肩袖损伤

肩袖损伤肩袖损伤的流行病学Uhthoffetal.[1]founda20%prevalenceinaseriesofcadaverdissectionsinwhichthemeanageofthedonorswas59.4years.Lehmanetal.[2]foundaprevalenceof17%inalargeseriesofcadaverdissections,withaprevalenceof30%indonorsolderthansixtyyearsofage.Theincidenceoffull-thicknesstearsoftherotatorcuffrangesfrom5%to40%.Furthermore,epidemiologicalstudiesshowanincreasingfrequencyofrotatorcufffailurewithadvancingage[3].1UhthoffHK,LoehrJ,SarkarK.Thepathogenesisofrotatorcufftears.In:TakagishiN,editor.Theshoulder.Tokyo:ProfessionalPostGraduateServices;1987:211-2.2LehmanC,CuomoF,KummerFJ,ZuckermanJD.Theincidenceoffullthicknessrotatorcufftearsinalargecadavericpopulation.BullHospJtDis.1995;54(1):30-1.3BiglianiLU,MorrisonDS.Relationshipbetweenacromialmorphologyandrotatorcufftears.OrthopTrans.1986;10:216.当我们在临床上遇到疑似病人，只有X片而无MRI检查时，1我们能从X片中得到什么信息？2我们印象中的可疑诊断有哪些？3针对性的体查有哪些？GazzolaS,BleakneyRR.Currentimagingoftherotatorcuff[J].SportsMedArthrosc,2011,19(3):300-9.cysticchangeofthegreatertuberosity1读X片GazzolaS,BleakneyRR.Currentimagingoftherotatorcuff[J].SportsMedArthrosc,2011,19(3):300-9.normalsubacromialjointspace(≥7mm)(arrow)1superiorsubluxationofthehumeralhead(arrow)2notchedhumeralneck(arrowhead)TypeIcalcificationwithafluffy,fleecyappearancewithpoorlydefinedborders,withacutesymptomsandtermedtheresorptivephase.TypeIIcalcification,morediscreetandofhomogenousdensity,withwell-circumscribedborders,andintheformativephase.DePalmaAF,KruperJS.Long-termstudyofshoulderjointsaffliatedwithandtreatedforcalcifictendinitis[J].ClinOrthop.1961;20:61-72.calcifictendinopathy2可疑诊断1关于肩周炎肩周炎=冻结肩（《实用骨科学》第3版），是由于肩关节周围软组织病变而引起肩关节疼痛和活动功能障碍。国外报道Frozenshoulder40-60yearsofage,incidence2-5%[1].3phases[2]1)freezingphase2-9months,painandlossofmotionoftheglenohumeraljointinalldirection，usuallyworstatnightandwhenlyingontheaffectedside2)frozenphase4-12months,stiffnessreachesitsmaximum3)thawingphase5-12months,rangeofmotionreturnstonormal2肩峰下撞击综合症疼痛，主诉为三角肌下疼痛，并经常向下放射至前方的肱二头肌，夜间疼痛可影响睡眠1HandC,ClipshamK,ReesJL,etal.Long-termoutcomeoffrozenshoulder.JShoulderElbowSurg2008;17:231-6.2ReevesB.Thenaturalhistoryofthefrozenshouldersyndrome.ScandJRheumatol1975;4:193-6.3针对肩袖损伤的体查1冈上肌肩外展功能1emptycantest1)90degreesabduction2)30degreeshorizontalabduction(intheplaneofthescapula)3)thumbspointingdownward2fullcantest1)90degreesinthehorizontalplane2)rotated45degreesexternally3)withthethumbpointingupward3painfularctest60°-120°1)shoulderinexternalrotation2)palmfacingup4resistedisometricabduction1)thearminneutralrotation2)abductsthearmto90degrees1externalrotationstrengthtest=Patte’stest1)thepatient’selbowin90degrees2)intheplaneofthescapula2冈下肌和小圆肌肩外旋功能2externalrotationlagsign1)elbowpassivelyflexedto90degrees2)maximalexternalrotation3dropsign1)almostfullexternalrotation2)elbowflexedat90degrees4weaknesswithexternalrotation1)elbowsflexedto90degrees2)thethumbsup3)shouldersrotatedinternally20degrees3肩胛下肌肩内旋、后伸功能1liftofftestaskingthepatienttointernallyrotatethearmtoliftthehandposteriorlyoffoftheback2internalrotationlagsign3bellypress4bearhugtest4针对肩峰下撞击综合症的体查Hawkins-Kennedytest关于MRI肩袖解剖解剖足印（footprint）关于MRI正常肩袖的MRI斜冠状面正常肩袖的MRI斜矢状面正常肩袖的MRI横断面损伤肩袖的MRI魔法角magicanglephenomenonthefibersareat55degreestothemainmagneticfieldonT1EricksonSJ,ProstRW,TiminsME.The“magicangle”effect:backgroundphysicsandclinicalrelevance.Radiology.1993;188:23-25.我们在MRI上应得到的信息1肩袖走行及连续性2高信号3脂肪变性4肌肉萎缩5肌肉回缩6三角肌下、肩峰下囊滑液相连肩袖走行及连续性脂肪渗透（fattyinfiltration）FuchsB,WeishauptD,ZanettiM,HodlerJ,GerberC.Fattydegenerationofthemusclesoftherotatorcuff:assessmentbycomputedtomographyversusmagneticresonanceimaging.JShoulderElbowSurg1999;8:599-605.肌肉萎缩（muscleatrophy）1切线征[1]（tangentsign）2肩胛比（scapularratio）Scapularratiousestheratioofthesupraspinatusmuscleincrosssectiononthesagittalobliqueimagecomparedwiththesizeofthesupraspinatusfossa,andinsupraspinatusatrophytheratioislessthan50%[2].1ZanettiM,GerberC,HodlerJ.Quantitativeassessmentofthemusclesoftherotatorcuffwithmagneticresonanceimaging.InvestRadiol.1998;33:163-170.2ThomazeauH,RollandY,LucasC,etal.Atrophyofthesupraspinatusbelly.AssessmentbyMRIin55patientswithrotatorcuffpathology.ActaOrthopScand.1996;67:264-268.肩袖损伤的分类1全层撕裂1）小＜1cm2）中1-3cm3）大3-5cm4）巨大＞5cmDeOrioJK,CofieldRH.Resultsofasecondattemptatsurgicalrepairofafailedinitialrotator-cuffrepair.JBoneJointSurg.1984;66:563–567.肩袖损伤的分类2部分撕裂肩袖损伤的治疗手术VS保守1年龄Ageisoneofthemostusedparametersindecisionmakingforthesurgeryofthecuff[1].75years2撕裂大小Shimizu[2]recommendearlycuffrepairafterconfirmingthediagnosisofmassiverotatorcufftears.Partial-thicknessrotatorcufftearisafurtherindicationinthosepatientswithminimalriskoftearextension,minimalpain,anddysfunction[3].1TanakaM,ItoiE,SatoK,etal.Factorsrelatedtosuccessfuloutcomeofconservativetreatmentforrotatorcufftears.UpsJMedSci.2010;115:193-200.2ShimizuC,HoriiM,YamashitaF,etal.Prognosisofmassiverotatorcufftear.Chubuseisai.1990;33:392.3OzbaydarMU,BekmezciT,TonbulM,etal.Theresultsofarthroscopicrepairinpartialrotatorcufftears.ActaOrthopTraumatolTurc.2006;40:49–55.肩袖损伤的治疗肌腱的缝法开放手术骨质端的固定肩袖损伤的治疗手术方式的选择开放手术VS关节镜手术美国的一篇系统评价显示：术后6个月的ASES、UCLA、疼痛评分