肩關節(jié)疾病的診斷授課課件

肩關節(jié)疾病的診斷肩關節(jié)疾病的診斷1（優(yōu)選）肩關節(jié)疾病的診斷（優(yōu)選）肩關節(jié)疾病的診斷2肱二頭肌間溝肱二頭肌腱崗上肌滑囊和盂唇肩峰前外角下方約2cmROM前屈外展上抬001800Stage4:

noevidenceofsynovitis

tightinferiorfoldandjoint病程分期BursalSideNeer提出肩關節(jié)在運動的過程中有一些結構性因素和動力性因素與肩峰發(fā)生摩擦產生病理性疼痛Radiologynormal肩關節(jié)檢查壓疼點(Palpation)凍結肩凍結肩StagesofCalcifyingTendinitis:Uthoff’sClassificationPureimpingementwithnoinstability

肩關節(jié)解剖肱二頭肌間溝肱二頭肌腱3

骨結構BodyAnatomyScapulaClavicle 骨結構BodyAnato4

骨結構 BonyAnatomyHumerusRibs骨結構 Bony5

肌肉構成Anteriormusculatureoftheshouldergirdle肌肉構成Anteriorm6

肌肉構成Musculatureofposteriorshouldergirdle肌肉構成Musculat7

韌帶結構Shoulderligaments韌帶結構Shoulde8

滑囊和盂唇Shoulderjointcapsuleandcartilage滑囊和盂唇Shoulde9

血管和神經 BloodSupplyandIntervention血管和神經 Blood10肩關節(jié)的評估病史采集疼痛的原因損傷的機制以前的病史疼痛的位置時限程度彈響彈響的數(shù)量體溫的變化肩無力？肩疲勞?如何減輕疼痛?肩關節(jié)的評估病史采集?11ShoulderEvaluation(Observation)ElevationordepressionofshouldertipsPositionandshapeofclavicleAcromionprocessBicepsanddeltoidsymmetryPosturalassessment(kyphosis,lordosis,shoulders)PositionofheadandarmsScapularelevationandsymmetryScapularprotractionorwingingMusclesymmetryScapulohumeralrhythmShoulderEvaluation(Obse12

肩關節(jié)運動范圍檢查(Observation)肩胛盂肱關節(jié)與肩胛胸壁關節(jié)肱骨與肩胛骨的運動關系肩關節(jié)啟動三十度外展肩胛骨不參與運動外展三十度到九十度之間肱骨平均每上抬兩度肩胛骨外展向上旋轉一度the九十度以上肩胛骨肱骨呈11旋轉運動肩關節(jié)運動范圍檢查(Observat13

肩關節(jié)檢查壓疼點(Palpation)骨結構胸鎖關節(jié)鎖骨干肩鎖關節(jié)喙突肩峰肱骨頭肱骨大結節(jié)肱二頭肌間溝肩胛崗肩胛骨內緣肩胛骨外緣肩胛骨上角肩胛骨下角肩關節(jié)檢查壓疼點(Palpat14韌帶結構RadiologicalstagingofCalcifyingTendinitis:GartnerandHeyerClassification慢性損傷年齡（退變）StagesofCalcifyingTendinitis:Uthoff’sClassificationA2

Markedscuffing/damageoftheundersurfaceoftheacromion

&CAligament韌帶結構Stiffness:412monthsTeresmajorandminor避免做可能使肩關節(jié)疼痛的動作Stage2Bursalthicknessover2.手術指征規(guī)范保守治療無效主要是累計崗上肌、崗下肌、肩胛下肌RadiologicalmorphologyofCalcifyingTendinitis:

MoléClassification(1993)影像學沒有明確的陽性改變歷史1896年Duplay提出pereglanoiolitis盂肱關節(jié)周圍炎首次醫(yī)學描述肩僵硬

肩關節(jié)檢查壓疼點(Palpation)軟組織結構胸鎖關肩鎖關節(jié)喙鎖韌帶肩袖肌腱肩峰下滑囊肱二頭肌間溝肱二頭肌腱喙肩韌帶GlenohumeraljointcapsuleDeltoidRhomboidsLatissimusdorsiSerratusAnteriorLevatorscapulaeTrapeziusSupraspinatusInfraspinatusTeresmajorandminor韌帶結構肩關節(jié)檢查壓疼點15

