Dupuytren Chir

8/9/2019 Dupuytren Chir

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DGLGNKH NH NXYX[^]HF

H.]@XL@^

^]GK^HDHF^BOK]X]EKBGL

KFR^K^X^ NH LG DGKFBLKFKWXH A@XZHFH^





OKR^@L@EKH

•Bhllulhs juskj`rdhs

•Hnkjkbgtk`f nh b`llgehfh

J`rdgtk`fs f`nulgkrhs

Rtrubturhs lgdhllgkrhs

kfthrf`nulgkrhs

Yrëshfbh gf`rdglhnh b`llgeïfh nh typh

KKK



]GYYHLRGFG^@DKWXHR



L‛GY@FHZ]@RH YGLDGK]HD@[HFFH



L‛GY@FHZ]@RH YGLDGK]H RXYH]JKBKHLLH

H_^H]FHKF^H]FH

D@[HFFH



L‛GY@FHZ]@RH YGLDGK]H D@[HFFH

Jkmrhstrgfsvhrsglhs

Jkmrhssgekttglhs

Jkmrhsl`fektunkfglhs

Gp`fhvr`sh pgldgkrh pr`j`fnh



JKM]HR L@FEK^XNKFGLHR

•pr`l`fehft lh l`fe pgldgkrh

•hf ëvhftgkl

•ëpgkssksshdhft hf gvgftnhs jlëboksshurs

mgfnhlhtths prëthfnkfhushs



MGFNHLH^^HR Y]Ë^HFNKFHXRHR

s'grráthft gu plk nhjlhxk`f pgldgkrh nkstgl

Okgtus poysk`lèkquh



mgfnhlhtths prëthfnkfhushs

•kfshrtk`f sùs nhrdkquh

•b`ffhbtk`fs gvhb l‛gpfv pr`j`fnh



JKM]HR ̂ ]GFRZH]RGLHR

•Lket pgldgkrh trgfsvhrshsuphrjkbkhl(LY^R)

•Lket pgldgft kfthrnkektgl (LYK)

(lket pgldgft fgtgt`krh)•m`rn pr`xkdgl mkhf lkdktë

"rhbùvrh Zx, fhrjs, thfn`fs

•hf nkstgl sh pùrsukt pgr lhsgpfv nkektglhs

•hf pr`j`fnhur rha`kft l‛gpfvpr`j`fnh











•hf pr`j`fnhur rha`kft l‛gpfvpr`j`fnh









•hf pr`j`fnhur rha`kft l‛gpfvpr`j`fnh 1 bl`ks`f





BOKGRDG JKM]HX_• rëufk gu j`fn nhs b`ddkssurhs

•lhs hxpgfsk`fs prjnhs nu LYK

•l‛gpfv pr`j`fnh ht mgfnhlhtths rëtr`vgsbulgkrhs

•lhs hxpgfsk`fs nhs bl`ks`fs kfthrnkektglhs

•lhs hxpgfsk`fs pr`j`fnhs nhs jkmrhs l`fektunkfglhs

• gnoïrh gux bráths b`ddkssurglhs



L‛GY@FHZ]@RH YGLDGK]H

• G lg pgudh1•Jkmrhs l`fektunkfglhs

•Jkmrhs trgfsvhrsglhs

•Jkmrhs sgekttglhs

• Gux n`kets1

•jkmrhs bkrbulgkrhs 1

lkegdhft nh Blhlgfnlkegdhft nh Ergys`f



GY@FHZ]@RHRNKEK^GLHR

• jkmrhs bkrbulgkrhs

•gutùr nhs pënkbulhs

!hf grrkïrh 4 lket Blhlgfn (7?5?)

!hf gvgft 4 lket Ergys`f (7;>7)

• jhukllht suphrjkbkhl gnoïrh

•egkfhs nhs jlëboksshurs•gu nhrdh /b`rn`fs jkmrhux



JKM]@RH ]H^]GB^KLH

• F`nulhs

• @dmklkbgtk`fs

• Mrknhs



M]KNH YGLDGK]H

•Lg mrknh

•sh jkxh gu systïdh

b`ddkssurgl•sh thfn prèrhsskvhdhft

•jlëbokt lg D.Y.

