小儿骨科的临床基础

小儿骨科的临床基础病史现病史出生史（产伤骨折、臂丛神经麻痹、脑瘫等）发育史（侏儒、甲低、肌营养不良等）家族史（多指、多发骨软骨瘤病等）2020/11/42体格检查望（整体外观，冠状面、矢状面、水平面）患儿的面容（痛苦面容，21三体面容等）表皮的色泽和皮肤生长情况患儿身材比例肢体对称情况肢体长短情况肢体活动情况肢体畸形情况躯干部活动情况躯干部畸形情况患儿的步态2020/11/43体格检查触皮肤弹性皮肤变色情况局部肿胀情况，温度变化包块（位置、大小、质地、界限、温度、皮色、与周边关系、活动度、压缩性）压痛（位置，最大压痛点）反常活动、骨擦音、骨擦感紧张挛缩感痉挛感肌力（0~5级）2020/11/44肌力0级：无任何收缩1级：只可触及收缩，没有任何活动。2级：可于水平方向移动，不能对抗重力。3级：仅能对抗重力，不能对抗阻力。4级：能对抗一定程度的阻力5级：肌力正常LovettandMartin’s肌力分级法TexasScottishRiteHospital肌力分级法2020/11/45

NormalTimesofAppearanceandDisappearanceofInfantileReflexesandReactions

Palmar(hand)graspreflexPresentinneonatesandveryyounginfants;normallydisappearsbetweenages2and4moPlantar(foot)graspreflexPresentinneonatesandinfants;usuallydisappearsbetweenages9and12moMoro'sreflexPresentatbirth;graduallydisappearsbyages3-6mo：CNSStartlereflexAppearsatbirth;presentthroughoutlifeVerticalsuspensionpositioningReflexnormallydisappearsafterage4moPlacingreactionNormallypresentatbirthinfull-termneonates;upperlimbplacingusuallydisappearsbyages2-4moandlowerlimbplacingbyages1-2mo;bothresponsesmaypersistuptoage12moorolderWalkingorsteppingreflexNormallypresentatbirth;usuallydisappearsbyages1-2moCrossedextensionreflexPresentatbirth;normallydisappearsbyages1-2moWithdrawalreflexPresentatbirth;disappearsbetweenages1and2moPositivesupportresponse/leg-straighteningreflexPresentatbirth;normallydisappearsatabout4moExtensorthrustreflexPresentatbirth;normallypresentupto2moGalant'sreflex(trunkincurvation)Presentatbirth;disappearsatabout2-2½moRotationreflexTimeofdisappearancevariesTonicneckreflexesAsymmetricreflexpresentatbirth,normallydisappearsby4-6mo;symmetricreflexusuallypresentby5-8mo,oftendiminishedorabsentby12moLandau'sreflexNormallypresentfrom6moto24-30moParachutereactionAppearsatabout6mo;remainsthroughoutlifeNeckrightingreflexNormallypresentfrombirthtoabout6moBodyrightingreflexAppearsaround6mo;candisappearanytimeafter5yrorpersistthroughoutlifeOralreflexesUsuallydisappearat3-4mo;maybepresentlongerduringsleep2020/11/46深反射肱二头肌反射肱三头肌反射膝反射踝反射2020/11/47浅反射Babibski反射提睾反射Hoffmann反射括约肌反射腹壁反射2020/11/482020/11/49BrachioradialisC5-6RadialnerveTricepsbrachiiC6-8(T1)RadialnerveAnconeusC7-8RadialnerveSupinatorbrevisC5-7RadialnerveExtensorcarpiradialislongusC(5)6-7(8)RadialnerveExtensorcarpiradialisbrevisC(5)6-7(8)RadialnerveExtensorcarpiulnarisC6-8RadialnerveExtensordigitorumcommunisC6-8RadialnerveExtensorindicispropriusC6-8RadialnerveExtensordigitiminimipropriusC6-8RadialnerveExtensorpollicislongusC6-8RadialnerveExtensorpollicisbrevisC6-8RadialnerveAbductorpollicislongusC6-8RadialnervePronatorteresC6-7MediannerveFlexorcarpiradialisC6-7(8)MediannervePronatorquadratusC7-T1MediannervePalmarislongusC7-T1MediannerveFlexordigitorumsublimisC7-T1MediannerveFlexordigitorumprofundus(radialhalf)C7-T1MediannerveLumbricales1and2C7-T1MediannerveFlexorpollicislongusC8-T1MediannerveFlexorpollicisbrevis(lateralhead)C8-T1MediannerveAbductorpollicisbrevisC8-T1MediannerveOpponenspollicisC