肩關節(jié)特殊檢查(SpecialTests)肩關節(jié)功能范圍(ROM)前屈@180o后伸@50o外展@180o內收@40o內旋@90o外旋中立位600

外展位900

ManualMuscleTestingFivePointgradingsystem5=CompleteROMagainstgravity,withfullresistance4=CompleteROMagainstgravity,withsomeresistance3=CompleteROMagainstgravity,withnoresistance2=CompleteROM,withgravityomitted1=Somemusclecontractilitywithnojointmotion0=Nomusclecontractility肩關節(jié)特殊檢查(Special16

肩周炎的概念歷史1896年Duplay提出pereglanoiolitis盂肱關節(jié)周圍炎首次醫(yī)學描述肩僵硬演變Codman1934年命名為肩周炎1945年第一次使用adhesivecapsulitis粘連性肩關節(jié)囊炎現(xiàn)狀由于肩關節(jié)周圍炎的描述模糊不清，病理至今沒有病理生理學基礎肩周炎的概念歷史1896年Dupl17崗下肌Leg癥手術選擇關節(jié)鏡下肩峰成型術病因體內鈣的代謝紊亂A2

Markedscuffing/damageoftheundersurfaceoftheacromion

&CAligament二頭肌在盂唇損傷的病理作用AcromialSide

BursalSideSubacromialImpingementclassifications影像學沒有明確的陽性改變B1

Minorscuffing,haemorrhageorlocalinjectionandinflammation過度使用影像學沒有明確的陽性改變肩關節(jié)功能逐漸喪失

肩周炎是垃圾箱—棄用癥狀模糊不清多種疾病混淆沒有清晰的病理生理機制和證據(jù)給臨床帶來混亂崗下肌Leg癥肩周炎是垃圾箱—18

有必要對肩疼痛疾病分類凍結肩肩峰撞擊證肩袖損傷鈣化性肌腱炎盂唇損傷肩鎖關節(jié)骨性關節(jié)炎盂肱關節(jié)骨性關節(jié)炎有必要對肩疼痛疾病分類凍結肩19肩峰前外角下方約2cm肌腱炎滑囊炎PrimaryinstabilitywithcapsularandlabralinjurywithsecondaryimpingementwhichcanbeinternalimpingementorsubacromialA

calcificationdensehomogenouswithclearcontoursA2

Markedscuffing/damageoftheundersurfaceoftheacromion

&CAligamentRadiologicalmorphologyofCalcifyingTendinitis:

MoléClassification(1993)發(fā)病率白種人較高黃種人低肩峰前外角下方約2cmFrozenshoulder:Lundbergclassification全方位功能受限Acromionprocess結構性因素

肩峰的形態(tài)

肌腱的炎性退變增粗

滑囊炎容積增大

大結節(jié)骨折

凍結肩有明確的時限性疼痛有固定的曲線有固定的癥狀和體現(xiàn)沒有明確的發(fā)病原因最終結局是樂觀、一般不留關節(jié)障礙肩峰前外角下方約2cm20

病程分期冷凍期初期19個月疼痛凍結期中期32個月關節(jié)僵硬解凍期后期5個月至2年疼痛減輕功能恢復病程分期冷凍期初期19個月21FrozenShoulderClassificationsFrozenshoulder:LundbergclassificationStagesoffrozenshoulder:ReevesArthroscopicstagesofadhesivecapsulitis:NeviaserFrozenShoulderClassification22FrozenShoulder:LundbergClassificationA.Primaryfrozenshoulder:

Shoulderelevation<135degLimitationofmovementonlyatglenohumeralarticulationRadiologynormalOthercausesietrauma,OA,RA,HemiplegiaetcexcludedB.Secondaryfrozenshoulder:

DecreasedrangeofmovementfollowingtraumaorotherknowncauseFrozenShoulder:LundbergClas23StagesofFrozenShoulder:Reeves

ReevesB,ScandJRheumatol,4:193196,1975Painfulstage:1036weeksStiffness:412monthsRecovery:524monthsStagesofFrozenShoulder:Ree24凍結肩是一種自限性疾病