•suphrjkbkglksh lh pënkbulh

•Lh pënkbulh

•nhvkhft trgfsvhrsgl



M]KNHNKEK^GLH

g.Gxkglhm.Lgtërglh

b.Rpkrglh







]KRWXH ZGRBXL@-FH]ZHX_











LH ]KRWXH ZGRBXL@-FH]ZHX_

G ufh kfjluhfbh sur lg strgtëekhdënkb`-bokrurekbglh nh lg prksh hfbogreh nh lg dglgnkh nh nupuytrhf



GY@FHZ]@^@DKH

•Kfjluhfbh lh rksquh bokrurekbgl

•Rurtùt sk 1

!Dgfquh nh j`rdgtk`f!]ëpëtktkvh

!Gvhb shfsgtk`f nh nëbogreh ëlhbtrkquh

!Yhtkt trùmlh shfsktkj thdp`rgkrh ù rësknuhl

!kft`lërgfbh gu jr`kn

!

J`rdh nkektglh



GY@FHZ]@^@DKH

• Fh n`kt pgs átrh pùrsukvkh sk rësultgt f`f pr`mgft

• Hst é nksbuthr sk kfthrvhftk`f prëvuh é bùrt thrdh

!ngfs lhs j`rdhs `û hllh rksquh n‛guedhfthr lh rksquhbokrurekbgl

• kfj`rdhr lh pgtkhft n‛ufh p`sskmlh lësk`f vgsbul`-fhrvhush é dkfkdg

! Rgfs b`fsëquhfbh phrbhptkmlh kddënkgth

!Dgks kfjluhfågft lh rksquh bokrurekbgl



N@KE^ F@F

ZKH]EH

•Lh pëboë `rkekfhl

•Lh roudgt`lèuh

0



LH ̂ ]GK^HDHF^ BOK]X]EKBGL

•G-t-kl uf kftërát 0•Hst kl gftge`fksth nh l‛gp`fëvr`t`dkh 0

•Wu‛hllh hst sg plgbh hxgbth 0



LH ̂ ]HYKHN NHBKRK@FFHL

• Lh typh nh

nupuytrhf• Lh typh nh pgtkhft

• Lhs trgkthdhfts







NKJJH]HF^HR J@]DHR GFG^@DKWXHR









LG BLGRRKJKBG^K@F HF R^GNH FH RXJJK^YGR !

•Wuh n`kt-`f brgkfnrh 0

!

Xfh mrknh mkhf kfnkvknuglksëh sur uf n`ket gvhbufh rëtrgbtk`f kdp`rtgfth

!Xf hfvgoksshdhft hf dgssh nh lg dgkf gvhb ufh

jkmr`sh el`mglh phu rëtrgbtëh•Lh plus kdp`rtgft hst l‛gsphbt el`mgl nh lg

dgkf



LG M]KNH





LG DGKF

•Lhs grtkbulgtk`fs

•Lg phgu•Lhs pgto`lèkhs gss`bkëhs



LHR G]^KBXLG^K@FR

• Lg rgknhur grtkbulgkrh

!DY 1 agdgks rgknh

!KYY 1 lh prkfbkpgl pr`mlïdh!KYN 1

" jlëbokh pgrj`ks rgknh

" Oyphr-hxthfsk`f

• D`kfs eáfgfth bgr pgs n‛gbbr`bogeh

• Fëbhsskth uf gll`fehdhft thfnkfhux

• Yr`mlïdh nh lg mùt`ffkïrh



Mùt`ffkïrhNksthfsk`f nh lg mgfnhlhtth dënkgfh nh l‛gppgrhkl hxthfshur

]ëtrgbtk`f nhs mgfnhlhtths lgtërglhs



LG YHGX

• Hpgkssh ht kfjkltrëh!Yrksh hf dgssh pgr lg dglgnkh

• F`dmrhushs `dmklkbgtk`fs

!F`f trgktëhs pgr l‛gp`fëvr`t`dkh

• Gnoërhfth

!Ygs nh rksquh n‛kfthrp`sktk`f vgsbul`-fhrvhush

!Nksshbtk`f plus nkjjkbklh

• Bkbgtrkbkhllh

!

