膝关节评估_9-17

1、膝关节评估 膝部韌帶拉傷膝部韌帶拉傷 内侧副轫带内侧副轫带(MCL)/(MCL)/外侧副轫带外侧副轫带( (LCL) LCL) 内翻压力测试内翻压力测试(Varus Stress test)(Varus Stress test)(圖右)外侧副轫带 外翻压力测试外翻压力测试Valgus Stress testValgus Stress test(圖左)内侧副轫带 pGrade 0: 无松弛 pGrade 1: 1cm 2 膝部韌帶拉傷膝部韌帶拉傷 前十字轫带前十字轫带(ACL), (ACL), 后十字轫带后十字轫带(PCL)(PCL) u前十字轫带: 膝弯屈时放松(030度),伸直时紧张 u后十

2、字轫带: 膝弯屈时紧张(90度),伸直时放松 3 PCL ACL. 4 最常见原因 跑动中急停改变方向造成一巨大扭转力 而损伤 高处跳下造成膝扭转 前十字轫带 - - 非碰撞接触损伤 后十字轫带损伤后十字轫带损伤 胫骨下陷(sag sign) 常见骑摩托车撞击前档板后损伤 5 前十字轫带(ACL) ; (ACL) ; 后十字轫带(PCL)(PCL) 90-前抽屉试验/ /后后抽屉试验030 :前十字- 紧张 90 : 后十字- 紧张 前抽屉试验(+)表示胫骨被拉向前超過0.5cm， 前十字轫带可能断裂 后抽屉试验(+)(+)表示胫骨被向後推離股骨超過0.5cm 后十字轫带可能断裂 6 抽屉试验

3、的盲点抽屉试验的盲点 1.腘旁腱(腿后腱)肌(hamstring)太紧會拉不動 伪伪 阴性阴性 2. 2.当后当后十字轫带损伤时会使胫骨原先就处在后退的 位置(sag sign) 伪阳性伪阳性 7 Lachman test u对前十字轫带损伤最敏感对前十字轫带损伤最敏感ACL ACL u膝弯屈2530然后拉动胫骨远离股骨 u若轻易被拉开表示前十字轫带断裂 8 前十字轫带旋转轴移动测试前十字轫带旋转轴移动测试(ACL Pivot shift test)(ACL Pivot shift test) 给一拉力将胫骨前拉在膝弯屈0-30时, 然后给 予股骨向内侧的压迫 前十字轫带稳定度 如果出现卡住

4、突然半脱位 pivot shift test(+) 9 膝部膝部 Knee UnhappyKnee Unhappy TriadTriad 膝盖扭伤合并内侧副韧带、前十字形韧带和半 月软骨损伤的合并性严重损伤 需碰撞的运动常见运动伤害 机转: 外侧碰撞力量在膝盖此时脚掌还紧贴在地 面产生一个外转的扭力 前十字形韧带损伤可连带外側/內側结构的破坏 10 u小的撕脱性骨哲折 在胫骨近端和前十 字轫带有关 扭转伤害 Segond Fx 11 前十字轫带损伤在前十字轫带损伤在X X线表现线表现 A Fat-Suppressed Proton- Density weighted Sagittal imag

5、e u实心条状 12 MRI下正常前十字轫带 T1-weighted MRI T1-weighted MRI 13 MRI appearances in ACL u在应当出现前十字轫带的位 置却看不到代表就是有损伤 uSagittal image shows complete (or near-complete) nonvisualization of the ACL with ill-defined edema and hemorrhage in the usual location of the ACL in the intercondylar notch. 14 MRI appearan

6、ces in ACL tear T1-weighted MRI Proton-density weighted fat- suppressed sagittal image 轫带边缘不规则部份断裂 15 Diagnosis : Partial tear of the proximal anteromedial band of the ACL 半月軟骨损伤半月軟骨损伤 关节活动时卡住 McMurray testMcMurray test：平躺膝弯屈给与内转外转的力 外转的力 外侧半月軟骨(Lat. Meniscus(左圖) 内转的力 内侧半月軟骨(Med. meniscus(右圖 ) 检查有无杂

7、音(click sign) 16 meniscus 半月軟骨 Apleys testApleys test：下压且旋转：下压且旋转 若有明显疼痛在膝盖处表示阳性 17 臏骨痛臏骨痛(Patellofemeral Pain)(Patellofemeral Pain) 宾骨碾磨测试(patellofemoral grind test) Apprehension test（恐懼） 宾骨被向外推时病病人会有恐慌表情 18 宾骨股骨疼痛综合征宾骨股骨疼痛综合征 与造成膝关节外側压力大的任何因素相关的生物 力学缺损都可能造成疼痛 Q angle 角度過大 足部過度pronation （flatfoot）

