frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件

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概述Overview临床常见病，多发病特点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特点Feature局部慢性，无外伤史治疗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）手术治疗Treatment限制致伤活动，或纠正不良姿势，维持关Strainoflumbarmuscles

腰肌劳损CommoncauseoflumbarpainLocaltenderness,startpointorendpointofmusclesBackpain,relieveafterrestoractivitiesErectorspainaemusclespasm

Strainoflumbarmuscles

腰肌劳损CTreatmentSelfcaretherapy,changepositionPhysiotherapy,massageLocalsteroidinjectionAnti-inflammatorydrugsTreatmentSelfcaretherapy,cSupraspinousligamentinjury

interspinousligamentinjuryCommoncauseofbackpainSupraspinourligamentinjurycommoninmiddlethoracicsegmentInterspinousligamentinjurycommoninlowerlumbarsegmentSupraspinousligamentinjury

iNotraumahistoryBendorhyperextensionpainLocaltendernessSteroidinjectionPhysiotherapyormassageimmobilizationNotraumahistoryBursitis

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

Bursitis

滑囊炎Bursaearesacslinedwithamembranesimilartosynovium;theyusuallyarelocatedaboutjointsorwhereskin,tendon,ormusclemovesoverabonyprominence.mayormaynotcommunicatewithajoint.Function:reducefriction,protectdelicatestructuresfrompressure.

frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件Bursaearesimilartotendonsheathsandthesynovialmembranesofjointsandaresubjecttothesamedisturbances:(1)acuteorchronictrauma,(2)acuteorchronicpyogenicinfection,and(3)low-gradeinflammatoryconditionssuchasgout,syphilis,tuberculosis,orrheumatoidarthritis.BursaearesimilartotendonsTwotypesofbursae:normallypresent(asoverthepatellaandolecranon)andadventitiousones(suchasdevelopoverabunion,anosteochondroma,orkyphosisofthespine).Adventitiousbursaeareproducedbyrepeatedtraumaorconstantfrictionorpressure.Twotypesofbursae:normallyTreatment---thecauseofthebursitisSystemiccauses,suchasgoutorsyphilis,andlocaltraumaorirritantsshouldbeeliminated,and,whennecessary,thepatient'soccupationorpostureshouldbechanged.Oneormoreofthefollowinglocalmeasuresusuallyarehelpful:rest,hotwetpacks,elevation,and,ifnecessary,immobilizationoftheaffectedpart.frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件TreatmentAspirationandsteroidinjectionSurgicalproceduresusefulintreatingbursitisare(1)incisionanddrainagewhenanacutesuppurativebursitisfailstorespondtononsurgicaltreatment,(2)excisionofchronicallyinfectedandthickenedbursae,and(3)removalofanunderlyingbonyprominenceTreatmentAspirationandstero

StenosingTenosynovitis

狭窄性腱鞘炎moreofteninthehandandwristthananywhereelseinthebody.Aperitendinitismayaffectthesetendons,causingpain,swelling,andcrepitus.

StenosingTenosynovitis

狭窄性腱鞘Whenthelongflexortendonsareinvolved,triggerthumb,triggerfinger,orsnappingfingeroccurs.Thestenosisoccursatapointwherethedirectionofatendonchanges,forhereafibroussheathactsasapulley,andfrictionismaximal.Althoughthetenosynoviumlubricatesthesheath,frictioncancauseareactionwhentherepetitionofaparticularmovementisnecessary,asinwindingafinecoilofwireorstackinglaundry.

WhenthelongflexortendonsaDEQUERVAINDISEASEStenosingtenosynovitisoftheabductorpollicislongusandextensorpollicisbrevistendonsWhentheextensorpollicisbrevisandtheabductorpollicislongustendonsinthefirstdorsalcompartmentareaffected,theconditionisnamedaftertheSwissphysician,DeQuervain,whodescribedhisexperiencein1895.