Mrknh rëtrgbtklh p`st `përgt`krh





LHR YGÔ@L@EKHR GRR@BKHHR

• Lg tëf`syf`vkth f`nulgkrh!Ykïeh nkgef`stkquh ht toërgphutkquh

!J`rdhs nùlùrhushs

!Jgkmlh rëtrgbtk`f sguj qugfn ml`bgeh

!Gss`bkgtk`f jrëquhfth é ufh mrknh nh nupuytrhf

" ^rgkthr lhs nhux pr`mlïdhs hf dádh thdps

• Lhs dgkfs fhur`lèkquhs

• Lg dgkf nkgmëtkquh 1 kfjkltrgtk`f0, rksquhs `p.

• Lhs dgkfs nh Agbùn



LH ̂ ]HYKHN NHBKRK@FFHL

• Lh typh nh

nupuytrhf• Lh typh nh pgtkhft

• Lhs trgkthdhfts

=/ l t n tk t



•Nkgtoïsh ht jgbthurs jgv`rksgft

•]ëbknkvksth

•Gfxkhux ù puskllgfkdh•Geh

•Nhdgfnh j`fbtk`ffhllh ù b`fj`rt

•Ëv`lutk`f b`ftr`-lgtërglh

•Gbtkvktë pr`jhssk`ffhllh ht thdps n‛grrát

=/ lh typh nh pgtkhft



NKGÔHRH

• Bùsskfhts poglgfekhfs

• Lhnnhro`sh

• Lgphyr`fkh• Gtthkfth nhs n`ket rgnkgux

• Gtthkfths mklgtërglhs• Gtthkfths ëthfnuhs

• Gtthkfths jëdkfkfhs



JGB^HX]R JGZ@]KRGF^R

•Yrënksp`sktk`f jgdklkglh(=9%)

•Nkgmëtkquh ++++•Hpklhpskh (egrnhfgl)

•Glb``lkquhs +++++

•^rgudgtksdhs nëblhfbogfts!G.^.



LHR ]HBKNKZKR^HR

•]ksquh `përgt`krh plus ergfn•Fëbhssktë n‛ufh kfthrvhftk`f plus rgnkbglh

!erhjjh nh phgu t`tglh

!Yùr fh pgs gv`kr é lh rë`përhr

•^hfkr b`dpth nhs rësultgts prëbënhfts

!Dgkf b`ftr`-lgtërglh



^H]]GKF YR[BO@L@EKWXH

• Brktïrh nh bo`kx dgahur

!Gfxkhux" Gle`nystr`pokh

" Lg prhdkïrh bgush n‛ëbohb sëvïrh

!Yuskllgfkdh" Dguvgksh rëënubgtk`f

" Dëb`fthfthdhft ht pr`bënurh



L‛GEH

• D`kfs nh nhdgfnh j`fbtk`ffhllh• D`kfs nh thdps nh rëbknkvh

• D`kfs nh rksquh nh rëbknkvh

!Lh suaht ahufh g ufh j`rdh prëb`bh ht n`fb plus sëvïrh

• Ygrj`ks nhdgfnhur n‛uf trgkthdhft ufkquhrgnkbgl

!Bokrurekh hfvksgehgmlh pùr ufh j`rdh skdplh

• Yr`boh nh lg rhtrgkth plutþt gp`fëvr`t`dkh

!Ygs n‛grrát ht gtthfnrh jkf n‛gbtkvktë







2/ LHR ̂ ]GK^HDHF^R

•Lg m`ffh b`ffgkssgfbh nhs

p`sskmklktës toërgphutkquhs!Dënkbglhs

!Bokrurekbglhs!Gmsthftk`ffksths







B@DDH Y@X] ^@X^HR LHR DGLGNKHR



B@DDH Y@X] ̂ @X^HR LHR DGLGNKHRËZ@LX^KZHR

•L‛ënubgtk`f nu pgtkhft hst hsshftkhllh

•Lg b``rnkfgtk`f dënkb`-bokrurekbglh rgssurgfthpùr luk

•Lg b`ffgkssgfbh n‛ufh ëv`lutk`f kdprëvkskmlhsur lh l`fe bùrs n`kt átrh n‛hdmlëh prëbksëh!gkfsk quh lh p`sskmlh rhbùrs é uf trgkthdhft bokrurekbgl

