神经精神与运动1（模块2）运动系统慢性疾病 运动系统慢性损伤 肩关节周围炎腱鞘炎股骨头坏死 浙江大学医学院八年制教学课件

浙江大学医学院八年制教学 神经精神与运动1（模块2） 运动系统慢性疾病 肩关节周围炎、腱鞘炎 股骨头坏死 浙江大学医学院附属二院骨科 吴立东 Bursitis 滑囊炎 运动系统慢性损伤 nBursae are sacs lined with a membrane similar to synovium; they usually are located about joints or where skin, tendon, or muscle moves over a bony prominence. nmay or may not communicate with a joint. nFunction: reduce friction, protect delicate structures from pressure. nBursae are similar to tendon sheaths and the synovial membranes of joints and are subject to the same disturbances: (1) acute or chronic trauma, (2) acute or chronic pyogenic infection, and (3) low-grade inflammatory conditions such as gout, syphilis, tuberculosis, or rheumatoid arthritis. nTwo types of bursae: normally present (as over the patella and olecranon) and adventitious ones (such as develop over a bunion, an osteochondroma, or kyphosis of the spine). Adventitious bursae are produced by repeated trauma or constant friction or pressure. Treatment-the cause of the bursitis Systemic causes, such as gout or syphilis, and local trauma or irritants should be eliminated, and, when necessary, the patients occupation or posture should be changed. One or more of the following local measures usually are helpful: rest, hot wet packs, elevation, and, if necessary, immobilization of the affected part. nSurgical procedures useful in treating bursitis are (1) aspiration and injection of an appropriate drug, (2) incision and drainage when an acute suppurative bursitis fails to respond to nonsurgical treatment, (3) excision of chronically infected and thickened bursae, and (4) removal of an underlying bony prominence. Carpal Tunnel Syndrome 腕管综合症 (another name: tardy median palsy) results from compression of the median nerve within the carpal tunnel. The syndrome consists predominantly of tingling and numbness in the typical median nerve distribution in the radial three and one-half digits (thumb, index, long, radial side of ring). Pain occurs diffusely in the hand and radiates up the forearm. Thenar atrophy usually is seen later in the course of the nerve compression. nThe syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Schuind et al. studied biopsy specimens of the flexor tendon synovium from 21 patients with “idiopathic“ carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue undergoing degeneration under repeated mechanical stress. Diagnosis nParesthesia over the sensory distribution of the median nerve is the most frequent symptom; it occurs more often in women and frequently causes the patient to awaken several hours after getting to sleep with burning and numbness of the hand that is relieved by exercise. The Tinel sign may be demonstrated in most patients by percussing the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar muscles has been reported in about half of the patients treated by operation. nAcute flexion of the wrist for 60 seconds in some but not all patients or strenuous use of the hand increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms. Gellman et al. evaluated the clinical usefulness of commonly administered provocative tests, including wrist flexion, nerve percussion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and in 50 control hands. Diagnosis nThe most sensitive test was the wrist flexion test, whereas nerve percussion was the most specific and the least sensitive. They also found that with the wrist in neutral position, the mean pressure within the carpal tunnel in patients with carpal tunnel syndrome was 32 mm Hg. This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures in the control subjects with the wrist in neutral position were 25 mm Hg, 31 mm Hg with the wrist in flexion, and 30 mm Hg with the wrist in extension. nSensibility testing in peripheral nerve compression syndromes was investigated, found that threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies. nElectrodiagnostic studies are reliable confirmatory tests. Ultrasonography has been used to show the movement of the flexor tendons within the carpal tunnel, but it does not clearly show soft tissue planes. Early