肩關(guān)節(jié)失穩(wěn)和肩袖損失專家講座

SHOULDERINSTABILITYANDROTATORCUFFINJURIESJ.GARCIA肩關(guān)節(jié)失穩(wěn)和肩袖損失第1頁INTRODUCTIONShoulderinjuriescomprise8-13%ofallathletesinjuriesResultfrom.repetitiveoverloadactivities:swimming,tennis...ordirecttrauma(collision):football,rugby…肩關(guān)節(jié)失穩(wěn)和肩袖損失第2頁INCIDENCESPORTS%TYPEOFLESIONSBaseball11-17AC,imping.,RCtenditisWrestling17Glenohumsubluxordislocation,ACTennis56RCtendinitis,imping.Volley-ball44Bicepstendinitis,imping.Javelinthrowers29Bicepstendinitis,imping.etc…肩關(guān)節(jié)失穩(wěn)和肩袖損失第3頁SHOULDERANATOMYBones:humeralheadandglenoidCartilageandlabrumCapsuleandligamentsMuscles

BELTRAN肩關(guān)節(jié)失穩(wěn)和肩袖損失第4頁P(yáng)LASTICITYOFLABRUMArticularcartilage,andglenoidlabrum.LabrumwhichhavesomeplasticityseenondifferentpositionsExternalrotationofhumerusInternalrotation肩關(guān)節(jié)失穩(wěn)和肩袖損失第5頁ANTERIORCAPSULEINSERTIONTypeIII,themoremedialinsertion,ispronetoanteriorglenohumeralinstabilityFromBELTRANImagingoforthopedicsportsinjuriesSPRINGER,p1293typesofinsertion肩關(guān)節(jié)失穩(wěn)和肩袖損失第6頁SHOULDERBIOMECHANICSShoulderisthemostmobilejointinthehumanbodyFunctionrequirescoordinatedmotionof4joints.scapuloclavicular.acromioclavicular.glenohumeral.scapulothoracic

肩關(guān)節(jié)失穩(wěn)和肩袖損失第7頁SHOULDERBIOMECHANICSMotion0-180%inelevationinternalandexternalrotation150%anteriorandposteriorrotation170%肩關(guān)節(jié)失穩(wěn)和肩袖損失第8頁STABILIZINGMECHANISMSOFGLENOHUMERALJOINTPASSIVEMECHANISMS.Size,shape,tiltottheglenoidfossa.Negativeintracapsularpressure.Adhesion,cohesionofarticularsurfaces.Ligamentsandcapsule.Glenoidlabrum.Oseousbonerestraints:acromion,coracoidprocess肩關(guān)節(jié)失穩(wěn)和肩袖損失第9頁STABILIZINGMECHANISMSOFGLENOHUMERALJOINTACTIVESTABILIZINGMECHANISMS.longheadofthebicepstendon.rotatorcuffmuscles.subscapularismuscleCoronalSagittalAxialArthroMR肩關(guān)節(jié)失穩(wěn)和肩袖損失第10頁"VICIOUSCIRCLE"OFSHOULDERINJURIESPainoccursinwomenespeciallywhenthereisaphysiologicinstabilitythatmaybemultidirectionalSTONE1994INSTABILITYCOMPRESSIONIMPINGEMENTPAINMUSCULARIMBALANCEROTATORCUFFWEAKNESS肩關(guān)節(jié)失穩(wěn)和肩袖損失第11頁LAXITYvsINSTABILITY

DefinitionsLAXITY:theabilitytopassivelytranslatehumeralheadtotheglenoidfossaINSTABILITY:aclinicalconditioninwhichsymptomsareproducedbytheunwantedtranslationoftheumeralhead,givingrisetopainordiminishedshoulderfunction肩關(guān)節(jié)失穩(wěn)和肩袖損失第12頁SHOULDERINSTABILITYThislectureismainlydevotedtogleno-humeralinstabilityduetotimelimitations,butDONOTFORGETpleasescapular,clavicular,acromio-clavicular,sternoclavicularinjurieswhicharealsoseeninsportsactivities肩關(guān)節(jié)失穩(wěn)和肩袖損失第13頁THEOVERHEADNTHROWING