hf bgs n‛ëbohb nh lg prksh hf bogreh dënkbglh.



LH ]ÞLH NH LG Y]KRH HF BOG]EH

]OXDG^@L@EKWXH Y]HDKÏ]H

•Hst n`fb ëvknhft ht hsshftkhl•Hst lg dhkllhurh kftr`nubtk`f é lg prksh

hf bogreh bokrurekbglh qugfn hllhs‛kdp`sh





LG BOK]X]EKH F‛HR^ AGDGKR

GF@NKFH

•Dgks rhsth skdplh pùr lhs j`rdhs skdplhs (o`rs

gle`)•Hllhs hst gstrhkefgfth ht b`dplkquëh pùr lhs

j`rdhs sëvïrhs

•Hllhs nhvkhft ngfehrhush pùr lhs j`rdhsrëbknkvgfths



LHR ̂ ]@KR E]GFNR Y]KFBKYHR J@FNG^HX]R NHL‛KFNKBG^K@F BOK]X]EKBGLH

•L‛hxërïsh nu dgxkdud nh tkssus pgto`lèkquh

•Lg p`sskmklktë nh ehsths gss`bkës

•Lg shulh rhssùrbh hf bgs n‛ëbohb nu trgkthdhft

dënkbgl



GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

]ëshbtk`f nh l‛hfshdmlh nu tkssus

pgto`lèkquhRùs GL], gdmu

Ygfshdhfts 78 a. (2s, Dgb bgso)

]ëënubgtk`f l`feuh, `rtoïsh

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH





GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH





GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH





GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH





GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH





GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH





GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

DGB BGRO



DGB BGRO

DGB BGRO



DGB BGRO

DGB BGRO



DGB BGRO

•Egefh nh lg phgu

•Lkdkth lh rksquh n‛oëdgt`dhs

•F‛guedhfth pgs lh rksquh kfjhbtkhux

•Fh lkdkth pgs lh rksquh nh rëbknkvhs

•]gll`feh lh thdps nh bkbgtrksgtk`f

]HHNXBG^K@F Y@R^ @Y



]HHNXBG^K@F Y@R^-@Y

• Kfnksphfsgmlh

• Kddënkgth

•Nùbh ht kfn`l`rh•Ygrj`ks gss`bkëh é ufh `rtoïsh

nyfgdkquh

•Yr`l`feëh : shdgkfhs

•Yuks gut`-rëënubgtk`f (2 d`ks)

LHR B@DYLKBG^K@FR



LHR B@DYLKBG^K@FR

•Fëbr`sh butgfëh

• Ksboëdkh nkektglh, gdputgtk`f•Mrknh bkbgtrkbkhllh

• Kfjhbtk`fs

•RGFN



KRBOHDKH



KRBOHDKH

KFJHB^K@F



KFJHB^K@F

KFJHB^K@F



KFJHB^K@F

KFJHB^K@F



KFJHB^K@F

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

•KFB@FZHFKHF^R!Mhgubùp plus lùrn

!B`dplkbgtk`fs plus jrëquhfths"RGFN

"Rkf`f j`fbtk`f nh lg sëvërktë ( phu nh surprkshs)

!Yhrskstgfbh nu jlhssud svt rgttgboëh é lg bokrurekh pgs élg Nupuytrhf («

bkbgtrkbh tëd`kf

³)

!Ygs nh s`lutk`fs nh rgttrgpgeh hf bgs n‛ëbohb (dgl vëbu)

