肌腱滑囊及關(guān)節(jié)囊的慢性損傷性炎癥課件

1、神經(jīng)精神與運(yùn)動(dòng)1（模塊2）運(yùn)動(dòng)系統(tǒng)慢性疾病肩關(guān)節(jié)周圍炎、腱鞘炎股骨頭壞死神經(jīng)精神與運(yùn)動(dòng)1（模塊2）運(yùn)動(dòng)系統(tǒng)慢性損傷Chronic injury of soft tissue 概述Overview臨床常見病，多發(fā)病涉及骨，關(guān)節(jié)，肌肉，肌腱，韌帶，筋膜及其相關(guān)的血管神經(jīng)分類：軟組織，骨，軟骨慢性損傷及周圍神經(jīng)卡壓概述Overview臨床常見病，多發(fā)病特點(diǎn)Feature 局部慢性，無外傷史有特定部位壓痛點(diǎn)和腫塊，可放射痛局部無明顯炎癥表現(xiàn)近期有與疼痛部位相關(guān)的過度活動(dòng)史部分病人偶導(dǎo)致運(yùn)動(dòng)系統(tǒng)慢性損傷的工種，坐姿和工作習(xí)慣或職業(yè)特點(diǎn)Feature 局部慢性，無外傷史治療 Treatment限制致傷活動(dòng)

2、，或糾正不良姿勢(shì)，維持關(guān)節(jié)的不負(fù)重活動(dòng)積極物理治療，按摩推拿，外敷及熏蒸。正確合理使用腎上腺皮質(zhì)激素非甾體消炎鎮(zhèn)痛藥的合理使用（短期；外用；緩釋劑，腸溶劑，栓劑；腎功能不佳者可選用短半衰期藥物）手術(shù)治療 Treatment限制致傷活動(dòng)，或糾正不良姿勢(shì)，維持關(guān)Strain of lumbar muscles腰肌勞損Common cause of lumbar painLocal tenderness, start point or end point of musclesBack pain, relieve after rest or activitiesErector spainae musc

3、le spasm Strain of lumbar muscles腰肌勞損CTreatment Self care therapy, change positionPhysiotherapy, massageLocal steroid injectionAnti-inflammatory drugsTreatment Self care therapy, cSupraspinous ligament injuryinterspinous ligament injuryCommon cause of back painSupraspinour ligament injury common in

4、middle thoracic segmentInterspinous ligament injury common in lower lumbar segmentSupraspinous ligament injuryiNo trauma historyBend or hyperextension painLocal tendernessSteroid injectionPhysiotherapy or massageimmobilizationNo trauma historyBursitis 滑囊炎滑囊是位于人體摩擦頻繁或壓力較大部位的一種緩沖結(jié)構(gòu)。分為恒定滑囊，繼發(fā)性滑囊或附加滑囊 B

5、ursitis 滑囊炎 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: reduce friction, protect delicate structures from pressure. 肌腱滑囊及關(guān)節(jié)囊的慢性損傷性炎癥課件

6、肌腱滑囊及關(guān)節(jié)囊的慢性損傷性炎癥課件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, syphilis, tuberculosis, or rheumatoid ar

7、thritis. Bursae are similar to tendon sTwo 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 pressure.Tw

8、o types of bursae: normally 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: r

9、est, hot wet packs, elevation, and, if necessary, immobilization of the affected part. 肌腱滑囊及關(guān)節(jié)囊的慢性損傷性炎癥課件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 treatmen

10、t, (2) excision of chronically infected and thickened bursae, and (3) removal of an underlying bony prominenceTreatment Aspiration and steroStenosing Tenosynovitis狹窄性腱鞘炎more often in the hand and wrist than anywhere else in the body. A peritendinitis may affect these tendons, causing pain, swelling,

11、 and crepitus. Stenosing Tenosynovitis狹窄性腱鞘When the long flexor tendons are involved, trigger thumb, 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 te

12、nosynovium lubricates the sheath, friction can cause a reaction when the repetition of a particular movement is necessary, as in winding a fine coil of wire or stacking laundry. When the long flexor tendons aDE QUERVAIN DISEASEStenosing tenosynovitis of the abductor pollicis longus and extensor poll

13、icis brevis tendons When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895. . DE QUERVAIN DISEASEStenosing tWomen are affected 10 time

14、s 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 presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpableWomen are affec