8-T1Mediannerve2020/11/410FlexorcarpiulnarisC7-T1UlnarnerveFlexordigitorumprofundus(ulnarhalf)C7-T1UlnarnerveInterosseiC8-T1UlnarnerveLumbricales3and4C8-T1UlnarnerveFlexorpollicisbrevis(medialhead)C8-T1UlnarnerveFlexordigitiminimibrevisC8-T1UlnarnerveAbductordigitiminimiC8-T1UlnarnerveOpponensdigitiminimiC8-T1UlnarnervePalmarisbrevisC8-T1UlnarnerveAdductorpollicisC8-T1Ulnarnerve2020/11/4112020/11/412PlantarisL5-S1TibialnerveTibialisposteriorL5-S1TibialnerveFlexordigitorumlongusL5-S1TibialnerveFlexorhallucislongusL5-S1TibialnerveBicepsfemoris(shorthead)L5-S2CommonperonealnerveTibialisanteriorL4-S1DeepperonealnervePeroneustertiusL4-S1DeepperonealnerveExtensordigitorumlongusL4-S1DeepperonealnerveExtensorhallucislongusL4-S1DeepperonealnerveExtensordigitorumbrevisL4-S1DeepperonealnerveExtensorhallucisbrevisL4-S1DeepperonealnervePeroneuslongusL4-S1SuperficialperonealnervePeroneusbrevisL4-S1SuperficialperonealnerveFlexordigitorumbrevisL4-S1MedialplantarnerveFlexorhallucisbrevisL5-S1MedialplantarnerveAbductorhallucisL4-S1MedialplantarnerveLumbricales(medial1or2)L4-S1MedialplantarnerveQuadratusplantaeS1-2LateralplantarnerveAdductorhallucisL5-S2LateralplantarnerveAbductordigitiquintiS1-2LateralplantarnerveFlexordigitiquintibrevisS1-2LateralplantarnerveLumbricales(lateral2or3)S1-2LateralplantarnerveInterosseiS1-2Lateralplantarnerve2020/11/413临床检查腹壁反射敲击试验Barlow试验Coleman试验（足外翻）Ely试验（股直肌）足前进角前弯试验Galeazzi征Gower试验髋关节旋转实验Nelaton线Ober试验Ortolani试验Patrick试验Phelps股薄肌试验Thomas试验腘窝角Trenderlenburg试验2020/11/414体格检查动（肢体活动范围）屈：关节弯曲活动，关节向远离中立位的方向活动。伸：关节伸直活动，关节向靠近中立位的方向活动。过伸：关节伸展超过中立位的范围（膝关节和肘关节）内收：肢体向靠近身体的中线的方向移动外展：肢体向远离身体的中线的方向移动旋后：前臂或手部的掌面向前或指向身体的前面旋前：前臂或手部的掌面向后或指向身体的后面内翻：向内翻转（中立位）外翻：向外翻转（中立位）内旋：向着身体轴线的方向旋转外旋：远离身体轴线的方向旋转2020/11/415Flexion:Actofbendingajoint;amotionawayfromthezerostartingposition.Extension:Actofstraighteningajoint;areturnmotiontothezerostartingposition.Hyperextension:Whenthemotionoppositetoflexionisanextremeorabnormalextension(asmaybeseenwiththekneeorelbowjoint),andthejointextendsbeyondthezerostartingposition.Abduction:Lateralmovementofthelimbsawayfromthemedianplaneofthebody,orlateralbendingoftheheadortrunk.Adduction:Movementofalimbtowardthemedianplaneofthebody.Supination:Actofturningtheforearmorhandsothatthepalmofthehandfacesupwardortowardtheanteriorsurfaceofthebody.Pronation:Turningofthepalmofthehandsothatitfacesdownwardortowardtheposteriorsurfaceofthebody.Inversion:Aninwardturningmotion(seenprimarilyinthesubtalarjointofthefoot).Eversion:Anoutwardturningmotion.Internal(inward)rotation:Processofturningonanaxistowardthebody.External(outward)rotation:Processofturningonanaxisawayfromthebody(oppositemotionofinternalrotation).2020/11/416体格检查颈椎（屈、伸、左侧屈、右侧屈、左环转、右环转）2020/11/417体格检查腰椎（屈、伸、左侧屈、右侧屈、左旋转、右旋转）2020/11/418体格检查肩关节（屈、伸、外展、上举、前伸、后伸、左环转、右环转）2020/11/4192020/11/4202020/11/4212020/11/422体格检查肘关节（屈、伸）2020/11/423前臂（旋前、旋后）体格检查2020/11/424体格检查腕关节（掌屈、背屈、尺偏、桡偏）60°60°30°20°2020/11/425体格检查掌指关节和指间关节（屈