肌腱滑囊及关节囊的慢性损伤性炎症

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 运动系统慢性损伤Chronicinjuryofsofttissue 概述Overview 临床常见病 多发病涉及骨 关节 肌肉 肌腱 韧带 筋膜及其相关的血管神经分类 软组织 骨 软骨慢性损伤及周围神经卡压 特点Feature 局部慢性 无外伤史有特定部位压痛点和肿块 可放射痛局部无明显炎症表现近期有与疼痛部位相关的过度活动史部分病人偶导致运动系统慢性损伤的工种 坐姿和工作习惯或职业 治疗Treatment 限制致伤活动 或纠正不良姿势 维持关节的不负重活动积极物理治疗 按摩推拿 外敷及熏蒸 正确合理使用肾上腺皮质激素非甾体消炎镇痛药的合理使用 短期 外用 缓释剂 肠溶剂 栓剂 肾功能不佳者可选用短半衰期药物 手术 Strainoflumbarmuscles腰肌劳损 CommoncauseoflumbarpainLocaltenderness startpointorendpointofmusclesBackpain relieveafterrestoractivitiesErectorspainaemusclespasm Treatment Selfcaretherapy changepositionPhysiotherapy massageLocalsteroidinjectionAnti inflammatorydrugs Supraspinousligamentinjuryinterspinousligamentinjury CommoncauseofbackpainSupraspinourligamentinjurycommoninmiddlethoracicsegmentInterspinousligamentinjurycommoninlowerlumbarsegment NotraumahistoryBendorhyperextensionpainLocaltendernessSteroidinjectionPhysiotherapyormassageimmobilization Bursitis滑囊炎滑囊是位于人体摩擦频繁或压力较大部位的一种缓冲结构 分为恒定滑囊 继发性滑囊或附加滑囊 Bursaearesacslinedwithamembranesimilartosynovium theyusuallyarelocatedaboutjointsorwhereskin tendon ormusclemovesoverabonyprominence mayormaynotcommunicatewithajoint Function reducefriction protectdelicatestructuresfrompressure Bursaearesimilartotendonsheathsandthesynovialmembranesofjointsandaresubjecttothesamedisturbances 1 acuteorchronictrauma 2 acuteorchronicpyogenicinfection and 3 low gradeinflammatoryconditionssuchasgout syphilis tuberculosis orrheumatoidarthritis Twotypesofbursae normallypresent asoverthepatellaandolecranon andadventitiousones suchasdevelopoverabunion anosteochondroma orkyphosisofthespine Adventitiousbursaeareproducedbyrepeatedtraumaorconstantfrictionorpressure Treatment thecauseofthebursitisSystemiccauses suchasgoutorsyphilis andlocaltraumaorirritantsshouldbeeliminated and whennecessary thepatient soccupationorpostureshouldbechanged Oneormoreofthefollowinglocalmeasuresusuallyarehelpful rest hotwetpacks elevation and ifnecessary immobilizationoftheaffectedpart Treatment AspirationandsteroidinjectionSurgicalproceduresusefulintreatingbursitisare 1 incisionanddrainagewhenanacutesuppurativebursitisfailstorespondtononsurgicaltreatment 2 excisionofchronicallyinfectedandthickenedbursae and 3 removalofanunderlyingbonyprominence StenosingTenosynovitis狭窄性腱鞘炎 moreofteninthehandandwristthananywhereelseinthebody Aperitendinitismayaffectthesetendons causingpain swelling andcrepitus Whenthelongflexortendonsareinvolved triggerthumb triggerfinger orsnappingfingeroccurs Thestenosisoccursatapointwherethedirectionofatendonchanges forhereafibroussheathactsasapulley andfrictionismaximal Althoughthetenosynoviumlubricatesthesheath frictioncancauseareactionwhentherepetitionofaparticularmovementisnecessary asinwindingafinecoilofwireorstackinglaundry DEQUERVAINDISEASE StenosingtenosynovitisoftheabductorpollicislongusandextensorpollicisbrevistendonsWhentheextensorpollicisbrevisandtheabductorpollicislongustendonsinthefirstdorsalcompartmentareaffected theconditionisnamedaftertheSwissphysician DeQuervain whodescribedhisexperiencein1895 Womenareaffected10timesmorefrequentlythanmen Thecauseisalmostalwaysrelatedtooveruse eitherinthehomeoratwork orisassociatedwithrheumatoidarthritis Thepresentingsymptomsusuallyarepainandtendernessattheradialstyloid Sometimesathickeningofthefibroussheathispalpable diagnosis TheFinkelsteintestusuallyispositive ongraspingthepatient sthumbandquicklyabductingthehandulnarward thepainoverthestyloidtipisexcruciating AlthoughFinkelsteinstatesthatthistestis probablythemostpathognomonicobjectivesign itisnotdiagnostic thepatient shistoryandoccupation