肩袖損傷教學(xué)課件

1、肩袖損傷肩袖損傷肩袖損傷的流行病學(xué)Uhthoff et al.1 found a 20% prevalence in a series of cadaver dissections in which the mean age of the donors was 59.4 years. Lehman et al.2 found a prevalence of 17% in a large series of cadaver dissections, with a prevalence of 30% in donors older than sixty years of age. The inci

2、dence of full-thickness tears of the rotator cuffranges from 5% to 40%. Furthermore, epidemiologicalstudies show an increasing frequency of rotator cuff failure with advancing age3.1 Uhthoff HK, Loehr J, Sarkar K. The pathogenesis of rotator cuff tears. In: Takagishi N, editor. The shoulder. Tokyo:

3、Professional PostGraduate Services;1987: 211-2.2 Lehman C, Cuomo F, Kummer FJ, Zuckerman JD. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Jt Dis. 1995;54(1):30-1.3 Bigliani LU, Morrison DS. Relationship between acromial morphology and rotator cuff tea

4、rs. Orthop Trans. 1986;10:216.肩袖損傷的流行病學(xué)Uhthoff et al.1 fou 當(dāng)我們?cè)谂R床上遇到疑似病人，只有X片而無(wú)MRI檢查時(shí)，1 我們能從X片中得到什么信息？2 我們印象中的可疑診斷有哪些？3 針對(duì)性的體查有哪些？ 當(dāng)我們?cè)谂R床上遇到疑似病人，只有X片而無(wú)MRI檢查時(shí)， Gazzola S, Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9. cystic change of the greater tuberosity1 讀X

5、片Gazzola S, Bleakney RR.CurrentGazzola S, Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9. normal subacromial joint space (7mm) (arrow)1 superior subluxation of the humeral head (arrow)2 notched humeral neck (arrowhead)Gazzola S, Bleakney RR.CurrentType I calcic

6、ation with a uffy, eecy appearance with poorly dened borders, with acute symptoms and termed the resorptive phase. Type II calcication, more discreet and of homogenous density, with well-circumscribed borders, and in the formative phase.DePalma AF, Kruper JS. Long-term study of shoulder joints affli

7、ated with and treated for calcic tendinitisJ. Clin Orthop.1961;20:61-72.calcic tendinopathyType I calcication with a u2 可疑診斷1 關(guān)于肩周炎 肩周炎=凍結(jié)肩（實(shí)用骨科學(xué)第3版），是由于肩關(guān)節(jié)周?chē)浗M織病變而引起肩關(guān)節(jié)疼痛和活動(dòng)功能障礙。國(guó)外報(bào)道 Frozen shoulder 40-60 years of age, incidence 2-5%1.3 phases2freezing phase 2-9 months, pain and loss of motion of t

8、he glenohumeral joint in all direction，usually worst at night and when lying on the affected side2) frozen phase 4-12 months, stiffness reaches its maximumthawing phase 5-12 months, range of motion returns to normal 2 肩峰下撞擊綜合癥 疼痛，主訴為三角肌下疼痛，并經(jīng)常向下放射至前方的肱二頭肌，夜間疼痛可影響睡眠1 Hand C, Clipsham K, Rees JL, et a

9、l. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg 2008;17:231-6.2 Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;4:193-6.2 可疑診斷1 關(guān)于肩周炎 肩周炎=凍結(jié)肩（實(shí)用骨科3 針對(duì)肩袖損傷的體查1 岡上肌 肩外展功能1 empty can test1) 90 degrees abduction2) 30 degrees horizontal abduction (in t

10、he plane of the scapula)3) thumbs pointing downward3 針對(duì)肩袖損傷的體查1 岡上肌 肩外展功能1 em2 full can test1) 90 degrees in the horizontal plane2) rotated 45degrees externally3) with the thumb pointing upward2 full can testpainful arc test 60-1201) shoulder in external rotation2) palm facing uppainful arc test4 re

11、sisted isometric abduction1) the arm in neutral rotation2) abducts the arm to 90 degrees4 resisted isometric abduction1 external rotation strength test=Pattes test1) the patients elbow in 90 degrees2) in the plane of the scapula2 岡下肌和小圓肌 肩外旋功能1 external rotation strength t2 external rotation lag sig

12、n1) elbow passively flexed to 90 degrees2) maximal external rotation2 external rotation lag sign3 drop sign1) almost full external rotation2) elbow flexed at 90 degrees3 drop sign4 weakness with external rotation1) elbows flexed to 90 degrees2) the thumbs up3) shoulders rotated internally 20 degrees

