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CHRISTIAN DUMONTIER
CENTRE DE LA MAIN, URGENCES MAIN GUADELOUPE
▸ Douleur, spontanée
▸ Diminution de la force
▸ Inflammation péri-tendineuse
▸ Saillies osseuses
▸ Ruptures
LE DOIGT À RESSAUT ET
DIAGNOSTICS DIFFÉRENTIELS
EPIDÉMIOLOGIE
▸ 3 femmes / 1 homme
▸ Idiopathique
▸ Accrochage en flexioncartilage.
ou extension
The A-1 pulley may triple in thickness as
the histologic inner gliding layer of the A-1 pulley
or of the thumb, splinting alone does n
the triggering. Splinting appears to be
changes from the spindle-shaped fibroblasts and option for patients with mild triggering
ovoid cells normally seen to cells with chondrocyte wish to undergo a steroid injection or as
▸ Surtout Annulaire et Pouce, index et auriculaire plus rares
characteristics.
It has been proposed that tendovaginitis is a more
to injection.
▸ Souvent plusieurs doigts atteints +++ changes are found in the retinacular sheath and peri-
tendinous tissue rather than in the tenosynovium. The
in initial management of the symptom
digit. Injection of the involved flexor te
2 terms continue to be used interchangeably in the provides long-term relief of symptoms
literature. 92% of affected digits with up to 3 inje
tamethasone sodium phosphate is the
Conservative Treatment choice because it is water soluble, does
Activity modification, nonsteroidal anti-inflamma- residue in the tendon sheath, is not kno
tory drugs, splinting, steroid injection, and surgical tenosynovitis, and it causes less fat ne
release all have been used in the management of injection is placed in the tissue around
PHYSIOPATHOLOGIE
▸ Friction entre le bord
distal de la poulie et le
tendon lors de la flexion
▸ Métaplasie cartilagineuse
de la couche interne
▸ Augmentation épaisseur
(x 3) de la poulie
▸ Pas d’inflammation de la
gaine (mais des tissus
péri-tendineux)
Poulie Tendon
CLINIQUE
▸ Blocage
Imagerie ?: Non, mais l’échographie bien faite est
un élément diagnostic important surtout dans les
formes douloureuses pures ou atypiques
Epaississement de la poulie
Modification du tendon
On observe en échographie:
hypervascularisation (91%),
synovite liquidienne (55%),
tendinose (48%), tendinose
avec synovite liquidienne (39%)
TRAITEMENT MÉDICAL ?
▸ AINS (bof ?)
Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I
and II systematic review. J Am Acad Orthop Surg 2007;15:166–171.
RÉSULTATS DES INFILTRATIONS
Schubert C et al. Corticosteroid injection therapy for trigger finger or thumb: a retrospective
review of 577 digits. Hand (N Y). 2013 Dec;8(4):439-44.
Sheikh E et al. A prospective randomized trial comparing the effectiveness of one versus two
(staged) corticosteroid injections for the treatment of stenosing tenosynovitis. Hand (N Y). 2014
Sep;9(3):340-5.
Castellanos J et al. Long-term effectiveness of corticosteroid injections for trigger finger and
thumb. J Hand Surg Am. 2015 Jan;40(1):121-6.
INFILTRATIONS DE CORTICOÏDES EST DOULOUREUSE ?
▸ Elle est plus élevée chez les patient(e)s qui ont peur
d’avoir mal, qui sont catastrophistes, dépressifs, et en
fonction du médecin (Julka). Ces facteurs n’expliquent
cependant que 28% de la douleur
▸ Meilleure précision
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.
IFS CHEZ LES DIABÉTIQUES ?
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
REPÈRES ANATOMIQUES POUR LES INFILTRATIONS ?
140 The Journal of Hand Surgery / Vol. 31A No. 1 January 2006
digital proximalTechnique
pour of l’auriculaire
Percutaneous Release
Percutaneous release can be performed in the clinic
setting. Local anesthetic mixed with corticosteroid is
administered and the palmar base of the affected
▸ Bord radial pisiforme - milieu du pli
finger is prepared sterilely. The patient is asked to
flex the affected digit actively. The surgeon then
digital proximal pour l’index
hyperextends the finger. This brings the flexor tendon
sheath directly under the skin and allows the neuro-
vascular bundles to displace to either side.
An 18-gauge needle or other device is inserted at the
▸ Sur le plis digital distal
proximal aspect of the A1 pulley. Care should be taken
to stay centered over the flexor tendon sheath to avoid
neurovascular structures and to enter the skin perpen-
dicularly with the bevel of the needle parallel to the
▸ Repères de Littler (d milieu pulpe-pli
tendon. Alternatively some investigators have advo-
cated inserting the needle slightly more distally in the
du travail en flexion, 62% si A1 et A2)warned that fat necrosis or skin depigmentation are
potential complications of subcutaneous injection.
Intrasheath injections generally do not result in com-
potential
2 B),
complications
and the
plications;
with care
A-1 pulley
however,
taken to
of
tendon
subcutaneous
dissection is continued down to the level of the flexor
Intrasheath
tendon injections generally do not result
is visualized
protect rupture
injection.
(Figs.in com-
has been re-
the neurovascular
2 A,
Peterson WW, Manske PR, Bollinger BA, Lesker PA, McCarthy JA. Effect of pulley
pulley (check for any tightness of the palmar pulley of ManskeOpen
Open release of the A-1 pulley has been used to treat
FDS tendons may be performed to check that all triggering is
and ifrelease
pulley.
gone.
of as
so release
This bundle
thewell).