reports of magnetic resonance imaging (MRI) in carpal tunnel syndrome are promising. A major advantage of MRI is its high soft tissue contrast, which gives detailed images of both bones and soft tissues. Care should be taken not to confuse this syndrome with nerve compression caused by a cervical disc herniation, thoracic outlet structures, and median nerve compression proximally in the forearm and at the elbow. Treatment nIf mild symptoms have been present and there is no thenar muscle atrophy, the injection of hydrocortisone into the carpal tunnel may afford relief. Great care should be taken not to inject directly into the nerve. Injection also can be used as a diagnostic tool in patients without bony or tumorous blocking of the canal; 65% of these cases probably are caused by a nonspecific synovial edema, and these seem to respond more favorably to injection. Injection also helps to eliminate the possibility of other syndromes, especially cervical disc or thoracic outlet syndrome. Some patients prefer to receive injections two or three times before a surgical procedure is carried out. If the response is positive and there is no muscle atrophy, conservative treatment with splinting and injection is reasonable. Treatment nIf signs and symptoms are persistent and progressive, especially if they include thenar atrophy, division of the deep transverse carpal ligament is indicated. The results of surgery are good in most instances, and benefits seem to last in most patients. nAlthough thenar atrophy may disappear, it resolves slowly, if at all. As noted earlier, when symptoms of median nerve compression develop during treatment of an acute Colles fracture, the constricting bandages and cast should be loosened and the wrist should be extended to neutral position. When median nerve palsy develops after a Colles fracture and has gone unrecognized for several weeks, surgery is indicated without further delay. Stenosing Tenosynovitis 狭窄性腱鞘炎 nmore often in the hand and wrist than anywhere else in the body. nA peritendinitis may affect these tendons, causing pain, swelling, and crepitus. nWhen the long flexor tendons are involved, trigger thumb, trigger finger, or snapping finger occurs. The stenosis occurs at a point where the direction of a tendon changes, for here a fibrous sheath acts as a pulley, and friction is maximal. Although the tenosynovium lubricates the sheath, friction can cause a reaction when the repetition of a particular movement is necessary, as in winding a fine coil of wire or stacking laundry. DE QUERVAIN DISEASE nStenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons nWhen the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895. nWomen are affected 10 times more frequently than men. The cause is almost always related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable. diagnosis The The FinkelsteinFinkelstein test usually is positive: test usually is positive: “on grasping the patients thumb and “on grasping the patients thumb and quickly abducting the hand quickly abducting the hand ulnarwardulnarward, , the pain over the the pain over the styloidstyloid tip is tip is excruciating.“ Although excruciating.“ Although FinkelsteinFinkelstein states that this test is “probably the states that this test is “probably the most most pathognomonicpathognomonic objective sign,“ it objective sign,“ it is not diagnostic; the patients history is not diagnostic; the patients history and occupation, the roentgenograms, and occupation, the roentgenograms, and other physical findings must also and other physical findings must also be considered.be considered. Treatment nConservative treatment, consisting of rest on a splint and the injection of a steroid preparation into the tendon sheath, is most successful within the first 6 weeks after onset. nWhen pain persists, surgery is the treatment of choice (complete relief ). TRIGGER FINGER AND THUMB 弹响指和弹响拇 nStenosing tenosynovitis, leading to inability to extend the flexed digit (“triggering“) usually is seen after 45 years of age. nPatients may note a lump or knot in the palm. The lump