15、ted 10 times modiagnosisThe Finkelstein test usually is positive: on grasping the patients thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating. Although Finkelstein states that this test is probably the most pathognomonic objective sign, it is not diagnostic

16、; the patients history and occupation, the roentgenograms, and other physical findings must also be considered. diagnosisThe Finkelstein test TreatmentConservative treatment, consisting of rest on a splint and the injection of a steroid preparation into the tendon sheath, is most successful within t

17、he first 6 weeks after onset. Steroid injectionWhen pain persists, surgery is the treatment of choice (complete relief )TreatmentConservative treatmenTRIGGER FINGER AND THUMB彈響指和彈響拇Stenosing tenosynovitis, leading to inability to extend the flexed digit (triggering) usually is seen after 45 years of

18、 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 examiners fingertip and will move with the tendon. The ten

19、don nodule usually is at the entry of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.TRIGGER FINGER AND THUMB彈響指和彈TreatmentTreatment of trigger digits usually is nonoperative in the uncomplicated patient who presents a short time after onset of symptoms. Nonoperat

20、ive 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 patientsTreatmentTreatment of trigger Ganglion Ganglion TreamentSqueezeAspiration and steroid injection

21、OperationTreamentSqueezeLateral 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 equ

22、al gender incidence. Activities that require repetitive supination and pronation of the forearm with the elbow in near full extension. Lateral epicondylitis肱骨外上髁炎LaTenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle. Pain usually is

23、 exacerbated by resisted wrist dorsiflexion and forearm supination, 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.

24、 肌腱滑囊及關(guān)節(jié)囊的慢性損傷性炎癥課件Regardless of the underlying cause, nonoperative treatment 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, sof

25、t tissue mobilization, friction massage, stretching and strengthening exercises, and counter-force bracing. Regardless of the underlying cSteroid injectionIf prolonged (6 to 12 months), operative treatment may be considered; it is effective in 90% of properly selected patients. Steroid injectionAdhe

26、sive Capsulitis（frozen shoulder.）肩周炎或稱凍結(jié)肩或五十肩肩周，肌腱，滑囊及關(guān)節(jié)囊的慢性損傷性炎癥，主要表現(xiàn)為活動(dòng)時(shí)疼痛，功能受限Adhesive Capsulitis肩部結(jié)構(gòu)肩部外層肌肉為三角肌內(nèi)層為肩袖，由岡上肌，岡下肌，肩胛下肌和小圓肌及肌腱組成肱二頭肌長(zhǎng)頭關(guān)節(jié)囊滑囊肩胛盂和肱骨頭肩部結(jié)構(gòu)肩部外層肌肉為三角肌Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) o

27、r plain roentgenograms were designated as primary, and those with precipitant traumatic injuries as secondary. This division helps in planning treatment but does not necessarily predict outcome. Frozen shoulders in patients wNo formal inclusion criteria. There are no universally accepted criteria fo

28、r 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 population is approximately 2%. (an increased incidence associated with, including diabetes mellitus (up to 5 times m

29、ore), 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 period of immobility, the etiologies of which are diverseNo formal inclusion criteria. Rotator cuff肩袖岡上肌，岡下肌，肩胛下肌和小圓

30、肌Supraspinatus，infraspinatus，subscapular muscle，teres minorPain may disappearDysfunctionRotator cuff肩袖岡上肌，岡下肌，肩胛下肌和小圓肌Primary Frozen ShoulderPrimary frozen shoulder is a vague entity that only rarely recurs in the same shoulder. The clinical course of primary (idiopathic) frozen shoulder consists of

31、 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 arm less, pain leading to stiffness ensues. Primary Froz

32、en ShoulderPrimaryPrimary 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 trouble getting to their wallet

33、s 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 IPrimary Frozen ShoulderPhase IIITh

34、awing. 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

35、or adjustment in ways of performing activities of daily living. Primary Frozen ShoulderPhase ISecondary 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

36、phases of classic frozen shoulder may not all be present and may not follow the previously outlined chronology; fortunately, treatment for the two entities is similar. Secondary Frozen ShoulderUnlikDiagnosistests in patients with a frozen shoulder (including plain film roentgenograms) usually are no

37、rmal, except in those with medical disorders such as diabetes or 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 bri

38、sement of adhesions from forcefully injecting fluid into the joint. 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. Diagnosistests in patients witDifferential diagnosisCervical spondylosisRotator cuff