MECHANISMCenterofrotationThecurvedharrowrepresentsthepathanddirectionofthegreatertuberosityasthearmexternallyrotatesBELTRAN肩關(guān)節(jié)失穩(wěn)和肩袖損失第14頁IMAGINGTECHNIQUES

RADIOGRAPHYAP,axialviewsCT,ARTHRO-CTMRI,ARTHRO-MR肩關(guān)節(jié)失穩(wěn)和肩袖損失第15頁RADIOGRAPHYAntero-inferiordislocationonAPandNeerviews.AxialviewisbetterthanNeertoappreciatecorrectlythehumeralheadpositionAxialview肩關(guān)節(jié)失穩(wěn)和肩袖損失第16頁ARTHRO-CTArthro-CTforstagingoflesionsafterbilateralgleno-humeraldislocation:humeralheadbonedefectsandglenoidlesions肩關(guān)節(jié)失穩(wěn)和肩袖損失第17頁ARTHRO-MRArthro-MRtechnique:iodinecontrastanddilutedGd.RadiographyafterfluoscopicguidanceandMR(3planes,T1wFSandT2w)肩關(guān)節(jié)失穩(wěn)和肩袖損失第18頁ANTERIORINSTABILITYMorefrequent90%Recurrences>50%Inyoungpatients,aftertrauma肩關(guān)節(jié)失穩(wěn)和肩袖損失第19頁ABNORMALITIESINANTERIORINSTABILITYAvulsionofgelnoidlabrum75%IGHligamentlesion,HILL-SACHS50%SLAPlesions25%CapsulelaxityRotatorcuffteras(olderpatients)20%肩關(guān)節(jié)失穩(wěn)和肩袖損失第20頁ANTERO-INFERIORDISLOCATIONFirstepisodeThirdrecurrence肩關(guān)節(jié)失穩(wěn)和肩袖損失第21頁BONELESIONSAFTERANTERO-INFERIORDISLOCATIONDislocationAfterreduction,Hill–Sachslesion肩關(guān)節(jié)失穩(wěn)和肩袖損失第22頁ASSOCIATIONOFLESIONSBankartlesiontype4Hill–Sachslesion(samepatient)肩關(guān)節(jié)失穩(wěn)和肩袖損失第23頁BANKARTLESIONSArthro-MR:BankarttypeIII4typesofBankartto1:small,3severe,4fracture肩關(guān)節(jié)失穩(wěn)和肩袖損失第24頁ASSOCIATIONOFLESIONSAvulsion,fractureandloosebodyFromBELTRAN,Radiographics1994,666肩關(guān)節(jié)失穩(wěn)和肩袖損失第25頁P(yáng)OSTERIORINSTABILITYLesscommon<5%Unidirectionalisuncommon.Commonlybidirectional(postandinf)ormultidirectional

Inepilepsy,ethanol,elcetricityshock(3Erule)Alsoduringrepetitiveappliedathleticforces:swimming,throwing,punching,andinsportscollisionsuchasfootball肩關(guān)節(jié)失穩(wěn)和肩袖損失第26頁P(yáng)OSTERIORINSTABILITYClinicaldiagnosismuchmoredifficultthaninanteriorinstabilityImagingtechniquesareimportantEspeciallythefirstradiographicevaluationisESSENTIAL肩關(guān)節(jié)失穩(wěn)和肩袖損失第27頁P(yáng)OSTERIORINSTABILITYPosteriordislocationwithfractureofanterioraspectofthehumeralhead(inverseofHill.Sachsinjury)肩關(guān)節(jié)失穩(wěn)和肩袖損失第28頁P(yáng)OSTERIORINSTABILITYPosteriordislocationwith"poteriorBankart"

