肌腱滑囊及关节囊的慢性损伤性炎症课件

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 Chronic injury of soft tissuetissue 2概述概述OverviewOverviewn 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 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 TreatmentTreatmentn 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 musclesStrain 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 Treatment n nSelf care therapy,change positionn nPhysiotherapy,massagen nLocal steroid injectionn nAnti-inflammatory drugsTreatment Self care therapy,c7Supraspinous ligament injurySupraspinous ligament injuryinterspinous 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 history9BursitisBursitis 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15Treatment Treatment 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 prominenceTreatment Aspiration and stero16Stenosing 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 mo20diagnosisdiagnosisThe The FinkelsteinFinkelstein test usually test usually is positive:on grasping the is positive:on grasping the patients thumb and quickly patients thumb and quickly abducting the hand ulnarward,abducting the hand ulnarward,the pain over the styloid tip the pain over the styloid tip is excruciating.Although is excruciating.Although Finkelstein states that this Finkelstein states that this test is probably the most test is probably the most pathognomonic objective sign,pathognomonic objective sign,it is not diagnostic;the it is not diagnostic;the patients history and patients history and occupation,the occupation,the roentgenograms,and other roentgenograms,and other physical findings must also be physical findings must also be considered.considered.diagnosisThe Finkelstein test 21TreatmentTreatmentn 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 Stenosing tenosynovitis,leading to inability to extend the flexed digit inability to extend the flexed digit(triggering)usually is seen after 45(triggering)usually is seen after 45 years of age.years of age.n nPatients may note a lump or knot in the Patients may note a lump or knot in the palm.The lump may be the thickened area in palm.The lump may be the thickened area in the first annular part of the flexor the first annular part of the flexor sheath,or a nodule or fusiform swelling of sheath,or a nodule or fusiform swelling of the flexor tendon just distal to it.The the flexor tendon just distal to it.The nodule can be palpated by the examiners nodule can be palpated by the examiners fingertip and will move with the tendon.fingertip and will move with the tendon.The tendon nodule usually is at the entry The tendon nodule usually is at the entry of the tendon into the proximal annulus at of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.the level of the metacarpophalangeal joint.TRIGGER FINGER AND THUMB弹响指和弹23TreatmentTreatmentn nTreatment of trigger digits Treatment of trigger digits usually is nonoperative in usually is nonoperative in the uncomplicated patient the uncomplicated patient who presents a short time who presents a short time after onset of symptoms.after onset of symptoms.Nonoperative methods Nonoperative methods include stretching,night include stretching,night splinting,and combinations splinting,and combinations of heat and ice.of heat and ice.Corticosteroid injection is Corticosteroid injection is effective after one effective after one injection injection n nSurgical release reliably Surgical release reliably relieves the symptom for relieves the symptom for most patientsmost patientsTreatmentTreatment of trigger 24Ganglion Ganglion Ganglion 25TreamentTreamentn nSqueezen nAspiration and steroid injectionn nOperationTreamentSqueeze26Lateral epicondylitis肱骨外上髁炎n nLateral epicondylitis(tennis Lateral epicondylitis(tennis Lateral epicondylitis(tennis Lateral epicondylitis(tennis elbow),a familiar term used to elbow),a familiar term used to elbow),a familiar term used to elbow),a familiar term used to described a myriad of symptoms described a myriad of symptoms described a myriad of symptoms described a myriad of symptoms about the lateral aspect of the about the lateral aspect of the about the lateral aspect of the about the lateral aspect of the elbow,occurs more frequently in elbow,occurs more frequently in elbow,occurs more frequently in elbow,occurs more frequently in nonathletes than athletes,with a nonathletes than athletes,with a nonathletes than athletes,with a nonathletes than athletes,with a peak incidence in the early fifth peak incidence in the early fifth peak incidence in the early fifth peak incidence in the early fifth decade and a nearly equal gender decade and a nearly equal gender decade and a nearly equal gender decade and a nearly equal gender incidence.incidence.incidence.incidence.n nActivities that require repetitive Activities that require repetitive Activities that require repetitive Activities that require repetitive supination and pronation of the supination and pronation of the supination and pronation of the supination and pronation of the forearm with the elbow in near forearm with the elbow in near forearm with the elbow in near forearm with the elbow in near full extension.full extension.full extension.full 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 CapsulitisAdhesive Capsulitis（frozen shoulder.