医学专题-肩袖损伤

肩袖损伤(sǔnshāng)第一页，共四十四页。肩袖损伤(sǔnshāng)的流行病学Uhthoffetal.[1]founda20%prevalenceinaseriesofcadaverdissectionsinwhichthemeanageofthedonorswas59.4years.Lehmanetal.[2]foundaprevalenceof17%inalargeseriesofcadaverdissections,withaprevalenceof30%indonorsolderthansixtyyearsofage.Theincidenceoffull-thicknesstearsoftherotatorcuffrangesfrom5%to40%.Furthermore,epidemiologicalstudiesshowanincreasingfrequencyofrotatorcufffailurewithadvancingage[3].1UhthoffHK,LoehrJ,SarkarK.Thepathogenesisofrotatorcufftears.In:TakagishiN,editor.Theshoulder.Tokyo:ProfessionalPostGraduateServices;1987:211-2.2LehmanC,CuomoF,KummerFJ,ZuckermanJD.Theincidenceoffullthicknessrotatorcufftearsinalargecadavericpopulation.BullHospJtDis.1995;54(1):30-1.3BiglianiLU,MorrisonDS.Relationshipbetweenacromialmorphologyandrotatorcufftears.OrthopTrans.1986;10:216.第二页，共四十四页。

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(dédào)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？第三页，共四十四页。编辑ppt

GazzolaS,BleakneyRR.Currentimagingoftherotatorcuff[J].SportsMedArthrosc,2011,19(3):300-9.cysticchangeofthegreatertuberosity1读X片第四页，共四十四页。编辑pptGazzolaS,BleakneyRR.Currentimagingoftherotatorcuff[J].SportsMedArthrosc,2011,19(3):300-9.normalsubacromialjointspace(≥7mm)(arrow)1superiorsubluxationofthehumeralhead

(arrow)2notchedhumeralneck(arrowhead)第五页，共四十四页。编辑pptTypeIcalcificationwithafluffy,fleecyappearancewithpoorlydefinedborders,withacutesymptomsandtermedtheresorptivephase.TypeIIcalcification,morediscreetandofhomogenousdensity,withwell-circumscribedborders,andintheformativephase.DePalmaAF,KruperJS.Long-termstudyofshoulderjointsaffliatedwithandtreatedforcalcifictendinitis[J].ClinOrthop.1961;20:61-72.calcifictendinopathy第六页，共四十四页。编辑ppt2可疑(kěyí)诊断1关于肩周炎肩周炎=冻结(dòngjié)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]freezingphase2-9months,painandlossofmotionoftheglenohumeraljointinalldirection，usuallyworstatnightandwhenlyingontheaffectedside2)frozenphase4-12months,stiffnessreachesitsmaximumthawingphase5-12months,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.第七页，共四十四页。编辑ppt3针对肩袖损伤(sǔnshāng)的体查1冈上肌肩外展功能(gōngnéng)1emptycantest1)90degreesabduction2)30degreeshorizontalabduction(intheplaneofthescapula)3)thumbspointingdownward第八页，共四十四页。编辑ppt2fullcantest1)90degreesinthehorizontalplane2)rotated45degreesexternally3)withthethumbpointingupward第九页，共四十四页。编辑pptpainfularctest60°-120°1)shoulderinexternalrotation2)palmfacingup第十页，共四十四页。编辑ppt4resistedisometricabduction1)thearminneutralrotation2)abductsthearmto90degrees第十一页，共四十四页。编辑ppt1externalrotationstrengthtest=Patte’stest1)thepatient’selbowin90degrees2)intheplaneofthescapula2冈下肌和小圆肌肩外旋功能(gōngnéng)第十二页，共四十四页。编辑ppt2externalrotationlagsign1)elbowpassivelyflexedto90degrees2)maximalexternalrotation第十三页，共四十四页。编辑ppt3dropsign1)almostfullexternalrotation2)elbowflexedat90degrees第十四页，共四十四页。编辑ppt4weaknesswithexternalrotation1)elbowsflexedto90degrees2)thethumbsup3)shouldersrotatedinternally20degrees第十五页，共四十四页。编辑ppt3肩胛(jiānjiǎ)下肌肩内旋、后伸功能1liftofftestaskingthepatienttointernallyrotatethearmtoliftthehandposteriorlyoffoftheback第十六页，共四十四页。编辑ppt2