.DEQUERVAINDISEASEStenosingtWomenareaffected10timesmorefrequentlythanmen.Thecauseisalmostalwaysrelatedtooveruse,eitherinthehomeoratwork,orisassociatedwithrheumatoidarthritis.Thepresentingsymptomsusuallyarepainandtendernessattheradialstyloid.SometimesathickeningofthefibroussheathispalpableWomenareaffected10timesmodiagnosisTheFinkelsteintestusuallyispositive:"ongraspingthepatient'sthumbandquicklyabductingthehandulnarward,thepainoverthestyloidtipisexcruciating."AlthoughFinkelsteinstatesthatthistestis"probablythemostpathognomonicobjectivesign,"itisnotdiagnostic;thepatient'shistoryandoccupation,theroentgenograms,andotherphysicalfindingsmustalsobeconsidered.

diagnosisTheFinkelsteintestTreatmentConservativetreatment,consistingofrestonasplintandtheinjectionofasteroidpreparationintothetendonsheath,ismostsuccessfulwithinthefirst6weeksafteronset.SteroidinjectionWhenpainpersists,surgeryisthetreatmentofchoice(completerelief)TreatmentConservativetreatmenTRIGGERFINGERANDTHUMB

弹响指和弹响拇Stenosingtenosynovitis,leadingtoinabilitytoextendtheflexeddigit("triggering")usuallyisseenafter45yearsofage.Patientsmaynotealumporknotinthepalm.Thelumpmaybethethickenedareainthefirstannularpartoftheflexorsheath,oranoduleorfusiformswellingoftheflexortendonjustdistaltoit.Thenodulecanbepalpatedbytheexaminer'sfingertipandwillmovewiththetendon.Thetendonnoduleusuallyisattheentryofthetendonintotheproximalannulusatthelevelofthemetacarpophalangealjoint.TRIGGERFINGERANDTHUMB

弹响指和弹TreatmentTreatmentoftriggerdigitsusuallyisnonoperativeintheuncomplicatedpatientwhopresentsashorttimeafteronsetofsymptoms.Nonoperativemethodsincludestretching,nightsplinting,andcombinationsofheatandice.CorticosteroidinjectioniseffectiveafteroneinjectionSurgicalreleasereliablyrelievesthesymptomformostpatientsTreatmentTreatmentoftriggerGanglionGanglionTreamentSqueezeAspirationandsteroidinjectionOperationTreamentSqueezeLateralepicondylitis

肱骨外上髁炎Lateralepicondylitis(tenniselbow),afamiliartermusedtodescribedamyriadofsymptomsaboutthelateralaspectoftheelbow,occursmorefrequentlyinnonathletesthanathletes,withapeakincidenceintheearlyfifthdecadeandanearlyequalgenderincidence.Activitiesthatrequirerepetitivesupinationandpronationoftheforearmwiththeelbowinnearfullextension.Lateralepicondylitis

