肌腱滑囊及关节囊的慢性损伤性炎症课件

浙江大学医学院八年制教学浙江大学医学院八年制教学神经精神与运动1（模块2）运动系统慢性疾病肩关节周围炎、腱鞘炎股骨头坏死浙江大学医学院附属二院骨科吴立东浙江大学医学院八年制教学神经精神与运动1（模块2）1运动系统慢性损伤运动系统慢性损伤Chronic injury of soft tissue 2概述概述Overviewn n临床常见病，多发病n n涉及骨，关节，肌肉，肌腱，韧带，筋膜及其相关的血管神经n n分类：软组织，骨，软骨慢性损伤及周围神经卡压概述Overview临床常见病，多发病3特点特点Feature n n局部慢性，无外伤史n n有特定部位压痛点和肿块，可放射痛n n局部无明显炎症表现n n近期有与疼痛部位相关的过度活动史n n部分病人偶导致运动系统慢性损伤的工种，坐姿和工作习惯或职业特点Feature 局部慢性，无外伤史4治疗治疗 Treatmentn n限制致伤活动，或纠正不良姿势，维持关节的不负重活动n n积极物理治疗，按摩推拿，外敷及熏蒸。n n正确合理使用肾上腺皮质激素n n非甾体消炎镇痛药的合理使用（短期；外用；缓释剂，肠溶剂，栓剂；肾功能不佳者可选用短半衰期药物）n n手术治疗 Treatment限制致伤活动，或纠正不良姿势，维持关5Strain of lumbar muscles腰肌劳损腰肌劳损n nCommon cause of lumbar painn nLocal tenderness,start point or end point of musclesn nBack pain,relieve after rest or activitiesn nErector spainae muscle spasm Strain of lumbar muscles腰肌劳损C6Treatment n nSelf care therapy,change positionn nPhysiotherapy,massagen nLocal steroid injectionn nAnti-inflammatory drugsTreatment Self care therapy,c7Supraspinous ligament injuryinterspinous ligament injuryn nCommon cause of back painn nSupraspinour ligament injury common in middle thoracic segmentn nInterspinous ligament injury common in lower lumbar segmentSupraspinous ligament injuryi8n nNo trauma historyn nBend or hyperextension painn nLocal tendernessn nSteroid injectionn nPhysiotherapy or massagen nimmobilizationNo trauma history9Bursitis 滑囊炎滑囊是位于人体摩擦频繁或压力较大部位的一种缓冲结构。分为恒定滑囊，继发性滑囊或附加滑囊 Bursitis 滑囊炎 10n nBursae 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.n nmay or may not communicate with a joint.n nFunction:reduce friction,protect delicate structures from pressure.肌腱滑囊及关节囊的慢性损伤性炎症课件11肌腱滑囊及关节囊的慢性损伤性炎症课件12n nBursae 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 arthritis.Bursae are similar to tendon s13n nTwo 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.Two types of bursae:normally 14Treatment-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:rest,hot wet packs,elevation,and,if necessary,immobilization of the affected part.肌腱滑囊及关节囊的慢性损伤性炎症课件15Peoplebetweentheagesof40and70aremorecommonlyaffected.VascularizedFibularGrafting股骨头核心活检结果最为准确，组织病理学空心钉植入钽棒植入StenosingTenosynovitis狭窄性腱鞘炎(Osgood-Schlatterdisease)(Osteochondroldiseaseofthetibialtubercle)Approximately10%ofpatientshavelong-termproblems.Lateralsubluxationofthefemoralheadfromtheacetabulum,SteroidinjectionSalterandThompsonclassificationPhysiotherapy,massageTreatment n nAspiration and steroid injectionn nSurgical procedures useful in treating bursitis are(1)incision and drainage when an acute suppurative bursitis fails to respond to nonsurgical treatment,(2)excision of chronically infected and thickened bursae,and(3)removal of an underlying bony prominencePeople between the ages of 40 16Stenosing Tenosynovitis狭窄性腱鞘炎n nmore often in the hand and wrist than anywhere else in the body.n nA peritendinitis may affect these tendons,causing pain,swelling,and crepitus.Stenosing Tenosynovitis狭窄性腱鞘17n nWhen 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 tenosynovium 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 a18DE QUERVAIN DISEASEn nStenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons n nWhen 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.n n.DE QUERVAIN DISEASEStenosing t19n nWomen are affected 10 times 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 affected 10 times mo20diagnosisThe The FinkelsteinFinkelstein test usually is test usually is positive:on grasping the patients positive:on grasping the patients thumb and quickly abducting the thumb and quickly abducting the hand ulnarward,the pain over the hand ulnarward,the pain over the styloid tip is excruciating.styloid tip is excruciating.Although Finkelstein states that Although Finkelstein states that this test is probably the most this test is probably the most pathognomonic objective sign,it pathognomonic objective sign,it is not diagnostic;the patients is not diagnostic;the patients history and occupation,the history and occupation,the roentgenograms,and other roentgenograms,and other physical findings must also be physical findings must also be considered.considered.diagnosisThe Finkelstein test 21Treatmentn nConservative treatment,consisting of rest on a splint and the injection of a steroid preparation into the tendon sheath,is most successful within