不必憂慮凍結肩是一種自限性疾病

不必憂慮25

如何確診凍結肩

病史沒有明確的原因疼痛的特點疼痛逐漸加重，夜間疼痛關節(jié)僵硬逐漸盂肱關節(jié)的活動度減少肌肉無損傷肌力無明顯改變

如何確診凍結肩

病史26

臨床檢查肩關節(jié)功能ROM前屈外展上抬001800外旋00600內旋體側7胸椎棘突全方位功能受限臨床檢查肩關節(jié)功能27ArthroscopicstagesofFrozenShoulder:Nevasier

Neviaser,OrthopClinNorthAm,18:439443,1987

ArthroscopicstagesofFrozen28肩峰前外角下方約2cm肱骨頭與喙肩弓持續(xù)撞擊肩周炎的概念SubacromialImpingementclassificationsLatissimusdorsiA1

Minorscuffing,haemorrhageorlocalinjectionandinflammationGradingofimpingementchanges:Milgrom’sultrasoundclassificationStage2:fibrosisandtendinitis,age2540,recurrentpainwithactivityShoulderjointcapsuleandcartilage肱二頭肌間溝肱二頭肌腱BursalSideRadiologicalmorphologyofCalcifyingTendinitis:

MoléClassification(1993)Stage1:

Erythematous/fibrinoussynovium

patientpresentsasimpingement

Stage2:

Red,angry,thicksynovium,

thick,contractedinterval,tight

jointspaceadhesionsintheinferiorfold

Stage3:

Pinksynovium

contractedinferiorfold,tightjointspace

Stage4:

noevidenceofsynovitis

tightinferiorfoldandjoint

肩峰前外角下方約2cmStage1:

Erythema29肩關節(jié)疾病的診斷授課課件30

輔助檢查

影像學沒有明確的陽性改變輔助檢查影像學沒有明確的陽性改變31MRIMRI32

肩峰撞擊癥何為肩峰撞擊癥肩峰撞擊癥的概念

Neer提出肩關節(jié)在運動的過程中有一些結構性因素和動力性因素與肩峰發(fā)生摩擦產生病理性疼痛包括內容肩峰的形態(tài)Bigliani分型肌腱炎滑囊炎肩峰撞擊癥何為肩峰撞擊癥33肩關節(jié)疾病的診斷授課課件34

結構性因素

肩峰的形態(tài)

肌腱的炎性退變增粗

滑囊炎容積增大

大結節(jié)骨折撞擊的病理

結構性因素

肩峰的形態(tài)

35

動力性因素

肩胛骨失效

肌腱過度負荷

盂肱關節(jié)不穩(wěn)定

重復性微細創(chuàng)傷動力性因素

肩胛骨失效

36撞擊產生的機制崗上肌出口撞擊產生的機制37肩關節(jié)疾病的診斷授課課件38肩關節(jié)疾病的診斷授課課件391140Stage2:fibrosisandtendinitis,age2540,recurrentpainwithactivity肌腱炎滑囊炎Primaryinstabilitybecauseofgeneralisedligamentouslaxitywithsecondaryimpingement過度使用BursalSide影像學沒有明確的陽性改變解凍期后期5個月至2年疼痛減輕功能恢復肱二頭肌間溝肱二頭肌腱肌腱炎滑囊炎BonyAnatomy肩關節(jié)檢查壓疼點(Palpation)影像學評估

模擬撞擊原理Stage2:fibrosisandtendinit41模擬撞擊原理2模擬撞擊原理242肩關節(jié)疾病的診斷授課課件43肩關節(jié)疾病的診斷授課課件44肩關節(jié)疾病的診斷授課課件45肩關節(jié)疾病的診斷授課課件46SubacromialImpingementclassificationsStagesofsubacromialimpingement:Neer’sclassificationStagesofsubacromialimpingementinathletes:Jobe’sclassificationGradingofimpingementchanges:Milgrom’sultrasoundclassificationImpingementlesions:CopelandLevyclassificationSubacromialImpingementclassi47Stagesofsubacromialimpingement:

Neer’sclassification

Historicalinterest,stagesdonotnecessarilyfollowoneanother

Stagesofsubacromialimpingem48Stage1:oedemaandhaemorrhage,age<25,reversible

Stage2:fibrosisandtendinitis,age2540,recurrentpainwithactivity

Stage3:bonespursandtendonrupture,age>40,progressivedisability

Stage1:oedemaandhaemorrhag49Stagesofsubacromialimpingementinathletes:

Jobe’sclassification(1989)

1.