肱骨外上髁炎LaTendernessispresentoverthelateralepicondyleapproximately5mmdistalandanteriortothemidpointofthecondyle.Painusuallyisexacerbatedbyresistedwristdorsiflexionandforearmsupination,andthereispainwhengraspingobjects.Plainroentgenogramsusuallyarenegative;occasionallycalcifictendinitismaybepresent.MRIdemonstratestendonthickeningwithincreasedT1andT2signalsbutgenerallyisnotindicated.frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件Regardlessoftheunderlyingcause,nonoperativetreatmentissuccessfulin95%ofpatientswithtenniselbowInitialnonoperativetreatmentincludesrest,ice,injections,andphysicaltherapycenteredaroundtreatmentsuchasultrasound,electricalstimulation,manipulation,softtissuemobilization,frictionmassage,stretchingandstrengtheningexercises,andcounter-forcebracing.RegardlessoftheunderlyingcSteroidinjectionIfprolonged(6to12months),operativetreatmentmaybeconsidered;itiseffectivein90%ofproperlyselectedpatients.SteroidinjectionAdhesiveCapsulitis（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AdhesiveCapsulitis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肩部结构肩部外层肌肉为三角肌Frozenshouldersinpatientswhoreportnoincitingeventandwithnoabnormalityonexamination(otherthanlossofmotion)orplainroentgenogramsweredesignatedas"primary,"andthosewithprecipitanttraumaticinjuriesas"secondary."Thisdivisionhelpsinplanningtreatmentbutdoesnotnecessarilypredictoutcome.FrozenshouldersinpatientswNoformalinclusioncriteria.Ternalrotationfrequentlyislostinitially,followedbylossofflexionandexternalrotation.Theincidenceoffrozenshoulderinthegeneralpopulationisapproximately2%.(anincreasedincidenceassociatedwith,includingdiabetesmellitus(upto5timesmore),cervicaldiscdisease,hyperthyroidism,intrathoracicdisorders,andtrauma).Peoplebetweentheagesof40and70aremorecommonlyaffected.Commontoalmostallpatientsisaperiodofimmobility,theetiologiesofwhicharediverseNoformalinclusioncriteria.Rotatorcuff肩袖冈上肌，冈下肌，肩胛下肌和小圆肌Supraspinatus，infraspinatus，subscapularmuscle，teresminorPainmaydisappearDysfunctionRotatorcuff肩袖冈上肌，冈下肌，肩胛下肌和小圆肌PrimaryFrozenShoulderPrimaryfrozenshoulderisavagueentitythatonlyrarelyrecursinthesameshoulder.Theclinicalcourseofprimary(idiopathic)frozenshoulderconsistsofthreephases.PhaseI—Pain.Patientsusuallyhaveagradualonsetofdiffuseshoulderpain,whichisprogressiveoverweekstomonths.Thepainusuallyisworseatnightandisexacerbatedbylyingontheaffectedside.Asthepatientusesthearmless,painleadingtostiffnessensues.PrimaryFrozenShoulderPrimaryPrimaryFrozenShoulderPhaseII—Stiffness.Patientsseekpainreliefbyrestrictingmovement.Thisheraldsthebeginningofthestiffnessphase,whichusuallylasts4to12months.Patientsdescribedifficultywithactivitiesofdailyliving;menhavetroublegettingtotheirwalletsandwomenwithfasteningbrassieres.Asstiffnessprogresses,adullacheispresentnearlyallthetime(especiallyatnight),andthisoftenisaccompaniedbysharppainduringrangeofmotionatornearthenewendpointsofmotion.PrimaryFrozenShoulderPhaseIPrimaryFrozenShoulderPhaseIII—Thawing.Thisphaselastsforweeksormonths,andasmotionincreases,paindiminishes.Withouttreatment(otherthanbenignneglect)motionreturnisgradualinmostbutmayneverobjectivelyreturntonormal,althoughmostpatientssubjectivelyfeelnearnormal,perhapsasaresultofcompensationoradjustmentinwaysofperformingactivitiesofdailyliving.PrimaryFrozenShoulderPhaseISecondaryFrozenShoulderUnlikepatientswithidiopathicfrozenshoulder,patientswithsecondaryfrozenshouldercanrecallaspecificprecipitatingevent,possiblyrelatedtooveruseorinjury.Thethreephasesofclassicfrozenshouldermaynotallbepresentandmaynotfollowthepreviouslyoutlinedchronology;fortunately,treatmentforthetwoentitiesissimilar.SecondaryFrozenShoulderUnlikDiagnosistestsinpatientswithafrozenshoulder(includingplainfilmroentgenograms)usuallyarenormal,exceptinthosewithmedicaldisorderssuchasdiabetesorthyroiddisease.Bonescanshavebeenreportedtobepositiveinsomepatients.Arthrogramscharacteristicallyshowareducedjointvolumewithirregularmargins.Clinicalimprovementhasbeenreportedafterarthrographybecauseofbrisementofadhesionsfromforcefullyinjectingfluidintothejoint.Avolumeoflessthan10mlandlackoffillingoftheaxillaryfoldcurrentlyareacceptedarthrographicfindingsindicativeofafrozenshoulder.DiagnosistestsinpatientswitDifferentialdiagnosisCervicalspondylosisRotatorcufftearDifferentialdiagnosisCervicalTreatmentTraditionally,frozenshoulderhasbeenconsideredaself-limitingcondition,lasting12to18months.Approximately10%ofpatientshavelong-termproblems.Patientsseekingcareearlierusuallyrecovermorequickly.Dominantshoulderinvolvementhasbeenreportedtobepredictiveofagoodresult,whereasoccupationandtreatmentprogramsarenotstatisticallysignificant.Obviously,thebesttreatmentoffrozenshoulderisprevention(secondaryfrozenshoulder),butearlyinterventionisofparamountimportance;agoodunderstandingofthepathologicalprocessbythepatientandthephysicianalsoisimportant.

