PASTAINJURY

国家临床重点专科武汉协和医院骨科,科主任：杨述华,PASTA Injury of Rotator Cuff,华中科技大学同济医学院附属协和医院骨科 关节镜及运动医学中心孟春庆 王洪 何宇 吴星火 王小红,Rotator Cuff,Supraspinatus：大结节上方，外展Infraspinatus：大结节后方，外旋Teres Minor：大结节后方，外旋Subscapularis：小结节前方，内收内旋,Shoulder pain,（冻结肩）,Rotator cuff injury,Clinical ManifestationTraumatic history：急性损伤，重复性或累积性损伤史Pain and tenderness：多位于肩前方，活动或增加负 荷后加重，被动外旋或过度内收时加重，夜间疼痛加重Malfunction：上举和外展功能受限Muscle atryphy：3周Arthrogriposis(关节挛缩）：3月,Rotator cuff injury,Sign: Neer test （撞击试验）,检查者立于患者背后，一手固定肩胛骨，另一只手保持肩关节内旋位，使患肢拇指尖向下，然后使患肩前屈过顶。此时肩峰与肱骨大结节产生撞击，如果诱发出疼痛，即为阳性。见于肩袖损伤，冻结肩，OA，肩袖钙化等,检查者立于患者后方，使患者肩关节内收位前屈90度，肘关节屈曲90度，前臂保持水平。检查者用力使患侧前臂向下至肩关节内旋，出现疼痛者为试验阳性。,Rotator cuff injury,Sign：Hawkins试验,Rotator cuff injury,Sign：Drop sign（落臂试验）,检查者站在患者身后，将患者肩关节外展至90度以上，嘱患者自行保持肩外展90100度的位置，肩无力坠落者为阳性.,Rotator cuff injury,Sign： Pain arc sign（疼痛弧）,患臂上举60120度范围内出现肩前方或肩峰下区疼痛,在 常规X线片显示肩袖损伤者肱骨头上移和肱骨大结节畸形，其阳性率为78，特异性为98。 正常肱骨头和肩峰间的距离是=7mm，如果少于7mm往往提示有肩袖的撕裂。,X-ray,MRI,分级 MRI表现0级 正常，表现为均匀一致的低信号1级 T1WI或PDWI上见有线形的或散在性 的信号增高但形态正常Neer一期2级 T1WI或PDWI上见有信号增高并见肩 袖的变细或不规则Neer二期3级 T2WI上信号增高涉及整个肌腱，肌 腱连续性中断Neer三期,0级,又称为肌腱炎，这时肩袖的连续性是完整的，但是在冈上肌肌腱内见信号的增高。1级的信号改变在质子加权图像中显示最为清晰，为中等信号。这种信号的改变最为可能是由于水肿、炎症反应和出血所引起。对应于Neer期在这一级中，滑囊内通常是没有液体的，肩袖和三角肌间的脂肪层是清晰可见的。和MRI相比不同，在这一级中，关节造影检查是正常的。,1级,T1WI或PDWI上见有信号增高并见肩袖的变细或不规则，对应于Neer的II期纤维化，对应于手术的部分撕裂。滑囊内通常有积液。,变细,2级,T2WI上信号增高涉及整个肌腱，肌腱连续性中断，对应于Neer的III期撕裂，对应于手术的完全性撕裂。滑囊内多有积液。,3级,Partial tear： 关节囊面部分撕裂：PASTA（60） 滑囊面部分撕裂（40） Complete tear,Typing,PASTA损伤定义,肩袖PASTA损伤，并不是以pasta这个人名命名的一种疾病，而是Partial Articular Sided Tendon Avulsion，即关节囊面肩袖部分撕裂。,关节囊面部分撕裂PASTA,滑囊面部分撕裂,Signs and symptoms,These are often very similar to rotator cuff tears in general. 症状和一般肩袖损伤类似The pain is typically felt over the upper arm rather than the shoulder itself. It is often persistent and recurrent and worse when lifting the arm out to the side (abduction) or in front (elevation). With a PASTA pain is frequently the predominant feature.上臂疼痛，外展和前伸时持续性、反复发作的疼痛It may be painful to lie on the shoulder at night.夜间痛The arm may feel weak particularly when lifting the arm above shoulder height.肩上举及外展无力There may be a clicking or grinding sensation within the shoulder.可有弹响或摩擦感,Treatment:,The pain associated with a rotator cuff tear may settle with rest and avoidance of exacerbating activities.休息Rehabilitation may reduce the pain associated with a tear and improve the function of the shoulder. 康复Anti-inflammatory medication may help relieve the pain.抗炎Injections of corticosteroids (steroid) may improve pain.激素封闭If non-operative management does not improve the level of pain and function surgery may be indicated. This would typically involve an arthroscopic repair of the damaged tendon.关节镜手术,Indication of surgery,疼痛超过9个月保守治疗6个月，疼痛加重合并3型肩峰,Operation,关节镜下肩袖撕裂缝合修复术,Rehabilitation,Shoulder surgery typically involves significant rehabilitation. It may take at least 6 to 12 months for pain to settle and full function to recover. Dedication to the rehabilitation recommended programme is likely to influence the outcome of surgery.Following surgery it is likely immobilisation in a sling will be required from 4-6 weeks. It is typically 3 months before resistance work is commenced and it may 5-6 months before a return to contact sports. The long term outcome is typically good with improvement in pain although there may be some limitation of strength and range of movement.,患者李*，男，33岁。左肩关节摔伤后抬举活动障碍8月入院专科情况：左肩关节大结节处压痛，左肩抬举受限，Neer sign（+），Pain arc sign（+） X-