肩袖損傷cufftear課件

肩袖是什麼？肩峰下間隙肩關(guān)節(jié)解剖肩關(guān)節(jié)解剖肩關(guān)節(jié)解剖肩袖損傷有哪些表現(xiàn)？疼痛疼痛弧60°~120°肩上活動(dòng)疼:間斷/持續(xù)，程度休息或夜間疼力弱weakness外展及外旋時(shí)明顯彈響click不穩(wěn)instability疼痛弧肩疼的鑒別診斷肩以外因素肩疼特點(diǎn)肩本身疼可放散至上臂疼（C5，C6）Palmsign手掌征：盂肱、肩峰下Fingersign手指征：肩鎖、胸鎖不能患側(cè)臥很少伴有手麻肩疼的部位：盂肱、肩峰下、肩鎖等物理檢查(1)物理檢查(2)一般檢查:畸形ROM:主動(dòng),被動(dòng)肌肉萎縮肌力:外展,外旋物理檢查(3)物理檢查(4)岡上肌實(shí)驗(yàn)Jobetest/Yocum’s：wholeSSPPalm-uptest(Dalton1989):前屈90°抗阻，對(duì)SSP最前部分敏感外旋抗阻力弱：SSP？置體側(cè)敏感ISP&

minorLift-offtest（Gerber,1991)：腰中部，SSC下部分Lift-offlagsign(1996)Belly-presstest:SSC上部分

物理檢查(5)

Lagtest

肩胛下肌腱Lift-offtestLift-offlagsignBelly-presstestIRRSTHawkin’simpingementtestNeer’simpingementsignERLS-externalrotationlagsignHornblower’ssignDroparmsignExternalrotationresisitance物理檢查(5)Gerber’ssubcoracoidimpingementtestHamner’smodifiedrelocationtest(2000):Internalimpingement:90°,110°,120°Speed’stestYergason’stest肩關(guān)節(jié)檢查—牽拉試驗(yàn)物理檢查(4)封閉試驗(yàn)（撞擊試驗(yàn)）外展抗阻疼1%利多卡因10ml,肩峰下滑囊封閉封閉后外展抗阻疼明顯減輕或消失Therent(裂縫)test

TipofFingerPalpatingEminenceandSulcus

大結(jié)節(jié)觸摸試驗(yàn)肘屈90°,肩外展60°一手觸大結(jié)節(jié),一手固定肘并旋轉(zhuǎn)大結(jié)節(jié)處可及彈響+疼subscapularisLift-offtest:distalpartBelly-presstest:proximalpart特殊檢查X線片:Y位:肩峰形態(tài),骨刺大結(jié)節(jié)硬化及囊性變肩峰下間隙（7~13）肩鎖關(guān)節(jié)造影超聲檢查CT&CTAMRI&MRA關(guān)節(jié)鏡關(guān)節(jié)造影造影劑進(jìn)入肩峰下滑囊CTArthrographyMRI的診斷價(jià)值全厚撕裂敏感性：不壓脂：80%；壓脂：100%部分撕裂敏感性：不壓脂：15%；壓脂：35%乒乓球—小撕裂于—舉重運(yùn)動(dòng)員MRI（-），MRA（+）投擲教練—巨大撕裂投擲運(yùn)動(dòng)員—大撕裂超聲的診斷價(jià)值全撕裂：部分撕裂敏感性特異性準(zhǔn)確性66.7~100%75~94%90%以上敏感性特異性準(zhǔn)確性66.7~93%94%94.9%肩峰撞擊征中二頭肌腱部分?jǐn)嗔鸭缧渚薮笏毫鸭缧湫∷毫鸭缧渌毫眩ú糠郑┘珀P(guān)節(jié)不穩(wěn)的檢查肩關(guān)節(jié)不穩(wěn)的檢查平移試驗(yàn)Translation，anterior/posterior：凹陷征（Sulcussign）-下方移位抽屜試驗(yàn)恐懼試驗(yàn)“clunk”test：外展90，外旋90，推肱骨頭向前Relocationtest—releasetest平移試驗(yàn)translation肩關(guān)節(jié)檢查IsthistrueshoulderpainHowdidthepainstartWhichMovementexacerbateSucksign前抽屜試驗(yàn)外展80~120°前屈0~20°外旋0~30°肩胛骨固定clunktest外展90°外旋壓肱骨頭向前感覺(jué)前盂唇有摩擦音為陽(yáng)性恐懼試驗(yàn)

Theapprehensiontest外展90°緩慢增加外旋同時(shí)壓肱骨頭向前恐懼相，有要脫出感單純疼非陽(yáng)性復(fù)位及反跳試驗(yàn)