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 cuffRotator 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 ShoulderPrimary Frozen Shouldern nPrimary frozen shoulder is a vague entity Primary frozen shoulder is a vague entity that only rarely recurs in the same that only rarely recurs in the same shoulder.The clinical course of primary shoulder.The clinical course of primary(idiopathic)frozen shoulder consists of(idiopathic)frozen shoulder consists of three phases.three phases.n nPhase IPain.Patients usually have a Phase IPain.Patients usually have a gradual onset of diffuse shoulder pain,gradual onset of diffuse shoulder pain,which is progressive over weeks to months.which is progressive over weeks to months.The pain usually is worse at night and is The pain usually is worse at night and is exacerbated by lying on the affected side.exacerbated by lying on the affected side.As the patient uses the arm less,pain As the patient uses the arm less,pain leading to stiffness ensues.leading to stiffness ensues.Primary Frozen ShoulderPrimary36Primary Frozen ShoulderPrimary 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 ShoulderPrimary 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 ShoulderSecondary 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 ShoulderUnlik39DiagnosisDiagnosisn ntests in patients with a frozen shoulder tests in patients with a frozen shoulder(including plain film roentgenograms)(including plain film roentgenograms)usually are normal,except in those with usually are normal,except in those with medical disorders such as diabetes or medical disorders such as diabetes or thyroid disease.Bone scans have been thyroid disease.Bone scans have been reported to be positive in some patients.reported to be positive in some patients.n nArthrograms characteristically show a Arthrograms characteristically show a reduced joint volume with irregular reduced joint volume with irregular margins.Clinical improvement has been margins.Clinical improvement has been reported after arthrography because of reported after arthrography because of brisement of adhesions from forcefully brisement of adhesions from forcefully injecting fluid into the joint.A volume of injecting fluid into the joint.A volume of less than 10 ml and lack of filling of the less than 10 ml and lack of filling of the axillary fold currently are accepted axillary fold currently are accepted arthrographic findings indicative of a arthrographic findings indicative of a frozen shoulder.frozen shoulder.Diagnosistests in patients wit40Differential diagnosisDifferential diagnosisn nCervical spondylosisn nRotator cuff tearDifferential diagnosisCervical41TreatmentTreatmentn nTraditionally,frozen shoulder has been Traditionally,frozen shoulder has been considered a self-limiting condition,lasting considered a self-limiting condition,lasting 12 to 18 months.12 to 18 months.n nApproximately 10%of patients have long-term Approximately 10%of patients have long-term problems.Patients seeking care earlier problems.Patients seeking care earlier usually recover more quickly.Dominant usually recover more quickly.Dominant shoulder involvement has been reported to be shoulder involvement has been reported to be predictive of a good result,whereas predictive of a good result,whereas occupation and treatment programs are not occupation and treatment programs are not statistically significant.Obviously,the best statistically significant.Obviously,the best treatment of frozen shoulder is prevention treatment of frozen shoulder is prevention(secondary frozen shoulder),but early(secondary frozen shoulder),but early intervention is of paramount importance;a intervention is of paramount importance;a good understanding of the pathological process good understanding of the pathological process by the patient and the physician also is by the patient and the physician also is important.important.TreatmentTraditionally,frozen42TreatmentTreatmentn 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 43TreatmentTreatmentn nAlthough a frozen shoulder usually is self-Although a frozen shoulder usually is self-limiting and resolves in 12 to 18 months,limiting and resolves in 12 to 18 months,many patients do not wish to wait that long many patients do not wish to wait that long for resolution of symptoms and request for resolution of symptoms and request active intervention long before 12 months.active intervention long before 12 months.With appropriate patient selection,With appropriate patient selection,significant improvement can be obtained in significant improvement can be obtained in approximately 70%of patients.approximately 70%of patients.n nClosed manipulation under anesthesiaClosed manipulation under anesthesian nOpen release of contracturesOpen release of contracturesTreatmentAlthough a frozen sho44TreatmentTreatmentn nArthroscopic Arthroscopic release is an release is an option when closed option when closed manipulation fails manipulation fails or for patients who or for patients who have had prolonged,have had prolonged,recalcitrant recalcitrant adhesive adhesive capsulitis.capsulitis.TreatmentArthroscopic release 45Chondromalacia patellaChondromalacia 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 Disorders of actively growing epiphyses.The growing epiphyses.The disorder may be localized disorder may be localized to a single epiphysis or to a single epiphysis or occasionally may involve occasionally may involve two or more epiphyses two or more epiphyses simultaneously or simultaneously or successively.The cause successively.The cause generally is unknown,but generally is unknown,but evidence indicates a lack evidence indicates a lack of vascularity that may be of vascularity that may be the result of trauma the result of trauma(quadriceps),infection,(quadriceps),infection,or congenital or congenital malformation.malformation.OSGOOD-SCHLATTER DISEASE 48THANK YOUSUCCESS2024/7/149可编辑THANK YOUSUCCESS2023/8/124TreatmentTreatmentn 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 weeksTreatmentSelf limited disease50Legg-Calve-Perthes DiseasePerthes病 n nThe cause：chronic injury n nThe clinical sign：pain and limp，Thomas sign n nplain roentgenographic changes n nBone scintigraphyn nMRI n nTreatment Legg-Calve-Perthes DiseasePer51Lloyd-Roberts、Catterall and Salamon classificationn nclassified patients with this disease into groups according to the amount of involvement of the capital femoral epiphysis:n ngroup I,partial head or less than hal