肌腱滑囊及关节囊的慢性损伤性炎症.ppt

浙江大学医学院八年制教学,神经精神与运动1（模块2）运动系统慢性疾病肩关节周围炎、腱鞘炎股骨头坏死浙江大学医学院附属二院骨科吴立东,运动系统慢性损伤Chronicinjuryofsofttissue,概述Overview,临床常见病，多发病涉及骨，关节，肌肉，肌腱，韧带，筋膜及其相关的血管神经分类：软组织，骨，软骨慢性损伤及周围神经卡压,特点Feature,局部慢性，无外伤史有特定部位压痛点和肿块，可放射痛局部无明显炎症表现近期有与疼痛部位相关的过度活动史部分病人偶导致运动系统慢性损伤的工种，坐姿和工作习惯或职业,治疗Treatment,限制致伤活动，或纠正不良姿势，维持关节的不负重活动积极物理治疗，按摩推拿，外敷及熏蒸。正确合理使用肾上腺皮质激素非甾体消炎镇痛药的合理使用（短期；外用；缓释剂，肠溶剂，栓剂；肾功能不佳者可选用短半衰期药物）手术,Strainoflumbarmuscles腰肌劳损,CommoncauseoflumbarpainLocaltenderness,startpointorendpointofmusclesBackpain,relieveafterrestoractivitiesErectorspainaemusclespasm,Treatment,Selfcaretherapy,changepositionPhysiotherapy,massageLocalsteroidinjectionAnti-inflammatorydrugs,Supraspinousligamentinjuryinterspinousligamentinjury,CommoncauseofbackpainSupraspinourligamentinjurycommoninmiddlethoracicsegmentInterspinousligamentinjurycommoninlowerlumbarsegment,NotraumahistoryBendorhyperextensionpainLocaltendernessSteroidinjectionPhysiotherapyormassageimmobilization,Bursitis滑囊炎滑囊是位于人体摩擦频繁或压力较大部位的一种缓冲结构。分为恒定滑囊，继发性滑囊或附加滑囊,Bursaearesacslinedwithamembranesimilartosynovium;theyusuallyarelocatedaboutjointsorwhereskin,tendon,ormusclemovesoverabonyprominence.mayormaynotcommunicatewithajoint.Function:reducefriction,protectdelicatestructuresfrompressure.,Bursaearesimilartotendonsheathsandthesynovialmembranesofjointsandaresubjecttothesamedisturbances:(1)acuteorchronictrauma,(2)acuteorchronicpyogenicinfection,and(3)low-gradeinflammatoryconditionssuchasgout,syphilis,tuberculosis,orrheumatoidarthritis.,Twotypesofbursae:normallypresent(asoverthepatellaandolecranon)andadventitiousones(suchasdevelopoverabunion,anosteochondroma,orkyphosisofthespine).Adventitiousbursaeareproducedbyrepeatedtraumaorconstantfrictionorpressure.,Treatment-thecauseofthebursitisSystemiccauses,suchasgoutorsyphilis,andlocaltraumaorirritantsshouldbeeliminated,and,whennecessary,thepatientsoccupationorpostureshouldbechanged.Oneormoreofthefollowinglocalmeasuresusuallyarehelpful:rest,hotwetpacks,elevation,and,ifnecessary,immobilizationoftheaffectedpart.,Treatment,AspirationandsteroidinjectionSurgicalproceduresusefulintreatingbursitisare(1)incisionanddrainagewhenanacutesuppurativebursitisfailstorespondtononsurgicaltreatment,(2)excisionofchronicallyinfectedandthickenedbursae,and(3)removalofanunderlyingbonyprominence,StenosingTenosynovitis狭窄性腱鞘炎,moreofteninthehandandwristthananywhereelseinthebody.Aperitendinitismayaffectthesetendons,causingpain,swelling,andcrepitus.,Whenthelongflexortendonsareinvolved,triggerthumb,triggerfinger,orsnappingfingeroccurs.Thestenosisoccursatapointwherethedirectionofatendonchanges,forhereafibroussheathactsasapulley,andfrictionismaximal.Althoughthetenosynoviumlubricatesthesheath,frictioncancauseareactionwhentherepetitionofaparticularmovementisnecessary,asinwindingafinecoilofwireorstackinglaundry.,DEQUERVAINDISEASE,StenosingtenosynovitisoftheabductorpollicislongusandextensorpollicisbrevistendonsWhentheextensorpollicisbrevisandtheabductorpollicislongustendonsinthefirstdorsalcompartmentareaffected,theconditionisnamedaftertheSwissphysician,DeQuervain,whodescribedhisexperiencein1895.,Womenareaffected10timesmorefrequentlythanmen.Thecauseisalmostalwaysrelatedtooveruse,eitherinthehomeoratwork,orisassociatedwithrheumatoidarthritis.Thepresentingsymptomsusuallyarepainandtendernessattheradialstyloid.Sometimesathickeningofthefibroussheathispalpable,diagnosis,TheFinkelsteintestusuallyispositive:ongraspingthepatientsthumbandquicklyabductingthehandulnarward,thepainoverthestyloidtipisexcruciating.AlthoughFinkelsteinstatesthatthistestisprobablythemostpathognomonicobjectivesign,itisnotdiagnostic;thepatientshistoryandoccupation,theroentgenograms,andotherphysicalfindingsmustalsobeconsidered.,Treatment,Conservativetreatment,consistingofrestonasplintandtheinjectionofasteroidpreparationintothetendonsheath,ismostsuccessfulwithinthefirst6weeksafteronset.SteroidinjectionWhenpainpersists,surgeryisthetreatmentofchoice(completerelief),TRIGGERFINGERANDTHUMB弹响指和弹响拇,Stenosingtenosynovitis,leadingtoinabilitytoextendtheflexeddigit(triggering)usuallyisseenafter45yearsofage.Patientsmaynotealumporknotinthepalm.Thelumpmaybethethickenedareainthefirstannularpartoftheflexorsheath,oranoduleorfusiformswellingoftheflexortendonjustdistaltoit.Thenodulecanbepalpatedbytheexaminersfingertipandwillmovewiththetendon.Thetendonnoduleusuallyisattheentryofthetendonintotheproximalannulusatthelevelofthemetacarpophalangealjoint.,Treatment,Treatmentoftriggerdigitsusuallyisnonoperativeintheuncomplicatedpatientwhopresentsashorttimeafteronsetofsymptoms.Nonoperativemethodsincludestretching,nightsplinting,andcombinationsofheatandice.CorticosteroidinjectioniseffectiveafteroneinjectionSurgicalreleasereliablyrelievesthesymptomformostpatients,Ganglion,Treament,SqueezeAspirationandsteroidinjectionOperation,Lateralepicondylitis肱骨外上髁炎,Lateralepicondylitis(tenniselbow),afamiliartermusedtodescribedamyriadofsymptomsaboutthelateralaspectoftheelbow,occursmorefrequentlyinnonathletesthanathletes,withapeakincidenceintheearlyfifthdecadeandanearlyequalgenderincidence.Activitiesthatrequirerepetitivesupinationandpronationoftheforearmwiththeelbowinnearfullextension.,Tendernessispresentoverthelateralepicondyleapproximately5mmdistalandanteriortothemidpointofthecondyle.Painusuallyisexacerbatedbyresistedwristdorsiflexionandforearmsupination,andthereispainwhengraspingobjects.Plainroentgenogramsusuallyarenegative;occasionallycalcifictendinitismaybepresent.MRIdemonstratestendonthickeningwithincreasedT1andT2signalsbutgenerallyisnotindicated.,Regardlessoftheunderlyingcause,nonoperativetreatmentissuccessfulin95%ofpatientswithtenniselbowInitialnonoperativetreatmentincludesrest,ice,injections,andphysicaltherapycenteredaroundtreatmentsuchasultrasound,electricalstimulation,manipulation,softtissuemobilization,frictionmassage,stretchingandstrengtheningexercises,andcounter-forcebracing.,SteroidinjectionIfprolonged(6to12months),operativetreatmentmaybeconsidered;itiseffectivein90%ofproperlyselectedpatients.,AdhesiveCapsulitis（frozenshoulder.）