Pureimpingementwithnoinstability

2.

Primaryinstabilitywithcapsularandlabralinjurywithsecondaryimpingementwhichcanbeinternalimpingementorsubacromial

3.

Primaryinstabilitybecauseofgeneralisedligamentouslaxitywithsecondaryimpingement

4.

Pureinstabilityandnoimpingement

Stagesofsubacromialimpingem50Gradingofimpingementchanges:Milgrom’sultrasoundclassification

Stage1Bursalthickness1.5to2.0mm

Stage2Bursalthicknessover2.0mm

Stage3Partialorfullthicknesstearoftherotatorcuff

Gradingofimpingementchanges51AcromialSide

BursalSide0

Normalsmoothsurface

A1

Minorscuffing,haemorrhageorlocalinjectionandinflammationA2

Markedscuffing/damageoftheundersurfaceoftheacromion

&CAligamentA3

Bareboneareassurface

A1

Minorscuffing,haemorrhageorlocalinjectionandinflammationA2

Markedscuffing/damageoftheundersurfaceoftheacromion

&CAligamentA3

BareboneareasB0

NormalsmoothsurfaceB1

Minorscuffing,haemorrhageorlocalinjectionandinflammationB2

Majorscuffingofcuff,partialthicknesstearB3

FullthicknesstearB4

MassivecufftearAcromialSide

Bursal520

Normal-smoothsurface

A1

Minorscuffing,haemorrhageorlocalinjectionandinflammationAcromialSide0

Normal-smoothsurface

53A1

Minorscuffing,haemorrhageorlocalinjectionandinflammationA1

Minorscuffing,haemorrha54肩關節(jié)疾病的診斷授課課件55A2

Markedscuffing/damageoftheundersurfaceoftheacromion

&CAligamentBareboneareasA3

A2

Markedscuffing/damage56B0

Normal-smoothsurfaceB1

Minorscuffing,haemorrhageorlocalinjectionandinflammationBursalSideB0

Normal-smoothsurfaceB157B0

Normal-smoothsurfaceB3

FullthicknesstearB0

Normal-smoothsurfaceB358B4

MassivecufftearB4

Massivecufftear59撞擊癥的癥狀疼痛發(fā)病疼痛成隱匿性進展部位肩前外側有時放射至肘方式肩關節(jié)運動到某一部位夜間疼痛只在患側臥位時疼撞擊癥的癥狀疼痛60

特殊檢查

NeerHawkins特殊檢查Neer61影像學檢查影像學檢查62撞擊綜合癥－治療保守治療休息避免做可能使肩關節(jié)疼痛的動作前后部肩袖肌力練習撞擊綜合癥－治療保守治療63撞擊綜合癥－治療保守治療肩峰下注射玻璃酸鈉（施沛特）2支得保松＋布比卡因肩峰前外角下方約2cm不超過2次撞擊綜合癥－治療保守治療64撞擊綜合癥－治療手術指征規(guī)范保守治療無效手術選擇關節(jié)鏡下肩峰成型術手術要點肩峰成型＋喙肩韌帶切斷＋滑囊清掃撞擊綜合癥－治療手術指征規(guī)范保守治療無效65肩關節(jié)疾病的診斷授課課件66肩關節(jié)疾病的診斷授課課件67肩關節(jié)疾病的診斷授課課件68