A-1(D)
also
pulley
is
has been
A traction
trigger digits for more than 100 years. Some sur-
1.19 mm deeptotoperform
the dermis at A-1
usedoftothetreat
tenolysis
subcutaneous, averaging
the thumb MCP
FDP an
trigger digits for more than 100 years. Some sur- geons prefer an open pulley release
excision on flexor tendon biomechanics. J Orthop Res 1986;4:96 –101
geons prefer to perform an open A-1 pulley release
under be used
local to infiltrate
anesthetic theabsence
so the flexor tendon
flexion
sheath with can on
of triggering
crease,
be the
and
seenvolar
may be transected
under local anesthetic so the absence of triggering
skin incision. The A-1 pulley
aspect of thebefore
intraoperatively should
with
be
a deep
released
hand overlying
closure ofthe theMC
144 The Journal of Hand Surgery / Vol. 31A No. 1 January 2006
flexum IPP)
investigators to prevent flexor tendon rupture and Diseased tenosynovium surrounding the tendon is
irreversible damage to the median nerve.26 removed. Intratendinous nodules are excised care-
Bruijnzeel H, Neuhaus V, Fostvedt S, Jupiter JB, Mudgal CS, Ring DC. Adverse
events of open A1 pulley release for idiopathic trigger finger. J Hand Surg Am. 2012
Aug;37(8):1650-6
COMPLICATIONS DU TRAITEMENT CHIRURGICAL
▸ Douleur persistante
▸ Raideur
▸ Oedème
▸ Infection superficielle
▸ 19 réoperations (2.4 %)
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:497–500
AUTRES TECHNIQUES - USSR
▸ En cas de flexum, d’évolution 142 The Journal of Hand Surgery / Vol. 31A No. 1 January 2006
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
Le Viet D, Tsionos T, Bouloudenine M, Hannouche D. Trigger finger treatment byand A-3 pulleys.
▸ La résection intra-tendineuse
de l’épaississement (nodule) -
Seradge et Kleinert
AUTRES TECHNIQUES
Films Dr Desmoineaux
AU POUCE
Patel RM. Hand Surface Landmarks and Measurements in the Treatment of Trigger Thumb. J Hand Surg
2013;38A:1166–1171
DOIGT À RESSAUT DE L’ENFANT
▸ Blocage MP
ACCROCHAGE SOUS LA POULIE A3
▸ Joueur de Bowling
▸ Dos de la MP
▸ Rare
▸ Poirier ( 1889 , Arch gén med ), Langeskiold ( 1950 , Acta Chir scand ) :
2 cas
▸ Dégénérative = ostéophyte
▸ Il décrit la
maladie en
1895 et fait de
suite le
rapprochement
avec les doigts
à ressaut
TENOSYNOVITE DE DE QUERVAIN
▸ Diagnostic clinique
▸ TTT médical
ANATOMIE
2 tendons
VARIATIONS ANATOMIQUES
▸ L’APL comporte de 2 à 9 bandelettes
tendineuses
3
2
1
VARIATIONS ANATOMIQUES
▸ Existence d’un septum qui divise
partiellement ou totalement le compartiment
en deux
Septum
EPB
APL
FRÉQUENCE DU SEPTUM
Moyenne
Séries anatomiques
46 %
11 études 29 % à 77,5%
Séries chirurgicales
67 %
10 études 46 à 91%
▸ Plus rarement:
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
VALIDITÉ DES TESTS
Sensibilité Spécificité
Eischoff-
89 % 14 %
Finkelstein
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
PEUT-ON SAVOIR QUEL TENDON EST PLUS PARTICULIÈREMENT ATTEINT ?
▸ Si plus de douleur en
extension résistée de la
MP du pouce qu’en
abduction palmaire
résistée
Alexander RD, Catalano LW, Barron OA, Glickel SZ: The extensor pollicis brevis entrapment test in the
treatment of de Quervain’s disease. J Hand Surg [Am] 2002;27:813–816.
IMAGERIE NÉCESSAIRE ?
vue axiale
Coté
asymptomatique
EPAISSISSEMENT DU RETINACULUM AVEC KYSTE
HYPERVASCULARISATION AU DOPPLER
Epaississement Tendon
EFFET DE CONSTRICTION
liquide liquide
R
▸ Il associe:
▸ Orthèse de repos
▸ Infiltration,
▸ A.I.N.S.
Infiltration
Infiltration Attelle AINS Repos
+
seule seule seuls seul
Attelle
Taux
de 83% 61% 14% 0% 0 %
guérison
50% Récidives
restent avant 6
guéris à 1 mois
An
Evaluation des traitements de la TSDQ, a pooled quantitative literature evaluation Richie, 2003,
J Am Board Fam Pract
COMPLICATIONS DES INFILTRATIONS
▸ Souffrance cutanée
▸ Sous échographie ?
TÉNOSYNOVITE DE DE QUERVAIN: TRAITEMENT CHIRURGICAL
▸ Libération de la partie
postérieure de la
coulisse
TÉNOSYNOVITE DE DE QUERVAIN: TRAITEMENT CHIRURGICAL
▸ Synovectomie si nécessaire
TÉNOSYNOVITE DE DE QUERVAIN: TRAITEMENT CHIRURGICAL
▸ Dr Desmoineaux
TÉNOSYNOVITE DE DE QUERVAIN: DIAGNOSTIC DIFFÉRENTIEL
▸ Syndrome de Wartenberg et
Syndrome du bracelet montre de
Matzendorff = compression de la
branche sensitive du nerf radial
au poignet
▸ Ténosynovite ou bursite
(« ténobursite »)
▸ Douleur vive
▸ Oedème, gonflement
▸ Glaçage
▸ IFs si échec
CONCLUSION(S)
▸ TTT médical