肩袖损伤PPT课件

肩袖损伤,肩袖损伤的流行病学,Uhthoffetal.1founda20%prevalenceinaseriesofcadaverdissectionsinwhichthemeanageofthedonorswas59.4years.Lehmanetal.2foundaprevalenceof17%inalargeseriesofcadaverdissections,withaprevalenceof30%indonorsolderthansixtyyearsofage.Theincidenceoffull-thicknesstearsoftherotatorcuffrangesfrom5%to40%.Furthermore,epidemiologicalstudiesshowanincreasingfrequencyofrotatorcufffailurewithadvancingage3.,1UhthoffHK,LoehrJ,SarkarK.Thepathogenesisofrotatorcufftears.In:TakagishiN,editor.Theshoulder.Tokyo:ProfessionalPostGraduateServices;1987:211-2.2LehmanC,CuomoF,KummerFJ,ZuckermanJD.Theincidenceoffullthicknessrotatorcufftearsinalargecadavericpopulation.BullHospJtDis.1995;54(1):30-1.3BiglianiLU,MorrisonDS.Relationshipbetweenacromialmorphologyandrotatorcufftears.OrthopTrans.1986;10:216.,-,3,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？,-,4,GazzolaS,BleakneyRR.CurrentimagingoftherotatorcuffJ.SportsMedArthrosc,2011,19(3):300-9.,cysticchangeofthegreatertuberosity,1读X片,-,5,GazzolaS,BleakneyRR.CurrentimagingoftherotatorcuffJ.SportsMedArthrosc,2011,19(3):300-9.,normalsubacromialjointspace(7mm)(arrow),1superiorsubluxationofthehumeralhead(arrow)2notchedhumeralneck(arrowhead),-,6,TypeIcalcicationwithauffy,eecyappearancewithpoorlydenedborders,withacutesymptomsandtermedtheresorptivephase.TypeIIcalcication,morediscreetandofhomogenousdensity,withwell-circumscribedborders,andintheformativephase.,DePalmaAF,KruperJS.Long-termstudyofshoulderjointsaffliatedwithandtreatedforcalcictendinitisJ.ClinOrthop.1961;20:61-72.,calcictendinopathy,-,7,2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Frozenshoulder40-60yearsofage,incidence2-5%1.3phases2freezingphase2-9months,painandlossofmotionoftheglenohumeraljointinalldirection，usuallyworstatnightandwhenlyingontheaffectedside2)frozenphase4-12months,stiffnessreachesitsmaximumthawingphase5-12months,rangeofmotionreturnstonormal2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,1HandC,ClipshamK,ReesJL,etal.Long-termoutcomeoffrozenshoulder.JShoulderElbowSurg2008;17:231-6.2ReevesB.Thenaturalhistoryofthefrozenshouldersyndrome.ScandJRheumatol1975;4:193-6.,-,8,3针对肩袖损伤的体查,1冈上肌肩外展功能,1emptycantest1)90degreesabduction2)30degreeshorizontalabduction(intheplaneofthescapula)3)thumbspointingdownward,-,9,2fullcantest1)90degreesinthehorizontalplane2)rotated45degreesexternally3)withthethumbpointingupward,-,10,painfularctest60-1201)shoulderinexternalrotation2)palmfacingup,-,11,4resistedisometricabduction1)thearminneutralrotation2)abductsthearmto90degrees,-,12,1externalrotationstrengthtest=Pattestest1)thepatientselbowin90degrees2)intheplaneofthescapula,2冈下肌和小圆肌肩外旋功能,-,13,2externalrotationlagsign1)elbowpassivelyflexedto90degrees2)maximalexternalrotation,-,14,3dropsign1)almostfullexternalrotation2)elbowflexedat90degrees,-,15,4weaknesswithexternalrotation1)elbowsflexedto90degrees2