运动系统慢性损伤概述和诊断

1、运动系统慢性损伤概述和诊断 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

2、溶剂，栓剂；肾功能不佳者可选用短半衰期药物）手术Strain of lumbar muscles腰肌劳损Common cause of lumbar painLocal tenderness, start point or end point of musclesBack pain, relieve after rest or activitiesErector spainae muscle spasm Treatment Self care therapy, change positionPhysiotherapy, massageLocal steroid injectionAnti-in

3、flammatory drugsSupraspinous ligament injuryinterspinous ligament injuryCommon cause of back painSupraspinour ligament injury common in middle thoracic segmentInterspinous ligament injury common in lower lumbar segmentNo trauma historyBend or hyperextension painLocal tendernessSteroid injectionPhysi

4、otherapy or massageimmobilizationBursitis 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 Bursae are sacs lined with a membrane similar to synovium; they usually are located about joints or where skin, tendon, or muscle moves over a bony prominence. may or may not communicate with a joint.Function: r

5、educe friction, protect delicate structures from pressure. Bursae are similar to tendon sheaths and the synovial membranes of joints and are subject to the same disturbances: (1) acute or chronic trauma, (2) acute or chronic pyogenic infection, and (3) low-grade inflammatory conditions such as gout,

6、 syphilis, tuberculosis, or rheumatoid arthritis. Two types of bursae: normally present (as over the patella and olecranon) and adventitious ones (such as develop over a bunion, an osteochondroma, or kyphosis of the spine). Adventitious bursae are produced by repeated trauma or constant friction or

7、pressure.Treatment-the cause of the bursitis Systemic causes, such as gout or syphilis, and local trauma or irritants should be eliminated, and, when necessary, the patients occupation or posture should be changed. One or more of the following local measures usually are helpful: rest, hot wet packs,

8、 elevation, and, if necessary, immobilization of the affected part. Treatment Aspiration and steroid injectionSurgical procedures useful in treating bursitis are (1) incision and drainage when an acute suppurative bursitis fails to respond to nonsurgical treatment, (2) excision of chronically infect

9、ed and thickened bursae, and (3) removal of an underlying bony prominenceStenosing Tenosynovitis狭窄性腱鞘炎more often in the hand and wrist than anywhere else in the body. A peritendinitis may affect these tendons, causing pain, swelling, and crepitus. When the long flexor tendons are involved, trigger t

10、humb, trigger finger, or snapping finger occurs. The stenosis occurs at a point where the direction of a tendon changes, for here a fibrous sheath acts as a pulley, and friction is maximal. Although the tenosynovium lubricates the sheath, friction can cause a reaction when the repetition of a partic

11、ular movement is necessary, as in winding a fine coil of wire or stacking laundry. DE QUERVAIN DISEASEStenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartmen

12、t are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895. . Women are affected 10 times more frequently than men. The cause is almost always related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The p

13、resenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpablediagnosisThe Finkelstein test usually is positive: on grasping the patients thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating.

14、 Although Finkelstein states that this test is probably the most pathognomonic objective sign, it is not diagnostic; the patients history and occupation, the roentgenograms, and other physical findings must also be considered. TreatmentConservative treatment, consisting of rest on a splint and the i

15、njection of a steroid preparation into the tendon sheath, is most successful within the first 6 weeks after onset. Steroid injectionWhen pain persists, surgery is the treatment of choice (complete relief )TRIGGER FINGER AND THUMB弹响指和弹响拇Stenosing tenosynovitis, leading to inability to extend the flex

16、ed digit (triggering) usually is seen after 45 years of age. Patients may note a lump or knot in the palm. The lump may be the thickened area in the first annular part of the flexor sheath, or a nodule or fusiform swelling of the flexor tendon just distal to it. The nodule can be palpated by the exa

17、miners fingertip and will move with the tendon. The tendon nodule usually is at the entry of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.TreatmentTreatment of trigger digits usually is nonoperative in the uncomplicated patient who presents a short time after on

18、set of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and ice. Corticosteroid injection is effective after one injection Surgical release reliably relieves the symptom for most patientsGanglion TreamentSqueezeAspiration and steroid injectionOperationLate

19、ral epicondylitis肱骨外上髁炎Lateral epicondylitis (tennis elbow), a familiar term used to described a myriad of symptoms about the lateral aspect of the elbow, occurs more frequently in nonathletes than athletes, with a peak incidence in the early fifth decade and a nearly equal gender incidence. Activit

20、ies that require repetitive supination and pronation of the forearm with the elbow in near full extension. Tenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm s

