肩關(guān)節(jié)失穩(wěn)和肩袖損失培訓(xùn)課件

1、肩關(guān)節(jié)失穩(wěn)和肩袖損失肩關(guān)節(jié)失穩(wěn)和肩袖損失INTRODUCTION Shoulder injuries comprise 8-13% of all athletes injuries Result from . repetitive overload activities:swimming,tennis. . or direct trauma(collision) :football,rugby2肩關(guān)節(jié)失穩(wěn)和肩袖損失INTRODUCTION Shoulder injurieINCIDENCE SPORTS % TYPE OF LESIONS Baseball 11-17 AC , imping.

2、,RC tenditis Wrestling 17 Glenohum sublux or dislocation,AC Tennis 56 RC tendinitis,imping. Volley-ball 44 Biceps tendinitis,imping. Javelin throwers 29 Biceps tendinitis,imping. etc 3肩關(guān)節(jié)失穩(wěn)和肩袖損失INCIDENCE SPORTS % SHOULDER ANATOMY Bones : humeral head and glenoid Cartilage and labrum Capsule and liga

3、ments Muscles BELTRAN 4肩關(guān)節(jié)失穩(wěn)和肩袖損失SHOULDER ANATOMY Bones : humerPLASTICITY OF LABRUMArticular cartilage, and glenoid labrum.Labrum which have some plasticity seen on different positionsExternal rotation of humerus Internal rotation 5肩關(guān)節(jié)失穩(wěn)和肩袖損失PLASTICITY OF LABRUMArticular ANTERIOR CAPSULE INSERTIONTy

4、pe III ,the more medial insertion ,is prone to anterior glenohumeral instabilityFrom BELTRAN Imaging of orthopedic sports injuries SPRINGER 2007,p 1293 types of insertion6肩關(guān)節(jié)失穩(wěn)和肩袖損失ANTERIOR CAPSULE INSERTIONTypeSHOULDER BIOMECHANICSShoulder is the most mobile joint in the human body Function require

5、s coordinated motion of 4 joints . scapuloclavicular . acromioclavicular . glenohumeral . scapulothoracic 7肩關(guān)節(jié)失穩(wěn)和肩袖損失SHOULDER BIOMECHANICSShoulder SHOULDER BIOMECHANICS Motion 0-180% in elevation internal and external rotation 150% anterior and posterior rotation 170%8肩關(guān)節(jié)失穩(wěn)和肩袖損失SHOULDER BIOMECHANICS

6、 MotioSTABILIZING MECHANISMS OF GLENOHUMERAL JOINT PASSIVE MECHANISMS .Size,shape,tilt ot the glenoid fossa .Negative intracapsular pressure .Adhesion,cohesion of articular surfaces .Ligaments and capsule .Glenoid labrum .Oseous bone restraints :acromion,coracoid process9肩關(guān)節(jié)失穩(wěn)和肩袖損失STABILIZING MECHAN

7、ISMS OF GLENSTABILIZING MECHANISMS OF GLENOHUMERAL JOINT ACTIVE STABILIZING MECHANISMS . long head of the biceps tendon . rotator cuff muscles . subscapularis muscleCoronal SagittalAxial ArthroMR10肩關(guān)節(jié)失穩(wěn)和肩袖損失STABILIZING MECHANISMS OF GLENVICIOUS CIRCLE OF SHOULDER INJURIESPain occurs in women especia

8、lly when there is a physiologic instability that may be multidirectional STONE 1994INSTABILITYCOMPRESSIONIMPINGEMENTPAINMUSCULAR IMBALANCEROTATOR CUFFWEAKNESS11肩關(guān)節(jié)失穩(wěn)和肩袖損失VICIOUS CIRCLE OF SHOULDER ILAXITY vs INSTABILITYDefinitions LAXITY : the ability to passively translate humeral head to the gleno

9、id fossaINSTABILITY : a clinicalcondition in which symptoms are produced by the unwanted translation of the umeral head ,giving rise to pain or diminished shoulder function12肩關(guān)節(jié)失穩(wěn)和肩袖損失LAXITY vs INSTABILITYDefinitiSHOULDER INSTABILITY This lecture is mainly devoted to gleno-humeral instability due to

10、 time limitations ,but DO NOT FORGET please scapular,clavicular ,acromio-clavicular, sternoclavicular injuries which are also seen in sports activities13肩關(guān)節(jié)失穩(wěn)和肩袖損失SHOULDER INSTABILITY This lecTHE OVERHEAD N THROWING MECHANISMCenter of rotationThe curved harrow represents the path and direction of th

