肩关疾病的诊断王少山PPT课件

1、.,1,肩关节疾病的诊断,山东省中医院运动损伤骨科 王少山,.,2,肩关节的疾病你知道多少,普通人 医务工作者 骨科医生 运动医学医师 肩关节疾病的特征 疼痛 关节僵硬,.,3,肩关节解剖,.,4,骨结构,Body Anatomy Scapula Clavicle,.,5,骨结构,Bony Anatomy Humerus Ribs,.,6,肌肉构成,Anterior musculature of the shoulder girdle,.,7,肌肉构成,Musculature of posterior shoulder girdle,.,8,韧带结构,Shoulder ligaments,.,

2、9,滑囊和盂唇,Shoulder joint capsule and cartilage,.,10,血管和神经,Blood Supply and Intervention,.,11,肩关节的评估,病史采集 疼痛的原因 损伤的机制 以前的病史 疼痛的位置 时限 程度 弹响 弹响的数量 体温的变化 肩无力？ 肩疲劳? 如何减轻疼痛,?,.,12,Shoulder Evaluation (Observation),Elevation or depression of shoulder tips Position and shape of clavicle Acromion process Bicep

3、s and deltoid symmetry Postural assessment (kyphosis, lordosis, shoulders),Position of head and arms Scapular elevation and symmetry Scapular protraction or winging Muscle symmetry Scapulohumeral rhythm,.,13,肩关节运动范围检查(Observation),肩胛盂肱关节与肩胛胸壁关节 肱骨与肩胛骨的运动关系 肩关节启动三十度外展肩胛骨不参与运动 外展三十度到九十度之间肱骨平均每上抬两度肩胛骨外

4、展向上旋转一度the 九十度以上肩胛骨肱骨呈1：1旋转运动,.,14,肩关节检查压疼点 (Palpation),骨结构 胸锁关节 锁骨干 肩锁关节 喙突 肩峰 肱骨头 肱骨大结节 肱二头肌间沟 肩胛岗 肩胛骨内缘,肩胛骨外缘 肩胛骨上角 肩胛骨下角,.,15,肩关节检查压疼点 (Palpation),软组织结构 胸锁关 肩锁关节 喙锁韧带 肩袖肌腱 肩峰下滑囊 肱二头肌间沟肱二头肌腱 喙肩韧带,Glenohumeral joint capsule Deltoid Rhomboids Latissimus dorsi Serratus Anterior Levator scapulae Trap

5、ezius Supraspinatus Infraspinatus Teres major and minor,.,16,肩关节特殊检查 (Special Tests),肩关节功能范围(ROM) 前屈 180o 后伸 50o 外展 180o 内收 40o 内旋 90o 外旋 中立位 600 外展位 900,Manual Muscle Testing Five Point grading system 5 = Complete ROM against gravity, with full resistance 4 = Complete ROM against gravity, with some

6、 resistance 3 = Complete ROM against gravity, with no resistance 2 = Complete ROM, with gravity omitted 1 = Some muscle contractility with no joint motion 0 = No muscle contractility,.,17,肩周炎的概念,历史 1896年Duplay提出 pereglanoiolitis 盂肱关节周围炎 首次医学描述肩僵硬 演变 Codman1934年命名为肩周炎 1945年J.S.Neviase第一次使用adhesive ca

7、psulitis粘连性肩关节囊炎 现状 由于肩关节周围炎的描述模糊不清，病理至今没有病理生理学基础,.,18,肩周炎是垃圾箱 弃用,症状模糊不清 多种疾病混淆 没有清晰的病理生理机制和证据 给临床带来混乱,.,19,有必要对肩疼痛疾病分类,冻结肩 肩峰撞击证 肩袖损伤 钙化性肌腱炎 盂唇损伤 肩锁关节骨性关节炎 盂肱关节骨性关节炎,.,20,冻结肩,有明确的时限性 疼痛有固定的曲线 有固定的症状和体现 没有明确的发病原因 最终结局是乐观、一般不留关节障碍,.,21,病程分期,冷冻期 初期 1-9个月 疼痛 冻结期 中期 3-2个月 关节僵硬 解冻期 后期 5个月至2年 疼痛减轻功能恢复,.,2

