肩袖损伤cufftear课件

肩袖是什麽？肩峰下间隙四块肌肉:冈上肌:外展,固定肱骨头〔肩胛上神经〕冈下肌:旋后〔肩胛上神经〕小圆肌:旋后〔腋神经〕肩胛下肌:内旋〔肩胛下神经〕肩袖出口:肩峰、喙肩韧带、肩锁关节肩峰下滑囊〔肩胛上神经〕肩关节解剖肩关节解剖肩关节解剖肩袖损伤有哪些表现？疼痛疼痛弧60°~120°肩上活动疼:间断/持续，程度休息或夜间疼力弱weakness外展及外旋时明显弹响click不稳instability疼痛弧肩疼的鉴别诊断肩以外因素肩疼特点肩本身疼可放散至上臂疼〔C5，C6〕Palmsign手掌征：盂肱、肩峰下Fingersign手指征：肩锁、胸锁不能患侧卧很少伴有手麻肩疼的部位：盂肱、肩峰下、肩锁等物理检查(1)一般检查诱发试验封闭试验其它损伤:盂肱关节不稳

SLAP损伤肩锁关节损伤内撞击喙突撞击综合征物理检查(2)一般检查:畸形ROM:主动,被动肌肉萎缩肌力:外展,外旋物理检查(3)诱发试验:压疼大结节,喙肩韧带,肩峰前缘大结节触摸试验Renttest外展抗阻30°、90°及牵拉抗阻试验Neer撞击征侧向撞击Hawkins试验〔1980〕IRRST_=internalrotationresistancestresstest(Zaslav,2001)物理检查(4)冈上肌实验Jobetest/Yocum’s：wholeSSPPalm-uptest(Dalton1989):前屈90°抗阻，对SSP最前局部敏感外旋抗阻力弱：SSP？置体侧敏感ISP&minorLift-offtest〔Gerber,1991)：腰中部，SSC下局部Lift-offlagsign(1996)Belly-presstest:SSC上局部

物理检查(5)

Lagtest

肩胛下肌腱Lift-offtestLift-offlagsignBelly-presstestIRRSTHawkin’simpingementtestNeer’simpingementsignERLS-externalrotationlagsignHornblower’ssignDroparmsignExternalrotationresisitance物理检查(5)Gerber’ssubcoracoidimpingementtestHamner’smodifiedrelocationtest(2000):Internalimpingement:90°,110°,120°Speed’stestYergason’stest肩关节检查—牵拉试验物理检查(4)封闭试验〔撞击试验〕外展抗阻疼1%利多卡因10ml,肩峰下滑囊封闭封闭后外展抗阻疼明显减轻或消失Therent(裂缝)test

TipofFingerPalpatingEminenceandSulcus

大结节触摸试验肘屈90°,肩外展60°一手触大结节,一手固定肘并旋转大结节处可及弹响+疼subscapularisLift-offtest:distalpartBelly-presstest:proximalpart特殊检查X线片:Y位:肩峰形态,骨刺大结节硬化及囊性变肩峰下间隙〔7~13〕肩锁关节造影超声检查CT&CTAMRI&MRA关节镜关节造影造影剂进入肩峰下滑囊CTArthrographyMRI的诊断价值全厚撕裂敏感性：不压脂：80%；压脂：100%局部撕裂敏感性：不压脂：15%；压脂：35%乒乓球—小撕裂于—举重运发动MRI〔-〕，MRA〔+〕投掷教练—巨大撕裂投掷运发动—大撕裂超声的诊断价值全撕裂：局部撕裂敏感性特异性准确性66.7~100%75~94%90%以上敏感性特异性准确性66.7~93%94%94.9%肩峰撞击征中二头肌腱局部断裂肩袖巨大撕裂肩袖小撕裂肩袖撕裂〔局部〕肩关节不稳的检查肩关节不稳的检查平移试验Translation，anterior/posterior：凹陷征〔Sulcussign〕-下方移位抽屉试验恐惧试验“clunk〞test：外展90，外旋90，推肱骨头向前Relocationtest—releasetest平移试验translation肩关节检查IsthistrueshoulderpainHowdidthepainstartWhichMovementexacerbateSucksign前抽屉试验外展80~120°前屈0~20°外旋0~30°肩胛骨固定clunktest外展90°外旋压肱骨头向前感觉前盂唇有摩擦音为阳性恐惧试验

