肩關(guān)疾病的診斷王少山PPT課件

1、.,1,肩關(guān)節(jié)疾病的診斷,山東省中醫(yī)院運(yùn)動損傷骨科 王少山,.,2,肩關(guān)節(jié)的疾病你知道多少,普通人 醫(yī)務(wù)工作者 骨科醫(yī)生 運(yùn)動醫(yī)學(xué)醫(yī)師 肩關(guān)節(jié)疾病的特征 疼痛 關(guān)節(jié)僵硬,.,3,肩關(guān)節(jié)解剖,.,4,骨結(jié)構(gòu),Body Anatomy Scapula Clavicle,.,5,骨結(jié)構(gòu),Bony Anatomy Humerus Ribs,.,6,肌肉構(gòu)成,Anterior musculature of the shoulder girdle,.,7,肌肉構(gòu)成,Musculature of posterior shoulder girdle,.,8,韌帶結(jié)構(gòu),Shoulder ligaments,.,

2、9,滑囊和盂唇,Shoulder joint capsule and cartilage,.,10,血管和神經(jīng),Blood Supply and Intervention,.,11,肩關(guān)節(jié)的評估,病史采集 疼痛的原因 損傷的機(jī)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,?,.,12,Shoulder Evaluation (Observation),Elevation or depression of shoulder tips Position and shape of clavicle Acromion process Bicep

3、s and deltoid symmetry Postural assessment (kyphosis, lordosis, shoulders),Position of head and arms Scapular elevation and symmetry Scapular protraction or winging Muscle symmetry Scapulohumeral rhythm,.,13,肩關(guān)節(jié)運(yùn)動范圍檢查(Observation),肩胛盂肱關(guān)節(jié)與肩胛胸壁關(guān)節(jié) 肱骨與肩胛骨的運(yùn)動關(guān)系 肩關(guān)節(jié)啟動三十度外展肩胛骨不參與運(yùn)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

4、展向上旋轉(zhuǎn)一度the 九十度以上肩胛骨肱骨呈1：1旋轉(zhuǎn)運(yùn)動,.,14,肩關(guān)節(jié)檢查壓疼點(diǎn) (Palpation),骨結(jié)構(gòu) 胸鎖關(guān)節(jié) 鎖骨干 肩鎖關(guān)節(jié) 喙突 肩峰 肱骨頭 肱骨大結(jié)節(jié) 肱二頭肌間溝 肩胛崗 肩胛骨內(nèi)緣,肩胛骨外緣 肩胛骨上角 肩胛骨下角,.,15,肩關(guān)節(jié)檢查壓疼點(diǎn) (Palpation),軟組織結(jié)構(gòu) 胸鎖關(guān) 肩鎖關(guān)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,Glenohumeral joint capsule Deltoid Rhomboids Latissimus dorsi Serratus Anterior Levator scapulae Trap

5、ezius Supraspinatus Infraspinatus Teres major and minor,.,16,肩關(guān)節(jié)特殊檢查 (Special Tests),肩關(guān)節(jié)功能范圍(ROM) 前屈 180o 后伸 50o 外展 180o 內(nèi)收 40o 內(nèi)旋 90o 外旋 中立位 600 外展位 900,Manual Muscle Testing Five Point grading system 5 = Complete ROM against gravity, with full resistance 4 = Complete ROM against gravity, with some

6、 resistance 3 = Complete ROM against gravity, with no resistance 2 = Complete ROM, with gravity omitted 1 = Some muscle contractility with no joint motion 0 = No muscle contractility,.,17,肩周炎的概念,歷史 1896年Duplay提出 pereglanoiolitis 盂肱關(guān)節(jié)周圍炎 首次醫(yī)學(xué)描述肩僵硬 演變 Codman1934年命名為肩周炎 1945年J.S.Neviase第一次使用adhesive ca

7、psulitis粘連性肩關(guān)節(jié)囊炎 現(xiàn)狀 由于肩關(guān)節(jié)周圍炎的描述模糊不清，病理至今沒有病理生理學(xué)基礎(chǔ),.,18,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(jī)制和證據(jù) 給臨床帶來混亂,.,19,有必要對肩疼痛疾病分類,凍結(jié)肩 肩峰撞擊證 肩袖損傷 鈣化性肌腱炎 盂唇損傷 肩鎖關(guān)節(jié)骨性關(guān)節(jié)炎 盂肱關(guān)節(jié)骨性關(guān)節(jié)炎,.,20,凍結(jié)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(jié)局是樂觀、一般不留關(guān)節(jié)障礙,.,21,病程分期,冷凍期 初期 1-9個月 疼痛 凍結(jié)期 中期 3-2個月 關(guān)節(jié)僵硬 解凍期 后期 5個月至2年 疼痛減輕功能恢復(fù),.,2

