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Casos Clínicos

17. Fratura de estresse do navicular do pe

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31 anos, masculino, procedente de São Paulo, bra


ID: Atleta profissional de atletismo (salto triplo), 31 anos, masculino, procedente de São Paulo, brasileiro

QD: Dor no pe direito há 20 dias

HPMA: Refere dor no pe de caráter insidioso durante os treinamentos de corridas e saltos.
Progressão da dor com limitação funcional aos movimentos de maior impacto.
Piora da dor durante um salto levando a claudicação e dificuldade para apoiar o pe na posição ortostática.

AP: Fratura de estresse de maleolo tibial do pe direito submetido à osteossíntese com parafusos (2) há 12 anos

IC: NDN

ex. físico:

- Inspeção normal
- Marcha claudicante
- Palpação dolorosa da região dorsal do pe na topografia do navicular
- Dor durante a posição de flexão plantar e apoio unipodálico

- Radiografias simples do pe AP e perfil: destaca-se calcificação grosseira na face dorsal da articulação talonavicular (RX1, RX2, RX3)







- Ressonância magnetica do tornozelo D: fratura transversa no terço lateral do navicular, atingindo as superfícies articulares com o cuneiforme intermedio e com o tálus. (RNM1, RNM2)





- Tomografia computadorizada do pe: fratura transversa da porção media do osso navicular, com extensão às articulações talonavicular, cuneonavicular, sem desalinhamentos ou diástases significativas. Artropatia degenerativa tibiotalar, subtalar e talonavicular, caracterizada por leve redução dos espaços articulares e osteofitose marginal. Destaca-se calcificação grosseira na face dorsal da articulação talonavicular, que mede 2 mm. Fratura antiga do processo ântero-dorsal do calcâneo, com esclerose das superfícies apostas, relacionado a não união (pseudoartrose). Material metálico de fixação em maleolo mediaI. (CT1,CT2, CT3)







- Conduta: bota tipo Robofoot durante 6 semanas sem apoio

O Controle evolutivo da fratura por tomografia computadorizada revelou-se inalterado com relação exame anterior.

Paciente apresentava persistência da dor com limitação para os treinamentos.

Realizada osteossíntese percutânea com parafuso canulado de alta compressão em titânio de 4,5 mm guiado por radioscopia

Radiografias pós-operatórias: (RXcir1,RXcir2)





Retorno aos treinamentos após 6 semanas sem dor.

  LITeRATURA

A Fratura de estresse do Navicular

Primeiramente descritas por Towne e colaboradores em 1970, considerada inicialmente uma fratura rara, representando 0,7% a 2,4% das fraturas por estresse nos esportes.

As fraturas por estresse do osso navicular são muitas vezes causas de dor não diagnosticada nos pes dos atletas. O período medio entre o início dos sintomas e o diagnóstico da fratura e de sete meses. A dor e localizada na região dorsal do pe e irradiada para o arco plantar medial.

As fraturas podem ser parciais ou completas e apresentam-se com orientação linear no plano sagital, envolvem a superfície articular distal e geralmente não apresentam desvios.

O diagnóstico deve ser lembrado sempre que um atleta queixar-se de dor de caráter difuso no pe, identificada no exame físico pela palpação dolorosa do arco longitudinal medial. O exame radiográfico dificilmente permitirá a realização do diagnóstico, embora as radiografias em incidência dorsoplantar devam ser preferencialmente realizadas com ampliação e o pe na posição de supinação.

Algumas alterações anatômicas associadas são encontradas nas radiografias simples, como: a esclerose da margem articular do navicular, metatarso aducto, index minus e fraturas de estresse no 2º, 3º e 4º ossos metatarsais.

O tratamento das fraturas sem desvio consiste na imobilização suropodálica durante seis semanas sem apoio para a deambulação. O retorno integral ao esporte e descrito entre 16 e 20 semanas. O tratamento cirúrgico está indicado nas fraturas com desvio, cominuição ou com retarde de consolidação e consiste na fixação percutânea com ou sem exposição da fratura. O enxerto ósseo pode ser utilizado nos casos crônicos com pseudoartrose ou retarde consolidação.

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