11、e greater tuberosity a sthe arm externally rotates BELTRAN 200714肩關(guān)節(jié)失穩(wěn)和肩袖損失THE OVERHEAD N THROWING MECHAIMAGING TECHNIQUES RADIOGRAPHY AP,axial views CT, ARTHRO-CT MRI, ARTHRO-MR15肩關(guān)節(jié)失穩(wěn)和肩袖損失IMAGING TECHNIQUES 15肩關(guān)RADIOGRAPHYAntero-inferior dislocation on AP and Neer views.Axial view is better than N

12、eer to appreciate correctly the humeral head position Axial view16肩關(guān)節(jié)失穩(wěn)和肩袖損失RADIOGRAPHYAntero-inferior disARTHRO-CTArthro-CT for staging of lesions after bilateral gleno-humeral dislocation : humeral head bone defects and glenoid lesions17肩關(guān)節(jié)失穩(wěn)和肩袖損失ARTHRO-CTArthro-CT for stagingARTHRO-MRArthro-MR te

13、chnique :iodine contrast and diluted Gd.Radiography after fluoscopic guidance and MR (3 planes,T1 w FS and T2w)18肩關(guān)節(jié)失穩(wěn)和肩袖損失ARTHRO-MRArthro-MR technique :ANTERIOR INSTABILITY More frequent 90% Recurrences 50% In young patients,after trauma19肩關(guān)節(jié)失穩(wěn)和肩袖損失ANTERIOR INSTABILITY MABNORMALITIES IN ANTERIOR IN

14、STABILITY Avulsion of gelnoid labrum 75% IGH ligament lesion,HILL-SACHS 50% SLAP lesions 25% Capsule laxity Rotator cuff teras (older patients) 20%20肩關(guān)節(jié)失穩(wěn)和肩袖損失ABNORMALITIES IN ANTERIOR INSTANTERO-INFERIOR DISLOCATIONFirst episode Third recurrence21肩關(guān)節(jié)失穩(wěn)和肩袖損失ANTERO-INFERIOR DISLOCATIONFirBONE LESIONS

15、 AFTER ANTERO-INFERIOR DISLOCATIONDislocation After reduction ,Hill Sachs lesion 22肩關(guān)節(jié)失穩(wěn)和肩袖損失BONE LESIONS AFTER ANTERO-INFEASSOCIATION OF LESIONSBankart lesion type 4 Hill Sachs lesion (same patient)23肩關(guān)節(jié)失穩(wěn)和肩袖損失ASSOCIATION OF LESIONSBankart BANKART LESIONSArthro-MR :Bankart type III4 types of Bankar

16、t to 1:small,3 severe,4 fracture24肩關(guān)節(jié)失穩(wěn)和肩袖損失BANKART LESIONSArthro-MR :BankASSOCIATION OF LESIONS Avulsion,fracture and loose body From BELTRAN,Radiographics 1994,66625肩關(guān)節(jié)失穩(wěn)和肩袖損失ASSOCIATION OF LESIONS AvulsioPOSTERIOR INSTABILITY Less common 5% Unidirectional is uncommon.Commonly bidirectional (post

17、and inf ) or multidirectional In epilepsy,ethanol,elcetricity shock ( 3 E rule) Also during repetitive applied athletic forces: swimming,throwing,punching,and in sports collision such as football26肩關(guān)節(jié)失穩(wěn)和肩袖損失POSTERIOR INSTABILITY Less cPOSTERIOR INSTABILITYClinical diagnosis much more difficult than

18、in anterior instabilityImaging techniques are important Especially the first radiographic evaluation is ESSENTIAL 27肩關(guān)節(jié)失穩(wěn)和肩袖損失POSTERIOR INSTABILITYClinical POSTERIOR INSTABILITYPosterior dislocation withfracture of anterior aspect of the humeral head(inverse of Hill.Sachs injury)28肩關(guān)節(jié)失穩(wěn)和肩袖損失POSTERIO

19、R INSTABILITYPosteriorPOSTERIOR INSTABILITYPosterior dislocation with poteriorBankart From TIRMAN ,MRI clinics N Am 1997,88329肩關(guān)節(jié)失穩(wěn)和肩袖損失POSTERIOR INSTABILITYPosteriorMICROINSTABILITY OF SHOULDER Microinstability concerns the 1/3 sup joint in sportmen and sportwomen ,especially for risk of SLAP lesio