13、4 weakness with external rotat3 肩胛下肌 肩內(nèi)旋、后伸功能1 lift off test asking the patient to internally rotate the arm to lift the hand posteriorly off of the back3 肩胛下肌 肩內(nèi)旋、后伸功能1 lift off Sports Med Arthrosc,2011,19(3):300-9.我們?cè)贛RI上應(yīng)得到的信息1 Zanetti M, Gerber C, Hodler J.1) almost full external rotationLindley

14、 K, Jones GL.J Shoulder Elbow Surg 1999;8:599-605.美國(guó)的一篇系統(tǒng)評(píng)價(jià)顯示：術(shù)后6個(gè)月的ASES、UCLA、疼痛評(píng)分及再斷裂方面，兩者無(wú)顯著差異，只有短期疼痛，關(guān)節(jié)鏡優(yōu)于開(kāi)放手術(shù)。1 superior subluxation of the humeral head (arrow)2) in the plane of the scapulaGerber C, Wirth SH, Farshad M (2011) Treatment options for massive rotator cuff tears.2 full can testAtrop

15、hy of theranges from 5% to 40%.4）巨大 5cmScand J Rheumatol 1975;4:193-6.Current imaging of the rotator cuffJ.According to Gerber et al.2 found a prevalence of 17% in a large series of cadaver dissections, with a prevalence of 30% in donors older than sixty years of age.1 Zanetti M, Gerber C, Hodler J.

16、Tokyo: Professional PostGraduate Services;1987: 211-2.2 internal rotation lag signSports Med Arthrosc,2011,19(3)3 belly press3 belly press4 bear hug test4 bear hug test4 針對(duì)肩峰下撞擊綜合癥的體查4 針對(duì)肩峰下撞擊綜合癥的體查Hawkins-Kennedy testHawkins-Kennedy test關(guān)于MRI肩袖解剖關(guān)于MRI肩袖解剖解剖足?。╢ootprint）解剖足印（footprint）關(guān)于MRI正常肩袖的MRI

17、斜冠狀面關(guān)于MRI正常肩袖的MRI 正常肩袖的MRI 斜矢狀面正常肩袖的MRI 斜矢正常肩袖的MRI 橫斷面正常肩袖的MRI 橫斷2) in the plane of the scapula3 肩胛下肌 肩內(nèi)旋、后伸功能Orthop Trans.asking the patient to internally rotate the arm to lift the hand posteriorly off of the backFurthermore, epidemiological6 三角肌下、肩峰下囊滑液相連2）中 1-3cmFatty degeneration of the muscles

18、 of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging.1961;20:61-72.The incidence of full thickness rotator cuff tears in a large cadaveric population.4 針對(duì)肩峰下撞擊綜合癥的體查1 我們能從X片中得到什么信息？脂肪滲透（fatty infiltration）我們?cè)贛RI上應(yīng)得到的信息1) elbows flexed to 90 degrees2) frozen phase

19、 4-12 months, stiffness reaches its maximum2) frozen phase 4-12 months, stiffness reaches its maximumCurrent imaging of the rotator cuffJ.1 切線(xiàn)征1 （tangent sign）1) the arm in neutral rotation損傷肩袖的MRI2) in the plane of the scapula魔法角 magic angle phenomenonthe fibers are at 55 degrees to the main magnet

20、ic field on T1Erickson SJ, Prost RW, Timins ME. The “magic angle” effect: background physics and clinical relevance. Radiology. 1993;188:23-25.魔法角 magic angle phenomenon我們?cè)贛RI上應(yīng)得到的信息1 肩袖走行及連續(xù)性2 高信號(hào)3 脂肪變性4 肌肉萎縮5 肌肉回縮6 三角肌下、肩峰下囊滑液相連我們?cè)贛RI上應(yīng)得到的信息1 肩袖走行及連續(xù)性 肩袖走行及連續(xù)性 肩袖走行及連續(xù)性脂肪滲透（fatty infiltration）Fuchs

21、 B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 1999;8:599-605.脂肪滲透（fatty infiltration）Fuchs 肌肉萎縮（muscle atrophy）1 切線(xiàn)征1 （tangent sign）2 肩胛比（scapular ratio

22、）Scapular ratio uses the ratio of the supraspinatus muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa, and in supraspinatus atrophy the ratio is less than 50%2.1 Zanetti M, Gerber C, Hodler J. Quantitative assessment of themuscles of the rotator

23、cuff with magnetic resonance imaging. Invest Radiol. 1998;33:163-170.2 Thomazeau H, Rolland Y, Lucas C, et al. Atrophy of thesupraspinatus belly. Assessment by MRI in 55 patients withrotator cuff pathology. Acta Orthop Scand. 1996;67:264-268.肌肉萎縮（muscle atrophy）1 切線(xiàn)征1 （肩袖損傷的分類(lèi)1 全層撕裂 1）小 1cm 2）中 1-3c