theroentgenograms andotherphysicalfindingsmustalsobeconsidered Treatment Conservativetreatment consistingofrestonasplintandtheinjectionofasteroidpreparationintothetendonsheath ismostsuccessfulwithinthefirst6weeksafteronset SteroidinjectionWhenpainpersists surgeryisthetreatmentofchoice completerelief TRIGGERFINGERANDTHUMB弹响指和弹响拇 Stenosingtenosynovitis leadingtoinabilitytoextendtheflexeddigit triggering usuallyisseenafter45yearsofage Patientsmaynotealumporknotinthepalm Thelumpmaybethethickenedareainthefirstannularpartoftheflexorsheath oranoduleorfusiformswellingoftheflexortendonjustdistaltoit Thenodulecanbepalpatedbytheexaminer sfingertipandwillmovewiththetendon Thetendonnoduleusuallyisattheentryofthetendonintotheproximalannulusatthelevelofthemetacarpophalangealjoint Treatment Treatmentoftriggerdigitsusuallyisnonoperativeintheuncomplicatedpatientwhopresentsashorttimeafteronsetofsymptoms Nonoperativemethodsincludestretching nightsplinting andcombinationsofheatandice CorticosteroidinjectioniseffectiveafteroneinjectionSurgicalreleasereliablyrelievesthesymptomformostpatients Ganglion Treament SqueezeAspirationandsteroidinjectionOperation Lateralepicondylitis肱骨外上髁炎 Lateralepicondylitis tenniselbow afamiliartermusedtodescribedamyriadofsymptomsaboutthelateralaspectoftheelbow occursmorefrequentlyinnonathletesthanathletes withapeakincidenceintheearlyfifthdecadeandanearlyequalgenderincidence Activitiesthatrequirerepetitivesupinationandpronationoftheforearmwiththeelbowinnearfullextension Tendernessispresentoverthelateralepicondyleapproximately5mmdistalandanteriortothemidpointofthecondyle Painusuallyisexacerbatedbyresistedwristdorsiflexionandforearmsupination andthereispainwhengraspingobjects Plainroentgenogramsusuallyarenegative occasionallycalcifictendinitismaybepresent MRIdemonstratestendonthickeningwithincreasedT1andT2signalsbutgenerallyisnotindicated Regardlessoftheunderlyingcause nonoperativetreatmentissuccessfulin95 ofpatientswithtenniselbowInitialnonoperativetreatmentincludesrest ice injections andphysicaltherapycenteredaroundtreatmentsuchasultrasound electricalstimulation manipulation softtissuemobilization frictionmassage stretchingandstrengtheningexercises andcounter forcebracing SteroidinjectionIfprolonged 6to12months operativetreatmentmaybeconsidered itiseffectivein90 ofproperlyselectedpatients AdhesiveCapsulitis frozenshoulder 肩周炎或称冻结肩或五十肩肩周 肌腱 滑囊及关节囊的慢性损伤性炎症 主要表现为活动时疼痛 功能受限 肩部结构 肩部外层肌肉为三角肌内层为肩袖 由冈上肌 冈下肌 肩胛下肌和小圆肌及肌腱组成肱二头肌长头关节囊滑囊肩胛盂和肱骨头 Frozenshouldersinpatientswhoreportnoincitingeventandwithnoabnormalityonexamination otherthanlossofmotion orplainroentgenogramsweredesignatedas primary andthosewithprecipitanttraumaticinjuriesas secondary Thisdivisionhelpsinplanningtreatmentbutdoesnotnecessarilypredictoutcome Noformalinclusioncriteria Therearenouniversallyacceptedcriteriaforthediagnosisoffrozenshoulder internalrotationfrequentlyislostinitially followedbylossofflexionandexternalrotation Theincidenceoffrozenshoulderinthegeneralpopulationisapproximately2 anincreasedincidenceassociatedwith includingdiabetesmellitus upto5timesmore cervicaldiscdisease hyperthyroidism intrathoracicdisorders andtrauma Peoplebetweentheagesof40and70aremorecommonlyaffected Commontoalmostallpatientsisaperiodofimmobility theetiologiesofwhicharediverse Rotatorcuff肩袖 冈上肌 冈下肌 肩胛下肌和小圆肌Supraspinatus infraspinatus subscapularmuscle teresminorPainmaydisappearDysfunction PrimaryFrozenShoulder Primaryfrozenshoulderisavagueentitythatonlyrarelyrecursinthesameshoulder Theclinicalcourseofprimary idiopathic frozenshoulderconsistsofthreephases PhaseI Pain Patientsusuallyhaveagradualonsetofdiffuseshoulderpain