TreatmentTraditionally,frozenTreatmentInitialtreatmentisnonoperative,withemphasisplacedoncontrolofpainandinflammation.passiveandactiverange-of-motionexercises.Abductionshouldbeavoidedinitiallytopreventimpingementuntiljointmotionbecomesmoresupple.PhysiotherapySteroidinjectionNSAIDSdrugsTreatmentInitialtreatmentisTreatmentAlthoughafrozenshoulderusuallyisself-limitingandresolvesin12to18months,manypatientsdonotwishtowaitthatlongforresolutionofsymptomsandrequestactiveinterventionlongbefore12months.Withappropriatepatientselection,significantimprovementcanbeobtainedinapproximately70%ofpatients.ClosedmanipulationunderanesthesiaOpenreleaseofcontracturesTreatmentAlthoughafrozenshoTreatmentArthroscopicreleaseisanoptionwhenclosedmanipulationfailsorforpatientswhohavehadprolonged,recalcitrantadhesivecapsulitis.TreatmentArthroscopicreleaseChondromalaciapatella

髌骨软骨软化症Chondromalaciapatella

髌骨软骨软化症Epiphysitisoftibialtuberosity

胫骨结节骨骺炎(Osgood-Schlatterdisease)

(Osteochondroldiseaseofthetibialtubercle)Commonage12-14ysEpiphysitisoftibialtuberosi

OSGOOD-SCHLATTERDISEASE

Disordersofactivelygrowingepiphyses.Thedisordermaybelocalizedtoasingleepiphysisoroccasionallymayinvolvetwoormoreepiphysessimultaneouslyorsuccessively.Thecausegenerallyisunknown,butevidenceindicatesalackofvascularitythatmaybetheresultoftrauma(quadriceps),infection,orcongenitalmalformation.

OSGOOD-SCHLATTERDISEASETreatmentSelflimiteddiseaseObservation,remaineminanceofTTSurgeryrarelyisindicatedthedisorderusuallybecomesasymptomaticwithouttreatmentorwithsimpleconservativemeasuressuchastherestrictionofactivitiesorcastimmobilizationfor3to6weeksTreatmentSelflimiteddiseaseLegg-Calve-PerthesDisease

Perthes病

Thecause：chronicinjuryTheclinicalsign：painandlimp，ThomassignplainroentgenographicchangesBonescintigraphyMRITreatmentLegg-Calve-PerthesDisease

PerLloyd-Roberts、CatterallandSalamonclassificationclassifiedpatientswiththisdiseaseintogroupsaccordingtotheamountofinvolvementofthecapitalfemoralepiphysis:groupI,partialheadorlessthanhalfheadinvolvement;groupsIIandIII,morethanhalfheadinvolvementandsequestrumformation;groupIV,involvementoftheentireepiphysis.Lloyd-Roberts、CatterallandSaheadatriskTheynotedcertainroentgenographicsignsdescribedas"headatrisk"correlatedpositivelywithpoorresults,especiallyinpatientsingroupsII,III,andIV.Thesehead-at-risksignsincludeLateralsubluxationofthefemoralheadfromtheacetabulum,Speckledcalcificationlateraltothecapitalepiphysis,Diffusemetaphysealreaction(metaphysealcysts),Ahorizontalphysis,Gagesign,aradiolucentV-shapeddefectinthelateralepiphysisandadjacentmetaphysis.headatriskTheynotedcertainContainmentbyfemoralvarusderotationalosteotomyforolderchildreningroupsII,III,andIVwithhead-at-risksigns.Contraindicationsincludeanalreadymalformedfemoralheadanddelayoftreatmentofmorethan8monthsfromonsetofsymptoms.SurgeryisnotrecommendedforanygroupIchildrenoranychildwithoutthehead-at-risksigns.ContainmentbyfemoralvarusSalterandThompsonclassificationSalterandThompsonadvocateddeterminingtheextentofinvolvementbydescribingtheextentofasubchondralfractureinthesuperolateralportionofthefemoralhead.Iftheextentofthefracture(line)islessthan50%ofthesuperiordomeofthefemoralhead,theinvolvementisconsideredtypeA,andgoodresultscanbeexpected.Iftheextentofthefractureismorethan50%ofthedome,theinvolvementisconsideredtypeB,andfairorpoorresultscanbeexpected.SalterandThompsonclassificaAccordingtoSalterandThompson,thissubchondralfractureanditsentireextentcanbeobservedroentgenographicallyearlierandmorereadilythantryingtodeterminetheCatterallclassification.Furthermore,accordingtotheseauthors,ifthefemoralheadisgradedastypeB,thenprobablyanoperationsuchasaninnominateosteotomyshouldbecarriedoutAccordingtoSalterandThompsHerringclassificationHerringclassification