Relocationtest—releasetest仰臥，肩置床沿外展外旋至有脫出感位置向后施力于肱骨近端疼減輕外旋角度增加突然松手疼增加，并恐懼感CTArthrographyAcuteBankart-MRIBankart-MRAMRA后上盂唇損傷投擲運(yùn)動(dòng)員MRA顯示后上盂唇撕裂MRA后上盂唇損傷投擲運(yùn)動(dòng)員加速初期疼有時(shí)卡哪些原因引起肩袖損傷？外因：外傷、撞擊、疲勞通過(guò)內(nèi)因:退變、老化、血供不足起作用哪些原因引起肩袖損傷？急性創(chuàng)傷撞擊盂肱關(guān)節(jié)不穩(wěn)勞損傷（repetitivetensilefailure)肩袖創(chuàng)傷性撕裂傷

（avulsiontear）撕裂原因正常健康組織：極少撕裂

GROUP1創(chuàng)傷較大：如肩脫位7~9%肌腱張力及彈性下降：

GROUP2年齡》40多年、以上肢為主的體育運(yùn)動(dòng)運(yùn)動(dòng)性早老（Athleticallyacceleratedaging）反復(fù)肩疼，治療（包括封閉）緩解乏血管區(qū)

外力可以很小損傷病理明確的一次外傷史腱組織退變：鈣沉積、纖維樣增厚、硬化及瘢痕形成、細(xì)胞變性、壞死腱組織部分撕裂及不規(guī)則瘢痕形成，間質(zhì)細(xì)胞增殖肩袖勞損傷

repetitivetensilefailure損傷原因原發(fā)：投擲運(yùn)動(dòng)員：尤其減速期繼發(fā)：盂肱關(guān)節(jié)不穩(wěn)原發(fā)傷投擲加速期：角速度達(dá)1100°/s旋轉(zhuǎn)：7000°/s減速期；盂肱牽拉力≈90%體重岡上、岡下、小圓肌離心式收縮表現(xiàn)：肌腱下表面的部分撕裂繼發(fā)傷GH不穩(wěn)：occult↓移位增加↓肩袖活動(dòng)增加抵抗移位↓疲勞↙↘繼發(fā)撞擊→肩袖損傷肩峰撞擊肩峰撞擊的概念關(guān)于肩峰肩峰融合:18~25歲(18~19)

不融合4型:PreMeso:最多MetaBasi肩峰形狀:關(guān)于肩峰肩峰形狀:Bigliani三型正常(尸解及門(mén)診):Ⅰ18%,Ⅱ及Ⅲ各41%撕裂者:Ⅲ66~80%,Ⅰ3~6%,Ⅱ28%本所30例:Ⅲ27%,Ⅰ7%,Ⅱ66%關(guān)于肩峰Wuh&Snyder:肩峰厚度（前中1/3交界）A：〈8mmB：8—12mmC：〉12mm肩峰斜率<35°及長(zhǎng)度

爭(zhēng)議動(dòng)物實(shí)驗(yàn)：肩峰前下加墊，均產(chǎn)生滑囊側(cè)撕裂，無(wú)關(guān)節(jié)側(cè)撕裂肩袖損傷分類(lèi)肩袖部分撕裂分三型：關(guān)節(jié)側(cè)型滑囊側(cè)型腱間型

肩袖損傷分類(lèi)完全撕裂程度分類(lèi)小：<1cm中度:1-3cm大:3-5cm廣泛:>5cm

DefinitionofmassivetearTear>5cm,orientation?tearsofatleast

2tendonsofrotatorcuffTearsizebysquarecentimeter:greaterthan20cm2lengthofdetachmentfromtheheadmultipliedbythemedializationofthecuff治療肩袖損傷的關(guān)節(jié)鏡下治療肩袖損傷的關(guān)節(jié)鏡下治療Arthroscopicsubacromialdecompression-AS(A)DASD

advantagesvsopenExcellentvisualizationofGHVisualizationforpartialthicknesstearLesstraumatoDeltoidOutpatientsurgeryDecreasedrecoverytimeASD

indicationHistory&exam.consistentwithimpingementsyndromeDiscomfortelevatedin90°-120°NightpainFullROM&lackofresponsetoseveralmonthsofnon-operativeRxExpressionsofcuffdisease,eitherpartialorcompleteASDforarticularsideteariscontroversialASD

roomsetupLateraldecubitusposition(LDP)isprefered15°forwardflexion30°abdSuspendwith10-15poundsRolledtowelintheaxillatopretectbra.PlexusLowerthesystolicBPto90-95mmHgApartcamerafromshaver-suctiontopreventtanglingASD

