膝关节OA的规范化诊治

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,膝关节OA的规范化诊治,平顶山市二院宝丰分院骨科 安学良,Evaluation Warning:The document was created with Spire.Presentation for.NET,解读,指,指南,怎么诊,断,断？,怎么治,疗,疗？,为什么,是,是这样,？,？,为什么,这,这样做,？,？,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝关节OA规范化治疗,规范化诊断,规范化治疗,Evaluation Warning:The document was created with Spire.Presentation for.NET,规范化,诊,诊断,诊断过,程,程规范,诊断描,述,述规范,Evaluation Warning:The document was created with Spire.Presentation for.NET,规范化,诊,诊断过,程,程,病史：,现病史,：,：,起病、,起,起因、,主,主要症,状,状、伴,随,随症状,等,等,既往史,：,：,损伤、,运,运动、,职,职业,家族史,体格检,查,查,X线检,查,查,临床检,验,验,ISOA评分,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝OA,病,病史组,成,成规范,（,（,现病史,）,局部症,状,状：,疼痛能,明,明确定,位,位（内,侧,侧、外,侧,侧、髌,股,股关节,、,、前方,、,、后方,、,、症状,弥,弥散）,1、症,状,状类型,：,：,疼痛：,性,性质、,程,程度、,加,加重及,减,减轻的,时,时间、,体,体位、,与,与运动,的,的关系,等,等因素,。,。,肿胀：,准,准确部,位,位、程,度,度、加,重,重及减,轻,轻的因,素,素。,运动障,碍,碍（活,动,动范围,减,减少）,。,。,机械性,症,症状：,摩,摩擦、,交,交锁、,解,解锁、,打,打软腿,、,、无力,等,等。,2、症,状,状特点,发作方,式,式：突,然,然、隐,袭,袭、间,断,断；,持续时,间,间,使症状,加,加重与,减,减轻的,因,因素,3、干,扰,扰措施,及,及其反,应,应,4、对,工,工作及,生,生活的,影,影响,全身症,状,状,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝OA,病,病史组,成,成规范,（,（,现病史,）,全身症,状,状：其,它,它关节,疼,疼痛及,障,障碍、,发,发热、,怕,怕冷、,痉,痉挛、,腹,腹泻及,便,便秘、,头,头痛、,眩,眩晕、,尿,尿量及,性,性质、,尿,尿痛、,视,视力等,眼,眼部症,状,状、水,肿,肿或浮,肿,肿,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝OA,病,病史组,成,成规范,既往史,：,：继发,？,？原发,？,？,原发：,多,多关节,、,、既往,史,史（-,）,）、手,术,术意义,不,不大,继发：,单,单关节,、,、既往,史,史（+,）,）、手,术,术多能,获,获效,家族史,：,：,Evaluation Warning:The document was created with Spire.Presentation for.NET,病史应,尽,尽可能,详,详尽！,Evaluation Warning:The document was created with Spire.Presentation for.NET,局部症,状,状,疼痛,肿胀,僵硬：,膝,膝关节,少,少见，,脊,脊柱、,手,手、髋,多,多见。,障碍,机械症,状,状,Evaluation Warning:The document was created with Spire.Presentation for.NET,局部症,状,状,（疼痛,）,）,疼痛的,部,部位：,内,内侧、,外,外侧、,前,前、后,，,，深、,浅,浅,疼痛的,类,类型：,缓解及,加,加重的,因,因素,与运动,及,及生活,的,的关系,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝关节,疼,疼痛类,型,型及意,义,义,钝痛：,多,多慢性,炎,炎性疼,痛,痛，提,示,示滑膜,、,、滑囊,炎,炎症，,关,关节或,骨,骨内压,升,升高，,关,关节周,围,围肌肉,肌,肌腱痉,挛,挛。,隐痛：,病,病变来,自,自软骨,下,下骨、,关,关节囊,、,、膝周,滑,滑囊，,病,病损较,轻,轻，一,般,般为无,菌,菌性炎,症,症或微,骨,骨折。,胀痛：,来,来自关,节,节囊或,膝,膝周滑,囊,囊，积,液,液多。,软,软骨下,骨,骨的水,肿,肿也表,现,现为胀,痛,痛，一,般,般呈静,息,息持续,或,或运动,后,后持续,的,的全关,节,节胀痛,。,。,酸痛：,可,可以来,自,自骨及,关,关节周,围,围软组,织,织，与,血,血管病,变,变及代,谢,谢障碍,有,有关，,困痛：,具,具有胀,痛,痛与酸,痛,痛的意,义,义,凉痛或,冷,冷痛：,血,血管功,能,能障碍,，,，,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝关节,疼,疼痛类,型,型及意,义,义,锐痛：,急,急性炎,症,症、痉,挛,挛、骨,损,损伤、,牵,牵拉、,游,游离体,或,或半月,板,板绞锁,。,。神经,受,受到急,性,性、严,重,重刺激,而,而表现,的,的疼痛,。,。