Theapprehensiontest外展90°缓慢增加外旋同时压肱骨头向前恐惧相，有要脱出感单纯疼非阳性复位及反跳试验

Relocationtest—releasetest仰卧，肩置床沿外展外旋至有脱出感位置向后施力于肱骨近端疼减轻外旋角度增加突然松手疼增加，并恐惧感CTArthrographyAcuteBankart-MRIBankart-MRAMRA后上盂唇损伤投掷运发动MRA显示后上盂唇撕裂MRA后上盂唇损伤投掷运发动加速初期疼有时卡哪些原因引起肩袖损伤？外因：外伤、撞击、疲劳通过内因:退变、老化、血供缺乏起作用哪些原因引起肩袖损伤？急性创伤撞击盂肱关节不稳劳损伤〔repetitivetensilefailure)肩袖创伤性撕裂伤

〔avulsiontear〕撕裂原因正常健康组织：极少撕裂GROUP1创伤较大：如肩脱位7~9%肌腱张力及弹性下降：GROUP2年龄?40多年、以上肢为主的体育运动运动性早老〔Athleticallyacceleratedaging〕反复肩疼，治疗〔包括封闭〕缓解乏血管区外力可以很小损伤病理明确的一次外伤史腱组织退变：钙沉积、纤维样增厚、硬化及瘢痕形成、细胞变性、坏死腱组织局部撕裂及不规那么瘢痕形成，间质细胞增殖肩袖劳损伤

repetitivetensilefailure损伤原因原发：投掷运发动：尤其减速期继发：盂肱关节不稳原发伤投掷加速期：角速度达1100°/s旋转：7000°/s减速期；盂肱牵拉力≈90%体重冈上、冈下、小圆肌离心式收缩表现：肌腱下外表的局部撕裂继发伤GH不稳：occult↓移位增加↓肩袖活动增加抵抗移位↓疲劳↙↘继发撞击→肩袖损伤肩峰撞击肩峰撞击的概念Neer,1972肩袖出口:肩峰前1/3下外表喙肩韧带肩锁关节3期损伤Stage1：水肿，出血：肩峰下滑囊Stage2：纤维化，肌腱炎Stage3：肩袖撕裂：局部，完全关于肩峰肩峰融合:18~25岁(18~19)

不融合4型:PreMeso:最多MetaBasi肩峰形状:关于肩峰肩峰形状:Bigliani三型正常(尸解及门诊):Ⅰ18%,Ⅱ及Ⅲ各41%撕裂者:Ⅲ66~80%,Ⅰ3~6%,Ⅱ28%本所30例:Ⅲ27%,Ⅰ7%,Ⅱ66%关于肩峰Wuh&Snyder:肩峰厚度〔前中1/3交界〕A：〈8mmB：8—12mmC：〉12mm肩峰斜率<35°及长度争议动物实验：肩峰前下加垫，均产生滑囊侧撕裂，无关节侧撕裂肩袖损伤分类肩袖局部撕裂分三型：关节侧型滑囊侧型腱间型

肩袖损伤分类完全撕裂程度分类小：<1cm中度:1-3cm大:3-5cm广泛:>5cm

DefinitionofmassivetearTear>5cm,orientation?tearsofatleast

2tendonsofrotatorcuffTearsizebysquarecentimeter:greaterthan20cm2lengthofdetachmentfromtheheadmultipliedbythemedializationofthecuff治疗消炎：休息：减少肩以上活动冰敷、理疗、封闭、药NSAID保守时间：至少6个月肌力：肩带肌，肩袖，三角肌手术：关节镜、修补术肩袖损伤的关节镜下治疗肩袖损伤的关节镜下治疗清理debridement打磨出新鲜面ASD肩峰成型喙肩韧带切断〔massive例外〕肩峰下滑囊切除肩锁关节下骨赘锁骨远端切除术缝合术Arthroscopicsubacromialdecompression-AS(A)DASD

advantagesvsopenExcellentvisualizationofGHVisualizationforpartialthicknesstearLesstraumatoDeltoidOutpatientsurgeryDecreasedrecoverytimeASD

indicationHistory&exam.consistentwithimpingementsyndromeDiscomfortelevatedin90°-120°NightpainFullROM&lackofresponsetoseveralmonthsofnon-operativeRxExpressionsofcuffdisease,eitherpartialorcompleteASDforarticularsideteariscontroversialASD

roomsetupLateraldecubitusposition(LDP)isprefered15°forwardflexion30°abdSuspendwith10-15poundsRolledtowelintheaxillatopretectbra.PlexusLowerthesystolicBPto90-95mmHgApartcamerafromshaver-suctiontopreventtanglingASD

bursoscopyEstablishposteriorbursalportalEstablishlateralbursalportal:3fingerbreadthsControlofbleedingRemoveinflamedbursaASD

fourstepsDetachtheCAlig.ExceptmassiveunreparabletearDefinetheanterolateralacromionAcromialresectionfromposteriortoanteriorAcromionresectionfromlateraltomedial关节镜下肩峰成型术