the first 6 weeks after onset.n nSteroid injectionn nWhen pain persists,surgery is the treatment of choice(complete relief)TreatmentConservative treatmen22TRIGGER FINGER AND THUMB弹响指和弹响拇n nStenosing tenosynovitis,leading to inability to Stenosing tenosynovitis,leading to inability to extend the flexed digit(triggering)usually is extend the flexed digit(triggering)usually is seen after 45 years of age.seen after 45 years of age.n nPatients may note a lump or knot in the palm.Patients may note a lump or knot in the palm.The lump may be the thickened area in the first The lump may be the thickened area in the first annular part of the flexor sheath,or a nodule or annular part of the flexor sheath,or a nodule or fusiform swelling of the flexor tendon just distal fusiform swelling of the flexor tendon just distal to it.The nodule can be palpated by the to it.The nodule can be palpated by the examiners fingertip and will move with the examiners fingertip and will move with the tendon.The tendon nodule usually is at the entry tendon.The tendon nodule usually is at the entry of the tendon into the proximal annulus at the of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.level of the metacarpophalangeal joint.TRIGGER FINGER AND THUMB弹响指和弹23Treatmentn nTreatment of trigger digits Treatment of trigger digits usually is nonoperative in the usually is nonoperative in the uncomplicated patient who uncomplicated patient who presents a short time after presents a short time after onset of symptoms.onset of symptoms.Nonoperative methods include Nonoperative methods include stretching,night splinting,and stretching,night splinting,and combinations of heat and binations of heat and ice.Corticosteroid injection is Corticosteroid injection is effective after one injection effective after one injection n nSurgical release reliably Surgical release reliably relieves the symptom for most relieves the symptom for most patientspatientsTreatmentTreatment of trigger 24Ganglion Ganglion 25Treamentn nSqueezen nAspiration and steroid injectionn nOperationTreamentSqueeze26Lateral epicondylitis肱骨外上髁炎n nLateral epicondylitis(tennis elbow),Lateral epicondylitis(tennis elbow),a familiar term used to described a a familiar term used to described a myriad of symptoms about the myriad of symptoms about the lateral aspect of the elbow,occurs lateral aspect of the elbow,occurs more frequently in nonathletes than more frequently in nonathletes than athletes,with a peak incidence in athletes,with a peak incidence in the early fifth decade and a nearly the early fifth decade and a nearly equal gender incidence.equal gender incidence.n nActivities that require repetitive Activities that require repetitive supination and pronation of the supination and pronation of the forearm with the elbow in near full forearm with the elbow in near full extension.extension.Lateral epicondylitis肱骨外上髁炎La27n nTenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle.Pain usually is 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.肌腱滑囊及关节囊的慢性损伤性炎症课件28n nRegardless of the underlying cause,nonoperative treatment is successful in 95%of patients with tennis elbown n Initial nonoperative treatment includes rest,ice,injections,and physical therapy centered around treatment such as ultrasound,electrical stimulation,manipulation,soft tissue mobilization,friction massage,stretching and strengthening exercises,and counter-force bracing.Regardless of the underlying c29n nSteroid injectionn nIf prolonged(6 to 12 months),operative treatment may be considered;it is effective in 90%of properly selected patients.Steroid injection30Adhesive Capsulitis（frozen shoulder.）肩周炎或称冻结肩或五十肩肩周炎或称冻结肩或五十肩肩周，肌腱，滑囊及关节囊的慢性损伤性炎肩周，肌腱，滑囊及关节囊的慢性损伤性炎症，主要表现为活动时疼痛，功能受限症，主要表现为活动时疼痛，功能受限Adhesive Capsulitis31肩部结构肩部结构n n肩部外层肌肉为三角肌n n内层为肩袖，由冈上肌，冈下肌，肩胛下肌和小圆肌及肌腱组成n n肱二头肌长头n n关节囊n n滑囊n n肩胛盂和肱骨头肩部结构肩部外层肌肉为三角肌32Frozen shoulders in patients who report no inciting event and with no abnormality on examination(other than loss of motion)or 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 w33n nNo formal inclusion criteria.There are no universally accepted criteria for the diagnosis of frozen shoulder.internal rotation frequently is lost initially,followed by loss of flexion and external rotation.n nThe incidence of frozen shoulder in the general population is approximately 2%.