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1、肩关节疾病的诊断 山东省中医院运动损伤骨科王少山 肩关节的疾病你知道多少 普通人医务工作者骨科医生运动医学医师肩关节疾病的特征疼痛关节僵硬 肩关节解剖 骨结构 BodyAnatomyScapulaClavicle 骨结构 BonyAnatomyHumerusRibs 肌肉构成 Anteriormusculatureoftheshouldergirdle 肌肉构成 Musculatureofposteriorshouldergirdle 韧带结构 Shoulderligaments 滑囊和盂唇 Shoulderjointcapsuleandcartilage 血管和神经 BloodSupplya
2、ndIntervention 肩关节的评估 病史采集疼痛的原因损伤的机制以前的病史疼痛的位置时限程度弹响弹响的数量体温的变化肩无力 肩疲劳 如何减轻疼痛 ShoulderEvaluation Observation ElevationordepressionofshouldertipsPositionandshapeofclavicleAcromionprocessBicepsanddeltoidsymmetryPosturalassessment kyphosis lordosis shoulders PositionofheadandarmsScapularelevationandsymm
3、etryScapularprotractionorwingingMusclesymmetryScapulohumeralrhythm 肩关节运动范围检查 Observation 肩胛盂肱关节与肩胛胸壁关节肱骨与肩胛骨的运动关系肩关节启动三十度外展肩胛骨不参与运动外展三十度到九十度之间肱骨平均每上抬两度肩胛骨外展向上旋转一度the九十度以上肩胛骨肱骨呈1 1旋转运动 肩关节检查压疼点 Palpation 骨结构胸锁关节锁骨干肩锁关节喙突肩峰肱骨头肱骨大结节肱二头肌间沟肩胛岗肩胛骨内缘 肩胛骨外缘肩胛骨上角肩胛骨下角 肩关节检查压疼点 Palpation 软组织结构胸锁关肩锁关节喙锁韧带肩袖肌腱肩
4、峰下滑囊肱二头肌间沟肱二头肌腱喙肩韧带 GlenohumeraljointcapsuleDeltoidRhomboidsLatissimusdorsiSerratusAnteriorLevatorscapulaeTrapeziusSupraspinatusInfraspinatusTeresmajorandminor 肩关节特殊检查 SpecialTests 肩关节功能范围 ROM 前屈 180o后伸 50o外展 180o内收 40o内旋 90o外旋中立位600外展位900 ManualMuscleTestingFivePointgradingsystem5 CompleteROMagains
5、tgravity withfullresistance4 CompleteROMagainstgravity withsomeresistance3 CompleteROMagainstgravity withnoresistance2 CompleteROM withgravityomitted1 Somemusclecontractilitywithnojointmotion0 Nomusclecontractility 肩周炎的概念 历史1896年Duplay提出pereglanoiolitis盂肱关节周围炎首次医学描述肩僵硬演变Codman1934年命名为肩周炎1945年J S Nev
6、iase第一次使用adhesivecapsulitis粘连性肩关节囊炎现状由于肩关节周围炎的描述模糊不清 病理至今没有病理生理学基础 肩周炎是垃圾箱 弃用 症状模糊不清多种疾病混淆没有清晰的病理生理机制和证据给临床带来混乱 有必要对肩疼痛疾病分类 冻结肩肩峰撞击证肩袖损伤钙化性肌腱炎盂唇损伤肩锁关节骨性关节炎盂肱关节骨性关节炎 冻结肩 有明确的时限性疼痛有固定的曲线有固定的症状和体现没有明确的发病原因最终结局是乐观 一般不留关节障碍 病程分期 冷冻期初期1 9个月疼痛冻结期中期3 2个月关节僵硬解冻期后期5个月至2年疼痛减轻功能恢复 FrozenShoulderClassifications
7、Frozenshoulder LundbergclassificationStagesoffrozenshoulder ReevesArthroscopicstagesofadhesivecapsulitis Neviaser FrozenShoulder LundbergClassification A Primaryfrozenshoulder Shoulderelevation 135degLimitationofmovementonlyatgleno humeralarticulationRadiologynormalOthercausesietrauma OA RA Hemipleg