24、m 3）大 3-5cm 4）巨大 5cmDeOrio JK, Coeld RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg. 1984;66:563567.肩袖損傷的分類(lèi)1 全層撕裂DeOrio JK, Coeld肩袖損傷的分類(lèi)2 部分撕裂肩袖損傷的分類(lèi)2 部分撕裂肩袖損傷的治療手術(shù) VS 保守1 年齡 Age is one of the most used parameters in decision making for

25、the surgery of the cuff1. 75 years2 撕裂大小 Shimizu2 recommend early cuff repair after conrming the diagnosis of massive rotator cuff tears.Partial-thickness rotator cuff tear is a further indication in those patients with minimal risk of tear extension, minimal pain, and dysfunction3.1 Tanaka M, Itoi

26、E, Sato K, et al. Factors related to successful outcome of conservative treatment for rotator cuff tears. Ups J Med Sci. 2010;115:193-200. 2 Shimizu C, Horii M, Yamashita F, et al. Prognosis of massive rotator cuff tear. Chubuseisai. 1990;33:392.3 Ozbaydar MU, Bekmezci T, Tonbul M, et al. The result

27、s of arthroscopic repair in partial rotator cuff tears. Acta Orthop Traumatol Turc. 2006;40:4955.肩袖損傷的治療手術(shù) VS 保守1 Tanaka M, Ito肩袖損傷的治療肌腱的縫法肩袖損傷的治療肌腱的縫法1 external rotation strength test=Pattes testAm J Orthop (Belle Mead NJ),2010,39(12):592-600.Outcomes of arthroscopic versus open rotator cuff repair

28、: a systematic review of the literature.Partial-thickness rotator cuff tear is a further indication in those patients with minimal risk of tear extension, minimal pain, and dysfunction3.當(dāng)我們?cè)谂R床上遇到疑似病人，只有X片而無(wú)MRI檢查時(shí)，2 Thomazeau H, Rolland Y, Lucas C, et al.4 weakness with external rotationActa Orthop S

29、cand.1 superior subluxation of the humeral head (arrow)我們?cè)贛RI上應(yīng)得到的信息Chubuseisai.2010;115:193-200.Atrophy of theLindley K, Jones GL.Acta Orthop Scand.Gazzola S, Bleakney RR.Tokyo: Professional PostGraduate Services;1987: 211-2.J Should Elb Surg 20:S20S29.2 肩胛比（scapular ratio）Scapular ratio uses the r

30、atio of the supraspinatus muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa, and in supraspinatus atrophy the ratio is less than 50%2.The incidence of full thickness rotator cuff tears in a large cadaveric population.開(kāi)放手術(shù)骨質(zhì)端的固定1 external rotation

31、 strength t肩袖損傷的治療手術(shù)方式的選擇開(kāi)放手術(shù) VS 關(guān)節(jié)鏡手術(shù)美國(guó)的一篇系統(tǒng)評(píng)價(jià)顯示：術(shù)后6個(gè)月的ASES、UCLA、疼痛評(píng)分及再斷裂方面，兩者無(wú)顯著差異，只有短期疼痛，關(guān)節(jié)鏡優(yōu)于開(kāi)放手術(shù)。Lindley K, Jones GL. Outcomes of arthroscopic versus open rotator cuff repair: a systematic review of the literature. Am J Orthop (Belle Mead NJ),2010,39(12):592-600.肩袖損傷的治療手術(shù)方式的選擇Lindley K, Jones不可

32、修復(fù)肩袖損傷的判定According to Gerber et al. , imaging ndings that suggest an irreparable rotator cuff tear include 1）static superior subluxation of a glenohumeral joint with anacromiohumeral interval of 7 mm or less on an anteroposterior radiograph with the arm in neutral rotationGerber C, Wirth SH, Farshad

33、 M (2011) Treatment options for massive rotator cuff tears. J Should Elb Surg 20:S20S29.不可修復(fù)肩袖損傷的判定According to Gerberand 2) fatty inltration of the rotator cuff muscles at stage three or greater. and 2) fatty inltration of th不可修復(fù)肩袖損傷的治療1 肱三頭肌長(zhǎng)頭截?cái)? debridement associated with acromioplasty and burse

