肩周炎或称冻结肩或五十肩肩周肌腱.ppt

1、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 Chronic injury of soft tissue,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

2、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,Strain of lumbar muscles腰肌劳损,Common cause of lumbar pain Local tenderness, start point or end point of muscles Back pain, relieve after rest or activities Erector spainae muscle spasm,Treatment,Self ca

3、re therapy, change position Physiotherapy, massage Local steroid injection Anti-inflammatory drugs,Supraspinous ligament injuryinterspinous ligament injury,Common cause of back pain Supraspinour ligament injury common in middle thoracic segment Interspinous ligament injury common in lower lumbar seg

4、ment,No trauma history Bend or hyperextension pain Local tenderness Steroid injection Physiotherapy or massage immobilization,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,Bursae are sacs lined with a membrane similar to synovium; they usually are located about joints or where skin, tendo

5、n, or muscle moves over a bony prominence. may or may not communicate with a joint. Function: reduce friction, protect delicate structures from pressure.,Bursae are similar to tendon sheaths and the synovial membranes of joints and are subject to the same disturbances: (1) acute or chronic trauma, (

6、2) acute or chronic pyogenic infection, and (3) low-grade inflammatory conditions such as gout, syphilis, tuberculosis, or rheumatoid arthritis.,Two types of bursae: normally present (as over the patella and olecranon) and adventitious ones (such as develop over a bunion, an osteochondroma, or kypho

7、sis of the spine). Adventitious bursae are produced by repeated trauma or constant friction or pressure.,Treatment-the cause of the bursitis Systemic causes, such as gout or syphilis, and local trauma or irritants should be eliminated, and, when necessary, the patients occupation or posture should b

8、e changed. One or more of the following local measures usually are helpful: rest, hot wet packs, elevation, and, if necessary, immobilization of the affected part.,Treatment,Aspiration and steroid injection Surgical procedures useful in treating bursitis are (1) incision and drainage when an acute s

9、uppurative bursitis fails to respond to nonsurgical treatment, (2) excision of chronically infected and thickened bursae, and (3) removal of an underlying bony prominence,Stenosing Tenosynovitis狭窄性腱鞘炎,more often in the hand and wrist than anywhere else in the body. A peritendinitis may affect these

10、tendons, causing pain, swelling, and crepitus.,When the long flexor tendons are involved, trigger thumb, trigger finger, or snapping finger occurs. The stenosis occurs at a point where the direction of a tendon changes, for here a fibrous sheath acts as a pulley, and friction is maximal. Although th

11、e tenosynovium lubricates the sheath, friction can cause a reaction when the repetition of a particular movement is necessary, as in winding a fine coil of wire or stacking laundry.,DE QUERVAIN DISEASE,Stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons When

12、the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895. .,Women are affected 10 times more frequently than men. The cause is almost always

13、related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable,diagnosis,The Finkelstein test usually is positive: on grasping the p

14、atients thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating. Although Finkelstein states that this test is probably the most pathognomonic objective sign, it is not diagnostic; the patients history and occupation, the roentgenograms, and other physical findi

15、ngs must also be considered.,Treatment,Conservative treatment, consisting of rest on a splint and the injection of a steroid preparation into the tendon sheath, is most successful within the first 6 weeks after onset. Steroid injection When pain persists, surgery is the treatment of choice (complete

16、 relief ),TRIGGER FINGER AND THUMB弹响指和弹响拇,Stenosing tenosynovitis, leading to inability to extend the flexed digit (triggering) usually is seen after 45 years of age. Patients may note a lump or knot in the palm. The lump may be the thickened area in the first annular part of the flexor sheath, or a

17、 nodule or fusiform swelling of the flexor tendon just distal to it. The nodule can be palpated by the examiners fingertip and will move with the tendon. The tendon nodule usually is at the entry of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.,Treatment,Treatme

18、nt of trigger digits usually is nonoperative in the uncomplicated patient who presents a short time after onset of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and ice. Corticosteroid injection is effective after one injection Surgical release reliably

19、 relieves the symptom for most patients,Ganglion,Treament,Squeeze Aspiration and steroid injection Operation,Lateral epicondylitis肱骨外上髁炎,Lateral epicondylitis (tennis elbow), a familiar term used to described a myriad of symptoms about the lateral aspect of the elbow, occurs more frequently in nonat

20、hletes than athletes, with a peak incidence in the early fifth decade and a nearly equal gender incidence. Activities that require repetitive supination and pronation of the forearm with the elbow in near full extension.,Tenderness is present over the lateral epicondyle approximately 5 mm distal and