FromTIRMAN,MRIclinicsNAm1997,883肩關(guān)節(jié)失穩(wěn)和肩袖損失第29頁MICROINSTABILITYOFSHOULDERMicroinstabilityconcernsthe1/3supjointinsportmenandsportwomen,especiallyforriskofSLAPlesionsArthro-MRissuperiortonativeMRforagoodstagingoflesions,includingviewsinABERposition肩關(guān)節(jié)失穩(wěn)和肩袖損失第30頁MRinABERPOSITIONForanteriorshoulderinstabilityForcapsuleandlabruminjuriesForHILL–SACHSinjuriesWINTZELL1998肩關(guān)節(jié)失穩(wěn)和肩袖損失第31頁MULTIDIRECTIONALINSTABILITYInstabilitymorethaninonedirectionAntero-inferior,postero-inferior,or3directions

Oftenatraumatic(withouttrauma),orviolentinjury,orrepeatedmicrotrauma肩關(guān)節(jié)失穩(wěn)和肩袖損失第32頁ISOLATEDLABRUMTEARSTearswithoutinstabilityButsourceofdysfunctionIntheathleticpopulationInjurysimilartogleno-humeraldislocationSensationofinstability肩關(guān)節(jié)失穩(wěn)和肩袖損失第33頁LABRUMTEARSSLAPlesiontype2c,onarthro-MRSLAP=SsuperiorLlabrumAanteriorPposteriorARTHRO-MRISTHETECHNIQUEOFCHOICE肩關(guān)節(jié)失穩(wěn)和肩袖損失第34頁ROTATORCUFFINJURIESAgeisimportantinshoulderpathologyAccordingtoHoffmeyer<30y.laxityandinstability>30y.tendinopathies,tears>40y.tears,perforation>50y.gleno-humeralosteoarthritis(OA)Med.Hyg1998,56:2218肩關(guān)節(jié)失穩(wěn)和肩袖損失第35頁IMPINGEMENTSYNDROME95%ofrotatorcuff(RC)lesions,Neer1972Mechanicalinjuryfromcompressionofthesubacromialstructures:Suprasupinatus(SSP)tendon,greatertuberosityofhumerus,subacromialbursa

肩關(guān)節(jié)失穩(wěn)和肩袖損失第36頁SECONDARYIMPINGEMENTInyoungpatientsandathletesinvolvedinthrowingsports,shoulderimpingementcanoccurwithinstability肩關(guān)節(jié)失穩(wěn)和肩袖損失第37頁IMAGINGTECHNIQUES

RADIOGRAPHYSONOGRAPHYMRIANDARTHRO-MR肩關(guān)節(jié)失穩(wěn)和肩袖損失第38頁RADIOGRAPHYAP,neutralrotationInternalrotationExternalrotationNeerviewAtleastAPneutralandNeerviews,sometimesint.etext.rotation!肩關(guān)節(jié)失穩(wěn)和肩袖損失第39頁SONOGRAPHYTechnique.broadband-transducers5-12MHz.differenttypesofprobe,includingtype"hockey-stick-shaped"MultidirectionalapproachDynamicandcomparativestudy(bothsides)Onlyperpendicularstructures,becauseobliquitycreatesartefactsOperatordependant肩關(guān)節(jié)失穩(wěn)和肩袖損失第40頁SONOGRAPHYESSENTIALREQUIREMENTS:

.personnalexperience.rigourousexamination.verygoodknowledgeofanatomyPositionofprobeforanteriorapproachofsholuder肩關(guān)節(jié)失穩(wěn)和肩袖損失第41頁SONOGRAPHYFINDINGSDegenerativesuprasupinatustendonandtearPosttraumaticSSPtear肩關(guān)節(jié)失穩(wěn)和肩袖損失第42頁SIGNSOFRCTEARSDIRECTSIGNSOFCOMPLETETEAR1.Flatarea,scaleoftheborder2.Anechoiczonethroughthetendon3.Massivethinessofthetendon4.TendoninvisibleINDIRECTSIGNS1.Erosionsofthegreatertuberosity2.Subacromialbursitis,jointfluid3.Deltoidherniation4.MuscleatrophyPEETRONS肩關(guān)節(jié)失穩(wěn)和肩袖損失第43頁SONOGRAPHYEFFICIENCYINPARTIALRCTEARSSensitivity93%Specificity94%