8、2,Frozen Shoulder Classifications,Frozen shoulder: Lundberg classification Stages of frozen shoulder: Reeves Arthroscopic stages of adhesive capsulitis: Neviaser,.,23,Frozen Shoulder: Lundberg Classification,A. Primary frozen shoulder: Shoulder elevation 135 deg Limitation of movement only at gleno-

9、humeral articulation Radiology normal Other causes ie trauma, OA, RA, Hemiplegia etc excluded B. Secondary frozen shoulder: Decreased range of movement following trauma or other known cause,.,24,Stages of Frozen Shoulder: ReevesReeves B, Scand J Rheumatol, 4: 193-196, 1975,Painful stage: 10-36 weeks

10、 Stiffness: 4-12 months Recovery: 5-24 months,.,25,冻结肩是一种自限性疾病不必忧虑,.,26,如何确诊冻结肩,病史 没有明确的原因 疼痛的特点 疼痛逐渐加重，夜间疼痛 关节僵硬 逐渐盂肱关节的活动度减少 肌肉无损伤 肌力无明显改变,.,27,临床检查,肩关节功能 ROM 前屈外展上抬 00 - 1800 外 旋 00 - 600 内 旋 体侧- 7胸椎棘突 全方位功能受限,.,28,Arthroscopic stages of Frozen Shoulder: Nevasier Neviaser, Orthop Clin North Am, 1

11、8:439-443, 1987,.,29,Stage 1: Erythematous/ fibrinous synovium patient presents as impingement Stage 2: Red, angry, thick synovium, thick, contracted interval, tight joint space adhesions in the inferior fold Stage 3: Pink synovium contracted inferior fold, tight joint space Stage 4: no evidence of

12、synovitis tight inferior fold and joint,.,30,.,31,辅助检查,影像学没有明确的阳性改变,.,32,MRI,.,33,肩峰撞击症,何为肩峰撞击症 肩峰撞击症的概念 Neer提出肩关节在运动的过程中有一些结构性因素和动力性因素与肩峰发生摩擦产生病理性疼痛 包括内容 肩峰的形态 Bigliani分型 肌腱炎 滑囊炎,.,34,.,35,结构性因素 肩峰的形态 肌腱的炎性退变增粗 滑囊炎容积增大 大结节骨折,撞击的病理,.,36,动力性因素 肩胛骨失效 肌腱过度负荷 盂肱关节不稳定 重复性微细创伤,.,37,撞击产生的机制 岗上肌出口,.,38,.,39

13、,.,40,1,.,41,模拟撞击原理,.,42,模拟撞击原理2,.,43,.,44,.,45,.,46,.,47,Subacromial Impingement classifications,Stages of subacromial impingement: Neers classification Stages of subacromial impingement in athletes: Jobes classification Grading of impingement changes: Milgroms ultrasound classification Impingement

14、 lesions: Copeland Levy classification,.,48,Stages of subacromial impingement: Neers classification Historical interest, stages do not necessarily follow one another,.,49,Stage 1: oedema and haemorrhage , age 40, progressive disability,.,50,Stages of subacromial impingement in athletes: Jobes classi

15、fication (1989),1. Pure impingement with no instability 2. Primary instability with capsular and labral injury with secondary impingement which can be internal impingement or subacromial 3. Primary instability because of generalised ligamentous laxity with secondary impingement 4. Pure instability a

16、nd no impingement,.,51,Grading of impingement changes: Milgroms ultrasound classification,Stage 1 - Bursal thickness 1.5 to 2.0mm Stage 2 - Bursal thickness over 2.0mm Stage 3 - Partial or full thickness tear of the rotator cuff,.,52,Acromial Side Bursal Side,0 Normal - smooth surface A1 Minor scuff

17、ing, haemorrhage or local injection and inflammation A2 Marked scuffing / damage of the undersurface of the acromion& CA ligament A3 Bare bone areas,surface A1 Minor scuffing, haemorrhage or local injection and inflammation A2 Marked scuffing / damage of the undersurface of the acromion& CA ligament

18、 A3 Bare bone areas B0 Normal - smooth surface B1 Minor scuffing, haemorrhage or local injection and inflammation B2 Major scuffing of cuff, partial thickness tear B3 Full thickness tear B4 Massive cuff tear,.,53,0 Normal - smooth surface A1 Minor scuffing, haemorrhage or local injection and inflamm