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

•]hsth fëgfd`kfs prëbkhush!Rhul rhbùrs ngfs lhs j`rdhs

b`dplhxhs

!^rgkthdhft nhs pgto`lèkhs gss`bkëhs

!Dhkllhurh prëvhftk`f nhs j`rdhssëvïrhs

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

• DHKLLHX]H Y]HZHF^K@F NH LG ]HBKNKZH

!Ngfs lhs j`rdhs sëvïrhs

!Rurtùt hf bgs nh erhjjh nh phgu

!Y`sskmklktë nh rëhllh euërks`fs

GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

•Rhul rhbùrs ngfs lhs

j`rdhs b`dplhxhs" ]gknhurs grtkbulgkrhs

" Gf`dglkhs butgfëhs

• Mrknhs bkbgtrkbkhllhs

• @dmklkbgtk`fs" ]ëtrgbtk`fs thfnkfhushs



EHR^HR GRR@BKHR



EHR^HR GRR@BKHR

•Grtor`lysh

•Grtor`nïsh

•Erhjjh nh phgu

•Gll`fehdhft thfnkfhux





E]HJJH NH YHGX



E]HJJH NH YHGX

E]HJJH NH YHGX



E]HJJH NH YHGX



GY@FHZ]HB^@DKH



GY@FHZ]HB^@DKH

•Rhul rhbùrs hf bgs

n‛ëbohb nhl‛gp`fëvr`t`dkh!]ëbknkvhs

!B`dplkbgtk`fs



B@DYLKBG^K@FR NH L‛GY@FHZ]@^@DKH



B@DYLKBG^K@FR NH L GY@FHZ]@^@DKH

•]grhs

!Lësk`fs vgsbul`-fhrvhushs

" Zgsbulgkrhs phu pgrlgfths (sguj sk kfthrvhftk`f)

" Fhur`lèkquhs 1 nyshstoëskh, oyp`hstoëskh

! Kfjhbtkhushs

• Ygrj`ks sëvïrhs1

! rupturh thfnkfhush1 ^rïs b`dplhxhs é trgkthr

• Rkdplhs dgks bokrurekbglhs

!Cysth ëpknhrdkquh1 F`f hxbhptk`ffhl

]XY^X]H JLHBOKRRHX]



]XY^X]H JLHBOKRRHX]



]XY^X]H JLHBOKRRHX]

]XY^X]H JLHBOKRRHX]



]XY^X]H JLHBOKRRHX]



]XY^X]H JLHBOKRRHX]



]XY^X]H JLHBOKRRHX]

]XY^X]H JLHBOKRRHX]



]XY^X]H JLHBOKRRHX]









KFNKBG^K@F BOK]X]EKBGLH

LG ]Ë^]GB^K@F NKEK^GLH



• ]hsth lh shul ëlëdhft pr`f`stkquh

! Kl jgut gpprëohfnhr s`f nhvhfkr gu l`fe bùrs

! Kl hst kllèkquh nh b`ftkfuhr é gdëlk`rhr ufhrëtrgbtk`f pgldgkrh gu prkx n‛ufh geergvgtk`f nh lgrëtrgbtk`f nkektglh ++++++++++

" Dádh sk lh pgtkhft g uf egkf el`mgl n‛hxthfsk`f

" Bhlg dïfh gu pkrh pr`f`stkb!^ùth rëtrgbtk`f nkektglh ëv`lutkvh sùs trgkthdhft pgr

gp`fëvr`t`dkh nhvkhft ufh kfnkbgtk`f bokrurekbglh

LG ]H^]GB^K@F NKEK^GLH



• Lh jlhssud nkektgl s‛hfrgknkt prèrhsskvhdhft

• Lg rgknhur grtkbulgkrh hst lg prhdkïrh bgush n‛ëbohbnëjkfktkj nu trgkthdhft

!Hllh glùrnkt lhs sukths `përgt`krhs

" Nùlhur

" Nurëh n‛ëv`lutk`f

" Nkjjkbultë nh rëënubgtk`f

!Hllh nkdkfuh b`fsknërgmlhdhft lh rësultgt sur l‛hxthfsk`f

• Ylus `f gtthfn plus `f b`dpr`dht l‛gvhfkr ++++

HF BGR NH JLHRRXD NKEK^GL HZ@LX^KJ



•Kfnkbgtk`f bokrurekbglh

!Rk ëbohb nh lg bokrurekh 1

"

nh tùth jgå`f bhluk-bk hst kfëlubtgmlh" @f gftkbkph skdplhdhft bh b`fstgt

!@f `mtkhft uf egkf kdp`rtgft

"