whichisprogressiveoverweekstomonths Thepainusuallyisworseatnightandisexacerbatedbylyingontheaffectedside Asthepatientusesthearmless painleadingtostiffnessensues PrimaryFrozenShoulder PhaseII Stiffness Patientsseekpainreliefbyrestrictingmovement Thisheraldsthebeginningofthestiffnessphase whichusuallylasts4to12months Patientsdescribedifficultywithactivitiesofdailyliving menhavetroublegettingtotheirwalletsandwomenwithfasteningbrassieres Asstiffnessprogresses adullacheispresentnearlyallthetime especiallyatnight andthisoftenisaccompaniedbysharppainduringrangeofmotionatornearthenewendpointsofmotion PrimaryFrozenShoulder PhaseIII Thawing Thisphaselastsforweeksormonths andasmotionincreases paindiminishes Withouttreatment otherthanbenignneglect motionreturnisgradualinmostbutmayneverobjectivelyreturntonormal althoughmostpatientssubjectivelyfeelnearnormal perhapsasaresultofcompensationoradjustmentinwaysofperformingactivitiesofdailyliving SecondaryFrozenShoulder Unlikepatientswithidiopathicfrozenshoulder patientswithsecondaryfrozenshouldercanrecallaspecificprecipitatingevent possiblyrelatedtooveruseorinjury Thethreephasesofclassicfrozenshouldermaynotallbepresentandmaynotfollowthepreviouslyoutlinedchronology fortunately treatmentforthetwoentitiesissimilar Diagnosis testsinpatientswithafrozenshoulder includingplainfilmroentgenograms usuallyarenormal exceptinthosewithmedicaldisorderssuchasdiabetesorthyroiddisease Bonescanshavebeenreportedtobepositiveinsomepatients Arthrogramscharacteristicallyshowareducedjointvolumewithirregularmargins Clinicalimprovementhasbeenreportedafterarthrographybecauseofbrisementofadhesionsfromforcefullyinjectingfluidintothejoint Avolumeoflessthan10mlandlackoffillingoftheaxillaryfoldcurrentlyareacceptedarthrographicfindingsindicativeofafrozenshoulder Differentialdiagnosis CervicalspondylosisRotatorcufftear Treatment Traditionally frozenshoulderhasbeenconsideredaself limitingcondition lasting12to18months Approximately10 ofpatientshavelong termproblems Patientsseekingcareearlierusuallyrecovermorequickly Dominantshoulderinvolvementhasbeenreportedtobepredictiveofagoodresult whereasoccupationandtreatmentprogramsarenotstatisticallysignificant Obviously thebesttreatmentoffrozenshoulderisprevention secondaryfrozenshoulder butearlyinterventionisofparamountimportance agoodunderstandingofthepathologicalprocessbythepatientandthephysicianalsoisimportant Treatment Initialtreatmentisnonoperative withemphasisplacedoncontrolofpainandinflammation passiveandactiverange of motionexercises Abductionshouldbeavoidedinitiallytopreventimpingementuntiljointmotionbecomesmoresupple PhysiotherapySteroidinjectionNSAIDSdrugs Treatment Althoughafrozenshoulderusuallyisself limitingandresolvesin12to18months manypatientsdonotwishtowaitthatlongforresolutionofsymptomsandrequestactiveinterventionlongbefore12months Withappropriatepatientselection significantimprovementcanbeobtainedinapproximately70 ofpatients ClosedmanipulationunderanesthesiaOpenreleaseofcontractures Treatment Arthroscopicreleaseisanoptionwhenclosedmanipulationfailsorforpatientswhohavehadprolonged recalcitrantadhesivecapsulitis Chondromalaciapatella髌骨软骨软化症 Epiphysitisoftibialtuberosity胫骨结节骨骺炎 Osgood Schlatterdisease Osteochondroldiseaseofthetibialtubercle Commonage12 14ys OSGOOD SCHLATTERDISEASE Disordersofactivelygrowingepiphyses Thedisordermaybelocalizedtoasingleepiphysisoroccasionallymayinvolvetwoormoreepiphysessimultaneouslyorsuccessively Thecausegenerallyisunknown butevidenceindicatesalackofvascularitythatmaybetheresultoftrauma quadriceps infection orcongenitalmalformation