,Evaluation Warning:The document was created with Spire.Presentation for.NET,局部症,状,状,（肿胀,）,）,肿胀部,位,位,程度：,与疼痛,的,的关系,减轻与,加,加重的,因,因素,Evaluation Warning:The document was created with Spire.Presentation for.NET,局部症,状,状,（障碍,）,）,膝伸直,为,为中立,位,位(0,)，,它,它的正,常,常活动,范,范围为,：,：0,(,(伸),135(,屈,屈)，,过,过伸l0左,右,右。屈,膝,膝90,时，,可,可内旋10,、,、外旋20,。,。,主动运,动,动障碍,、,、被动,运,运动障,碍,碍,生活障,碍,碍：上,、,、下，,蹲,蹲，跳,、,、起坐,Evaluation Warning:The document was created with Spire.Presentation for.NET,局部症,状,状,（机械,症,症状）,绞锁：,弹响,无力,打软腿,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝关节,检,检查项,目,目规范,体型：,身,身高、,体,体重。,下肢力,线,线：膝,内,内翻、,膝,膝外翻,。,。,步态：,痛,痛性跛,行,行、膝,屈,屈曲畸,形,形、反,屈,屈畸形,。,。,代偿：,良,良性代,偿,偿、恶,性,性代偿,不稳：,髌,髌股、,内,内侧、,外,外侧、,前,前、后,活动范,围,围：主,动,动、被,动,动，0,165,特殊部,位,位：,股四头,肌,肌及拮,抗,抗协同,肌,肌、膝,周,周滑囊,、,、脂肪,垫,垫?、,韧,韧带、,皱,皱襞,半月板,：,：破裂,、,、脱位,相关部,位,位：,脊柱、,坐,坐骨神,经,经、闭,孔,孔神经,、,、隐神,经,经、血,管,管,Evaluation Warning:The document was created with Spire.Presentation for.NET,膝关节,检,检查项,目,目规范,详尽的物理检,查,查胜过所,有,有仪器,的,的辅助,检,检查,Evaluation Warning:The document was created with Spire.Presentation for.NET,OA的X线检,查,查,标准投,照,照,特殊体,位,位投照,下肢全,长,长照片,准确阅,读,读,Evaluation Warning:The document was created with Spire.Presentation for.NET,OA的X线分,级,级,Kellgren和Lawrecne的,放,放射学,分,分级标,准,准：分,五,五级。,0级,正,正常,；,；,I级,关,关,节,节间隙,可,可疑变,窄,窄，可,能,能有骨,赘,赘；,II级,有,有,明,明显骨,赘,赘，关,节,节间隙,轻,轻度变,窄,窄；,III,级,级,中,中,等,等量骨,赘,赘，关,节,节间隙,变,变窄较,明,明显，,软,软骨下,骨,骨质轻,度,度硬化,改,改变范,围,围较小,；,；,IV级,大,大量,骨,骨赘形,成,成，波,及,及软骨,面,面，关,节,节间隙,明,明显变,窄,窄，硬,化,化改变,极,极明显,，,，关节,肥,肥大及,明,明显畸,形,形。,Evaluation Warning:The document was created with Spire.Presentation for.NET,OA临,床,床检验,ESR,CRP,关节液,检,检查,血液,Evaluation Warning:The document was created with Spire.Presentation for.NET,ISOA评分,Evaluation Warning:The document was created with Spire.Presentation for.NET,VAS,疼,疼痛评,分,分,视觉评,分,分：0,-,-10,尺,Evaluation Warning:The document was created with Spire.Presentation for.NET,鉴别诊,断,断,明确2,点,点：,症状来,源,源：关,节,节内还,是,是关节,外,外,是否OA,Evaluation Warning:The document was created with Spire.Presentation for.NET,诊断标,准,准,近1个,月,月内反,复,复膝关,节,节疼痛,X线片,（,（站立,或,或负重,位,位）示,关,关节间,隙,隙变窄,、,、软骨,下,下骨硬,化,化和（,或,或）囊,性,性变、,关,关节缘,骨,骨赘形,成,成,关节液,（,（至少2次）,清,清亮、,黏,黏稠，WBC,2000个,/,/ml,中老年,患,患者（,40,岁,岁）,晨僵3 0min,活动时,有,有骨摩,擦,擦音（,感,感）,注：综,合,合临床,、,、实验,室,室及X,线,线检查,，,，符合1+2,条,条或1,+,+3+5+6,条,条或1,+,+4+5+6,条,条，可,诊,诊断膝,关,关节OA,Evaluation Warning:The document was created with Spire.Presentation for.NET,鉴别诊,断,断,RA,结核,反应性,关,关节炎,膝关节,周,周围疼,痛,痛,创伤性,关,关节炎,剥脱性,软,软骨炎,局限性,骨,骨坏死,化脓性,关,关节炎,滑膜皱,襞,襞损伤,或,或炎,Evaluation Warning:The document w