internalrotationlagsign第十七页，共四十四页。编辑ppt3bellypress第十八页，共四十四页。编辑ppt4bearhugtest第十九页，共四十四页。编辑ppt4针对(zhēnduì)肩峰下撞击综合症的体查第二十页，共四十四页。编辑pptHawkins-Kennedytest第二十一页，共四十四页。编辑ppt关于(guānyú)MRI肩袖解剖(jiěpōu)第二十二页，共四十四页。编辑ppt解剖(jiěpōu)足印（footprint）第二十三页，共四十四页。编辑ppt关于(guānyú)MRI正常(zhèngcháng)肩袖的MRI斜冠状面第二十四页，共四十四页。编辑ppt正常(zhèngcháng)肩袖的MRI斜矢状面第二十五页，共四十四页。编辑ppt正常(zhèngcháng)肩袖的MRI横断面第二十六页，共四十四页。编辑ppt损伤(sǔnshāng)肩袖的MRI第二十七页，共四十四页。编辑ppt魔法(mófǎ)角magicanglephenomenonthefibersareat55degreestothemainmagneticfieldonT1EricksonSJ,ProstRW,TiminsME.The“magicangle”effect:backgroundphysicsandclinicalrelevance.Radiology.1993;188:23-25.第二十八页，共四十四页。编辑ppt我们(wǒmen)在MRI上应得到的信息1肩袖走行及连续性2高信号(xìnhào)3脂肪变性4肌肉萎缩5肌肉回缩6三角肌下、肩峰下囊滑液相连第二十九页，共四十四页。编辑ppt

肩袖走行及连续性第三十页，共四十四页。编辑ppt脂肪(zhīfáng)渗透（fattyinfiltration）FuchsB,WeishauptD,ZanettiM,HodlerJ,GerberC.Fattydegenerationofthemusclesoftherotatorcuff:assessmentbycomputedtomographyversusmagneticresonanceimaging.JShoulderElbowSurg1999;8:599-605.第三十一页，共四十四页。编辑ppt肌肉(jīròu)萎缩（muscleatrophy）1切线(qiēxiàn)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.第三十二页，共四十四页。编辑ppt肩袖损伤(sǔnshāng)的分类1全层撕裂(sīliè)

1）小＜1cm2）中1-3cm3）大3-5cm4）巨大＞5cmDeOrioJK,CofieldRH.Resultsofasecondattemptatsurgicalrepairofafailedinitialrotator-cuffrepair.JBoneJointSurg.1984;66:563–567.第三十三页，共四十四页。编辑ppt肩袖损伤(sǔnshāng)的分类2部分(bùfen)撕裂第三十四页，共四十四页。编辑ppt肩袖损伤(sǔnshāng)的治疗手术(shǒushù)

VS保守1年龄Ageisoneofthemostusedparametersindecisionmakingforthesurgeryofthecuff[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.第三十五页，共四十四页。编辑ppt肩袖损伤(sǔnshāng)的治疗肌腱(jījiàn)的缝法第三十六页，共四十四页。编辑ppt开放手术(shǒushù)骨质端的固定第三十七页，共四十四页。编辑ppt肩袖损伤(sǔnshāng)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(xiǎnzhù)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):592-600.第三十八页，共四十四页。编辑ppt不可修复肩袖损伤(sǔnshāng)的判定AccordingtoGerberetal.,imagingfindingsthatsuggestanirreparablerotatorcufftearinclude1）staticsuperiorsubluxationofaglenohumeraljointwithanacromiohumeralintervalof7mmorlessonananteroposteriorradiographwiththearminneutralrotationGerberC,WirthSH,FarshadM(2011)Treatmentoptionsformassiverotatorcufftears.JShouldElbSurg20:S20–S29.第三十九页，共四十四页。编辑pptand2)fattyinfiltrationoftherotatorcuffmusclesatstagethreeorgreater.

第四十页，共四十四页。编辑ppt不可修复肩袖损伤(sǔnshāng)的治疗1肱三头(sān