肩关节检查法教案

1、肩关节检查法教案疼痛的部位和范围（颈项部）有无远端放射痛（上臂前部）涉及的肌力情况（三角肌）有无病理症（退变的夹杂症）全面检查（病理症）炎症：类风湿性关节炎神经性疼痛：周围神经疾病；中枢神经疾病血管性病变：动脉血栓，静脉炎肿瘤：压迫臂丛的肿瘤病史采集 HISTORY TAKING INTERVIEW疼痛的部位肩锁关节；大结节；结节间沟；前方肌肉的疼痛疼痛的性质锐痛（急性）；钝痛（慢性）有无夜间痛 （炎性）疼痛是否与活动有关：有关：撞击症，肩袖损伤肩关节检查 PHYSICAL EXAMINATION 望诊触诊活动度特殊检查望 诊 INSPECTION脱衣暴露至腰部两侧对比检查观察病人穿脱衣过程，

2、评估患肩功能依照先后方再前方的顺序观察病人肩部情况，注意有无肌肉 萎缩（陈旧性肩袖损伤常伴 有冈上肌/冈下肌萎缩）。望 诊Proximal tear of the long head of the biceps肱二头肌长头近端断裂Torticollis斜颈Anterior shoulder dislocation. 前脱位望 诊Winged scapulaSeparation of the acromioclavicular joint望 诊Sprengle deformity高位肩胛触 诊 PALPATION肩锁关节肩峰下间隙（滑囊炎）大结节 （肩袖损伤）结节间沟（肱二头肌腱）喙突触 诊 P

3、ALPATIONPrinciples for palpation of the shoulder. Bilaterally and comparatively, the examiner should palpate the bony contours and elements which might be involved in the impingement syndrome.触 诊 PALPATIONCross-body adduction test (arm crossed). This test is positive when it revives the acromioclavi

4、cular pain which the patient complains of.触 诊 PALPATIONPrinciple for palpation for cuff tears. Palpation is carried out on the anterior edge of the acromion. The presence of the bursa between the deltoid and the cuff should be noted.肩关节活动体位立位检查卧位检查（某些肩关节稳定性检查）活动性质被动活动主动活动被动活动Examination of passive e

5、xternal rotation, elbow to body, looking for asymmetry. Loss of rotation suggests capsule stiffness if x-rays are normal. An increase in passive external rotation will suggest a tear in the subscapularis.主动活动Analysis of scapulohumeral rhythm. In this patient the scapula pivots before glenohumeral ab

6、duction takes place giving this aspect of raising of the shoulder肩关节活动主动活动受限，被动活动不受限主动活动受限，被动活动也受限主动活动不受限，被动活动部分受限肩袖破裂冰冻肩创伤肩关节不稳定特殊检查常规检查肩袖检查不稳定检查肱二头肌检查常规检查quick test of combined motion- Apleys scratch test(快速联合运动)Codman signPalm sign test/Finger sign test常规检查Apleys scratch test摸背试验患者用手分别从同侧肩上方向后摸对侧

7、肩上方向后摸对侧肩胛上缘或用手从同侧肩下方向后摸对侧肩胛下缘。判断肩关节内旋及外旋功能。常规检查Codman sign病人坐位，检查者站于其背后，一手握住其肘部，旋转肱骨和肩关节；同时，另一手放在病人肩上，拇指在后，四指在前，用食指在肩峰下方前后依次触摸按压，若在某处出现压痛点，则为本征阳性。常见于肩周炎、冈上肌损伤、冈下肌或小圆肌的损伤或肌腱断裂、肩胛下肌损伤以及肱二头肌腱鞘炎。常规检查Palm sign test/Finger sign test目的：明确患者疼痛位置肩袖损伤相关检查非特异性检查特异性检查非特异性检查Impingement symptoms 撞击症Painful arcDr

8、op arm test 坠臂试验Impingement symptoms 撞击症Neer impingement signThe examiner performs maximal passive abduction in the scapula plane, with internal rotation, whilst stabilising the scapula.肩关节前屈30度，完全伸展+内旋大结节与肩峰之间的撞击对阳性患者，给予1%利多卡因5ml,肩峰下注射，数分钟后再次进行撞击试验。Neer impingement signPositivePain located to the s

