肩袖损伤演示课件

肩袖损伤肩袖损伤肩袖损伤肩袖损伤的流行病学Uhthoff et al.1 found a 20%prevalence in a series of cadaver dissections in which the mean age of the donors was 59.4 years.Lehman et al.2 found a prevalence of 17%in a large series of cadaver dissections,with a prevalence of 30%in donors older than sixty years of age.The incidence of full-thickness tears of the rotator cuffranges from 5%to 40%.Furthermore,epidemiologicalstudies show an increasing frequency of rotator cuff failure with advancing age3.1 Uhthoff HK,Loehr J,Sarkar K.The pathogenesis of rotator cuff tears.In:Takagishi N,editor.The shoulder.Tokyo:Professional PostGraduate Services;1987:211-2.2 Lehman C,Cuomo F,Kummer FJ,Zuckerman JD.The incidence of full thickness rotator cuff tears in a large cadaveric population.Bull Hosp Jt Dis.1995;54(1):30-1.3 Bigliani LU,Morrison DS.Relationship between acromial morphology and rotator cuff tears.Orthop Trans.1986;10:216.肩袖损伤的流行病学Uhthoff et al.1 fou当我们在临床上遇到疑似病人，只有X片而无MRI检查时，1 我们能从X片中得到什么信息？2 我们印象中的可疑诊断有哪些？3 针对性的体查有哪些？当我们在临床上遇到疑似病人，只有X片而无MRI检查时，3 Gazzola S,Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9.cystic change of the greater tuberosity1 读读X片片Gazzola S,Bleakney RR.Current4Gazzola S,Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9.normal subacromial joint space(7mm)(arrow)1 superior subluxation of the humeral head(arrow)2 notched humeral neck(arrowhead)Gazzola S,Bleakney RR.Current5Type I calcification with a fluffy,fleecy appearance with poorly defined borders,with acute symptoms and termed the resorptive phase.Type II calcification,more discreet and of homogenous density,with well-circumscribed borders,and in the formative phase.DePalma AF,Kruper JS.Long-term study of shoulder joints affliated with and treated for calcific tendinitisJ.Clin Orthop.1961;20:61-72.calcific tendinopathyType I calcification with a flu62 可疑诊断可疑诊断1 关于肩周炎关于肩周炎 肩周炎肩周炎=冻结肩（冻结肩（实用骨科学实用骨科学第第3版），是由于肩关版），是由于肩关节周围软组织病变而引起肩关节疼痛和活动功能障碍。节周围软组织病变而引起肩关节疼痛和活动功能障碍。国外报道 Frozen shoulder 40-60 years of age,incidence 2-5%1.3 phases21)freezing phase 2-9 months,pain and loss of motion of the glenohumeral joint in all direction，usually worst at night and when lying on the affected side2)frozen phase 4-12 months,stiffness reaches its maximum3)thawing phase 5-12 months,range of motion returns to normal 2 肩峰下撞击综合症肩峰下撞击综合症 疼痛，主诉为三角肌下疼痛，并经常向下放射至疼痛，主诉为三角肌下疼痛，并经常向下放射至前方的肱二头肌，夜间疼痛可影响睡眠前方的肱二头肌，夜间疼痛可影响睡眠1 Hand C,Clipsham K,Rees JL,et al.Long-term outcome of frozen shoulder.J Shoulder Elbow Surg 2008;17:231-6.2 Reeves B.The natural history of the frozen shoulder syndrome.Scand J Rheumatol 1975;4:193-6.2 可疑诊断1 关于肩周炎 肩周炎=冻结肩（实用骨科73 针对肩袖损伤的体查针对肩袖损伤的体查1 冈上肌 肩外展功能1 empty can test1)90 degrees abduction2)30 degrees horizontal abduction(in the plane of the scapula)3)thumbs pointing downward3 针对肩袖损伤的体查1 冈上肌 肩外展功能1 em82 full can test1)90 degrees in the horizontal plane2)rotated 45degrees externally3)with the thumb pointing upward2 full can test93painful arc test 60-1201)shoulder in external rotation2)palm facing uppainful arc test104 resisted isometric abduction1)the arm in neutral rotation2)abducts the arm to 90 degrees4 resisted isometric abduction111 external rotation strength test=Pattes test1)the patients elbow in 90 degrees2)in the plane of the scapula2 冈下肌和小圆肌 肩外旋功能1 external rotation strength t122 external rotation lag sign1)elbow passively flexed to 90 degrees2)maximal external rotation2 external rotation lag sign133 drop sign1)almost full external rotation2)elbow flexed at 90 degrees3 drop sign144 weakness with external rotation1)elbows flexed to 90 degrees2)the thumbs up3)shoulders rotated internally 20 degrees4 weakness with external rotat153 肩胛下肌 肩内旋、后伸功能1 lift off test asking the patient to internally rotate the arm to lift the hand posteriorly off of the back3 肩胛下肌 肩内旋、后伸功能1 lift off 16Sports Med Arthrosc,2011,19(3):300-9.