8、2,Frozen Shoulder Classifications,Frozen shoulder: Lundberg classification Stages of frozen shoulder: Reeves Arthroscopic stages of adhesive capsulitis: Neviaser,.,23,Frozen Shoulder: Lundberg Classification,A. Primary frozen shoulder: Shoulder elevation 135 deg Limitation of movement only at gleno-

9、humeral articulation Radiology normal Other causes ie trauma, OA, RA, Hemiplegia etc excluded B. Secondary frozen shoulder: Decreased range of movement following trauma or other known cause,.,24,Stages of Frozen Shoulder: ReevesReeves B, Scand J Rheumatol, 4: 193-196, 1975,Painful stage: 10-36 weeks

10、 Stiffness: 4-12 months Recovery: 5-24 months,.,25,凍結(jié)肩是一種自限性疾病不必憂慮,.,26,如何確診凍結(jié)肩,病史 沒有明確的原因 疼痛的特點(diǎn) 疼痛逐漸加重，夜間疼痛 關(guān)節(jié)僵硬 逐漸盂肱關(guān)節(jié)的活動度減少 肌肉無損傷 肌力無明顯改變,.,27,臨床檢查,肩關(guān)節(jié)功能 ROM 前屈外展上抬 00 - 1800 外 旋 00 - 600 內(nèi) 旋 體側(cè)- 7胸椎棘突 全方位功能受限,.,28,Arthroscopic stages of Frozen Shoulder: Nevasier Neviaser, Orthop Clin North Am, 1

11、8:439-443, 1987,.,29,Stage 1: Erythematous/ fibrinous synovium patient presents as impingement Stage 2: Red, angry, thick synovium, thick, contracted interval, tight joint space adhesions in the inferior fold Stage 3: Pink synovium contracted inferior fold, tight joint space Stage 4: no evidence of

12、synovitis tight inferior fold and joint,.,30,.,31,輔助檢查,影像學(xué)沒有明確的陽性改變,.,32,MRI,.,33,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(guān)節(jié)在運(yùn)動的過程中有一些結(jié)構(gòu)性因素和動力性因素與肩峰發(fā)生摩擦產(chǎn)生病理性疼痛 包括內(nèi)容 肩峰的形態(tài) Bigliani分型 肌腱炎 滑囊炎,.,34,.,35,結(jié)構(gòu)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(jié)節(jié)骨折,撞擊的病理,.,36,動力性因素 肩胛骨失效 肌腱過度負(fù)荷 盂肱關(guān)節(jié)不穩(wěn)定 重復(fù)性微細(xì)創(chuàng)傷,.,37,撞擊產(chǎn)生的機(jī)制 崗上肌出口,.,38,.,39

13、,.,40,1,.,41,模擬撞擊原理,.,42,模擬撞擊原理2,.,43,.,44,.,45,.,46,.,47,Subacromial Impingement classifications,Stages of subacromial impingement: Neers classification Stages of subacromial impingement in athletes: Jobes classification Grading of impingement changes: Milgroms ultrasound classification Impingement

14、 lesions: Copeland Levy classification,.,48,Stages of subacromial impingement: Neers classification Historical interest, stages do not necessarily follow one another,.,49,Stage 1: oedema and haemorrhage , age 40, progressive disability,.,50,Stages of subacromial impingement in athletes: Jobes classi

15、fication (1989),1. Pure impingement with no instability 2. Primary instability with capsular and labral injury with secondary impingement which can be internal impingement or subacromial 3. Primary instability because of generalised ligamentous laxity with secondary impingement 4. Pure instability a

16、nd no impingement,.,51,Grading of impingement changes: Milgroms ultrasound classification,Stage 1 - Bursal thickness 1.5 to 2.0mm Stage 2 - Bursal thickness over 2.0mm Stage 3 - Partial or full thickness tear of the rotator cuff,.,52,Acromial Side Bursal Side,0 Normal - smooth surface A1 Minor scuff

17、ing, haemorrhage or local injection and inflammation A2 Marked scuffing / damage of the undersurface of the acromion& CA ligament A3 Bare bone areas,surface A1 Minor scuffing, haemorrhage or local injection and inflammation A2 Marked scuffing / damage of the undersurface of the acromion& CA ligament

18、 A3 Bare bone areas B0 Normal - smooth surface B1 Minor scuffing, haemorrhage or local injection and inflammation B2 Major scuffing of cuff, partial thickness tear B3 Full thickness tear B4 Massive cuff tear,.,53,0 Normal - smooth surface A1 Minor scuffing, haemorrhage or local injection and inflamm

19、ation,Acromial Side,.,54,A1 Minor scuffing, haemorrhage or local injection and inflammation,.,55,.,56,A2 Marked scuffing / damage of the undersurface of the acromion& CA ligament,Bare bone areas,A3,.,57,B0 Normal - smooth surface,B1 Minor scuffing, haemorrhage or local injection and inflammation,Bur

20、sal Side,.,58,B0 Normal - smooth surface,B3 Full thickness tear,.,59,B4 Massive cuff tear,.,60,撞擊癥的癥狀,疼 痛 發(fā)病 疼痛成隱匿性進(jìn)展 部位 肩前外側(cè)有時放射至肘 方式 肩關(guān)節(jié)運(yùn)動到某一部位 夜間疼痛 只在患側(cè)臥位時疼,.,61,特殊檢查,Neer Hawkins,.,62,影像學(xué)檢查,.,63,撞擊綜合癥治療,保守治療 休息 避免做可能使肩關(guān)節(jié)疼痛的動作 前后部肩袖肌力練習(xí),.,64,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

21、2次,.,65,撞擊綜合癥治療,手術(shù)指征： 規(guī)范保守治療無效 手術(shù)選擇： 關(guān)節(jié)鏡下肩峰成型術(shù) 手術(shù)要點(diǎn)： 肩峰成型喙肩韌帶切斷滑囊清掃,.,66,.,67,.,68,.,69,肩袖損傷,肩袖的構(gòu)成 肩袖的位置 肩袖的肌腱走行和 方向 肩袖的作用,.,70,崗上肌,.,71,崗下肌 小圓肌,.,72,肩袖損傷的原因和機(jī)制,急性損傷 運(yùn)動 （過頂運(yùn)動）創(chuàng)傷 慢性損傷 年齡 （退變） 過度使用 骨贅 機(jī)械撞擊癥,.,73,臨床評估,病史 與凍結(jié)肩鑒別 疼痛 肩關(guān)節(jié)無力和功能障礙 臨床檢查 影像學(xué)評估 關(guān)節(jié)鏡評估,.,74,臨床評估方法,崗上肌 Jobe癥 崗下肌 Leg 癥 小圓肌 肩胛下肌 Lif

22、toff,.,75,影像學(xué)評估,超聲波 敏感性較高 準(zhǔn)確性差 磁共振 敏感性 準(zhǔn)確性均好 費(fèi)用高 基層醫(yī)院無配置,.,76,.,77,.,78,.,79,.,80,.,81,.,82,.,83,.,84,盂肱關(guān)節(jié)骨性關(guān)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(guān)節(jié)功能逐漸喪失,.,85,.,86,.,87,.,88,.,89,.,90,.,91,.,92,.,93,臨床表現(xiàn),疼痛 肩無力 肩關(guān)節(jié)障礙 對治療不敏感 肩僵硬 關(guān)節(jié)積液,.,94,臨床評估,有固定的疼痛點(diǎn) 有固定的壓痛點(diǎn) 研磨音,.,95,影像學(xué)評估,普通X線片 CT掃描 磁共振,.,96,盂唇損

23、傷,盂唇的解剖 與二頭肌長頭的關(guān)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,.,97,肱二頭肌腱有關(guān)的盂唇損傷,原發(fā)性肌腱病-結(jié)節(jié)間溝內(nèi)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(yùn)動投擲后的減速期,.,98,.,99,臨床評估檢查,Obrien Clunk Compression,.,100,鈣化性肌腱炎,主要是累計(jì)崗上肌、崗下肌、肩胛下肌 病因 體內(nèi)鈣的代謝紊亂 機(jī)制 大量鈣質(zhì)沉積在肌腱內(nèi) 疼痛原因 突然肌腱內(nèi)的沉積鈣大量釋放,.,101,Calcific Tendonitis Classifications,Stages of Calcifying Te

24、ndinitis:Uthoffs Classification Radiological classification of Calcifying Tendinitis : Bosworth Radiological morphology of Calcifying Tendinitis : Mol Classification Radiological staging of Calcifying Tendinitis : Gartner and Heyer Classification,.,102,Stages of Calcifying Tendinitis: Uhthoffs Classification,1 - Pre-calcific stage - Metaplasia of tenocytes into chondrocytes2 - Calcific stage Formative phase Resting phase Resorptive