10(2):297-300.
AUTRES TECHNIQUES
Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JC. Prospective randomized trial of open
versus percutaneous surgery for trigger digits. J Hand Surg 2001;26A:497500
Figure 5. Ulnar superficialis slip resection. The proximal part of the ulnar slip has been released at the level of the
Distally the ulnar slip has been transected distal to the A-3 pulley. The slip of tendon is delivered in the interval bet
and A-3 pulleys.
AUTRES TECHNIQUES
La rsection intra-tendineuse
de lpaississement (nodule) Seradge et Kleinert
AUTRES TECHNIQUES
Section sous endoscopie de la poulie A1
Films Dr Desmoineaux
AU POUCE
AU POUCE
AU POUCE
Patel RM. Hand Surface Landmarks and Measurements in the Treatment of Trigger Thumb. J Hand Surg
2013;38A:11661171
Joueur de Bowling
Douleur et oedme distal au pli digital IPP
Accrochage en flexion > 90, du FDP +++
RESSAUT DU COL-DE-CYGNE
Dos de la MP
Rupture / attnuation dune
bandelette sagittale
Luxation en flexion du tendon /
ressaut en extension de la MP +++
BLOCAGES MP
Rare
TENOSYNOVITE
DE DE QUERVAIN
Johann Fredrich (dit Fritz) de
Quervain (1868-1940) est suisse,
ctait lassistant puis le successeur
de Kocher.
TENDINITE DE DE QUERVAIN
Il dcrit la
maladie en
1895 et fait de
suite le
rapprochement
avec les doigts
ressaut
TENOSYNOVITE DE DE QUERVAIN
ANATOMIE
Tunnel osto-fibreux au bord
corso-radial du poignet
Contenant deux tendons:
Abductor pollicis longus
Extensor pollicis brevis
- Le rtinaculum
2 tendons
VARIATIONS ANATOMIQUES
LAPL comporte de 2 9 bandelettes
tendineuses
de 2 4 bandelettes dans 94% des cas
dans srie chirurgicale (Minimikawa, 1991)
EPB absent dans 5-7% des cas
2
1
VARIATIONS ANATOMIQUES
Existence dun septum qui divise
partiellement ou totalement le compartiment
en deux
Septum
EPB
APL
FRQUENCE DU SEPTUM
Moyenne
Sries anatomiques
11 tudes
29 % 77,5%
46 %
Sries chirurgicales
10 tudes
67 %
46 91%
TNOSYNOVITE DE DE QUERVAIN
CLINIQUE
Gonflement +/- kyste
Douleur spontane et la pression
Douleur lextension contrarie
Douleur la mise en tension
passive (Signe de Finkelstein, de
Eischoff, de Brunelli, WHAT,)
Plus rarement:
Apophysite externe du radius
Irritation nerf radial (Signe de
Matzdorff
MANUVRES PROVOCATRICES
MANOEUVRES PROVOCATRICES
LE TEST DE BRUNELLI
Serait plus prcis car visant faire
frotter les tendons contre la poulie
et non contre le radius
Pas de travail scientifique pour
valider cette hypothse
MANUVRES PROVOCATRICES
Goubau J et al. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive
test to diagnose de Quervain tenosynovitis than the Eichhoff's Test. J Hand Surg Eur 2014 Mar;39(3):286-92
Sensibilit
Spcificit
EischoffFinkelstein
89%
14%
WHAT test
99%
29%
Goubau J et al. The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive
test to diagnose de Quervain tenosynovitis than the Eichhoff's Test. J Hand Surg Eur 2014 Mar;39(3):286-92
Si plus de douleur en
extension rsiste de la
MP du pouce quen
abduction palmaire
rsiste
Evoquerait une souffrance
de lEPB plutt que lAPL
Sensibilit 81%, spcificit
50%
Alexander RD, Catalano LW, Barron OA, Glickel SZ: The extensor pollicis brevis entrapment test in the
treatment of de Quervains disease. J Hand Surg [Am] 2002;27:813816.
IMAGERIE NCESSAIRE ?
Lpaississement du rtinaculum
vue sag
vue axiale
Cot
asymptomatique
HYPERVASCULARISATION AU DOPPLER
Epaississement
Tendon
EFFET DE CONSTRICTION
liquide
liquide
R
Il associe:
Orthse de repos
Infiltration,
A.I.N.S.