19、ation,Acromial Side,.,54,A1 Minor scuffing, haemorrhage or local injection and inflammation,.,55,.,56,A2 Marked scuffing / damage of the undersurface of the acromion& CA ligament,Bare bone areas,A3,.,57,B0 Normal - smooth surface,B1 Minor scuffing, haemorrhage or local injection and inflammation,Bur

20、sal Side,.,58,B0 Normal - smooth surface,B3 Full thickness tear,.,59,B4 Massive cuff tear,.,60,撞击症的症状,疼 痛 发病 疼痛成隐匿性进展 部位 肩前外侧有时放射至肘 方式 肩关节运动到某一部位 夜间疼痛 只在患侧卧位时疼,.,61,特殊检查,Neer Hawkins,.,62,影像学检查,.,63,撞击综合症治疗,保守治疗 休息 避免做可能使肩关节疼痛的动作 前后部肩袖肌力练习,.,64,撞击综合症治疗,保守治疗 肩峰下注射 玻璃酸钠（施沛特）2支 得保松布比卡因 肩峰前外角下方约 2cm 不超过

21、2次,.,65,撞击综合症治疗,手术指征： 规范保守治疗无效 手术选择： 关节镜下肩峰成型术 手术要点： 肩峰成型喙肩韧带切断滑囊清扫,.,66,.,67,.,68,.,69,肩袖损伤,肩袖的构成 肩袖的位置 肩袖的肌腱走行和 方向 肩袖的作用,.,70,岗上肌,.,71,岗下肌 小圆肌,.,72,肩袖损伤的原因和机制,急性损伤 运动 （过顶运动）创伤 慢性损伤 年龄 （退变） 过度使用 骨赘 机械撞击症,.,73,临床评估,病史 与冻结肩鉴别 疼痛 肩关节无力和功能障碍 临床检查 影像学评估 关节镜评估,.,74,临床评估方法,岗上肌 Jobe症 岗下肌 Leg 症 小圆肌 肩胛下肌 Lif

22、toff,.,75,影像学评估,超声波 敏感性较高 准确性差 磁共振 敏感性 准确性均好 费用高 基层医院无配置,.,76,.,77,.,78,.,79,.,80,.,81,.,82,.,83,.,84,盂肱关节骨性关节炎,发病率 白种人较高 黄种人低 主要特征 年龄 发病缓慢 疼痛逐渐明显 肩关节功能逐渐丧失,.,85,.,86,.,87,.,88,.,89,.,90,.,91,.,92,.,93,临床表现,疼痛 肩无力 肩关节障碍 对治疗不敏感 肩僵硬 关节积液,.,94,临床评估,有固定的疼痛点 有固定的压痛点 研磨音,.,95,影像学评估,普通X线片 CT扫描 磁共振,.,96,盂唇损

23、伤,盂唇的解剖 与二头肌长头的关系 盂唇的作用 二头肌在盂唇损伤的病理作用 盂唇损伤的分型,.,97,肱二头肌腱有关的盂唇损伤,原发性肌腱病-结节间沟内的肌腱炎症 肱二头肌腱继发性腱病 肱骨头与喙肩弓持续撞击 过顶运动投掷后的减速期,.,98,.,99,临床评估检查,Obrien Clunk Compression,.,100,钙化性肌腱炎,主要是累计岗上肌、岗下肌、肩胛下肌 病因 体内钙的代谢紊乱 机制 大量钙质沉积在肌腱内 疼痛原因 突然肌腱内的沉积钙大量释放,.,101,Calcific Tendonitis Classifications,Stages of Calcifying Te

24、ndinitis:Uthoffs Classification Radiological classification of Calcifying Tendinitis : Bosworth Radiological morphology of Calcifying Tendinitis : Mol Classification Radiological staging of Calcifying Tendinitis : Gartner and Heyer Classification,.,102,Stages of Calcifying Tendinitis: Uhthoffs Classification,1 - Pre-calcific stage - Metaplasia of tenocytes into chondrocytes2 - Calcific stage Formative phase Resting phase Resorptive