PASTAINJURY

國家臨床重點(diǎn)?？莆錆h協(xié)和醫(yī)院骨科,科主任：楊述華,PASTA Injury of Rotator Cuff,華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬協(xié)和醫(yī)院骨科 關(guān)節(jié)鏡及運(yùn)動(dòng)醫(yī)學(xué)中心孟春慶 王洪 何宇 吳星火 王小紅,Rotator Cuff,Supraspinatus：大結(jié)節(jié)上方，外展Infraspinatus：大結(jié)節(jié)后方，外旋Teres Minor：大結(jié)節(jié)后方，外旋Subscapularis：小結(jié)節(jié)前方，內(nèi)收內(nèi)旋,Shoulder pain,（凍結(jié)肩）,Rotator cuff injury,Clinical ManifestationTraumatic history：急性損傷，重復(fù)性或累積性損傷史Pain and tenderness：多位于肩前方，活動(dòng)或增加負(fù) 荷后加重，被動(dòng)外旋或過度內(nèi)收時(shí)加重，夜間疼痛加重Malfunction：上舉和外展功能受限Muscle atryphy：3周Arthrogriposis(關(guān)節(jié)攣縮）：3月,Rotator cuff injury,Sign: Neer test （撞擊試驗(yàn)）,檢查者立于患者背后，一手固定肩胛骨，另一只手保持肩關(guān)節(jié)內(nèi)旋位，使患肢拇指尖向下，然后使患肩前屈過頂。此時(shí)肩峰與肱骨大結(jié)節(jié)產(chǎn)生撞擊，如果誘發(fā)出疼痛，即為陽性。見于肩袖損傷，凍結(jié)肩，OA，肩袖鈣化等,檢查者立于患者后方，使患者肩關(guān)節(jié)內(nèi)收位前屈90度，肘關(guān)節(jié)屈曲90度，前臂保持水平。檢查者用力使患側(cè)前臂向下至肩關(guān)節(jié)內(nèi)旋，出現(xiàn)疼痛者為試驗(yàn)陽性。,Rotator cuff injury,Sign：Hawkins試驗(yàn),Rotator cuff injury,Sign：Drop sign（落臂試驗(yàn)）,檢查者站在患者身后，將患者肩關(guān)節(jié)外展至90度以上，囑患者自行保持肩外展90100度的位置，肩無力墜落者為陽性.,Rotator cuff injury,Sign： Pain arc sign（疼痛弧）,患臂上舉60120度范圍內(nèi)出現(xiàn)肩前方或肩峰下區(qū)疼痛,在 常規(guī)X線片顯示肩袖損傷者肱骨頭上移和肱骨大結(jié)節(jié)畸形，其陽性率為78，特異性為98。 正常肱骨頭和肩峰間的距離是=7mm，如果少于7mm往往提示有肩袖的撕裂。,X-ray,MRI,分級(jí) MRI表現(xiàn)0級(jí) 正常，表現(xiàn)為均勻一致的低信號(hào)1級(jí) T1WI或PDWI上見有線形的或散在性 的信號(hào)增高但形態(tài)正常Neer一期2級(jí) T1WI或PDWI上見有信號(hào)增高并見肩 袖的變細(xì)或不規(guī)則Neer二期3級(jí) T2WI上信號(hào)增高涉及整個(gè)肌腱，肌 腱連續(xù)性中斷Neer三期,0級(jí),又稱為肌腱炎，這時(shí)肩袖的連續(xù)性是完整的，但是在岡上肌肌腱內(nèi)見信號(hào)的增高。1級(jí)的信號(hào)改變?cè)谫|(zhì)子加權(quán)圖像中顯示最為清晰，為中等信號(hào)。這種信號(hào)的改變最為可能是由于水腫、炎癥反應(yīng)和出血所引起。對(duì)應(yīng)于Neer期在這一級(jí)中，滑囊內(nèi)通常是沒有液體的，肩袖和三角肌間的脂肪層是清晰可見的。和MRI相比不同，在這一級(jí)中，關(guān)節(jié)造影檢查是正常的。,1級(jí),T1WI或PDWI上見有信號(hào)增高并見肩袖的變細(xì)或不規(guī)則，對(duì)應(yīng)于Neer的II期纖維化，對(duì)應(yīng)于手術(shù)的部分撕裂?；覂?nèi)通常有積液。,變細(xì),2級(jí),T2WI上信號(hào)增高涉及整個(gè)肌腱，肌腱連續(xù)性中斷，對(duì)應(yīng)于Neer的III期撕裂，對(duì)應(yīng)于手術(shù)的完全性撕裂?；覂?nèi)多有積液。,3級(jí),Partial tear： 關(guān)節(jié)囊面部分撕裂：PASTA（60） 滑囊面部分撕裂（40） Complete tear,Typing,PASTA損傷定義,肩袖PASTA損傷，并不是以pasta這個(gè)人名命名的一種疾病，而是Partial Articular Sided Tendon Avulsion，即關(guān)節(jié)囊面肩袖部分撕裂。,關(guān)節(jié)囊面部分撕裂PASTA,滑囊面部分撕裂,Signs and symptoms,These are often very similar to rotator cuff tears in general. 癥狀和一般肩袖損傷類似The pain is typically felt over the upper arm rather than the shoulder itself. It is often persistent and recurrent and worse when lifting the arm out to the side (abduction) or in front (elevation). With a PASTA pain is frequently the predominant feature.上臂疼痛，外展和前伸時(shí)持續(xù)性、反復(fù)發(fā)作的疼痛It may be painful to lie on the shoulder at night.夜間痛The arm may feel weak particularly when lifting the arm above shoulder height.肩上舉及外展無力There may be a clicking or grinding sensation within the shoulder.可有彈響或摩擦感,Treatment:,The pain associated with a rotator cuff tear may settle with rest and avoidance of exacerbating activities.休息Rehabilitation may reduce the pain associated with a tear and improve the function of the shoulder. 康復(fù)Anti-inflammatory medication may help relieve the pain.抗炎Injections of corticosteroids (steroid) may improve pain.激素封閉If non-operative management does not improve the level of pain and function surgery may be indicated. This would typically involve an arthroscopic repair of the damaged tendon.關(guān)節(jié)鏡手術(shù),Indication of surgery,疼痛超過9個(gè)月保守治療6個(gè)月，疼痛加重合并3型肩峰,Operation,關(guān)節(jié)鏡下肩袖撕裂縫合修復(fù)術(shù),Rehabilitation,Shoulder surgery typically involves significant rehabilitation. It may take at least 6 to 12 months for pain to settle and full function to recover. Dedication to the rehabilitation recommended programme is likely to influence the outcome of surgery.Following surgery it is likely immobilisation in a sling will be required from 4-6 weeks. It is typically 3 months before resistance work is commenced and it may 5-6 months before a return to contact sports. The long term outcome is typically good with improvement in pain although there may be some limitation of strength and range of movement.,患者李*，男，33歲。左肩關(guān)節(jié)摔傷后抬舉活動(dòng)障礙8月入院?？魄闆r：左肩關(guān)節(jié)大結(jié)節(jié)處壓痛，左肩抬舉受限，Neer sign（+），Pain arc sign（+） X-