34、ctomy3 partial repair4 arthroscopic tuberoplasty5 tendon transfers 1) latissimus dorsi transfers-superolateral rotator cuff tears2) pectoralis major transfers-irreparable tears of the subscapularis muscle 3) deltoid ap4) trapezius muscle transfer不可修復(fù)肩袖損傷的治療1 肱三頭肌長(zhǎng)頭截?cái)鄉(xiāng)atissimus dorsi transfers一篇關(guān)于背闊肌

35、修復(fù)巨大撕裂肩袖損傷的系統(tǒng)評(píng)價(jià)結(jié)果顯示：在45.5個(gè)月的隨訪(fǎng)期內(nèi)，Constant score, active forward elevation和active external rotation術(shù)后明顯優(yōu)于術(shù)前。Namdari S, Voleti P, Baldwin K, Glaser D, Huffman GR. Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a systematic review. J Bone Joint Surg Am,2012,94(10):891-8. Namdari S

36、, Voleti P, Baldwin K謝謝！謝謝！肩袖損傷的流行病學(xué)Uhthoff et al.1 found a 20% prevalence in a series of cadaver dissections in which the mean age of the donors was 59.4 years. Lehman et al.2 found a prevalence of 17% in a large series of cadaver dissections, with a prevalence of 30% in donors older than sixty yea

37、rs of age. The incidence of full-thickness tears of the rotator cuffranges from 5% to 40%. Furthermore, epidemiologicalstudies show an increasing frequency of rotator cuff failure with advancing age3.1 Uhthoff HK, Loehr J, Sarkar K. The pathogenesis of rotator cuff tears. In: Takagishi N, editor. Th

38、e shoulder. Tokyo: Professional PostGraduate Services;1987: 211-2.2 Lehman C, Cuomo F, Kummer FJ, Zuckerman JD. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Jt Dis. 1995;54(1):30-1.3 Bigliani LU, Morrison DS. Relationship between acromial morphology a

39、nd rotator cuff tears. Orthop Trans. 1986;10:216.肩袖損傷的流行病學(xué)Uhthoff et al.1 fou Gazzola S, Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9. cystic change of the greater tuberosity1 讀X片Gazzola S, Bleakney RR.Current1 external rotation strength test=Pattes test1) th

40、e patients elbow in 90 degrees2) in the plane of the scapula2 岡下肌和小圓肌 肩外旋功能1 external rotation strength tGazzola S, Bleakney RR.我們?cè)贛RI上應(yīng)得到的信息2 internal rotation lag sign1998;33:163-170.正常肩袖的MRI 橫斷面In: Takagishi N, editor.Acta Orthop Traumatol Turc.4 針對(duì)肩峰下撞擊綜合癥的體查freezing phase 2-9 months, pain and l

41、oss of motion of the glenohumeral joint in all direction，usually worst at night and when lying on the affected sideLatissimus dorsi tendon transfer for irreparable rotator cuff tears: a systematic review.3 Bigliani LU, Morrison DS.2 Thomazeau H, Rolland Y, Lucas C, et al.Gerber C, Wirth SH, Farshad

42、M (2011) Treatment options for massive rotator cuff tears.Quantitative assessment of theThe incidence of full thickness rotator cuff tears in a large cadaveric population.The shoulder.Chubuseisai.Long-term study of shoulder joints affliated with and treated for calcic tendinitisJ.1 切線(xiàn)征1 （tangent sig

43、n）我們?cè)贛RI上應(yīng)得到的信息2 external rotation lag sign1) elbow passively flexed to 90 degrees2) maximal external rotationGazzola S, Bleakney RR.2 exter關(guān)于MRI正常肩袖的MRI 斜冠狀面關(guān)于MRI正常肩袖的MRI 損傷肩袖的MRI損傷肩袖的MRI肌肉萎縮（muscle atrophy）1 切線(xiàn)征1 （tangent sign）2 肩胛比（scapular ratio）Scapular ratio uses the ratio of the supraspinatus

44、 muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa, and in supraspinatus atrophy the ratio is less than 50%2.1 Zanetti M, Gerber C, Hodler J. Quantitative assessment of themuscles of the rotator cuff with magnetic resonance imaging. Invest Radiol

45、. 1998;33:163-170.2 Thomazeau H, Rolland Y, Lucas C, et al. Atrophy of thesupraspinatus belly. Assessment by MRI in 55 patients withrotator cuff pathology. Acta Orthop Scand. 1996;67:264-268.肌肉萎縮（muscle atrophy）1 切線(xiàn)征1 （The incidence of full-thickness tears of the rotator cuff2) frozen phase 4-12 months, stiffness reaches its maximumLehman et al.我們?cè)贛RI上應(yīng)得到的信息studies show an increasing frequency of rotator cuff failure with advancing age3.J Shoulder Elbow Surg