may be the thickened area in the first annular part of the flexor sheath, or a nodule or fusiform swelling of the flexor tendon just distal to it. The nodule can be palpated by the examiners fingertip and will move with the tendon. The tendon nodule usually is at the entry of the tendon into the proximal annulus at the level of the metacarpophalangeal joint. nTreatment of trigger digits usually is nonoperative in the uncomplicated patient who presents a short time after onset of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and ice. Corticosteroid injection is effective after one injection nSurgical release reliably relieves the problem for most patients Lateral epicondylitis 肱骨外上髁炎 nLateral epicondylitis (tennis elbow), a familiar term used to described a myriad of symptoms about the lateral aspect of the elbow, occurs more frequently in nonathletes than athletes, with a peak incidence in the early fifth decade and a nearly equal gender incidence. nActivities that require repetitive supination and pronation of the forearm with the elbow in near full extension. nTenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm supination, and there is pain when grasping objects. Plain roentgenograms usually are negative; occasionally calcific tendinitis may be present. MRI demonstrates tendon thickening with increased T1 and T2 signals but generally is not indicated. nRegardless of the underlying cause, nonoperative treatment is successful in 95% of patients with tennis elbow. Initial nonoperative treatment includes rest, ice, injections, and physical therapy centered around treatment such as ultrasound, electrical stimulation, manipulation, soft tissue mobilization, friction massage, stretching and strengthening exercises, and counter-force bracing. nIf prolonged (6 to 12 months), operative treatment may be considered; it is effective in 90% of properly selected patients. Adhesive Capsulitis （frozen shoulder.） 肩周炎或称冻结肩 Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) or plain roentgenograms were designated as “primary,“ and those with precipitant traumatic injuries as “secondary.“ This division helps in planning treatment but does not necessarily predict outcome. nNo formal inclusion criteria. There are no universally accepted criteria for the diagnosis of frozen shoulder. internal rotation frequently is lost initially, followed by loss of flexion and external rotation. nThe incidence of frozen shoulder in the general population is approximately 2%. (an increased incidence associated with, including diabetes mellitus (up to 5 times more), cervical disc disease, hyperthyroidism, intrathoracic disorders, and trauma). People between the ages of 40 and 70 are more commonly affected. Common to almost all patients is a period of immobility, the etiologies of which are diverse; Primary Frozen Shoulder nPrimary frozen shoulder is a vague entity that only rarely recurs in the same shoulder. The clinical course of primary (idiopathic) frozen shoulder consists of three phases. nPhase IPain. Patients usually have a gradual onset of diffuse shoulder pain, which is progressive over weeks to months. The pain usually is worse at night and is exacerbated by lying on the affected side. As the patient uses the arm less, pain leading to stiffness ensues. Primary Frozen Shoulder nPhase IIStiffness. Patients seek pain relief by restricting movement. This heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities of daily living; men have trouble getting to their wallets and women with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this often is accompanied by sharp pain during range of motion at or near the new endpoints of motion. Primary Frozen Shoulder nPhase IIIThawing. This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect) motion return is gradual in most but may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or adjustment in ways of performing activities of daily living. Secondary Frozen Shoulder nUnlike patients with idiopathic frozen shoulder, patients with secondary frozen shoulder can recall a specific precipitating event, possibly related