1.Mostpatientscanbetreatedbynoncontainmentmethodsandobtaingoodresults(80%).2.Satisfactoryclinicalresultsfrequentlycanbeobtainedatlong-termfollow-updespiteanunsatisfactoryroentgenographicappearance.ConclusionsConclusions3.TheCatterallclassificationisavalidindicatorofresultsbutisnotapplicableasatherapeuticguide.4.Head-at-risksignsaddedlittletotheCatterallclassificationasaprognosticindicatorortherapeuticguide.5. AllofthefairandpoorresultswereinpatientswithCatterallIIIorIVinvolvementandonsetofthediseaseatage6orlater.3.TheCatterallclassificatioCarpalTunnelSyndrome

腕管综合症

(anothername:tardymedianpalsy)resultsfromcompressionofthemediannervewithinthecarpaltunnel.Thesyndromeconsistspredominantlyoftinglingandnumbnessinthetypicalmediannervedistributionintheradialthreeandone-halfdigits(thumb,index,long,radialsideofring).Painoccursdiffuselyinthehandandradiatesuptheforearm.Thenaratrophyusuallyisseenlaterinthecourseofthenervecompression.CarpalTunnelSyndrome

腕管综合症(Thesyndromefrequentlyisassociatedwithnonspecifictenosynovialedemaandrheumatoidtenosynovitis,asaretriggerfingeranddeQuervaindisease.Schuindetal.studiedbiopsyspecimensoftheflexortendonsynoviumfrom21patientswith"idiopathic"carpaltunnelsyndrome.Thefindingsweresimilarinallandweretypicalofaconnectivetissueundergoingdegenerationunderrepeatedmechanicalstress.ThesyndromefrequentlyisassDiagnosisParesthesiaoverthesensorydistributionofthemediannerveisthemostfrequentsymptom;moreofteninwomenandfrequentlycausesthepatienttoawakenseveralhoursaftergettingtosleepwithburningandnumbnessofthehandthatisrelievedbyexercise.TheTinelsignmaybedemonstratedinmostpatientsbypercussingthemediannerveatthewrist.Atrophytosomedegreeofthemedian-innervatedthenarmuscleshasbeenreportedinabouthalfofthepatientstreatedbyoperation.DiagnosisAcuteflexionofthewristfor60secondsinsomebutnotallpatientsorstrenuoususeofthehandincreasestheparesthesia.Applicationofabloodpressurecuffontheupperarmsufficienttoproducevenousdistentionmayinitiatethesymptoms.Gellmanetal.evaluatedtheclinicalusefulnessofcommonlyadministeredprovocativetests,includingwristflexion,nervepercussion,andthetourniquettest,in67handswithelectricalproofofcarpaltunnelsyndromeandin50controlhands.AcuteflexionofthewristforDiagnosisThemostsensitivetestwasthewristflexiontest,whereasnervepercussionwasthemostspecificandtheleastsensitive.Theyalsofoundthatwiththewristinneutralposition,themeanpressurewithinthecarpaltunnelinpatientswithcarpaltunnelsyndromewas32mmHg.Thispressureincreasedto99mmHgwith90degreesofwristflexionandto110mmHgwiththewristat90degreesofextension.Thepressuresinthecontrolsubjectswiththewristinneutralpositionwere25mmHg,31mmHgwiththewristinflexion,and30mmHgwiththewristinextension.DiagnosisThemostsensitiveteSensibilitytestinginperipheralnervecompressionsyndromeswasinvestigated,foundthatthresholdtestsofsensibilitycorrelatedaccuratelywithsymptomsofnervecompressionandelectrodiagnosticstudies.SensibilitytestinginperipheElectrodiagnosticstudiesarereliableconfirmatorytests.UltrasonographyhasbeenusedtoshowthemovementoftheflexortendonswithinthecarpaltunnelEarlyreportsofMRIincarpaltunnelsyndromearepromising.AmajoradvantageofMRIisitshighsofttissuecontrast,whichgivesdetailedimagesofbothbonesandsofttissues.Careshouldbetakennottoconfusethissyndromewithnervecompressioncausedbyacervicaldischerniation,thoracicoutletstructures,andmediannervecompressionproximallyintheforearmandattheelbow