21、upination, and there is pain when grasping objects. Plain roentgenograms usually are negative; occasionally calcific tendinitis may be present. MRI demonstrates tendon thickening with increased T1 and T2 signals but generally is not indicated. Regardless of the underlying cause, nonoperative treatme

22、nt is successful in 95% of patients with tennis elbow Initial nonoperative treatment includes rest, ice, injections, and physical therapy centered around treatment such as ultrasound, electrical stimulation, manipulation, soft tissue mobilization, friction massage, stretching and strengthening exerc

23、ises, and counter-force bracing. Steroid injectionIf prolonged (6 to 12 months), operative treatment may be considered; it is effective in 90% of properly selected patients. Adhesive Capsulitis（frozen shoulder.）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

24、成肱二头肌长头关节囊滑囊肩胛盂和肱骨头Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) or plain roentgenograms were designated as primary, and those with precipitant traumatic injuries as secondary. This division helps in planning treatment bu

25、t does not necessarily predict outcome. No formal inclusion criteria. There are no universally accepted criteria for the diagnosis of frozen shoulder. internal rotation frequently is lost initially, followed by loss of flexion and external rotation. The incidence of frozen shoulder in the general po

26、pulation is approximately 2%. (an increased incidence associated with, including diabetes mellitus (up to 5 times more), cervical disc disease, hyperthyroidism, intrathoracic disorders, and trauma). People between the ages of 40 and 70 are more commonly affected. Common to almost all patients is a p

27、eriod of immobility, the etiologies of which are diverseRotator cuff肩袖冈上肌，冈下肌，肩胛下肌和小圆肌Supraspinatus，infraspinatus，subscapular muscle，teres minorPain may disappearDysfunctionPrimary Frozen ShoulderPrimary frozen shoulder is a vague entity that only rarely recurs in the same shoulder. The clinical cou

28、rse of primary (idiopathic) frozen shoulder consists of three phases. Phase IPain. Patients usually have a gradual onset of diffuse shoulder pain, which is progressive over weeks to months. The pain usually is worse at night and is exacerbated by lying on the affected side. As the patient uses the a

29、rm less, pain leading to stiffness ensues. Primary Frozen ShoulderPhase IIStiffness. Patients seek pain relief by restricting movement. This heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities of daily living; men have troubl

30、e getting to their wallets and women with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this often is accompanied by sharp pain during range of motion at or near the new endpoints of motion.Primary Frozen ShoulderPhase IIIThawing

31、. This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect) motion return is gradual in most but may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or ad

32、justment in ways of performing activities of daily living. Secondary Frozen ShoulderUnlike patients with idiopathic frozen shoulder, patients with secondary frozen shoulder can recall a specific precipitating event, possibly related to overuse or injury. The three phases of classic frozen shoulder m

33、ay not all be present and may not follow the previously outlined chronology; fortunately, treatment for the two entities is similar. Diagnosistests in patients with a frozen shoulder (including plain film roentgenograms) usually are normal, except in those with medical disorders such as diabetes or

34、thyroid disease. Bone scans have been reported to be positive in some patients. Arthrograms characteristically show a reduced joint volume with irregular margins. Clinical improvement has been reported after arthrography because of brisement of adhesions from forcefully injecting fluid into the join

35、t. A volume of less than 10 ml and lack of filling of the axillary fold currently are accepted arthrographic findings indicative of a frozen shoulder. Differential diagnosisCervical spondylosisRotator cuff tearTreatmentTraditionally, frozen shoulder has been considered a self-limiting condition, las

36、ting 12 to 18 months.Approximately 10% of patients have long-term problems. Patients seeking care earlier usually recover more quickly. Dominant shoulder involvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. Obvi

37、ously, the best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of paramount importance; a good understanding of the pathological process by the patient and the physician also is important. TreatmentInitial treatment is nonoperative, with emphasis pl

38、aced on control of pain and inflammation. passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingement until joint motion becomes more supple. PhysiotherapySteroid injectionNSAIDS drugsTreatmentAlthough a frozen shoulder usually is self-limiting and reso

39、lves in 12 to 18 months, many patients do not wish to wait that long for resolution of symptoms and request active intervention long before 12 months. With appropriate patient selection, significant improvement can be obtained in approximately 70% of patients. Closed manipulation under anesthesiaOpe

40、n release of contracturesTreatmentArthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis.Chondromalacia patella髌骨软骨软化症Epiphysitis of tibial tuberosity胫骨结节骨骺炎(Osgood-Schlatter disease) (Osteochondrol disease of the tib

41、ial tubercle)Common age 12-14 ysOSGOOD-SCHLATTER DISEASE Disorders of actively growing epiphyses. The disorder may be localized to a single epiphysis or occasionally may involve two or more epiphyses simultaneously or successively. The cause generally is unknown, but evidence indicates a lack of vas