Treatment SelflimiteddiseaseObservation remaineminanceofTTSurgeryrarelyisindicatedthedisorderusuallybecomesasymptomaticwithouttreatmentorwithsimpleconservativemeasuressuchastherestrictionofactivitiesorcastimmobilizationfor3to6weeks Legg Calve PerthesDiseasePerthes病 Thecause chronicinjuryTheclinicalsign painandlimp ThomassignplainroentgenographicchangesBonescintigraphyMRITreatment Lloyd Roberts CatterallandSalamonclassification classifiedpatientswiththisdiseaseintogroupsaccordingtotheamountofinvolvementofthecapitalfemoralepiphysis groupI partialheadorlessthanhalfheadinvolvement groupsIIandIII morethanhalfheadinvolvementandsequestrumformation groupIV involvementoftheentireepiphysis headatrisk Theynotedcertainroentgenographicsignsdescribedas headatrisk correlatedpositivelywithpoorresults especiallyinpatientsingroupsII III andIV Thesehead at risksignsincludeLateralsubluxationofthefemoralheadfromtheacetabulum Speckledcalcificationlateraltothecapitalepiphysis Diffusemetaphysealreaction metaphysealcysts Ahorizontalphysis Gagesign aradiolucentV shapeddefectinthelateralepiphysisandadjacentmetaphysis ContainmentbyfemoralvarusderotationalosteotomyforolderchildreningroupsII III andIVwithhead at risksigns Contraindicationsincludeanalreadymalformedfemoralheadanddelayoftreatmentofmorethan8monthsfromonsetofsymptoms SurgeryisnotrecommendedforanygroupIchildrenoranychildwithoutthehead at risksigns SalterandThompsonclassification SalterandThompsonadvocateddeterminingtheextentofinvolvementbydescribingtheextentofasubchondralfractureinthesuperolateralportionofthefemoralhead Iftheextentofthefracture line islessthan50 ofthesuperiordomeofthefemoralhead theinvolvementisconsideredtypeA andgoodresultscanbeexpected Iftheextentofthefractureismorethan50 ofthedome theinvolvementisconsideredtypeB andfairorpoorresultscanbeexpected AccordingtoSalterandThompson thissubchondralfractureanditsentireextentcanbeobservedroentgenographicallyearlierandmorereadilythantryingtodeterminetheCatterallclassification Furthermore accordingtotheseauthors ifthefemoralheadisgradedastypeB thenprobablyanoperationsuchasaninnominateosteotomyshouldbecarriedout Herringclassification 1 Mostpatientscanbetreatedbynoncontainmentmethodsandobtaingoodresults 80 2 Satisfactoryclinicalresultsfrequentlycanbeobtainedatlong termfollow updespiteanunsatisfactoryroentgenographicappearance Conclusions 3 TheCatterallclassificationisavalidindicatorofresultsbutisnotapplicableasatherapeuticguide 4 Head at risksignsaddedlittletotheCatterallclassificationasaprognosticindicatorortherapeuticguide 5 AllofthefairandpoorresultswereinpatientswithCatterallIIIorIVinvolvementandonsetofthediseaseatage6orlater CarpalTunnelSyndrome腕管综合症 anothername tardymedianpalsy resultsfromcompressionofthemediannervewithinthecarpaltunnel Thesyndromeconsistspredominantlyoftinglingandnumbnessinthetypicalmediannervedistributionintheradialthreeandone halfdigits thumb index long radialsideofring Painoccursdiffuselyinthehandandradiatesuptheforearm Thenaratrophyusuallyisseenlaterinthecourseofthenervecompression Thesyndromefrequentlyisassociatedwithnonspecifictenosynovialedemaandrheumatoidtenosynovitis asaretriggerfingeranddeQuervaindisease Schuindetal studiedbiopsyspecimensoftheflexortendonsynoviumfrom21patientswith idiopathic carpaltunnelsyndrome Thefindingsweresimilarinallandweretypicalofaconnectivetissueundergoingdegenerationunderrepeatedmechanicalstress Diagnosis Paresthesiaoverthesensorydistributionofthemediannerveisthemostfrequentsymptom moreofteninwomenandfrequentlycausesthepatienttoawakenseveralhoursaftergettingtosleepwithburningandnumbnessofthehandthatisrelievedbyexercise