Suppression du geste traumatisant
Il est defficacit remarquable
83%
61%
50%
restent
guris 1
An
Rcidives
avant 6
mois
14%
AINS
seuls
Repos
seul
0%
0%
Evaluation des traitements de la TSDQ, a pooled quantitative literature evaluation Richie, 2003,
J Am Board Fam Pract
Souffrance cutane
Le plus souvent temporaire
Ne pas rpter les infiltrations, tre
bien profond
Sous chographie ?
TNOSYNOVITE DE DE QUERVAIN
Dr Desmoineaux
SYNDROME DU CROISEMENT
Notion dhyperutilisation (sportif)
Douleur vive
Au quart distal et externe de
lavant-bras ( 4 cm au-dessus de
la stylode radiale)
Oedme, gonflement
Parfois crpitation douloureuse
lors des mouvements de flexionextension du poignet (audible
parfois seulement au stthoscope)
TENDINITES PALMAIRES
Angulation carpienne
Soumis des Microtraumatismes
Exostoses S.T.T.
2
3
Tendinite mtabolique
Le Viet, Surg Radiol Anat 1993 , 15,
85-89
41 arthroses STT
IMAGERIE
Profil 30 de supination
(incidence de Garault)
Recherche de calcifications ET de
pathologie du pisiforme
Scanner et IRM si recherche de
pathologies du pisiforme
Immobilisation
AINS,
Physiothrapie
Infiltrations
FCU
TENDINITES DORSALES
TENDINITE EPL
Post-traumatique (Fracture du
radius) ou iatrogne (vis)
Douleur autour du Lister et la
rtropulsion du pouce
JAMAIS dinfiltration
Traitement chirurgical par
ouverture du 3me compartiment
et re-routage de lEPL
Rares
Epanchement synovial dans la gaine sous
le retinaculum qui est visible distal +/_
proximal au retinaculum (synovite en
bissac)
Parfois ruptures
Rechercher: PR, goutte, mycobactrie,
Rarement muscle surnumraire
Parfois idiopathique
TTT: tnosynovectomie
SYNDROME DE BARFRED
Diagnostic
diffrentiel TRES
difficile avec les
douleurs du
bord ulnaire et
les instabilits de
la RUD
Radiographies comparatives
poignets face
Ulna court
Dysplasie gouttire ulna (non
visible)
Pseudarthrose stylode ulnaire
Calcifications
CHOGRAPHIE ECU
Doit tre dynamique +++
Comparative
En pronation ET en supination
Tendinite, panchement (doppler)
Dysplasie tte ulnaire
Instabilit ECU
CHOGRAPHIE ECU
Subluxation
Luxation
CHOGRAPHIE ECU
Subluxation
Luxation
En bleu lECU, en jaune la gouttire ulnaire
Supination
Pronation = Rectitude
Supination = Angulation
IRM ECU
IRM en pr-opratoire
Tendinite/tnosynovite
Mdical, immobilisation en lgre extension du poignet,
coude libre, Infiltrations,
Subluxation
Mdical: Immobilisation en pronation 2-3 mois avec
contrle IRM mensuel de la cicatrisation (tennismen)
Ruptures
TEXTE
AUTRES
PATHOLOGIES
PLUS RARES
TENDINITES LA MAIN
LE CARPE BOSSU
LE DIAGNOSTIC DE CARPE BOSSU EST CLINIQUE MAIS LES IMAGES SONT BELLES
CLINIQUE
Asymptomatique +++
Gne esthtique
Douloureux (en appui)
Parfois associ :
Kyste (30%)
Tendinite des radiaux
Tendinite EIP (par accrochage et
frottement)
TRAITEMENT
Mdical:
Abstention
Orthses
Infiltrations
Chirurgical
Echec traitement mdical
Volume
Accrochage EIP
TRAITEMENT CHIRURGICAL
Incision transversale
esthtique
Excision dun ventuel
kyste
Excision de tous les
ostophytes jusquen zone
cartilagineuse saine +++
Ce qui napparait pas dans ces beaux dessins, ce sont les tendons ECRB/L qui gnent +++
la vision de linterligne articulaire et quil faut prserver
CONCLUSION(S)