Xfkquhdhft pùr lhs j`rdhs• Jgv`rgmlhs

• prëb`bhs





LHR BK NH L‛GY@FHZ]HB^@DKH



• Kl f‛y hf g pgs vrgkdhft 1

! r̂gkthdhft gftkb`geulgft hjjkbgbh

• Dgks 1!Ëvkthr lhs pgtkhfts é er`s rksquh n‛ëbohb

" Ëf`lksdh

" Gle`nystr`pokh

" Ëbohbs ù geergvgtk`f prëbënhfth p`st-`p

" L‛kfb`dprëohfsk`f nu trgkthdhft ht nh lg pgto`lèkh

L‛KFJ@]DG^K@F



• Rur lhs ngfehrs

• Rur lhs rksquhs nh rëbknkvhs

• Rur lh rksquh nh rësultgts kfb`dplhts

• Rur l‛gmshfbh nh s`lutk`fs nh rgttrgpgeh hf

bgs n‛ëbohb!nhrfkhr rhbùrs

LG R^]G^HEKH



• Gp`fëvr`t`dkh systëdgtkquh!Yùr lhs j`rdhs pgldgkrhs skdplhs

!Wuhlquh s`kt l‛gfeulgtk`f

!Hfvksgehgmlh pùr lhs j`rdhs nkektglhs

" Rk hllh fh lgkssh pgs ëv`luhr lh jlhssud

• Gp`fëvrhbt`dkh

!Nh shb`fnh kfthftk`f hf bgs n‛ëbohb

!Nh prhdkïrh kfthftk`f sk BK é l‛gp`fëvr`t`dkh• Gp`fëvr`t`dkh

nh rhtgrnhdhft hf bgs nh BK bokrurekbglh (pgllkgtkj)







B@FBLXRK@F



•Lg bokrurekh rhsth skdplh pùr lhs j`rdhsskdplhs!

(o`rs gle`)!Kl f‛hst pgs lëektkdh nh b`dpgrhr lhs ëbohbs nh

lg bokrurekh ngfs lhs j`rdhs sëvïrhs gvhb lhs m`fs

rësultgts `mthfus quhlquh s`kt lh trgkthdhft ngfslhs j`rdhs pgldgkrhs skdplhs



•Lg bokrurekh hst uf ëlëdhft hsshftkhl ht

sùvhft kfb`ftùrfgmlh nh l‛grshfgltoërgphutkquh

!R`f kftr`nubtk`f rëp`fn é nhs rïelhs n‟kfnkbgtk`fsht nh tkdkfe rkeùrhux



• Lg bokrurekh n`ffh lhs dhkllhurs dgks gussk lhs pkrhsrësultgts 1

!Lhs kfnkbgtk`fs n`kvhft n`fb átrh prunhfths ht austkjkëhs

!Kl jgut n`ffhr lg prk`rktë é l‛gp`fëvr`t`dkh" nïs qu‛hllh hst p`sskmlh

" Wugfn hllh phut gpp`rthr ufh gdëlk`rgtk`f pr`mgfth



• L‛gp`fëvr`t`dkh fh n`kt pgs rhtgrnhr lg dksh hfrùth nu trgkthdhft bokrurekbgl hf bgs nh rëtrgbtk`f

nkektglh ëv`lutkvh• Dádh hf bgs n‛gdëlk`rgtk`fs kdp`rtgfths nh lg

rëtrgbtk`f pgldgkrh ù el`mglh

L‛GY@FHZ]@^@DKH





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Dupuytren Chir