42、cularity that may be the result of trauma (quadriceps), infection, or congenital malformation. TreatmentSelf limited diseaseObservation, remain eminance of TTSurgery rarely is indicated the disorder usually becomes asymptomatic without treatment or with simple conservative measures such as the restr

43、iction of activities or cast immobilization for 3 to 6 weeksLegg-Calve-Perthes DiseasePerthes病 The cause： chronic injury The clinical sign：pain and limp， Thomas sign plain roentgenographic changes Bone scintigraphyMRI Treatment Lloyd-Roberts、Catterall and Salamon classificationclassified patients wi

44、th this disease into groups according to the amount of involvement of the capital femoral epiphysis: group I, partial head or less than half head involvement; groups II and III, more than half head involvement and sequestrum formation; group IV, involvement of the entire epiphysis. head at riskThey

45、noted certain roentgenographic signs described as head at risk correlated positively with poor results, especially in patients in groups II, III, and IV. These head-at-risk signs includeLateral subluxation of the femoral head from the acetabulum, Speckled calcification lateral to the capital epiphys

46、is, Diffuse metaphyseal reaction (metaphyseal cysts), A horizontal physis, Gage sign, a radiolucent V-shaped defect in the lateral epiphysis and adjacent metaphysis. Containment by femoral varus derotational osteotomy for older children in groups II, III, and IV with head-at-risk signs.Contraindicat

47、ions include an already malformed femoral head and delay of treatment of more than 8 months from onset of symptoms. Surgery is not recommended for any group I children or any child without the head-at-risk signs. Salter and Thompson classificationSalter and Thompson advocated determining the extent

48、of involvement by describing the extent of a subchondral fracture in the superolateral portion of the femoral head. If the extent of the fracture (line) is less than 50% of the superior dome of the femoral head, the involvement is considered type A, and good results can be expected. If the extent of

49、 the fracture is more than 50% of the dome, the involvement is considered type B, and fair or poor results can be expected. According to Salter and Thompson, this subchondral fracture and its entire extent can be observed roentgenographically earlier and more readily than trying to determine the Cat

50、terall classification. Furthermore, according to these authors, if the femoral head is graded as type B, then probably an operation such as an innominate osteotomy should be carried out Herring classification 1. Most patients can be treated by noncontainment methods and obtain good results (80%). 2.

51、 Satisfactory clinical results frequently can be obtained at long-term follow-up despite an unsatisfactory roentgenographic appearance. Conclusions3. The Catterall classification is a valid indicator of results but is not applicable as a therapeutic guide. 4. Head-at-risk signs added little to the C

52、atterall classification as a prognostic indicator or therapeutic guide. 5.All of the fair and poor results were in patients with Catterall III or IV involvement and onset of the disease at age 6 or later. Carpal Tunnel Syndrome腕管综合症 (another name: tardy median palsy) results from compression of the

53、median nerve within the carpal tunnel. The syndrome consists predominantly of tingling and numbness in the typical median nerve distribution in the radial three and one-half digits (thumb, index, long, radial side of ring). Pain occurs diffusely in the hand and radiates up the forearm. Thenar atroph

54、y usually is seen later in the course of the nerve compression. The syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Schuind et al. studied biopsy specimens of the flexor tendon synovium from 21 patient

55、s with idiopathic carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue undergoing degeneration under repeated mechanical stress. DiagnosisParesthesia over the sensory distribution of the median nerve is the most frequent symptom; more often in women and fr

56、equently causes the patient to awaken several hours after getting to sleep with burning and numbness of the hand that is relieved by exercise. The Tinel sign may be demonstrated in most patients by percussing the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar muscl

57、es has been reported in about half of the patients treated by operation. Acute flexion of the wrist for 60 seconds in some but not all patients or strenuous use of the hand increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may in

58、itiate the symptoms. Gellman et al. evaluated the clinical usefulness of commonly administered provocative tests, including wrist flexion, nerve percussion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and in 50 control hands. DiagnosisThe most sensitive test

59、was the wrist flexion test, whereas nerve percussion was the most specific and the least sensitive. They also found that with the wrist in neutral position, the mean pressure within the carpal tunnel in patients with carpal tunnel syndrome was 32 mm Hg. This pressure increased to 99 mm Hg with 90 de

60、grees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures in the control subjects with the wrist in neutral position were 25 mm Hg, 31 mm Hg with the wrist in flexion, and 30 mm Hg with the wrist in extension. Sensibility testing in peripheral nerve compression