肩周炎或称冻结肩或五十肩肩周，肌腱，滑囊及关节囊的慢性损伤性炎症，主要表现为活动时疼痛，功能受限,肩部结构,肩部外层肌肉为三角肌内层为肩袖，由冈上肌，冈下肌，肩胛下肌和小圆肌及肌腱组成肱二头肌长头关节囊滑囊肩胛盂和肱骨头,Frozenshouldersinpatientswhoreportnoincitingeventandwithnoabnormalityonexamination(otherthanlossofmotion)orplainroentgenogramsweredesignatedasprimary,andthosewithprecipitanttraumaticinjuriesassecondary.Thisdivisionhelpsinplanningtreatmentbutdoesnotnecessarilypredictoutcome.,Noformalinclusioncriteria.Ternalrotationfrequentlyislostinitially,followedbylossofflexionandexternalrotation.Theincidenceoffrozenshoulderinthegeneralpopulationisapproximately2%.(anincreasedincidenceassociatedwith,includingdiabetesmellitus(upto5timesmore),cervicaldiscdisease,hyperthyroidism,intrathoracicdisorders,andtrauma).Peoplebetweentheagesof40and70aremorecommonlyaffected.Commontoalmostallpatientsisaperiodofimmobility,theetiologiesofwhicharediverse,Rotatorcuff肩袖,冈上肌，冈下肌，肩胛下肌和小圆肌Supraspinatus，infraspinatus，subscapularmuscle，teresminorPainmaydisappearDysfunction,PrimaryFrozenShoulder,Primaryfrozenshoulderisavagueentitythatonlyrarelyrecursinthesameshoulder.Theclinicalcourseofprimary(idiopathic)frozenshoulderconsistsofthreephases.PhaseIPain.Patientsusuallyhaveagradualonsetofdiffuseshoulderpain,whichisprogressiveoverweekstomonths.Thepainusuallyisworseatnightandisexacerbatedbylyingontheaffectedside.Asthepatientusesthearmless,painleadingtostiffnessensues.,PrimaryFrozenShoulder,PhaseIIStiffness.Patientsseekpainreliefbyrestrictingmovement.Thisheraldsthebeginningofthestiffnessphase,whichusuallylasts4to12months.Patientsdescribedifficultywithactivitiesofdailyliving;menhavetroublegettingtotheirwalletsandwomenwithfasteningbrassieres.Asstiffnessprogresses,adullacheispresentnearlyallthetime(especiallyatnight),andthisoftenisaccompaniedbysharppainduringrangeofmotionatornearthenewendpointsofmotion.,PrimaryFrozenShoulder,PhaseIIIThawing.Thisphaselastsforweeksormonths,andasmotionincreases,paindiminishes.Withouttreatment(otherthanbenignneglect)motionreturnisgradualinmostbutmayneverobjectivelyreturntonormal,althoughmostpatientssubjectivelyfeelnearnormal,perhapsasaresultofcompensationoradjustmentinwaysofperformingactivitiesofdailyliving.,SecondaryFrozenShoulder,Unlikepatientswithidiopathicfrozenshoulder,patientswithsecondaryfrozenshouldercanrecallaspecificprecipitatingevent,possiblyrelatedtooveruseorinjury.Thethreephasesofclassicfrozenshouldermaynotallbepresentandmaynotfollowthepreviouslyoutlinedchronology;fortunately,treatmentforthetwoentitiesissimilar.,Diagnosis,testsinpatientswithafrozenshoulder(includingplainfilmroentgenograms)usuallyarenormal,exceptinthosewithmedicaldisorderssuchasdiabetesorthyroiddisease.Bonescanshavebeenreportedtobepositiveinsomepatients.Arthrogramscharacteristicallyshowareducedjointvolumewithirregularmargins.Clinicalimprovementhasbeenreportedafterarthrographybecauseofbrisementofadhesionsfromforcefullyinjectingfluidintothejoint.Avolumeoflessthan10mlandlackoffillingoftheaxillaryfoldcurrentlyareacceptedarthrographicfindingsindicativeofafrozenshoulder.,Differentialdiagnosis,CervicalspondylosisRotatorcufftear,Treatment,Traditionally,frozenshoulderhasbeenconsideredaself-limitingcondition,lasting12to18months.Approximately10%ofpatientshavelong-termproblems.Patientsseekingcareearlierusuallyrecovermorequickly.Dominantshoulderinvolvementhasbeenreportedtobepredictiveofagoodresult,whereasoccupationandtreatmentprogramsarenotstatisticallysignificant.Obviously,thebesttreatmentoffrozenshoulderisprevention(secondaryfrozenshoulder),butearlyinterventionisofparamountimportance;agoodunderstandingofthepathologicalprocessbythepatientandthephysicianalsoisimportant.,Treatment,Initialtreatmentisnonoperative,withemphasisplacedoncontrolofpainandinflammation.passiveandactiverange-of-motionexercises.Abductionshouldbeavoidedinitiallytopreventimpingementuntiljointmotionbecomesmoresupple.PhysiotherapySteroidinjectionNSAIDSdrugs,Treatment,Althoughafrozenshoulderusuallyisself-limitingandresolvesin12to18months,manypatientsdonotwishtowaitthatlongforresolutionofsymptomsandrequestactiveinterventionlongbefore12months.Withappropriatepatientselection,significantimprovementcanbeobtainedinapproximately70%ofpatients.ClosedmanipulationunderanesthesiaOpenreleaseofcontractures,Treatment,Arthroscopicreleaseisanoptionwhenclosedmanipulationfailsorforpatientswhohavehadprolonged,recalcitrantadhesivecapsulitis.,Chondromalaciapatella髌骨软骨软化症,Epiphysitisoftibialtuberosity胫骨结节骨骺炎,(Osgood-Schlatterdisease)(Osteochondroldiseaseofthetibialtubercle)Commonage12-14ys,OSGOOD-SCHLATTERDISEASE,Disordersofactivelygrowingepiphyses.Thedisordermaybelocalizedtoasingleepiphysisoroccasionallymayinvolvetwoormoreepiphysessimultaneouslyorsuccessively.Thecausegenerallyisunknown,butevidenceindicatesalackofvascularitythatmaybetheresultoftrauma(quadriceps),infection,orcongenitalmalformation.,Treatment,SelflimiteddiseaseObservation,remaineminanceofTTSurgeryrarelyisindicatedthedisorderusuallybecomesasymptomaticwithouttreatmentorwithsimpleconservativemeasuressuchastherestrictionofactivitiesorcastimmobilizationfor3to6weeks,Legg-Calve-PerthesDiseasePerthes病,Thecause：chronicinjuryTheclinicalsign：painandlimp，ThomassignplainroentgenographicchangesBonescintigraphyMRITreatment,Lloyd-Roberts、CatterallandSalamonclassification,classifiedpatientswiththisdiseaseintogroupsaccordingtotheamountofinvolvementofthecapitalfemoralepiphysis:groupI,partialheadorlessthanhalfheadinvolvement;groupsIIandIII,morethanhalfheadinvolvementandsequestrumformation;groupIV,involvementoftheentireepiphysis.,headatrisk,Theynotedcertainroentgenographicsignsdescribedasheadatriskcorrelatedpositivelywithpoorresults,especiallyinpatientsingroupsII,III,andIV.Thesehead-at-risksignsincludeLateralsubluxationofthefemoralheadfromtheacetabulum,Speckledcalcificationlateraltothecapitalepiphysis,Diffusemetaphysealreaction(metaphysealcysts),Ahorizontalphysis,Gagesign,aradiolucentV-shapeddefectinthelateralepiphysisandadjacentmetaphysis.,ContainmentbyfemoralvarusderotationalosteotomyforolderchildreningroupsII,III,andIVwithhead-at-risksigns.Contraindicationsincludeanalreadymalformedfemoralheadanddelayoftreatmentofmorethan8monthsfromonsetofsymptoms.SurgeryisnotrecommendedforanygroupIchildrenoranychildwithoutthehead-at-risksigns.,SalterandThompsonclassification,SalterandThompsonadvocateddeterminingtheextentofinvolvementbydescribingtheextentofasubchondralfractureinthesuperolateralportionofthefemoralhead.Iftheextentofthefracture(line)islessthan50%ofthesuperiordomeofthefemoralhead,theinvolvementisconsideredtypeA,andgoodresultscanbeexpected.Iftheextentofthefractureismorethan50%ofthedome,theinvolvementisconsideredtypeB,andfairorpoorresultscanbeexpected.,AccordingtoSalterandThompson,thissubchondralfractureanditsentireextentcanbeobservedroentgenographicallyearlierandmorereadilythantryingtodeterminetheCatterallclassification.Furthermore,accordingtotheseauthors,ifthefemoralheadisgradedastypeB,thenprobablyanoperationsuchasaninnominateosteotomyshouldbecarriedout,Herringclassification,1.Mostpatientscanbetreatedbynoncontainmentmethodsandobtaingoodresults(80%).2.Satisfactoryclinicalresultsfrequentlycanbeobtainedatlong-termfollow-updespiteanunsatisfactoryroentgenographicappearance.,Conclusions,3.TheCatterallclassificationisavalidindicatorofresultsbutisnotapplicableasatherapeuticguide.4.Head-at-risksignsaddedlittletotheCatterallclassificationasaprognosticindicatorortherapeuticguide.5.AllofthefairandpoorresultswereinpatientswithCatterallIIIorIVinvolvementandonsetofthediseaseatage6orlater.,CarpalTunnelSyndrome腕管综合症,(anothername:tardymedianpalsy)resultsfromcompressionofthemediannervewithinthecarpaltunnel.Thesyndromeconsistspredominantlyoftinglingandnumbnessinthetypicalmediannervedistributionintheradialthreeandone-halfdigits(thumb,index,long,radialsideofring).Painoccursdiffuselyinthehandandradiatesuptheforearm.Thenaratrophyusuallyisseenlaterinthecourseofthenervecompression.,Thesyndromefrequentlyisassociatedwithnonspecifictenosynovialedemaandrheumatoidtenosynovitis,asaretriggerfingeranddeQuervaindisease.Schuindetal.studiedbiopsyspecimensoftheflexortendonsynoviumfrom21patientswithidiopathiccarpaltunnelsyndrome.Thefindingsweresimilarinallandweretypicalofaconnectivetissueundergoingdegenerationunderrepeatedmechanicalstress.,Diagnosis,Paresthesiaoverthesensorydistributionofthemediannerveisthemostfrequentsymptom;moreofteninwomenandfrequentlycausesthepatienttoawakenseveralhoursaftergettingtosleepwithburningandnumbnessofthehandthatisrelievedbyexercise.TheTinelsignmaybedemonstratedinmostpatientsbypercussingthemediannerveatthewrist.Atrophytosomedegreeofthemedian-innervatedthenarmuscleshasbeenreportedinabouthalfofthepatientstreatedbyoperation.,Acuteflexionofthewristfor60secondsinsomebutnotallpatientsorstrenuoususeofthehandincreasestheparesthesia.Applicationofabloodpressurecuffontheupperarmsufficienttoproducevenousdistentionmayinitiatethesymptoms.Gellmanetal.evaluatedtheclinicalusefulnessofcommonlyadministeredprovocativetests,includingwristflexion,nervepercussion,andthetourniquettest,in67handswithelectricalproofofcarpaltunnelsyndromeandin50controlhands.,Diagnosis,Themostsensitivetestwasthewristflexiontest,whereasnervepercussionwasthemostspecificandtheleastsensitive.Theyalsofoundthatwiththewristinneutralposition,themeanpressurewithinthecarpaltunnelinpatientswithcarpaltunnelsyndromewas32mmHg.Thispressureincreasedto99mmHgwith90degreesofwristflexionandto110mmHgwiththewristat90degreesofextension.Thepressuresinthecontrolsubjectswiththewristinneutralpositionwere25mmHg,31mmHgwiththewristinflexion,and30mmHgwiththewristinextension.,Sensibilitytestinginperipheralnervecompressionsyndromeswasinvestigated,foundthatthresholdtestsofsensibilitycorrelatedaccuratelywithsymptomsofnervecompressionandelectrodiagnosticstudies.,Electrodiagnosticstudiesarereliableconfirmatorytests.UltrasonographyhasbeenusedtoshowthemovementoftheflexortendonswithinthecarpaltunnelEarlyreportsofMRIincarpaltunnelsyndromearepromising.AmajoradvantageofMRIisitshighsofttissuecontrast,whichgivesdetailedimagesofbothbonesandsofttissues.Careshouldbetakennottoconfusethissyndromewithnervecompressioncausedbyacervicaldischerniation,thoracicoutletstructures,andmediannervecompressionproximallyintheforearmandattheelbow,Treatment,Ifmildsymptomshavebeenpresentandthereisnothenarmuscleatrophy,theinjectionofhydrocortisoneintothecarpaltunnelmayaffordrelief.Greatcareshouldbetakennottoinjectdirectlyintothenerve.Injectionalsocanbeusedasadiagnostictoolinpatientswithoutbonyortumorousblockingofthecanal;,65%ofthesecasesprobablyarecausedbyanonspecificsynovialedema,andtheseseemtorespondmorefavorablytoinjection.Injectionalsohelpstoeliminatethepossibilityofothersyndromes,especiallycervicaldiscorthoracicoutletsyndrome.Somepatientsprefertoreceiveinjectionstwoorthreetimesbeforeasurgicalprocedureiscarriedout.Iftheresponseispositiveandthereisnomuscleatrophy,conservativetreatmentwithsplintingandinjectionisreasonable.,Treatment,Ifsignsandsymptomsarepersistentandprogressive,especiallyiftheyincludethenaratrophy,divisionofthedeeptransversecarpalligamentisindicated.Theresultsofsurgeryaregoodinmostinstances,andbenefitsseemtolastinmostpatients.,Althoughthenaratrophymaydisappear,itresolvesslowly,ifatall.Asnotedearlier,whensymptomsofmediannervecompressiondevelopduringtreatmentofanacuteCollesfracture,theconstrictingbandagesandcastshouldbeloosenedandthewristshouldbeextendedtoneutralposition.WhenmediannervepalsydevelopsafteraCollesfractureandhasgoneunrecognizedforseveralweeks,surgeryisindicatedwithoutfurtherdelay.,OsteonecrosisofFemoralhead成人股骨头无菌性坏死,Osteonecrosisofthefemoralheadisaprogressivediseasethatgenerallyaffectspatientsinthethirdthoughfifthdecadesoflife;ifleftuntreated,itleadstocompletedeteriorationofthehipjoint.Itisestimatedthatasmanyas20,000newcasesofosteonecrosisarediagnosedeachyearintheUnitedStates.,定义,ARCO+AAOS的标准ONFH是股骨头血供中断或受损，引起骨细胞及骨髓成分死亡及随后的修复，继而导致股骨头结构改变，股骨头塌陷，关节功能障碍的疾病,Osteonecrosisofthefemoralhead,非创伤性：常见病因是酒精中毒，激素是骨科常见病，多见于中青年，