21、 anterior to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm supination, and there is pain when grasping objects. Plain roentgenograms usually are negative; occasionally calcific tendinitis may be present. MRI demonstrates tendon thickening with in

22、creased T1 and T2 signals but generally is not indicated.,Regardless of the underlying cause, nonoperative treatment is successful in 95% of patients with tennis elbow Initial nonoperative treatment includes rest, ice, injections, and physical therapy centered around treatment such as ultrasound, el

23、ectrical stimulation, manipulation, soft tissue mobilization, friction massage, stretching and strengthening exercises, and counter-force bracing.,Steroid injection If prolonged (6 to 12 months), operative treatment may be considered; it is effective in 90% of properly selected patients.,Adhesive Ca

24、psulitis （frozen shoulder.） 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,Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) or plain roentgenograms were d

25、esignated as primary, and those with precipitant traumatic injuries as secondary. This division helps in planning treatment but does not necessarily predict outcome.,No formal inclusion criteria. There are no universally accepted criteria for the diagnosis of frozen shoulder. internal rotation frequ

26、ently is lost initially, followed by loss of flexion and external rotation. The incidence of frozen shoulder in the general population is approximately 2%. (an increased incidence associated with, including diabetes mellitus (up to 5 times more), cervical disc disease, hyperthyroidism, intrathoracic

27、 disorders, and trauma). People between the ages of 40 and 70 are more commonly affected. Common to almost all patients is a period of immobility, the etiologies of which are diverse,Rotator cuff肩袖,冈上肌，冈下肌，肩胛下肌和小圆肌 Supraspinatus，infraspinatus，subscapular muscle，teres minor Pain may disappear Dysfunc

28、tion,Primary Frozen Shoulder,Primary frozen shoulder is a vague entity that only rarely recurs in the same shoulder. The clinical course of primary (idiopathic) frozen shoulder consists of three phases. Phase IPain. Patients usually have a gradual onset of diffuse shoulder pain, which is progressive

29、 over weeks to months. The pain usually is worse at night and is exacerbated by lying on the affected side. As the patient uses the arm less, pain leading to stiffness ensues.,Primary Frozen Shoulder,Phase IIStiffness. Patients seek pain relief by restricting movement. This heralds the beginning of

30、the stiffness phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities of daily living; men have trouble getting to their wallets and women with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this of

31、ten is accompanied by sharp pain during range of motion at or near the new endpoints of motion.,Primary Frozen Shoulder,Phase IIIThawing. This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect) motion return is gradual in most but

32、 may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or adjustment in ways of performing activities of daily living.,Secondary Frozen Shoulder,Unlike patients with idiopathic frozen shoulder, patients with secondary frozen

33、 shoulder can recall a specific precipitating event, possibly related to overuse or injury. The three phases of classic frozen shoulder may not all be present and may not follow the previously outlined chronology; fortunately, treatment for the two entities is similar.,Diagnosis,tests in patients wi

34、th a frozen shoulder (including plain film roentgenograms) usually are normal, except in those with medical disorders such as diabetes or thyroid disease. Bone scans have been reported to be positive in some patients. Arthrograms characteristically show a reduced joint volume with irregular margins.

35、 Clinical improvement has been reported after arthrography because of brisement of adhesions from forcefully injecting fluid into the joint. A volume of less than 10 ml and lack of filling of the axillary fold currently are accepted arthrographic findings indicative of a frozen shoulder.,Differentia

36、l diagnosis,Cervical spondylosis Rotator cuff tear,Treatment,Traditionally, frozen shoulder has been considered a self-limiting condition, lasting 12 to 18 months. Approximately 10% of patients have long-term problems. Patients seeking care earlier usually recover more quickly. Dominant shoulder inv

37、olvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. Obviously, the best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of paramount importance; a good understandi

38、ng of the pathological process by the patient and the physician also is important.,Treatment,Initial treatment is nonoperative, with emphasis placed on control of pain and inflammation. passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingement until j

39、oint motion becomes more supple. Physiotherapy Steroid injection NSAIDS drugs,Treatment,Although a frozen shoulder usually is self-limiting and resolves in 12 to 18 months, many patients do not wish to wait that long for resolution of symptoms and request active intervention long before 12 months. W

40、ith appropriate patient selection, significant improvement can be obtained in approximately 70% of patients. Closed manipulation under anesthesia Open release of contractures,Treatment,Arthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitra

41、nt adhesive capsulitis.,Chondromalacia patella髌骨软骨软化症,Epiphysitis of tibial tuberosity胫骨结节骨骺炎,(Osgood-Schlatter disease) (Osteochondrol disease of the tibial tubercle) Common age 12-14 ys,OSGOOD-SCHLATTER DISEASE,Disorders of actively growing epiphyses. The disorder may be localized to a single epip

42、hysis or occasionally may involve two or more epiphyses simultaneously or successively. The cause generally is unknown, but evidence indicates a lack of vascularity that may be the result of trauma (quadriceps), infection, or congenital malformation.,Treatment,Self limited disease Observation, remai

43、n eminance of TT Surgery rarely is indicated the disorder usually becomes asymptomatic without treatment or with simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeks,Legg-Calve-Perthes DiseasePerthes病,The cause： chronic injury The clinical sign：p

44、ain and limp， Thomas sign plain roentgenographic changes Bone scintigraphy MRI Treatment,Lloyd-Roberts、Catterall and Salamon classification,classified patients with this disease into groups according to the amount of involvement of the capital femoral epiphysis: group I, partial head or less than ha

45、lf head involvement; groups II and III, more than half head involvement and sequestrum formation; group IV, involvement of the entire epiphysis.,head at risk,They noted certain roentgenographic signs described as head at risk correlated positively with poor results, especially in patients in groups

46、II, III, and IV. These head-at-risk signs include Lateral subluxation of the femoral head from the acetabulum, Speckled calcification lateral to the capital epiphysis, Diffuse metaphyseal reaction (metaphyseal cysts), A horizontal physis, Gage sign, a radiolucent V-shaped defect in the lateral epiph

47、ysis and adjacent metaphysis.,Containment by femoral varus derotational osteotomy for older children in groups II, III, and IV with head-at-risk signs. Contraindications include an already malformed femoral head and delay of treatment of more than 8 months from onset of symptoms. Surgery is not reco

48、mmended for any group I children or any child without the head-at-risk signs.,Salter and Thompson classification,Salter and Thompson advocated determining the extent of involvement by describing the extent of a subchondral fracture in the superolateral portion of the femoral head. If the extent of t

49、he fracture (line) is less than 50% of the superior dome of the femoral head, the involvement is considered type A, and good results can be expected. If the extent of the fracture is more than 50% of the dome, the involvement is considered type B, and fair or poor results can be expected.,According

50、to Salter and Thompson, this subchondral fracture and its entire extent can be observed roentgenographically earlier and more readily than trying to determine the Catterall classification. Furthermore, according to these authors, if the femoral head is graded as type B, then probably an operation su

51、ch as an innominate osteotomy should be carried out,Herring classification,1. Most patients can be treated by noncontainment methods and obtain good results (80%). 2. Satisfactory clinical results frequently can be obtained at long-term follow-up despite an unsatisfactory roentgenographic appearance

52、.,Conclusions,3. The Catterall classification is a valid indicator of results but is not applicable as a therapeutic guide. 4. Head-at-risk signs added little to the Catterall classification as a prognostic indicator or therapeutic guide. 5.All of the fair and poor results were in patients with Catt

53、erall III or IV involvement and onset of the disease at age 6 or later.,Carpal Tunnel Syndrome腕管综合症,(another name: tardy median palsy) results from compression of the median nerve within the carpal tunnel. The syndrome consists predominantly of tingling and numbness in the typical median nerve distr

54、ibution in the radial three and one-half digits (thumb, index, long, radial side of ring). Pain occurs diffusely in the hand and radiates up the forearm. Thenar atrophy usually is seen later in the course of the nerve compression.,The syndrome frequently is associated with nonspecific tenosynovial e

55、dema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Schuind et al. studied biopsy specimens of the flexor tendon synovium from 21 patients with idiopathic carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue undergoing degener

56、ation under repeated mechanical stress.,Diagnosis,Paresthesia over the sensory distribution of the median nerve is the most frequent symptom; more often in women and frequently causes the patient to awaken several hours after getting to sleep with burning and numbness of the hand that is relieved by

57、 exercise. The Tinel sign may be demonstrated in most patients by percussing the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar muscles has been reported in about half of the patients treated by operation.,Acute flexion of the wrist for 60 seconds in some but not a

58、ll patients or strenuous use of the hand increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms. Gellman et al. evaluated the clinical usefulness of commonly administered provocative tests, including wrist fl

59、exion, nerve percussion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and in 50 control hands.,Diagnosis,The most sensitive test was the wrist flexion test, whereas nerve percussion was the most specific and the least sensitive. They also found that with the wrist in neutral position, the mean pressure within the carpal tunnel in patients with carpal tunnel syndrome was 32 mm Hg. This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures i