肩袖损伤2015ppt

肩袖损伤的关节镜治疗戴永立蚌埠三院骨科E-mail:[e-mail]概念和功能由冈上肌、冈下肌、肩胛下肌及小圆肌之肌腱在肱骨头前、上、后方形成的袖套样肌样结构。在任何运动或静止状态保持肱盂关节稳定，并使之成为运动的轴心和支点维持上臂各种姿势和完成各种运动功能。41325肩胛骨3.喙突4.肱骨头5.关节盂1.锁骨2.肩峰肩关节解剖之骨骼41325肩胛骨3.喙突4.肱骨头5.关节盂1.锁骨2.肩峰肩关节骨骼肩袖解剖肩袖解剖组成和功能冈上肌(肩胛上神经):上臂外展并固定肱骨头于肩盂上并防止肱骨头上移冈下肌(肩胛上神经):上臂下垂位时使上臂外旋小圆肌(腋神经):臂外旋肩胛下肌(肩胛下神经):臂下垂位时内旋肩关节病因退变学说血运学说撞击学说创伤学说冈上肌止点附近血供来源于大结节骨膜滋养血管，肌腹血供来源于肩胛上动脉，而止点近端1cm处有明显的乏血管区肩峰发育异常、肩锁关节增生肥大、高位肱骨大结节、肩峰下骨赘形成——肩峰下撞击综合征分类按损伤程度：挫伤不完全断裂完全断裂分类按断裂口方向横行纵行按肌腱断裂范围小型撕裂：单一肌腱撕裂范围小于肌腱横径1/2大型撕裂：单一肌腱撕裂范围大于肌腱横径1/2广泛撕裂：范围累及两个及两个以上的肩袖肌腱，伴有肩袖组织的退缩缺损临床表现临床表现外伤史：急性损伤、重复性或累积性损伤史疼痛与压痛：多位于肩前方活动或增加负荷后加重被动外旋或过度内收时加重夜间症状加重功能障碍：上举和外展功能受限肌肉萎缩：3周继发性关节挛缩：3月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.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.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parametersindecisionmakingforthesurgeryofthecuff[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、疼痛评分及再断裂方面，两者无显著差异，只有短期疼痛，关节镜优于开放手术。LindleyK,JonesGL.Outcomesofarthroscopicversusopenrotatorcuffrepair:asystematicreviewoftheliterature.AmJOrthop(BelleMeadNJ),2010,39(12):