TheTinelsignmaybedemonstratedinmostpatientsbypercussingthemediannerveatthewrist Atrophytosomedegreeofthemedian innervatedthenarmuscleshasbeenreportedinabouthalfofthepatientstreatedbyoperation Acuteflexionofthewristfor60secondsinsomebutnotallpatientsorstrenuoususeofthehandincreasestheparesthesia Applicationofabloodpressurecuffontheupperarmsufficienttoproducevenousdistentionmayinitiatethesymptoms Gellmanetal evaluatedtheclinicalusefulnessofcommonlyadministeredprovocativetests includingwristflexion nervepercussion andthetourniquettest in67handswithelectricalproofofcarpaltunnelsyndromeandin50controlhands Diagnosis Themostsensitivetestwasthewristflexiontest whereasnervepercussionwasthemostspecificandtheleastsensitive Theyalsofoundthatwiththewristinneutralposition themeanpressurewithinthecarpaltunnelinpatientswithcarpaltunnelsyndromewas32mmHg Thispressureincreasedto99mmHgwith90degreesofwristflexionandto110mmHgwiththewristat90degreesofextension Thepressuresinthecontrolsubjectswiththewristinneutralpositionwere25mmHg 31mmHgwiththewristinflexion and30mmHgwiththewristinextension Sensibilitytestinginperipheralnervecompressionsyndromeswasinvestigated foundthatthresholdtestsofsensibilitycorrelatedaccuratelywithsymptomsofnervecompressionandelectrodiagnosticstudies Electrodiagnosticstudiesarereliableconfirmatorytests UltrasonographyhasbeenusedtoshowthemovementoftheflexortendonswithinthecarpaltunnelEarlyreportsofMRIincarpaltunnelsyndromearepromising AmajoradvantageofMRIisitshighsofttissuecontrast whichgivesdetailedimagesofbothbonesandsofttissues Careshouldbetakennottoconfusethissyndromewithnervecompressioncausedbyacervicaldischerniation thoracicoutletstructures andmediannervecompressionproximallyintheforearmandattheelbow Treatment Ifmildsymptomshavebeenpresentandthereisnothenarmuscleatrophy theinjectionofhydrocortisoneintothecarpaltunnelmayaffordrelief Greatcareshouldbetakennottoinjectdirectlyintothenerve Injectionalsocanbeusedasadiagnostictoolinpatientswithoutbonyortumorousblockingofthecanal 65 ofthesecasesprobablyarecausedbyanonspecificsynovialedema andtheseseemtorespondmorefavorablytoinjection Injectionalsohelpstoeliminatethepossibilityofothersyndromes especiallycervicaldiscorthoracicoutletsyndrome Somepatientsprefertoreceiveinjectionstwoorthreetimesbeforeasurgicalprocedureiscarriedout Iftheresponseispositiveandthereisnomuscleatrophy conservativetreatmentwithsplintingandinjectionisreasonable Treatment Ifsignsandsymptomsarepersistentandprogressive especiallyiftheyincludethenaratrophy divisionofthedeeptransversecarpalligamentisindicated Theresultsofsurgeryaregoodinmostinstances andbenefitsseemtolastinmostpatients Althoughthenaratrophymaydisappear itresolvesslowly ifatall Asnotedearlier whensymptomsofmediannervecompressiondevelopduringtreatmentofanacuteCollesfracture theconstrictingbandagesandcastshouldbeloosenedandthewristshouldbeextendedtoneutralposition WhenmediannervepalsydevelopsafteraCollesfractureandhasgoneunrecognizedforseveralweeks surgeryisindicatedwithoutfurtherdelay OsteonecrosisofFemoralhead成人股骨头无菌性坏死 Osteonecrosisofthefemoralheadisaprogressivediseasethatgenerallyaffectspatientsinthethirdthoughfifthdecadesoflife ifleftuntreated itleadstocompletedeteriorationofthehipjoint Itisestimatedthatasmanyas20 000newcasesofosteonecrosisarediagnosedeachyearintheUnitedStates 定义 ARCO AAOS的标准ONFH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 Osteonecrosisofthefemoralhead 非创伤性 常见病因是酒精中毒 激素是骨科常见病 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 缺乏有效防治方法多数患者最后不得不接受全髋关节置换术TotalHipArthroplasty ARCO分期 0期活检符合坏死 其余检查正常1期MR 骨扫描异常A3