肩袖損傷肩袖的構成肩袖的位置肩袖的肌腱走行和方向肩袖的作用肩袖損傷肩袖的構成69

崗上肌崗上肌70

崗下肌小圓肌崗下肌小圓肌71

肩袖損傷的原因和機制急性損傷運動（過頂運動）創(chuàng)傷慢性損傷年齡（退變）過度使用骨贅機械撞擊癥肩袖損傷的原因和機制急性損傷運動（過頂運動）72

臨床評估病史與凍結肩鑒別疼痛肩關節(jié)無力和功能障礙臨床檢查影像學評估關節(jié)鏡評估臨床評估病史與凍結肩鑒別73臨床評估方法崗上肌Jobe癥崗下肌Leg癥小圓肌肩胛下肌Lift—off臨床評估方法崗上肌Jobe癥74影像學評估超聲波敏感性較高準確性差磁共振敏感性準確性均好費用高基層醫(yī)院無配置影像學評估超聲波敏感性較高準確性差75肩關節(jié)疾病的診斷授課課件76肩關節(jié)疾病的診斷授課課件77肩關節(jié)疾病的診斷授課課件78肩關節(jié)疾病的診斷授課課件79肩關節(jié)疾病的診斷授課課件80肩關節(jié)疾病的診斷授課課件81肩關節(jié)疾病的診斷授課課件82肩關節(jié)疾病的診斷授課課件83

盂肱關節(jié)骨性關節(jié)炎發(fā)病率白種人較高黃種人低主要特征年齡發(fā)病緩慢疼痛逐漸明顯肩關節(jié)功能逐漸喪失盂肱關節(jié)骨性關節(jié)炎發(fā)病率白種人較高黃種人84肩關節(jié)疾病的診斷授課課件85肩關節(jié)疾病的診斷授課課件86肩關節(jié)疾病的診斷授課課件87肩關節(jié)疾病的診斷授課課件88肩關節(jié)疾病的診斷授課課件89肩關節(jié)疾病的診斷授課課件90肩關節(jié)疾病的診斷授課課件91肩關節(jié)疾病的診斷授課課件92

臨床表現(xiàn)疼痛肩無力肩關節(jié)障礙對治療不敏感肩僵硬關節(jié)積液臨床表現(xiàn)疼痛93

臨床評估有固定的疼痛點有固定的壓痛點研磨音臨床評估有固定的疼痛點94

影像學評估普通X線片CT掃描磁共振影像學評估普通X線片95

盂唇損傷盂唇的解剖與二頭肌長頭的關系盂唇的作用二頭肌在盂唇損傷的病理作用盂唇損傷的分型盂唇損傷盂唇的解剖96肱二頭肌腱有關的盂唇損傷原發(fā)性肌腱病結節(jié)間溝內的肌腱炎癥肱二頭肌腱繼發(fā)性腱病—肱骨頭與喙肩弓持續(xù)撞擊過頂運動投擲后的減速期肱二頭肌腱有關的盂唇損傷原發(fā)性肌腱病結節(jié)間溝內的肌腱炎癥97肩關節(jié)疾病的診斷授課課件98StagesofCalcifyingTendinitis:

Uhthoff’s

Classification避免做可能使肩關節(jié)疼痛的動作肩周炎是垃圾箱—棄用FivePointgradingsystemB1

Minorscuffing,haemorrhageorlocalinjectionandinflammation肩峰前外角下方約2cmLimitationofmovementonlyatglenohumeralarticulationScapulohumeralrhythmStage3:

Pinksynovium

contractedinferiorfold,tightjointspace4=CompleteROMagainstgravity,withsomeresistance肱骨與肩胛骨的運動關系Primaryinstabilitywithcapsularandlabralinjurywithsecondaryimpingementwhichcanbeinternalimpingementorsubacromial臨床評估檢查ObrienClunkCompressionStagesofCalcifyingTendiniti99鈣化性肌腱炎主要是累計崗上肌、崗下肌、肩胛下肌病因體內鈣的代謝紊亂機制大量鈣質沉積在肌腱內疼痛原因突然肌腱內的沉積鈣大量釋放鈣化性肌腱炎主要是累計崗上肌、崗下肌、肩胛下肌100CalcificTendonitisClassificationsStagesofCalcifyingTendinitis:Uthoff’sClassification

RadiologicalclassificationofCalcifyingTendinitis:BosworthRadiologicalmorphologyofCalcifyingTendinitis:MoléClassificationRadiologicalstagingofCalcifyingTendinitis:GartnerandHeyerClassificationCalcificTendonitisClassifica101StagesofCalcifyingTendinitis:

Uhthoff’s

Classification

1Precalcificstage