我们在MRI上应得到的信息1 Zanetti M,Gerber C,Hodler J.1)almost full external rotationLindley K,Jones GL.J Shoulder Elbow Surg 1999;8:599-605.美国的一篇系统评价显示：术后6个月的ASES、UCLA、疼痛评分及再断裂方面，两者无显著差异，只有短期疼痛，关节镜优于开放手术。1 superior subluxation of the humeral head(arrow)2)in the plane of the scapulaGerber C,Wirth SH,Farshad M(2011)Treatment options for massive rotator cuff tears.2 full can testAtrophy of theranges from 5%to 40%.4）巨大 5cmScand J Rheumatol 1975;4:193-6.Current imaging of the rotator cuffJ.According to Gerber et al.2 found a prevalence of 17%in a large series of cadaver dissections,with a prevalence of 30%in donors older than sixty years of age.1 Zanetti M,Gerber C,Hodler J.Tokyo:Professional PostGraduate Services;1987:211-2.2 internal rotation lag signSports Med Arthrosc,2011,19(3)173 belly press3 belly press184 bear hug test4 bear hug test194 针对肩峰下撞击综合症的体查针对肩峰下撞击综合症的体查4 针对肩峰下撞击综合症的体查20Hawkins-Kennedy testHawkins-Kennedy test21关于关于MRI肩袖解剖关于MRI肩袖解剖22解剖足印（解剖足印（footprint）解剖足印（footprint）23关于关于MRI正常肩袖的MRI 斜冠状面关于MRI正常肩袖的MRI 24正常肩袖的MRI 斜矢状面正常肩袖的MRI 斜矢25正常肩袖的MRI 横断面正常肩袖的MRI 横断262)in the plane of the scapula3 肩胛下肌 肩内旋、后伸功能Orthop Trans.asking the patient to internally rotate the arm to lift the hand posteriorly off of the backFurthermore,epidemiological6 三角肌下、肩峰下囊滑液相连2）中 1-3cmFatty degeneration of the muscles of the rotator cuff:assessment by computed tomography versus magnetic resonance imaging.1961;20:61-72.The incidence of full thickness rotator cuff tears in a large cadaveric population.4 针对肩峰下撞击综合症的体查1 我们能从X片中得到什么信息？脂肪渗透（fatty infiltration）我们在MRI上应得到的信息1)elbows flexed to 90 degrees2)frozen phase 4-12 months,stiffness reaches its maximum2)frozen phase 4-12 months,stiffness reaches its maximumCurrent imaging of the rotator cuffJ.1 切线征1（tangent sign）1)the arm in neutral rotation损伤肩袖的MRI2)in the plane of the scapula27魔法角 magic angle phenomenonthe fibers are at 55 degrees to the main magnetic field on T1Erickson SJ,Prost RW,Timins ME.The“magic angle”effect:background physics and clinical relevance.Radiology.1993;188:23-25.魔法角 magic angle phenomenon28我们在我们在MRI上应得到的信息上应得到的信息1 肩袖走行及连续性2 高信号3 脂肪变性4 肌肉萎缩5 肌肉回缩6 三角肌下、肩峰下囊滑液相连我们在MRI上应得到的信息1 肩袖走行及连续性29 肩袖走行及连续性 肩袖走行及连续性30脂肪渗透（fatty infiltration）Fuchs B,Weishaupt D,Zanetti M,Hodler J,Gerber C.Fatty degeneration of the muscles of the rotator cuff:assessment by computed tomography versus magnetic resonance imaging.J Shoulder Elbow Surg 1999;8:599-605.脂肪渗透（fatty infiltration）Fuchs 31肌肉萎缩（muscle atrophy）1 切线征1（tangent sign）2 肩胛比（scapular ratio）Scapular ratio uses the ratio of the supraspinatus muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa,and in supraspinatus atrophy the ratio is less than 50%2.1 Zanetti M,Gerber C,Hodler J.Quantitative assessment of themuscles of the rotator cuff with magnetic resonance imaging.Invest Radiol.1998;33:163-170.2 Thomazeau H,Rolland Y,Lucas C,et al.Atrophy of thesupraspinatus belly.Assessment by MRI in 55 patients withrotator cuff pathology.Acta Orthop Scand.1996;67:264-268.肌肉萎缩（muscle atrophy）1 切线征1（32肩袖损伤的分类1 全层撕裂 1）小 1cm 2）中 1-3cm 3）大 3-5cm 4）巨大 5cmDeOrio JK,Cofield RH.Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.J Bone Joint Surg.1984;66:563567.肩袖损伤的分类1 全层撕裂DeOrio JK,Cofield33肩袖损伤的分类2 部分撕裂肩袖损伤的分类2 部分撕裂34肩袖损伤的治疗手术 VS 保守1 年龄 Age is one of the most used parameters in decision making for the surgery of the cuff1.75 years2 撕裂大小 Shimizu2 recommend early cuff repair after confirming the diagnosis of massive rotator cuff tears.Partial-thickness rotator cuff tear is a further indication in those patients with minimal risk of tear extension,minimal pain,and dysfunction3.1 Tanaka M,Itoi E,Sato K,et al.Factors related to successful outcome of conservative treatment for rotator cuff tears.Ups J Med Sci.2010;115:193-200.2 Shimizu C,Horii M,Yamashita F,et al.Prognosis of massive rotator cuff tear.Chubuseisai.1990;33:392.3 Ozbaydar MU,Bekmezci T,Tonbul M,et al.The results of arthroscopic repair in partial rotator cuff tears.Acta Orthop Traumatol Turc.2006;40:4955.肩袖损伤的治疗手术 VS 保守1 Tanaka M,Ito35肩袖损伤的治疗肌腱的缝法肩袖损伤的治疗肌腱的缝法361 external rotation strength test=Pattes testAm J Orthop(Belle Mead NJ),2010,39(12):592-600.Outcomes of arthroscopic versus open rotator cuff repair:a systematic review of the literature.Partial-thickness rotator cuff tear is a further indication in those patients with minimal risk of tear extension,minimal pain,and dysfunction3.当我们在临床上遇到疑似病人，只有X片而无MRI检查时，2 Thomazeau H,Rolland Y,Lucas C,et al.4 weakness with external rotationActa Orthop Scand.1 superior subluxation of the humeral head(arrow)我们在MRI上应得到的信息Chubuseisai.2010;115:193-200.Atrophy of theLindley K,Jones GL.Acta Orthop Scand.Gazzola S,Bleakney RR.Tokyo:Professional PostGraduate Services;1987:211-2.J Should Elb Surg 20:S20S29.2 肩胛比（scapular ratio）Scapular ratio uses the ratio of the supraspinatus muscle in cross section on the sagittal oblique image compared with the size of the supraspinatus fossa,and in supraspinatus atrophy the ratio is less than 50%2.The incidence of full thickness rotator cuff tears in a large cadaveric population.开放手术骨质端的固定1 external rotation strength t37肩袖损伤的治疗手术方式的选择开放手术 VS 关节镜手术美国的一篇系统评价显示：术后6个月的ASES、UCLA、疼痛评分及再断裂方面，两者无显著差异，只有短期疼痛，关节镜优于开放手术。Lindley K,Jones GL.Outcomes of arthroscopic versus open rotator cuff repair:a systematic review of the literature.Am J Orthop(Belle Mead NJ),2010,39(12):592-600.肩袖损伤的治疗手术方式的选择Lindley K,Jones38不可修复肩袖损伤的判定According to Gerber et al.,imaging findings that suggest an irreparable rotator cuff tear include 1）static superior subluxation of a glenohumeral joint with anacromiohumeral interval of 7 mm or less on an anteroposterior radiograph with the arm in neutral rotationGerber C,Wirth SH,Farshad M(2011)Treatment options for massive rotator cuff tears.J Should Elb Surg 20:S20S29.不可修复肩袖损伤的判定According to Gerber39and 2)fatty infiltration of the rotator cuff muscles at stage three or greater.and 2)fatty infiltration of th40不可修复肩袖损伤的治疗1 肱三头肌长头截断2 debridement associated with acromioplasty and bursectomy3 partial repair4 arthroscopic tuberoplasty5 tendon transfers 1)latissimus dorsi transfers-superolateral rotator cuff tears2)pectoralis major transfers-irreparable tears of the subscapularis muscle 3)deltoid flap4)trapezius muscle transfer不可修复肩袖损伤的治疗1 肱三头肌长头截断41latissimus dorsi transfers一篇关于背阔肌修复巨大撕裂肩袖损伤的系统评价结果显示：在45.5个月的随访期内，Constant score,active forward elevation和active external rotation术后明显优于术前。Namdari S,Voleti P,Baldwin K,Glaser D,Huffman GR.Latissimus dorsi tendon transfer for irreparable rotator cuff tears:a systematic review.J Bone Joint Surg Am,2012,94(10):891-8.Namdari S,Voleti P,Baldwin K42谢谢！谢谢！43