)thethumbsup3)shouldersrotatedinternally20degrees,-,16,3肩胛下肌肩内旋、后伸功能,1liftofftestaskingthepatienttointernallyrotatethearmtoliftthehandposteriorlyoffoftheback,-,17,2internalrotationlagsign,-,18,3bellypress,-,19,4bearhugtest,-,20,4针对肩峰下撞击综合症的体查,-,21,Hawkins-Kennedytest,-,22,关于MRI,肩袖解剖,-,23,解剖足印（footprint）,-,24,关于MRI,正常肩袖的MRI斜冠状面,-,25,正常肩袖的MRI斜矢状面,-,26,正常肩袖的MRI横断面,-,27,损伤肩袖的MRI,-,28,魔法角magicanglephenomenonthefibersareat55degreestothemainmagneticfieldonT1EricksonSJ,ProstRW,TiminsME.The“magicangle”effect:backgroundphysicsandclinicalrelevance.Radiology.1993;188:23-25.,-,29,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,-,30,肩袖走行及连续性,-,31,脂肪渗透（fattyinfiltration）,FuchsB,WeishauptD,ZanettiM,HodlerJ,GerberC.Fattydegenerationofthemusclesoftherotatorcuff:assessmentbycomputedtomographyversusmagneticresonanceimaging.JShoulderElbowSurg1999;8:599-605.,-,32,肌肉萎缩（muscleatrophy）,1切线征1（tangentsign）2肩胛比（scapularratio）Scapularratiousestheratioofthesupraspinatusmuscleincrosssectiononthesagittalobliqueimagecomparedwiththesizeofthesupraspinatusfossa,andinsupraspinatusatrophytheratioislessthan50%2.,1ZanettiM,GerberC,HodlerJ.Quantitativeassessmentofthemusclesoftherotatorcuffwithmagneticresonanceimaging.InvestRadiol.1998;33:163-170.2ThomazeauH,RollandY,LucasC,etal.Atrophyofthesupraspinatusbelly.AssessmentbyMRIin55patientswithrotatorcuffpathology.ActaOrthopScand.1996;67:264-268.,-,33,肩袖损伤的分类,1全层撕裂1）小1cm2）中1-3cm3）大3-5cm4）巨大5cm,DeOrioJK,CoeldRH.Resultsofasecondattemptatsurgicalrepairofafailedinitialrotator-cuffrepair.JBoneJointSurg.1984;66:563567.,-,34,肩袖损伤的分类,2部分撕裂,-,35,肩袖损伤的治疗,手术VS保守1年龄Ageisoneofthemostusedparametersindecisionmakingforthesurgeryofthecuff1.75years2撕裂大小Shimizu2recommendearlycuffrepairafterconrmingthediagnosisofmassiverotatorcufftears.Partial-thicknessrotatorcufftearisafurtherindicationinthosepatientswithminimalriskoftearextension,minimalpain,anddysfunction3.,1TanakaM,ItoiE,SatoK,etal.Factorsrelatedtosuccessfuloutcomeofconservativetreatmentforrotatorcufftears.UpsJMedSci.2010;115:193-200.2ShimizuC,HoriiM,YamashitaF,etal.Prognosisofmassiverotatorcufftear.Chubuseisai.1990;33:392.3OzbaydarMU,BekmezciT,TonbulM,etal.Theresultsofarthroscopicrepairinpartialrotatorcufftears.ActaOrthopTraumatolTurc.2006;40:4955.,-,36,肩袖损伤的治疗,肌腱的缝法,-,37,开放手术骨质端的固定,-,38,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。,LindleyK,JonesGL.Outcomesofarthroscopicversusopenrotatorcuffrepair:asystematicreviewoftheliterature.AmJOrthop(BelleMeadNJ),2010,39(12):592-600.,-,39,不可修复肩袖损伤的判定,AccordingtoGerberetal.,imagingndingsthatsuggestanirreparablerotatorcufftearinclude1）staticsuperiorsubluxationofaglenohumeraljointwithanacromiohumeralintervalof7mmorlessonananteroposteriorradiographwiththearminneutralrotation,GerberC,WirthSH,FarshadM(2011)Treatmentoptionsformassiverotatorcufftears.JShouldElbSurg20:S20S29.,-,40,and2)fattyinltrationofthero