肩袖损伤.ppt

肩袖损伤肩袖损伤(snshng)(snshng)第一页，共四十四页。肩袖损伤(snshng)的流行病学Uhthoff et al.1 found a 20%prevalence in a series of cadaver dissections in which the mean age of the donors was 59.4 years.Lehman et al.2 found a prevalence of 17%in a large series of cadaver dissections,with a prevalence of 30%in donors older than sixty years of age.The incidence of full-thickness tears of the rotator cuffranges from 5%to 40%.Furthermore,epidemiologicalstudies show an increasing frequency of rotator cuff failure with advancing age3.1 Uhthoff HK,Loehr J,Sarkar K.The pathogenesis of rotator cuff tears.In:Takagishi N,editor.The shoulder.Tokyo:Professional PostGraduate Services;1987:211-2.2 Lehman C,Cuomo F,Kummer FJ,Zuckerman JD.The incidence of full thickness rotator cuff tears in a large cadaveric population.Bull Hosp Jt Dis.1995;54(1):30-1.3 Bigliani LU,Morrison DS.Relationship between acromial morphology and rotator cuff tears.Orthop Trans.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(d do)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。Gazzola S,Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9.cystic change of the greater tuberosity1 读读X片片第四页，共四十四页。Gazzola S,Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9.normal subacromial joint space(7mm)(arrow)1 superior subluxation of the humeral head(arrow)2 notched humeral neck(arrowhead)第五页，共四十四页。Type I calcification with a fluffy,fleecy appearance with poorly defined borders,with acute symptoms and termed the resorptive phase.Type II calcification,more discreet and of homogenous density,with well-circumscribed borders,and in the formative phase.DePalma AF,Kruper JS.Long-term study of shoulder joints affliated with and treated for calcific tendinitisJ.Clin Orthop.1961;20:61-72.calcific tendinopathy第六页，共四十四页。2 可疑可疑(ky)诊断诊断1 关于肩周炎关于肩周炎 肩周炎肩周炎=冻结冻结(dngji)肩（肩（实用骨科学实用骨科学第第3版），是由于肩关节版），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。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 Frozen shoulder 40-60 years of age,incidence 2-5%1.3 phases21)freezing phase 2-9 months,pain and loss of motion of the glenohumeral joint in all direction，usually worst at night and when lying on the affected side2)2)frozen phase 4-12 months,stiffness reaches its maximum3)thawing phase 5-12 months,range of motion returns to normal 4)2 肩峰下撞击综合症肩峰下撞击综合症 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肱二头肌，夜间疼痛可影响睡眠1 Hand C,Clipsham K,Rees JL,et al.Long-term outcome of frozen shoulder.J Shoulder Elbow Surg 2008;17:231-6.2 Reeves B.The natural history of the frozen shoulder syndrome.Scand J Rheumatol 1975;4:193-6.第七页，共四十四页。3 针对肩袖损伤针对肩袖损伤(snshng)的体查的体查1 冈上肌 肩外展功能(gngnng)1 empty can test1)90 degrees abduction2)30 degrees horizontal abduction(in the plane of the scapula)3)thumbs pointing downward第八页，共四十四页。2 full can test1.1)90 degrees in the horizontal plane2.2)rotated 45degrees externally3)with the thumb pointing upward第九页，共四十四页。3painful arc test4 60-1201.1)shoulder in external rotation2.2)palm facing up第十页，共四十四页。1.4 resisted isometric abduction1.1)the arm in neutral rotation2.2)abducts the arm to 90 degrees第十一页，共四十四页。1.1 external rotation strength test=Pattes test1.1)the patients elbow in 90 degrees2.2)in the plane of the scapula2 冈下肌和小圆肌 肩外旋功能(gngnng)第十二页，共四十四页。1.2 external rotation lag sign1.1)elbow passively flexed to 90 degrees2)maximal external rotation第十三页，共四十四页。1.3 drop sign1.1)almost full external rotation2)elbow flexed at 90 degrees第十四页，共四十四页。1.4 weakness with external rotation1.1)elbows flexed to 90 degrees2.2)the thumbs up3.3)shoulders rotated internally 20 degrees第十五页，共四十四页。3 肩胛(jinji)下肌 肩内旋、后伸功能1 lift off test asking the patient to internally rotate the arm to lift the hand posteriorly off of the back第十六页，共四十四页。1.2 internal rotation lag sign第十七页，共四十四页。1.3 belly press第十八页，共四十四页。1.4 bear hug test第十九页，共四十四页。4 针对针对(zhndu)肩峰下撞击综合症的体查肩峰下撞击综合症的体查第二十页，共四十四页。Hawkins-Kennedy test第二十一页，共四十四页。关于关于(guny)MRI肩袖解剖(jipu)第二十二页，共四十四页。解剖解剖(jipu)足印（足印（footprint）第二十三页，共四十四页。