ASD2~3年随访：StageⅡ：优良率83.3%~94.2%Partial：优良率66.7%~84%Fulltear：优良率60%±Massivetear：适合活动不大的老年人6~10年的随访：优良率81%19%不满意：其中15%再手术关节镜下肩峰成型术

ASD对运发动：投掷：68%优良〔Neerrating〕非投掷：90%优良投手：50%优良6~10年：33%运发动不能重返运动场Arthroscopictreatment

of

partialthicknessrotatorcufftear

PartialthicknesscufftearIntratendinous:

relatedtoage&repetitivetraumaArticular-sided:lackofhealing&tolarger(52+28)Bursal-sided:extrinsicimpingement,ASADPartialthicknesscufftearSupraspinatustendon(cadavera)MeanAPdimension25mm(19~27)Meanmedtolatthicknessoffootprint12mmAnterior11.6Midtendon12.1Posterior12Meandistancefromcartilagetofootprint1.9mmatinterval1.5mmatmid-tendon1.8mmatposterioredgePartialthicknesscufftearEllman’sclassification:Grade1:<3mmindepth(<25%)Grade2:3-6mm(<50%)Grade3:>6mmgreater50%(repair)WesleyMNottage:>7mmofexposedbonelateraltocartilageedge(indicateatleast50%thickness)PartialthicknesscufftearFrankACordasco:SADsufficient:Grade1&2ARepair:2BPartialthicknesscufftearPartialthicknesscufftear

Bursal-sided由肩峰下撞击引起ASAD效果好诊断困难：PartialthicknesscufftearPartialthicknesscufftearPartialthicknesscufftearArthroscopiccuffrepairFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftear镜下缝合的效果Gartsman(Texuas)73≥2年Sutureanchor90%优良TauroJC（NewJerseey532-3年Sutureanchor92.5%优良Baker203.2年OPEN80%优良88%满意17≥2年关节镜（1月）85%优良92%满意肩袖损伤的切开手术传统手术关节镜辅助三角肌纵劈小切口(ASD+mini-open)巨大撕裂的手术治疗关节镜：ASD/局部缝合切开修补术：经肩峰切口止点重建；松解局部重建：吊桥理论；局部/远位腱转移：肩胛下，三角肌/背阔肌，等半关节置换Hemiarthroplasty巨大撕裂的手术治疗ZanottiRM10例松解，缝合均有功能障碍1例肩胛上N伤2例再断KarasSE20例肩胛下肌腱转移+减压30月（23~70）17/20满意，19/20疼减轻，9/20弱不适BiglianiLU30重修52%满意，81%疼减轻；45%力弱GerberC16例背阔肌转移33月94%疼满意atrest81%onexertionLeHuecJC14例三角肌瓣+decron40月10例很满意；2例满意2例不满意巨大撕裂的手术治疗ArntzCT人工置换hemiarthroplasty21例随访：25~122月15/18疼明显减轻10例不疼4例过度OVERHEAD活动疼1例好，但又骨折加重ROM前屈66→109°3/18返修未发生假体松动Massivetearofcuff

arthroscopicmeaning&advantagesMinimizeDeltoidmorbidity.m.istheonlynormalm.aroundinmassivetearpat.PreservationisverydesirableMini-open:moredifficultAccuratearthroscopicevaluationAllowsforinferiorcap.releasePRNBicepstenodesisReh.“easier〞,butnotquickerCosmeticallydesirableMassivetearofcuff

arthroscopicreparability&difficultiesTechnicallychallengingbutpossibleEssentialextensiveexperienceinsmallerExtensivemobilizationrequiredEquipmentintensive

combineconvergentsuture&anchorfixationRelativelyquickerPreparationSomeresidualacromiohumeraldistancemaintainedProblems

uniqueto

large&massivetearStiffness:adhesionofcuffinferiorcapsularcontractureTendonretractionTendonquality:thin,friable,tenuousosteopeniaSurgicaltechniqueEUA:lossofpROMrestoredbygentlemanipulationPosition:eitherLDPorbeach:+gentletractionPortals:standardSurgicaltechnique

--GHarthroscopyBicepsCartilageSynovitis:partialsynovectomyIfpROM,manipulationfailedcapsularreleaseSurgicaltechnique

--SABBursaevaluationAssessmentofcuffreparability:

tear&qualityASD:notresectCAlig.unlesssecurecuffrepaircanbedone