8、髕骨过度外移 髕骨过高或过低(Patella alta(高位) or baja(低位) 19 Hamsting strain Hamsting strain Quadriceps strain Quadriceps strain 20 宾骨股骨疼痛综合征宾骨股骨疼痛综合征 股内斜肌(VMO vastus medialis oblique muscle) 肌力不足: 最重要的稳定肌肉 股骨前倾造成股骨过於內转足旋前 髋内转肌縮短;造成股骨過於內轉 髋外转肌力不足;造成股骨過於內转: Iliopsoas, Gluteal muscles 21 宾骨股骨疼痛综合征宾骨股骨疼痛综合征 治疗治疗 足弓使

9、用特殊鞋垫支撑 肌力训练: 髁腰肌(Iliopoas) and 股内斜肌 开放/闭锁链运动 伸展内侧腘旁腱肌和大腿内收肌群 避免 W W坐姿坐姿 22 宾骨肌腱炎宾骨肌腱炎(Patellar tendonitis)(Patellar tendonitis) 近端 : 跳跃膝(Jumpers knee) 远端 : Osgood-Schlatter Dz 23 InfrapatellarInfrapatellar bursitis bursitis Popliteal bursitis (Bakers cyst) 24 膝退化性关节炎 Figure 1 : 正常 Figure 2 : 有骨刺产生,

10、 关节腔变窄 Osteoarthritis: grading Department of Rheumatology and Medical Illustration, University of Manchester Grade 0 : No features Grade 1 : Doubtful narrowing of joint space and possible osteophytic lipping Grade 2 : Definite osteophytes and possible narrowing of joint space Grade 3 : Moderate mult

11、iple osteophytes, definite narrowing of joint space, and some sclerosis and possible deformity of bone ends nGrade 4 : Large osteophytes, marked narrowing of joint space, severe sclerosis , and definite deformity of bone ends 髂胫束综合症髂胫束综合症 (Iliotibial band syndrome )(Iliotibial band syndrome ) Ober t

12、est 27 Open and Closed-kinetic Chain Exercise uClosed-kinetic chain exercise provide a more significant compression force across the knee while activating cocontraction of the quadriceps and hamstring muscles. uOpen-chain exercise at low flexion angles may produce an increase in anterior shear force

13、s, that may cause laxity in the ACL. 28 Open and Closed-kinetic Chain Exercise uOpen-chain exercise generate more isolated muscle activities and allow for more specific strengthening training. Closed-chain better than Open-chain exercise in ACL reconstruction Avoid early open-chain exercise 29 反覆宾骨不

14、稳定的治疗 l目标: 减轻症状 Increase quadriceps strength a d endurance (VMO lateral structures). Use of passive restraints (Palumo-type bracing, McConnell taping) to augment stability during transition. lPatellar Taping Create a mechanical medial shift of the patella centralizing it with in the trochlea groove

15、and improving patellar tracking. 30 uTherapeutic Exercises lHeel slides / Wall slides() lPatellar mobilization 31 uTherapeutic Exercises lQuadriceps sets lStraight leg raises(SLR) all planes with brace in full extension until quadriceps strength is sufficient to prevent extension lag. Slowly raise i

16、t 6 to 10 inches off the floor. Hold this position for 5 seconds and then relax. Perform 3 sets of 20 repetitions, 4 to 5 days a week. 32 Nonioerative treatment of Recurrent Patellar Nonioerative treatment of Recurrent Patellar Instability (Lateral)Instability (Lateral) High EMG activity of the VMO

17、1.Leg press. 2.Lateral step-up. 3.Isometric quadriceps setting. 4.Hip adduction exercise. 33 General Guidelines for Nonioerative General Guidelines for Nonioerative treatment of Recurrent Patellar Instability treatment of Recurrent Patellar Instability (Lateral)(Lateral) lGradual restoration of flex

18、ibility (stretching) for noted deficits. 1.Iliotibial band 2.Quadriceps 34 Two-personTwo-person OberOber stretch stretch Cross-over Cross-over lateral lateral fascialfascial stretchstretch Self Self oberober stretch stretch Leaning lateral Leaning lateral fascialfascial stretch stretch Quadriceps se

19、lf-stretchQuadriceps self-stretch General Guidelines for Nonioerative General Guidelines for Nonioerative treatment of Recurrent Patellar Instability treatment of Recurrent Patellar Instability (Lateral)(Lateral) lGradual restoration of flexibility (stretching) for noted deficits. 3. Hamstring 4. Gastrocnemius 35 uTherapeutic Exercises lHamstring Curls Hold this position for 5 seconds and then relax. Perform 3 sets of 20 repetitions, 4 to 5 days a week, continuing for 3 to 4 weeks. lStraight Leg Raises(Prone) Tighten the hamstrings of the injured l