关于关于(guny)MRI正常(zhngchng)肩袖的MRI 斜冠状面第二十四页，共四十四页。正常(zhngchng)肩袖的MRI 斜矢状面第二十五页，共四十四页。正常(zhngchng)肩袖的MRI 横断面第二十六页，共四十四页。损伤(snshng)肩袖的MRI第二十七页，共四十四页。魔法(m f)角 magic angle phenomenonthe fibers are at 55 degrees to the main magnetic field on T1Erickson SJ,Prost RW,Timins ME.The“magic angle”effect:background physics and clinical relevance.Radiology.1993;188:23-25.第二十八页，共四十四页。我们我们(w men)在在MRI上应得到的信息上应得到的信息1 肩袖走行及连续性2 高信号(xnho)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。肩袖走行及连续性第三十页，共四十四页。脂肪(zhfng)渗透（fatty infiltration）Fuchs B,Weishaupt D,Zanetti M,Hodler J,Gerber C.Fatty degeneration of the muscles of the rotator cuff:assessment by computed tomography versus magnetic resonance imaging.J Shoulder Elbow Surg 1999;8:599-605.第三十一页，共四十四页。肌肉(jru)萎缩（muscle atrophy）1 切线(qixin)征1（tangent sign）2 肩胛比（scapular ratio）Scapular ratio uses the ratio of the supraspinatus muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa,and in supraspinatus atrophy the ratio is less than 50%2.1 Zanetti M,Gerber C,Hodler J.Quantitative assessment of themuscles of the rotator cuff with magnetic resonance imaging.Invest Radiol.1998;33:163-170.2 Thomazeau H,Rolland Y,Lucas C,et al.Atrophy of thesupraspinatus belly.Assessment by MRI in 55 patients withrotator cuff pathology.Acta Orthop Scand.1996;67:264-268.第三十二页，共四十四页。肩袖损伤(snshng)的分类1 全层撕裂(s li)1）小 1cm 2）中 1-3cm 3）大 3-5cm 4）巨大 5cmDeOrio JK,Cofield RH.Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.J Bone Joint Surg.1984;66:563567.第三十三页，共四十四页。肩袖损伤(snshng)的分类2 部分(b fen)撕裂第三十四页，共四十四页。肩袖损伤(snshng)的治疗手术(shush)VS 保守1 年龄 Age is one of the most used parameters in decision making for the surgery of the cuff1.75 years2 撕裂大小 Shimizu2 recommend early cuff repair after confirming the diagnosis of massive rotator cuff tears.Partial-thickness rotator cuff tear is a further indication in those patients with minimal risk of tear extension,minimal pain,and dysfunction3.1 Tanaka M,Itoi E,Sato K,et al.Factors related to successful outcome of conservative treatment for rotator cuff tears.Ups J Med Sci.2010;115:193-200.2 Shimizu C,Horii M,Yamashita F,et al.Prognosis of massive rotator cuff tear.Chubuseisai.1990;33:392.3 Ozbaydar MU,Bekmezci T,Tonbul M,et al.The results of arthroscopic repair in partial rotator cuff tears.Acta Orthop Traumatol Turc.2006;40:4955.第三十五页，共四十四页。肩袖损伤(snshng)的治疗肌腱(jjin)的缝法第三十六页，共四十四页。开放手术(shush)骨质端的固定第三十七页，共四十四页。肩袖损伤(snshng)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(xinzh)差异，只有短期疼痛，关节镜优于开放手术。Lindley K,Jones GL.Outcomes of arthroscopic versus open rotator cuff repair:a systematic review of the literature.Am J Orthop(Belle Mead NJ),2010,39(12):592-600.第三十八页，共四十四页。不可修复肩袖损伤(snshng)的判定According to Gerber et al.,imaging findings that suggest an irreparable rotator cuff tear include 1）static superior subluxation of a glenohumeral joint with anacromiohumeral interval of 7 mm or less on an anteroposterior radiograph with the arm in neutral rotationGerber C,Wirth SH,Farshad M(2011)Treatment options for massive rotator cuff tears.J Should Elb Surg 20:S20S29.第三十九页，共四十四页。and 2)fatty infiltration of the rotator cuff muscles at stage three or greater.第四十页，共四十四页。不可修复肩袖损伤(snshng)的治疗1 肱三头(sn tu)肌长头截断2 debridement associated with acromioplasty and bursectomy3 partial repair4 arthroscopic tuberoplasty5 tendon transfers 1)latissimus dorsi transfers-superolateral rotator cuff tears2)pectoralis major transfers-irreparable tears of the subscapularis muscle 3)deltoid flap4)trapezius muscle transfer第四十一页，共四十四页。latissimus dorsi transfers一篇关于背阔肌修复巨大撕裂肩袖损伤(snshng)的系统评价结果显示：在45.5个月的随访期内，Constant score,active forward elevation和active external rotation术后明显优于术前。Namdari S,Voleti P,Baldwin K,Glaser D,Huffman GR.Latissimus dorsi tendon transfer for irreparable rotator cuff tears:a systematic review.J Bone Joint Surg Am,2012,94(10):891-8.第四十二页，共四十四页。谢谢(xi xie)！第四十三页，共四十四页。内容(nirng)总结肩袖损伤。54(1):30-1.。当我们(w men)在临床上遇到疑似病人，只有X片而无MRI检查时，。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，两者无显著差异，只有短期疼痛，关节镜优于开放手术。谢谢第四十四页，共四十四页。