to overuse or injury. The three phases of classic frozen shoulder may not all be present and may not follow the previously outlined chronology; fortunately, treatment for the two entities is similar. Diagnosis ntests in patients with a frozen shoulder (including plain film roentgenograms) usually are normal, except in those with medical disorders such as diabetes or thyroid disease. Bone scans have been reported to be positive in some patients. nArthrograms characteristically show a reduced joint volume with irregular margins. Clinical improvement has been reported after arthrography because of brisement of adhesions from forcefully injecting fluid into the joint. A volume of less than 10 ml and lack of filling of the axillary fold currently are accepted arthrographic findings indicative of a frozen shoulder. Treatment nTraditionally, frozen shoulder has been considered a self- limiting condition, lasting 12 to 18 months. nApproximately 10% of patients have long-term problems. Patients seeking care earlier usually recover more quickly. Dominant shoulder involvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. Obviously, the best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of paramount importance; a good understanding of the pathological process by the patient and the physician also is important. Treatment nInitial treatment is nonoperative, with emphasis placed on control of pain and inflammation. n passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingement until joint motion becomes more supple. Treatment nAlthough a frozen shoulder usually is self-limiting and resolves in 12 to 18 months, many patients do not wish to wait that long for resolution of symptoms and request active intervention long before 12 months. With appropriate patient selection, significant improvement can be obtained in approximately 70% of patients. nClosed manipulation under anesthesia nOpen release of contractures Treatment nArthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis. Osteonecrosis of Femoral head 股骨头无菌性坏死 nOsteonecrosis of the femoral head is a progressive disease that generally affects patients in the third though fifth decades of life; if left untreated, it leads to complete deterioration of the hip joint. It is estimated that as many as 20,000 new cases of osteonecrosis are diagnosed each year in the United States. 定义 nARCO+AAOS的标准 nONFH是股骨头血供中断或受损，引起骨 细胞及骨髓成分死亡及随后的修复，继而 导致股骨头结构改变，股骨头塌陷，关节 功能障碍的疾病 Osteonecrosis of the femoral head n非创伤性：常见病因是酒精中毒，激素 n是骨科常见病，多见于中青年，双侧发病 ，约80%未有效治疗，1-4年内将发生股骨 头塌陷，缺乏有效防治方法 n多数患者不得不接受THA 诊断 n早期诊断-困难 n 高度重视病因，尤其重要 n 常常是一侧有症状作MR检查时，发现对 侧有早期ONFH n有酗酒，长期应用激素史 n 病人自己警惕意识强，主动检查 n晚期，X线片表现已很明显，容易诊断 n病史 n体格检查 nX线片 n骨功能检查FBE n 骨内压测定，骨内静脉造影，核心活检 ，放射性核素扫描ECT nCT nMR nX线片：敏感度差，适宜观察股骨头形态，光圆 度，高度，塌陷程度 nCT，敏感度低，不建议采用 nECT，敏感度高 n 仔细观察确实有冷区，可发现特早期（0或1 前期），出现热区，结合病史有助于诊断，但 特异性差 nMRI，敏感度特高，早期发现和诊断股骨头坏死 的敏感性和特异性达99%，应为首选 n股骨头核心活检结果最为准确，组织病理学 nARCO国际骨坏死分期的治疗原则 n0-2A期，可行髓芯减压术 n2B-3B期适用于截骨术或骨移植术，包括 带血运的骨移植 n3C期及以上，应考虑作人工髋关节置换术 骨移植术 n带缝匠肌蒂骨瓣 n带股直肌蒂骨瓣 n带臀中肌蒂骨瓣 n带股方肌蒂骨瓣 n带股外侧肌蒂骨瓣 n单纯游离腓骨移植 n吻合血管腓骨移植 n带旋髂深血管蒂髂骨瓣 n带血管蒂大转子骨-筋膜瓣 n股骨头内记忆合金球网植入 n双支撑骨柱移植 n支撑物加植骨 n空心钉植入 n钽棒植入 n n双支撑骨柱移植长期随访疗效10.2年 n2B 83% n2C 80% n3A 75% n3B 65% n3C 40% n4 28.6% 保头手术影响因素 n病变本身因素 n股骨头坏死范围和塌陷程度，部位 n技术因素 n减压有效与否 n坏死骨清除彻底与否 n植骨的血运保证与否 n机械支撑足够与否：部位，强度，面积 n良好的血供+足够大的支撑面积，足够强的支撑 强度 股骨头坏死的分期系列疗法 n根据年龄，坏死面积，坏死位置，塌陷危 险性等进行个体化选择治疗方法 n只要正确地掌握相应方法，才能获得较好 疗效 nONFH病人多较年轻，应首先考虑保存自 体股骨头 n0-1A：无症状，保守治疗 n药物：活血化瘀中药，葛根素，降脂药等 ，最好用于1前期者，可能有一定效果 n高压氧 n血液净化 n磁疗 n震波 n临床疗效有待于长期观察 n0-1A：有症状，行细针钻孔减压，有效率 60%，可植入自体骨髓细胞或第2代骨髓干 细胞 n目的：股骨头内减压，打通硬化带，促使 向坏死区增加血液循环 1A，1B,2A n粗通道髓芯减压，效可 n目的：减压，打通硬化带，增加血液循环 n可植入自体骨髓细胞，干细胞，自体骨， 同种异体骨，骨诱导活性材料等 1C，2A，2B，2C n骨移植，效果尚好 n目的，彻底清除坏死骨，充分植骨，重建 血循环，促进骨修复，恢复股骨头内生物 力学强度 n防止塌陷 n3A，3B，骨移植术，包括带血运的骨移植 ，效果差 3C期及以上 nTHA，但是无论是骨水泥或非骨水泥固定 的THA，用于骨坏死的远期疗效差于OA 的THA， n我们应该做的：明确的术前告知 n精确标准的手术 n术后的康复 n积极随访指导，病人日常 Diagnosis nPatients are typically asymptomatic early in the course of osteonecrosis and eventually have groin pain on ambulation. A thorough history and physical examination should be done to discover potential risk factors and determine the clinical status of t