9、ub-acromial space or anterior edge of acromionFalse positive Internal impingement Macdonald et al (2000) - Bankart 25% - SLAP 46.1 %Sensitivity = 88.7%Specificity = 30.5% Reliability =98%Impingement symptoms 撞击症Hawkins-Kennedy testThe patient is examined in sitting with their arm at 90 and their elb

10、ow flexed to 90, supported by the examiner to ensure maximal relaxation. The examiner then stabilises proximal to the elbow with their outside hand and with the other holds just proximal to the patients wrist. They then quickly move the arm into internal rotation. 大结节与喙肩弓撞击Hawkins-Kennedy testPositi

11、vePain located to the sub-acromial spaceFalse Positive - Internal impingement Macdonald et al (2000) - Bankart 25%- SLAP 46.1 % Sensitivity Specificity Accuracy PPV NPV Calis et al (%) 92.1 25 72.8 75.2 56.2 Ure et al (%) 62 69 NA NA NA非特异性检查Painful arc. TestPurpose ：A test used to identify subacrom

12、ial impingementTechnique：Patient is positioned in sitting. Clinical asks patient to abduct both arms through the full ROM and back down. Positive：Pain between 60-120 of abduction.Interpretation：A positive test indicates subacromial impingement.Painful arc. Test要求：前屈上举肩关节（肩胛骨平面）先完全上举后，再放下注意患者肢体有无旋转，以

13、避免或减少疼痛非特异性检查Drop arm test肩关节被动外展120度左右维持位置，慢慢放下双臂突然下降伴有疼痛即阳性Indications Rotator Cuff Tear SuspectedTechnique Examiner passively abducts shoulder to 160 degrees Patient attempts to slowly adduct arm to resting position at sideInterpretation: Signs of Rotator Cuff Tear Arm drops to side quickly and n

14、ot smoothly Gentle tap over abducted arm may force arm to give wayEfficacy Test Sensitivity: 27% Test Specificity: 88%特异性检查冈上肌检查：Jobe test，外旋延迟试验冈下肌检查：外旋延迟试验肩胛下肌检查：Lift-off testPress Belly test内旋延迟试验肱二头肌腱损伤（SLAP损伤）Obrien testSpeed test冈上肌检查Jobe supraspinatus test 外展90度，前屈30度（肩胛骨水平）（拇指向下）内旋时冈上肌肌束力线成一

15、直线抗阻力出现无力疼痛为阳性Jobe supraspinatus test Jobes test. This is to test the muscle. The examiner places the arm in a 90 abduction in the plane of the scapula and in internal rotation. He will then ask the patient to resist the pressure and determine the muscular strength of the supraspinatus. Pain will of

16、ten prevent this test from being carried out correctly.冈下肌检查肘关节屈曲90度不要碰到躯干外旋90度，前屈30度（排除三角肌影响）对抗阻力无力为阳性冈下肌检查外旋迟滞试验屈肘前伸肩关节30度，被动外旋肩关节，嘱维持住位置，放手后，若有肩袖破裂，外旋的肩关节会回弹。回弹超过手掌范围为阳性。肩胛下肌检查Lift-off test主动内旋后伸肩关节远离躯干对抗阻力无力者为阳性肩胛下肌检查Press belly testthe press-belly test be carried out comparatively by pressing o

17、n the elbows to quantify the strength of the supraspinatus muscle.肩胛下肌检查内旋迟滞试验屈肘后伸肩关节，检查者一手扶住病人肘关节，另一手握住病人腕关节，将其向后拉离病人背部，嘱病人维持住位置。放手回弹超过一个手掌范围为阳性。肩袖损伤的检查检查冈上肌和冈下肌 敏感性 特异性Jobe test +外旋迟滞试验 +检查肩胛下肌Lift-off +内旋迟滞试验 + +迟滞试验检出率高，但受患者活动度的限制肱二头肌肩胛盂损伤的检查Obrien testSpeed testYargason sign Obrien testOBriens

18、test consists of asking a patient whose arm, elbow in extension, is taken to anterior elevation at 90, slightly in adduction (15) and internal rotation (thumb down) then external rotation (thumb up) to resist a superoinferior pressure. The test is positive if pain appears in internal rotation and pronation, then disappears in external rotation and supination.Speed testSpeeds (or Gilcrests) test. Anterior elevation in staggered supination revives pain, which is more related to damage to the long head o