20、ns Arthro-MR is superior to native MR for a good staging of lesions,including views in ABER position30肩關(guān)節(jié)失穩(wěn)和肩袖損失MICROINSTABILITY OF SHOULDER MR in ABER POSITIONFor anterior shoulder instabilityFor capsule and labrum injuries For HILL SACHS injuriesWINTZELL 199831肩關(guān)節(jié)失穩(wěn)和肩袖損失MR in ABER POSITIONFor ante

21、rioMULTIDIRECTIONAL INSTABILITY Instability more than in one direction Antero-inferior,postero-inferior,or 3 directions Often atraumatic(without trauma) ,or violent injury,or repeated microtrauma32肩關(guān)節(jié)失穩(wěn)和肩袖損失MULTIDIRECTIONAL INSTABILITY ISOLATED LABRUM TEARS Tears without instability But source of dy

22、sfunction In the athletic population Injury similar to gleno-humeral dislocation Sensation of instability33肩關(guān)節(jié)失穩(wěn)和肩袖損失ISOLATED LABRUM TEARS Tears wiLABRUM TEARSSLAP lesion type 2 c ,on arthro-MRSLAP= S superior L labrum A anterior P posteriorARTHRO-MR IS THE TECHNIQUE OF CHOICE34肩關(guān)節(jié)失穩(wěn)和肩袖損失LABRUM TEAR

23、SSLAP lesion type 2ROTATOR CUFF INJURIES Age is important in shoulder pathology According to Hoffmeyer 30 y. tendinopathies,tears 40 y. tears,perforation 50 y. gleno-humeral osteoarthritis (OA) Med.Hyg 1998,56:221835肩關(guān)節(jié)失穩(wěn)和肩袖損失ROTATOR CUFF INJURIES Age isIMPINGEMENT SYNDROME 95% of rotator cuff(RC) l

24、esions,Neer 1972 Mechanical injury from compression of the subacromial structures :Suprasupinatus (SSP) tendon,greater tuberosity of humerus, subacromial bursa 36肩關(guān)節(jié)失穩(wěn)和肩袖損失IMPINGEMENT SYNDROME 95% of rSECONDARY IMPINGEMENTIn young patients and athletesinvolved in throwing sports,shoulder impingement

25、 can occur with instability37肩關(guān)節(jié)失穩(wěn)和肩袖損失SECONDARY IMPINGEMENTIn young IMAGING TECHNIQUES RADIOGRAPHY SONOGRAPHY MRI AND ARTHRO-MR38肩關(guān)節(jié)失穩(wěn)和肩袖損失IMAGING TECHNIQUES 38肩關(guān)RADIOGRAPHYAP ,neutral rotationInternalrotationExternal rotationNeer view At least AP neutral and Neer views,sometimes int. et ext. rotat

26、ion!39肩關(guān)節(jié)失穩(wěn)和肩袖損失RADIOGRAPHYAP ,neutral rotatioSONOGRAPHY Technique . broadband-transducers 5-12 MHz . different types of probe,including typehockey-stick-shaped Multidirectional approach Dynamic and comparative study ( both sides) Only perpendicular structures,because obliquity creates artefacts Ope

27、rator dependant40肩關(guān)節(jié)失穩(wěn)和肩袖損失SONOGRAPHY Technique . broadSONOGRAPHYESSENTIAL REQUIREMENTS: .personnal experience .rigourous examination .very good knowledge of anatomyPosition of probe for anterior approach of sholuder41肩關(guān)節(jié)失穩(wěn)和肩袖損失SONOGRAPHYESSENTIAL REQUIREMENSONOGRAPHY FINDINGSDegenerative suprasupin

28、atus tendon and tearPosttraumatic SSP tear42肩關(guān)節(jié)失穩(wěn)和肩袖損失SONOGRAPHY FINDINGSDegenerativSIGNS OF RC TEARS DIRECT SIGNS OF COMPLETE TEAR 1.Flat area,scale of the border 2.Anechoic zone through the tendon 3.Massive thiness of the tendon 4.Tendon invisible INDIRECT SIGNS 1.Erosions of the greater tuberosit

29、y 2. Subacromial bursitis,joint fluid 3. Deltoid herniation 4. Muscle atrophy PEETRONS 200043肩關(guān)節(jié)失穩(wěn)和肩袖損失SIGNS OF RC TEARS DIRECT SIGNSSONOGRAPHY EFFICIENCY IN PARTIAL RC TEARS Sensitivity 93 % Specificity 94% HOLSBEECK Mv Radiology 1995,197:443 BUT ONLY BY EXPERIENCED OPERATOR !44肩關(guān)節(jié)失穩(wěn)和肩袖損失SONOGRAPHY