(an increased incidence associated with,including diabetes mellitus(up to 5 times more),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.34Rotator cuff肩袖肩袖n n冈上肌，冈下肌，肩胛下肌和小圆肌n nSupraspinatus，infraspinatus，subscapular muscle，teres minorn nPain may disappearn nDysfunctionRotator cuff肩袖冈上肌，冈下肌，肩胛下肌和小圆肌35Primary Frozen Shouldern nPrimary frozen shoulder is a vague entity that Primary frozen shoulder is a vague entity that only rarely recurs in the same shoulder.The only rarely recurs in the same shoulder.The clinical course of primary(idiopathic)frozen clinical course of primary(idiopathic)frozen shoulder consists of three phases.shoulder consists of three phases.n nPhase IPhase IPain.Patients usually have a gradual Pain.Patients usually have a gradual onset of diffuse shoulder pain,which is onset of diffuse shoulder pain,which is progressive over weeks to months.The pain progressive over weeks to months.The pain usually is worse at night and is exacerbated by usually is worse at night and is exacerbated by lying on the affected side.As the patient uses lying on the affected side.As the patient uses the arm less,pain leading to stiffness ensues.the arm less,pain leading to stiffness ensues.Primary Frozen ShoulderPrimary36Primary Frozen Shouldern nPhase 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 wallets 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 I37Primary Frozen Shouldern nPhase IIIThawing.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 or adjustment in ways of performing activities of daily living.Primary Frozen ShoulderPhase I38Secondary Frozen Shouldern nUnlike patients with idiopathic frozen shoulder,patients with secondary frozen shoulder can recall a specific precipitating event,possibly related to overuse or injury.The three 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 ShoulderUnlik39Diagnosisn ntests in patients with a frozen shoulder(including tests in patients with a frozen shoulder(including plain film roentgenograms)usually are normal,plain film roentgenograms)usually are normal,except in those with medical disorders such as except in those with medical disorders such as diabetes or thyroid disease.Bone scans have diabetes or thyroid disease.Bone scans have been reported to be positive in some patients.been reported to be positive in some patients.n nArthrograms characteristically show a reduced Arthrograms characteristically show a reduced joint volume with irregular margins.Clinical joint volume with irregular margins.Clinical improvement has been reported after improvement has been reported after arthrography because of brisement of adhesions arthrography because of brisement of adhesions from forcefully injecting fluid into the joint.A from forcefully injecting fluid into the joint.A volume of less than 10 ml and lack of filling of volume of less than 10 ml and lack of filling of the axillary fold currently are accepted the axillary fold currently are accepted arthrographic findings indicative of a frozen arthrographic findings indicative of a frozen shoulder.shoulder.Diagnosistests in patients wit40Differential diagnosisn nCervical spondylosisn nRotator cuff tearDifferential diagnosisCervical41Treatmentn nTraditionally,frozen shoulder has been considered a Traditionally,frozen shoulder has been considered a self-limiting condition,lasting 12 to 18 months.self-limiting condition,lasting 12 to 18 months.n nApproximately 10%of patients have long-term Approximately 10%of patients have long-term problems.Patients seeking care earlier usually problems.Patients seeking care earlier usually recover more quickly.Dominant shoulder recover more quickly.Dominant shoulder involvement has been reported to be predictive of a involvement has been reported to be predictive of a good result,whereas occupation and treatment good result,whereas occupation and treatment programs are not statistically significant.Obviously,programs are not statistically significant.Obviously,the best treatment of frozen shoulder is prevention the best treatment of frozen shoulder is prevention(secondary frozen shoulder),but early intervention(secondary frozen shoulder),but early