HOLSBEECKMvRadiology1995,197:443BUTONLYBYEXPERIENCEDOPERATOR!肩關(guān)節(jié)失穩(wěn)和肩袖損失第44頁MAGNETICRESONANCEMRoffersamultiplanarapproachandagoodtissuedifferenciation(thebest)Examinationin3planes:coronal,sagittal,axialMultiplesequences:PDforanatomyT2wFSforsignalFE3DforcartilageArthro-MRforincompletetears,labrumtears

肩關(guān)節(jié)失穩(wěn)和肩袖損失第45頁MAGNETICRESONANCECoronalAxialSagittal肩關(guān)節(jié)失穩(wěn)和肩袖損失第46頁ANATOMICVARIATIONSTHATMAYPREDISPOSETOIMPINGEMENTAcromialshapeAcromiallateraltiltDiminishedarcheightCoracoidlenghtMusclehypertrophyOsacromialeDisplacedgreatertuberosityAcromialshapeflat,curved,hocked肩關(guān)節(jié)失穩(wěn)和肩袖損失第47頁ACROMIALSHAPEANDRCTEARSHockedacromiononAPandNEERviewsAtrhro-MRT1FS:completetearofSSPtendon肩關(guān)節(jié)失穩(wěn)和肩袖損失第48頁ROTATORCUFFTEARSFunctionalinfirmityElevationofRupperlimbimpossibleArthro-MR:completetearofSSPtendonwitretraction肩關(guān)節(jié)失穩(wěn)和肩袖損失第49頁ROTATORCUFFTEARSDimensionsoffullthicknesstearsclassifiedonbasisofgreatestdimensionsSmall<1cmMedium1-3cmIMPLICATIONFORTTLarge3-5cmMassive>5cmDeOrio,CofieldJBJSam1984,66(4):563肩關(guān)節(jié)失穩(wěn)和肩袖損失第50頁P(yáng)ARTIALRCTEARSInferiorSSPtearmorecommonthansuperiortearNottreatedmayleadtochronicpainandinvalidityMaypropagatetofullthicknesstearGradingofpartialtears1.less3mm2.3-6mm3.more6mm肩關(guān)節(jié)失穩(wěn)和肩袖損失第51頁P(yáng)ARTIALRCTEARSArthro-MR:inferiorpartialofthesuprasupinatustendon;noperforation,nopassageofcontrastmediuminsubacromialbursa肩關(guān)節(jié)失穩(wěn)和肩袖損失第52頁MULTIPLERCTEARSSometimesinfrasupinatusandsubscapularistearsareassociatedwithasuprasupinatustearAcompletegoodstagingiscompulsoryforchoosingthebesttt,especiallybeforeeventualsurgery(whichtypeofsurgicalrepair…)Forasuchevaluation,MRandsometimesarthroMR,arethetechniquesofchoice肩關(guān)節(jié)失穩(wěn)和肩袖損失第53頁MULTIPLERCTEARSSuprasupinatuscompletetear,retractionoftendon,muscleatrophywithinfrasupinatuspartialtearandmuscleatrophy.AlsoOAinAC肩關(guān)節(jié)失穩(wěn)和肩袖損失第54頁EXTENTOFRCTEARSTHOMAZEAUClinOrthopRelatRes1997,344:275肩關(guān)節(jié)失穩(wěn)和肩袖損失第55頁MUSCLEATROPHYMuscleatrophyfollowsarotatorcufftearnottreatedMuscleatrophyverywellappreciatedbyMRDependsonthelenghtofevolutionStage1.fewfattytrails2.moremusclethanfat3.muscle=fat4.morefatthanmuscleAfter6monthsofevolutionstage>2,after1yearstage4GoutalierDClinOrthop1994,304:78肩關(guān)節(jié)失穩(wěn)和肩袖損失第56頁MUSCLEATROPHYAnormalSSPmuscleoccupythewholesupraspinatusareaWhenatrophythevolumedecreased肩關(guān)節(jié)失穩(wěn)和肩袖損失第57頁ACROMIOCLAVICULARJOINTINJURIES

VeryofteninlookingforaneventualRCtear,anacromioclavicularjointinjuryisdiscovered,suchasosteoarthritiswithbonyspurs,andevenwithaninflammatorycomponent(b