肩袖损伤

肩袖损伤,肩袖损伤的流行病学,Uhthoff等1在一系列的尸体解剖中发现了20%的患病率，其中捐献者的平均年龄为59.4岁。雷曼等2在一大批尸体解剖中发现了17%的患病率，在60岁以上的捐赠者中，这一比例为30%。肩袖全层撕裂的发生率。范围从5%到40%不等。此外,流行病学研究表明，随着年龄的增长，肩袖损伤的频率越来越高3。,Uhthoff HK, Loehr J, Sarkar K.肌腱套撕裂的发病机制。:Takagishi N,编辑器。的肩膀。东京:专业研究生服务;1987:211-2。雷曼兄弟，库默夫，Kummer FJ, Zuckerman JD。全厚度肩袖撕裂的发生在一个大的尸体人群中。1995;54(1):30-1。3 . Bigliani LU, Morrison DS。肩袖与肩袖撕裂的关系。.反式。1986;10:216。,当我们在临床上遇到疑似病人，只有X片而无MRI检查时，1 我们能从X片中得到什么信息？2 我们印象中的可疑诊断有哪些？3 针对性的体查有哪些？,Gazzola S, Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9. Gazzola年代,Bleakney RR。肌腱套的电流成像J。2011年体育地中海Arthrosc,19(3):300 - 9。,cystic change of the greater tuberosity 大结节的囊性改变。,1 读X片,normal subacromial joint space (7mm) (arrow)正常峰下关节空间(7毫米)(箭头所指),1 superior subluxation of the humeral head (arrow)2 notched humeral neck (arrowhead)1、肱骨头(箭头)的上半脱位2、切口肱骨颈(箭头),Type I calcication with a uffy, eecy appearance with poorly dened borders, with acute symptoms and termed the resorptive phase. Type II calcication, more discreet and of homogenous density, with well-circumscribed borders, and in the formative phase.,DePalma AF, Kruper JS. Long-term study of shoulder joints affliated with and treated for calcic tendinitisJ. Clin Orthop.1961;20:61-72.,calcic tendinopathy,2 可疑诊断,1 关于肩周炎 肩周炎=冻结肩（实用骨科学第3版），是由于肩关节周围软组织病变而引起肩关节疼痛和活动功能障碍。国外报道 Frozen shoulder 40-60 years of age, incidence 2-5%1.3 phases2freezing phase 2-9 months, pain and loss of motion of the glenohumeral joint in all direction，usually worst at night and when lying on the affected side 冻结阶段2 - 9个月,痛苦和损失的盂肱关节的运动方向,通常最糟糕的晚上,当躺在受影响的一面2) frozen phase 4-12 months, stiffness reaches its maximum冻结期4-12个月，刚度达到最大值。thawing phase 5-12 months, range of motion returns to normal解冻期5-12个月，活动范围恢复正常。2 肩峰下撞击综合症 疼痛，主诉为三角肌下疼痛，并经常向下放射至前方的肱二头肌，夜间疼痛可影响睡眠,3 针对肩袖损伤的体查,1 冈上肌 肩外展功能,1 empty can test1) 90 degrees abduction2) 30 degrees horizontal abduction (in the plane of the scapula)3) thumbs pointing downward1悬空试验1)90度内旋2)30度水平外展(肩胛骨平面)3)拇指下行,2 full can test1) 90 degrees in the horizontal plane2) rotated 45degrees externally3) with the thumb pointing upward,painful arc test 60-1201) shoulder in external rotation2) palm facing up,4 resisted isometric abduction1) the arm in neutral rotation2) abducts the arm to 90 degrees,1 external rotation strength test=Pattes test1) the patients elbow in 90 degrees2) in the plane of the scapula,2 冈下肌和小圆肌 肩外旋功能,2 external rotation lag sign1) elbow passively flexed to 90 degrees2) maximal external rotation,3 drop sign1) almost full external rotation2) elbow flexed at 90 degrees,4 weakness with external rotation1) elbows flexed to 90 degrees2) the thumbs up3) shoulders rotated internally 20 degrees,3 肩胛下肌 肩内旋、后伸功能,1 lift off test asking the patient to internally rotate the arm to lift the hand posteriorly off of the back,2 internal rotation lag sign,3 belly press,4 bear hug test,4 针对肩峰下撞击综合症的体查,Hawkins-Kennedy test,关于MRI,肩袖解剖,解剖足印（footprint）,关于MRI,正常肩袖的MRI 斜冠状面,正常肩袖的MRI 斜矢状面,正常肩袖的MRI 横断面,损伤肩袖的MRI,魔法角 magic angle phenomenonthe fibers are at 55 degrees to the main magnetic field on T1Erickson SJ, Prost RW, Timins ME. The “magic angle” effect: background physics and clinical relevance. Radiology. 