bursoscopyEstablishposteriorbursalportalEstablishlateralbursalportal:3fingerbreadthsControlofbleedingRemoveinflamedbursaASD

fourstepsDetachtheCAlig.ExceptmassiveunreparabletearDefinetheanterolateralacromionAcromialresectionfromposteriortoanteriorAcromionresectionfromlateraltomedial對(duì)運(yùn)動(dòng)員：投擲：68%優(yōu)良（Neerrating）非投擲：90%優(yōu)良投手：50%優(yōu)良6~10年：33%運(yùn)動(dòng)員不能重返運(yùn)動(dòng)場(chǎng)Arthroscopictreatment

of

partialthicknessrotatorcufftear

PartialthicknesscufftearIntratendinous:

relatedtoage&repetitivetraumaArticular-sided:lackofhealing&tolarger(52+28)Bursal-sided:extrinsicimpingement,ASADPartialthicknesscufftearSupraspinatustendon(cadavera)MeanAPdimension25mm(19~27)Meanmedtolatthicknessoffootprint12mmAnterior11.6Midtendon12.1Posterior12Meandistancefromcartilagetofootprint1.9mmatinterval1.5mmatmid-tendon1.8mmatposterioredgePartialthicknesscufftearEllman’sclassification:Grade1:<3mmindepth(<25%)Grade2:3-6mm(<50%)Grade3:>6mmgreater50%(repair)WesleyMNottage:>7mmofexposedbonelateraltocartilageedge(indicateatleast50%thickness)PartialthicknesscufftearFrankACordasco:SADsufficient:Grade1&2ARepair:2BPartialthicknesscufftearPartialthicknesscufftear

Bursal-sided由肩峰下撞擊引起ASAD效果好診斷困難：PartialthicknesscufftearPartialthicknesscufftearPartialthicknesscufftearArthroscopiccuffrepairFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftearFullthicknesscufftear鏡下縫合的效果Gartsman(Texuas)73≥2年Sutureanchor90%優(yōu)良TauroJC（NewJerseey532-3年Sutureanchor92.5%優(yōu)良Baker203.2年OPEN80%優(yōu)良88%滿意17≥2年關(guān)節(jié)鏡（1月）85%優(yōu)良92%滿意ZanottiRM10例松解，縫合均有功能障礙1例肩胛上N傷2例再斷KarasSE20例肩胛下肌腱轉(zhuǎn)移+減壓30月（23~70）17/20滿意，19/20疼減輕，9/20弱不適BiglianiLU30重修52%滿意，81%疼減輕；45%力弱GerberC16例背闊肌轉(zhuǎn)移33月94%疼滿意atrest81%onexertionLeHuecJC14例三角肌瓣+decron40月10例很滿意；2例滿意2例不滿意ArntzCT人工置換hemiarthroplasty21例隨訪：25~122月15/18疼明顯減輕10例不疼4例過(guò)度OVERHEAD活動(dòng)疼1例好，但又骨折加重ROM前屈66→109°3/18返修未發(fā)生假體松動(dòng)Massivetearofcuff

arthroscopicmeaning&advantagesMinimizeDeltoidmorbidity.m.istheonlynormalm.aroundinmassivetearpat.PreservationisverydesirableMini-open:moredifficultAccuratearthroscopicevaluationAllowsforinferiorcap.releasePRNBicepstenodesisReh.“easier”,butnotquickerCosmeticallydesirableMassivetearofcuff

arthroscopicreparability&difficultiesTechnicallychallengingbutpossibleEssentialextensiveexperienceinsmallerExtensivemobilizationrequiredEquipmentintensive

combineconvergentsuture&anchorfixationRelativelyquickerPreparationSomeresidualacromiohumeraldistancemaintainedProblems

uniqueto

large&massivetearStiffness:adhesionofcuffinferiorcapsularcontractureTendonretractionTendonquality:thin,friable,tenuousosteopeniaSurgicaltechniqueEUA:lossofpROMrestoredbygentlemanipulationPosition:eitherLDPorbeach:+gentletractionPortals:standardSurgicaltechnique

--GHarthroscopyBicepsCartilageSynovitis:partialsynovectomyIfpROM,manipulationfailedcapsularreleaseSurgicaltechnique

--SABBursaevaluationAssessmentofcuffreparability:

tear&qualityASD:notresectCAlig.unlesssecurecuffrepaircanbedoneTuberositiespreparedSurgicaltechnique

methodsofmobilizationofcuffSuperio