ElectrodiagnosticstudiesareTreatmentIfmildsymptomshavebeenpresentandthereisnothenarmuscleatrophy,theinjectionofhydrocortisoneintothecarpaltunnelmayaffordrelief.Greatcareshouldbetakennottoinjectdirectlyintothenerve.Injectionalsocanbeusedasadiagnostictoolinpatientswithoutbonyortumorousblockingofthecanal;Treatment65%ofthesecasesprobablyarecausedbyanonspecificsynovialedema,andtheseseemtorespondmorefavorablytoinjection.Injectionalsohelpstoeliminatethepossibilityofothersyndromes,especiallycervicaldiscorthoracicoutletsyndrome.Somepatientsprefertoreceiveinjectionstwoorthreetimesbeforeasurgicalprocedureiscarriedout.Iftheresponseispositiveandthereisnomuscleatrophy,conservativetreatmentwithsplintingandinjectionisreasonable.65%ofthesecasesprobablyTreatmentIfsignsandsymptomsarepersistentandprogressive,especiallyiftheyincludethenaratrophy,divisionofthedeeptransversecarpalligamentisindicated.Theresultsofsurgeryaregoodinmostinstances,andbenefitsseemtolastinmostpatients.TreatmentIfsignsandsymptomsAlthoughthenaratrophymaydisappear,itresolvesslowly,ifatall.Asnotedearlier,whensymptomsofmediannervecompressiondevelopduringtreatmentofanacuteCollesfracture,theconstrictingbandagesandcastshouldbeloosenedandthewristshouldbeextendedtoneutralposition.WhenmediannervepalsydevelopsafteraCollesfractureandhasgoneunrecognizedforseveralweeks,surgeryisindicatedwithoutfurtherdelay.AlthoughthenaratrophymaydiOsteonecrosisofFemoralhead

成人股骨头无菌性坏死Osteonecrosisofthefemoralheadisaprogressivediseasethatgenerallyaffectspatientsinthethirdthoughfifthdecadesoflife;ifleftuntreated,itleadstocompletedeteriorationofthehipjoint.Itisestimatedthatasmanyas20,000newcasesofosteonecrosisarediagnosedeachyearintheUnitedStates.OsteonecrosisofFemoralhead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定义ARCO+AAOS的标准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，双侧发病，约80%未有效治疗，1-4年内将发生股骨头塌陷，缺乏有效防治方法多数患者最后不得不接受全髋关节置换术TotalHipArthroplastyOsteonecrosisofthefemoralhfrozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件ARCO分期0期活检符合坏死，其余检查正常1期MR、骨扫描异常A<15%,B15-30%,C>30%2期股骨头斑片状密度不均、硬化与囊肿形成，平片与CT没有塌陷表现，MR及骨扫描异常，髋臼无异常AMR<15%;B15-30%;C>30%3期正侧位片出现新月征A长度<15%或塌陷<2mm;B新月征长度15-30%或塌陷2-4mm;C>30%或塌陷>4mm4期关节面塌陷变扁，关节间隙狭窄，髋臼出现坏死变化，囊性变和骨赘ARCO分期0期活检符合坏死，其余检查正常frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件诊断早期诊断---困难高度重视病因，尤其重要常常是一侧有症状作MR检查时，发现对侧有早期ONFH有酗酒，长期应用激素史病人自己警惕意识强，主动检查晚期，X线片表现已很明显，容易诊断诊断早期诊断---困难病史体格检查X线片骨功能检查FBE

骨内压测定，骨内静脉造影，核心活检，放射性核素扫描ECTCTMR病史X线片：敏感度差，适宜观察股骨头形态，光圆度，高度，塌陷程度CT，敏感度低，不建议采用ECT，敏感度高仔细观察确实有冷区，可发现特早期（0或1前期），出现热区，结合病史有助于诊断，但特异性差MRI，敏感度特高，早期发现和诊断股骨头坏死的敏感性和特异性达99%，应为首选股骨头核心活检结果最为准确，组织病理学X线片：敏感度差，适宜观察股骨头形态，光圆度，高度，塌陷程度ARCO国际骨坏死分期的治疗原则0-2A期，可行髓芯减压术2B-3B期适用于截骨术或骨移植术，包括带血运的骨移植3C期及以上，应考虑作人工髋关节置换术ARCO国际骨坏死分期的治疗原则骨移植术