1993;188:23-25.,我们在MRI上应得到的信息,1 肩袖走行及连续性2 高信号3 脂肪变性4 肌肉萎缩5 肌肉回缩6 三角肌下、肩峰下囊滑液相连,肩袖走行及连续性,脂肪渗透（fatty infiltration）,Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999;8:599-605.,肌肉萎缩（muscle atrophy）,1 切线征1 （tangent sign）2 肩胛比（scapular ratio）Scapular ratio uses the ratio of the supraspinatus muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa, and in supraspinatus atrophy the ratio is less than 50%2.,1 Zanetti M, Gerber C, Hodler J. Quantitative assessment of themuscles of the rotator cuff with magnetic resonance imaging. Invest Radiol. 1998;33:163-170.2 Thomazeau H, Rolland Y, Lucas C, et al. Atrophy of thesupraspinatus belly. Assessment by MRI in 55 patients withrotator cuff pathology. Acta Orthop Scand. 1996;67:264-268.,肩袖损伤的分类,1 全层撕裂 1）小 1cm 2）中 1-3cm 3）大 3-5cm 4）巨大 5cm,DeOrio JK, Coeld RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg. 1984;66:563567.,肩袖损伤的分类,2 部分撕裂,肩袖损伤的治疗,手术 VS 保守1 年龄 Age is one of the most used parameters in decision making for the surgery of the cuff1. 75 years2 撕裂大小 Shimizu2 recommend early cuff repair after conrming the diagnosis of massive rotator cuff tears.Partial-thickness rotator cuff tear is a further indication in those patients with minimal risk of tear extension, minimal pain, and dysfunction3.,1 Tanaka M, Itoi E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci. 2010;115:193-200. 2 Shimizu C, Horii M, Yamashita F, et al. Prognosis of massive rotator cuff tear. Chubuseisai. 1990;33:392.3 Ozbaydar MU, Bekmezci T, Tonbul M, et al. The results of arthroscopic repair in partial rotator cuff tears. Acta Orthop Traumatol Turc. 2006;40:4955.,肩袖损伤的治疗,肌腱的缝法,开放手术骨质端的固定,肩袖损伤的治疗,手术方式的选择开放手术 VS 关节镜手术美国的一篇系统评价显示：术后6个月的ASES、UCLA、疼痛评分及再断裂方面，两者无显著差异，只有短期疼痛，关节镜优于开放手术。,Lindley K, Jones GL. Outcomes of arthroscopic versus open rotator cuff repair: a systematic review of the literature. Am J Orthop (Belle Mead NJ),2010,39(12):592-600.,不可修复肩袖损伤的判定,According to Gerber et al. , imaging ndings that suggest an irreparable rotator cuff tear include 1）static superior subluxation of a glenohumeral joint with anacromiohumeral interval of 7 mm or less on an anteroposterior radiograph with the arm in neutral rotation,Gerber C, Wirth SH, Farshad M (2011) Treatment options for massive rotator cuff tears. J Should Elb Surg 20:S20S29.,and 2) fatty inltration of the rotator cuff muscles at stage three or greater.,