intervention is of paramount importance;a good understanding is of paramount importance;a good understanding of the pathological process by the patient and the of the pathological process by the patient and the physician also is important.physician also is important.TreatmentTraditionally,frozen42Treatmentn nInitial treatment is nonoperative,with emphasis placed on control of pain and inflammation.n n passive and active range-of-motion exercises.Abduction should be avoided initially to prevent impingement until joint motion becomes more supple.n nPhysiotherapyn nSteroid injectionn nNSAIDS drugsTreatmentInitial treatment is 43Treatmentn nAlthough a frozen shoulder usually is self-Although a frozen shoulder usually is self-limiting and resolves in 12 to 18 months,many limiting and resolves in 12 to 18 months,many patients do not wish to wait that long for patients do not wish to wait that long for resolution of symptoms and request active resolution of symptoms and request active intervention long before 12 months.With intervention long before 12 months.With appropriate patient selection,significant appropriate patient selection,significant improvement can be obtained in approximately improvement can be obtained in approximately 70%of patients.70%of patients.n nClosed manipulation under anesthesiaClosed manipulation under anesthesian nOpen release of contracturesOpen release of contracturesTreatmentAlthough a frozen sho44Treatmentn nArthroscopic release Arthroscopic release is an option when is an option when closed manipulation closed manipulation fails or for patients fails or for patients who have had who have had prolonged,prolonged,recalcitrant adhesive recalcitrant adhesive capsulitis.capsulitis.TreatmentArthroscopic release 45Chondromalacia patella髌骨软骨软化症髌骨软骨软化症Chondromalacia patella髌骨软骨软化症46Epiphysitis of tibial tuberosity胫骨结节骨骺炎n n(Osgood-Schlatter disease)(Osteochondrol disease of the tibial tubercle)n nCommon age 12-14 ysEpiphysitis of tibial tuberosi47OSGOOD-SCHLATTER DISEASEOSGOOD-SCHLATTER DISEASE n nDisorders of actively growing Disorders of actively growing epiphyses.The disorder may epiphyses.The disorder may be localized to a single be localized to a single epiphysis or occasionally epiphysis or occasionally may involve two or more may involve two or more epiphyses simultaneously or epiphyses simultaneously or successively.The cause successively.The cause generally is unknown,but generally is unknown,but evidence indicates a lack of evidence indicates a lack of vascularity that may be the vascularity that may be the result of trauma(quadriceps),result of trauma(quadriceps),infection,or congenital infection,or congenital malformation.malformation.OSGOOD-SCHLATTER DISEASE 48Anti-inflammatorydrugsWithnewbearingsurfacesbecomingavailable,suchasceramiconceramic,metalonmetal,andhighlycross-linkedpolyethylene,resultsmayimproveevenmore.(anincreasedincidenceassociatedwith,includingdiabetesmellitus(upto5timesmore),cervicaldiscdisease,hyperthyroidism,intrathoracicdisorders,andtrauma).Greatcareshouldbetakennottoinjectdirectlyintothenerve.Thelumpmaybethethickenedareainthefirstannularpartoftheflexorsheath,oranoduleorfusiformswellingoftheflexortendonjustdistaltoit.Theclinicalcourseofprimary(idiopathic)frozenshoulderconsistsofthreephases.SalterandThompsonclassificationWomenareaffected10timesmorefrequentlythanmen.我们应该做的：明确的术前告知Paresthesiaoverthesensorydistributionofthemediannerveisthemostfrequentsymptom;moreofteninwomenandfrequentlycausesthepatienttoawakenseveralhoursaftergettingtosleepwithburningandnumbnessofthehandthatisrelievedbyexercise.Thecause：chronicinjuryBursaearesacslinedwithamembranesimilartosynovium;theyusuallyarelocatedaboutjointsorwhereskin,tendon,ormusclemovesoverabonyprominence.TRIGGERFINGERANDTHUMB弹响指和弹响拇Painusuallyisexacerbatedbyresistedwristdorsiflexionandforearmsupination,andthereispainwhengraspingobjects.BMP及生物因子植入ConclusionsPhaseIIIThawing.双支撑骨柱移植支撑物加植骨Treatmentn nSelf limited diseasen nObservation,remain eminance of TTn nSurgery rarely is indicated n nthe disorder usually becomes asymptomatic without treatment or with simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeksAnti-inflammatory drugsTreatme49Legg-Calve-Perthes DiseasePerthes病 n nThe cause：chronic injury n