带缝匠肌蒂骨瓣带股直肌蒂骨瓣带臀中肌蒂骨瓣带股方肌蒂骨瓣带股外侧肌蒂骨瓣单纯游离腓骨移植吻合血管腓骨移植带旋髂深血管蒂髂骨瓣带血管蒂大转子骨-筋膜瓣

股骨头内记忆合金球网植入双支撑骨柱移植支撑物加植骨空心钉植入钽棒植入BMP及生物因子植入…骨移植术双支撑骨柱移植长期随访疗效10.2年2B83%2C80%3A75%3B65%3C40%428.6%双支撑骨柱移植长期随访疗效10.2年保头手术影响因素病变本身因素股骨头坏死范围和塌陷程度，部位技术因素减压有效与否坏死骨清除彻底与否植骨的血运保证与否机械支撑足够与否：部位，强度，面积良好的血供+足够大的支撑面积，足够强的支撑强度保头手术影响因素病变本身因素股骨头坏死的分期系列疗法根据年龄，坏死面积，坏死位置，塌陷危险性等进行个体化选择治疗方法只要正确地掌握相应方法，才能获得较好疗效ONFH病人多较年轻，应首先考虑保存自体股骨头股骨头坏死的分期系列疗法根据年龄，坏死面积，坏死位置，塌陷危0-1A：无症状，保守治疗药物：活血化瘀中药，葛根素，降脂药等，最好用于1前期者，可能有一定效果高压氧血液净化磁疗震波临床疗效有待于长期观察0-1A：无症状，保守治疗0-1A：有症状，行细针钻孔减压，有效率60%，可植入自体骨髓细胞或第2代骨髓干细胞目的：股骨头内减压，打通硬化带，促使向坏死区增加血液循环0-1A：有症状，行细针钻孔减压，有效率60%，可植入自体骨1A，1B,2A粗通道髓芯减压，效可目的：减压，打通硬化带，增加血液循环可植入自体骨髓细胞，干细胞，自体骨，同种异体骨，骨诱导活性材料等1A，1B,2A粗通道髓芯减压，效可1C，2A，2B，2C骨移植，效果尚好目的，彻底清除坏死骨，充分植骨，重建血循环，促进骨修复，恢复股骨头内生物力学强度防止塌陷3A，3B，骨移植术，包括带血运的骨移植，效果差1C，2A，2B，2C骨移植，效果尚好3C期及以上THA，但是无论是骨水泥或非骨水泥固定的THA，用于骨坏死的远期疗效差于OA的THA，我们应该做的：明确的术前告知精确标准的手术术后的康复积极随访指导，病人日常3C期及以上THA，但是无论是骨水泥或非骨水泥固定的THA，

Diagnosis

Patientsaretypicallyasymptomaticearlyinthecourseofosteonecrosisandeventuallyhavegroinpainonambulation.Athoroughhistoryandphysicalexaminationshouldbedonetodiscoverpotentialriskfactorsanddeterminetheclinicalstatusofthepatient.Plainroentgenogramsshouldbeobtainedincludinganteroposteriorandlateralviews.Roentgenographicchangesseeninosteonecrosisdependonthestageofthedisease.Plainfilmsmayappearnormalintheearlystages,butchangesarenotedasthediseaseprogresses,suchasincreaseddensityorlucencyinthefemoralhead.

Diagnosis

PatientsaretypicaAdvancesinMRIhavemadeearlierdiagnosisofosteonecrosisofthefemoralheadpossibleandallowdeterminationoftheexactstageandextentofthepathologicalprocesswithoutuseofinvasivemethods.AdvancesinMRIhavemadeearlTreatmentCoredecompressionBoneGraftingVascularizedFibularGraftingOsteotomiesofProximalFemurTreatmentCoredecompressionResurfacingHemiarthroplastyTotalHipArthroplastyandBipolarHemiarthroplasty.Improvedresultsrecentlyhavebeenreportedwithmoderncementingtechniquesandpress-fitcementlesstotalhiparthroplastyinpatientswithosteonecrosis.Withnewbearingsurfacesbecomingavailable,suchasceramiconceramic,metalonmetal,andhighlycross-linkedpolyethylene,resultsmayimproveevenmore.Theresultsofprimarytotaljointreplacementforosteonecrosisarenowapproachingthosereportedforosteoarthritisinaged-matchedpatients.ResurfacingHemiarthroplastyfrozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件frozenshoulder肩周炎或称冻结肩或五十肩肩周肌腱课件谢谢大家!Thankyouverymuchforyourattention!谢谢大家!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