39、 tearDifferential diagnosisCervicalTreatmentTraditionally, frozen shoulder has been considered a self-limiting condition, lasting 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

40、reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. Obviously, the best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of paramount importance; a good understanding of the patholog

41、ical process by the patient and the physician also is important. TreatmentTraditionally, frozenTreatmentInitial treatment is nonoperative, with emphasis placed on control of pain and inflammation. passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingem

42、ent until joint motion becomes more supple. PhysiotherapySteroid injectionNSAIDS drugsTreatmentInitial treatment is TreatmentAlthough a frozen shoulder usually is self-limiting and resolves in 12 to 18 months, many patients do not wish to wait that long for resolution of symptoms and request active

43、intervention long before 12 months. With appropriate patient selection, significant improvement can be obtained in approximately 70% of patients. Closed manipulation under anesthesiaOpen release of contracturesTreatmentAlthough a frozen shoTreatmentArthroscopic release is an option when closed manip

44、ulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis.TreatmentArthroscopic release Chondromalacia patella髕骨軟骨軟化癥Chondromalacia patella髕骨軟骨軟化癥Epiphysitis of tibial tuberosity脛骨結(jié)節(jié)骨骺炎(Osgood-Schlatter disease) (Osteochondrol disease of the tibial tubercle)Common age 12

45、-14 ysEpiphysitis of tibial tuberosiOSGOOD-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

46、 vascularity that may be the result of trauma (quadriceps), infection, or congenital malformation. OSGOOD-SCHLATTER DISEASE THANK YOUSUCCESS2022/10/449可編輯THANK YOUSUCCESS2022/10/34TreatmentSelf limited diseaseObservation, remain eminance of TTSurgery rarely is indicated the disorder usually becomes

47、asymptomatic without treatment or with simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeksTreatmentSelf limited diseaseLegg-Calve-Perthes DiseasePerthes病 The cause： chronic injury The clinical sign：pain and limp， Thomas sign plain roentgenograph

48、ic changes Bone scintigraphyMRI Treatment Legg-Calve-Perthes DiseasePerLloyd-Roberts、Catterall and Salamon classificationclassified patients with 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

49、; groups II and III, more than half head involvement and sequestrum formation; group IV, involvement of the entire epiphysis. Lloyd-Roberts、Catterall and Sahead at riskThey noted certain roentgenographic signs described as head at risk correlated positively with poor results, especially in patients

50、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 epiphysis, Diffuse metaphyseal reaction (metaphyseal cysts), A horizontal physis, Gage sign, a radiolucent V-shaped defect in the late

51、ral epiphysis and adjacent metaphysis. head at riskThey noted certainContainment by femoral varus derotational osteotomy for older children in groups II, III, and IV with head-at-risk signs.Contraindications include an already malformed femoral head and delay of treatment of more than 8 months from

52、onset of symptoms. Surgery is not recommended for any group I children or any child without the head-at-risk signs. Containment by femoral varus Salter and Thompson classificationSalter and Thompson advocated determining the extent of involvement by describing the extent of a subchondral fracture in

53、 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 the fracture is more than 50% of the dome, the involvement is consi

54、dered type B, and fair or poor results can be expected. Salter and Thompson classificaAccording to Salter and Thompson, this subchondral fracture and its entire extent can be observed roentgenographically earlier and more readily than trying to determine the Catterall classification. Furthermore, ac

55、cording 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 According to Salter and ThompsHerring classificationHerring classification 1. Most patients can be treated by noncontainment methods and obtain good res

56、ults (80%). 2. Satisfactory clinical results frequently can be obtained at long-term follow-up despite an unsatisfactory roentgenographic appearance. Conclusions Conclusions3. The Catterall classification is a valid indicator of results but is not applicable as a therapeutic guide. 4. Head-at-risk s

57、igns added little to the Catterall 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. 3. The Catterall classificatioCarpal Tunnel Syndrome腕管綜合癥 (another na

58、me: tardy median palsy) results from compression of the 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 diffusel

59、y in the hand and radiates up the forearm. Thenar atrophy usually is seen later in the course of the nerve compression. Carpal Tunnel Syndrome腕管綜合癥 (The syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease.

60、Schuind et al. studied biopsy specimens of the flexor tendon synovium from 21 patients with idiopathic carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue undergoing degeneration under repeated mechanical stress. The syndrome frequently is assDiagnosisPar