30、 EFFICIENCY IN MAGNETIC RESONANCE MR offers a multiplanar approach and a good tissue differenciation (the best) Examination in 3 planes:coronal,sagittal,axial Multiple sequences :PD for anatomy T2 w FS for signal FE 3 D for cartilage Arthro-MR for incomplete tears,labrum tears 45肩關(guān)節(jié)失穩(wěn)和肩袖損失MAGNETIC R

31、ESONANCE45肩關(guān)節(jié)失穩(wěn)和肩袖損失MAGNETIC RESONANCECoronalAxialSagittal46肩關(guān)節(jié)失穩(wěn)和肩袖損失MAGNETIC RESONANCECoronalAxialANATOMIC VARIATIONS THAT MAY PREDISPOSE TO IMPINGEMENTAcromial shapeAcromial lateral tiltDiminished arch eightCoracoid lenghtMuscle hypertrophyOs acromialeDisplaced greater tuberosity Acromial shape f

32、lat,curved, hocked 47肩關(guān)節(jié)失穩(wěn)和肩袖損失ANATOMIC VARIATIONS THAT MAY P肩關(guān)節(jié)失穩(wěn)和肩袖損失培訓(xùn)課件ROTATOR CUFF TEARSFunctional infirmityElevation of R upper limb impossibleArthro-MR :complete tear of SSP tendon wit retraction49肩關(guān)節(jié)失穩(wěn)和肩袖損失ROTATOR CUFF TEARSFunctional iROTATOR CUFF TEARSDimensions of full thickness tears cla

33、ssified on basis of greatest dimensions Small 5 cm De Orio ,Cofield JBJS am 1984 ,66(4):56350肩關(guān)節(jié)失穩(wěn)和肩袖損失ROTATOR CUFF TEARSDimensions oPARTIAL RC TEARS Inferior SSP tear more common than superior tear Not treated may lead to chronic pain and invalidity May propagate to full thickness tear Grading of p

34、artial tears 1. less 3 mm 2. 3-6 mm 3. more 6 mm51肩關(guān)節(jié)失穩(wěn)和肩袖損失PARTIAL RC TEARS Inferior SSP PARTIAL RC TEARS Arthro-MR : inferior partial of the suprasupinatus tendon;no perforation,no passage of contrast medium in subacromial bursa52肩關(guān)節(jié)失穩(wěn)和肩袖損失PARTIAL RC TEARS Arthro-MR : iMULTIPLE RC TEARSSometimes i

35、nfrasupinatus and subscapularis tears are associated with a suprasupinatus tearA complete good staging is compulsory for choosing the best tt ,especially before eventual surgery (which type of surgical repair)For a such evaluation, MR and sometimes arthroMR , are the techniques of choice53肩關(guān)節(jié)失穩(wěn)和肩袖損失

36、MULTIPLE RC TEARSSometimes infMULTIPLE RC TEARSSuprasupinatus complete tear,retraction of tendon,muscle atrophywith infrasupinatus partial tear and muscle atrophy .Also OA in AC54肩關(guān)節(jié)失穩(wěn)和肩袖損失MULTIPLE RC TEARSSuprasupinatuEXTENT OF RC TEARSTHOMAZEAUClin Orthop Relat Res 1997,344:27555肩關(guān)節(jié)失穩(wěn)和肩袖損失EXTENT O

37、F RC TEARSTHOMAZEAU55肩MUSCLE ATROPHY Muscle atrophy follows a rotator cuff tear not treatedMuscle atrophy very well appreciated by MRDepends on the lenght of evolution Stage 1. few fatty trails 2. more muscle than fat 3. muscle=fat 4. more fat than muscle After 6 months of evolution stage 2,after 1

38、year stage 4 Goutalier D Clin Orthop 1994,304:7856肩關(guān)節(jié)失穩(wěn)和肩袖損失MUSCLE ATROPHY Muscle atrophy MUSCLE ATROPHYA normal SSP muscle occupy the whole supraspinatus areaWhen atrophy the volume decreased57肩關(guān)節(jié)失穩(wěn)和肩袖損失MUSCLE ATROPHYA normal SSP musACROMIOCLAVICULAR JOINT INJURIES Very often in looking for an eventual RC tear ,an acromioclavicular joint injury is discovered,such as osteoarthritis with bony spurs ,and even with an inflammatory component(bone marrow edema , joint flui