8、iaetcexcludedB Secondaryfrozenshoulder Decreasedrangeofmovementfollowingtraumaorotherknowncause StagesofFrozenShoulder ReevesReevesB ScandJRheumatol 4 193 196 1975 Painfulstage 10 36weeksStiffness 4 12monthsRecovery 5 24months 冻结肩是一种自限性疾病不必忧虑 如何确诊冻结肩 病史没有明确的原因疼痛的特点疼痛逐渐加重 夜间疼痛关节僵硬逐渐盂肱关节的活动度减少肌肉无损伤肌力无
9、明显改变 临床检查 肩关节功能ROM前屈外展上抬00 1800外旋00 600内旋体侧 7胸椎棘突全方位功能受限 ArthroscopicstagesofFrozenShoulder NevasierNeviaser OrthopClinNorthAm 18 439 443 1987 Stage1 Erythematous fibrinoussynoviumpatientpresentsasimpingementStage2 Red angry thicksynovium thick contractedinterval tightjointspaceadhesionsintheinferio
10、rfoldStage3 Pinksynoviumcontractedinferiorfold tightjointspaceStage4 noevidenceofsynovitistightinferiorfoldandjoint 辅助检查 影像学没有明确的阳性改变 MRI 肩峰撞击症 何为肩峰撞击症肩峰撞击症的概念Neer提出肩关节在运动的过程中有一些结构性因素和动力性因素与肩峰发生摩擦产生病理性疼痛包括内容肩峰的形态Bigliani分型肌腱炎滑囊炎 结构性因素肩峰的形态肌腱的炎性退变增粗滑囊炎容积增大大结节骨折 撞击的病理 动力性因素肩胛骨失效肌腱过度负荷盂肱关节不稳定重复性微细创伤 撞击
11、产生的机制岗上肌出口 1 模拟撞击原理 模拟撞击原理2 SubacromialImpingementclassifications Stagesofsubacromialimpingement Neer sclassificationStagesofsubacromialimpingementinathletes Jobe sclassificationGradingofimpingementchanges Milgrom sultrasoundclassificationImpingementlesions CopelandLevyclassification Stagesofsubacro
12、mialimpingement Neer sclassificationHistoricalinterest stagesdonotnecessarilyfollowoneanother Stage1 oedemaandhaemorrhage age40 progressivedisability Stagesofsubacromialimpingementinathletes Jobe sclassification 1989 1 Pureimpingementwithnoinstability2 Primaryinstabilitywithcapsularandlabralinjurywi
13、thsecondaryimpingementwhichcanbeinternalimpingementorsubacromial3 Primaryinstabilitybecauseofgeneralisedligamentouslaxitywithsecondaryimpingement4 Pureinstabilityandnoimpingement Gradingofimpingementchanges Milgrom sultrasoundclassification Stage1 Bursalthickness1 5to2 0mmStage2 Bursalthicknessover2
14、 0mmStage3 Partialorfullthicknesstearoftherotatorcuff AcromialSideBursalSide 0Normal smoothsurfaceA1Minorscuffing haemorrhageorlocalinjectionandinflammationA2Markedscuffing damageoftheundersurfaceoftheacromion CAligamentA3Bareboneareas surfaceA1Minorscuffing haemorrhageorlocalinjectionandinflammatio
15、nA2Markedscuffing damageoftheundersurfaceoftheacromion CAligamentA3BareboneareasB0Normal smoothsurfaceB1Minorscuffing haemorrhageorlocalinjectionandinflammationB2Majorscuffingofcuff partialthicknesstearB3FullthicknesstearB4Massivecufftear 0Normal smoothsurfaceA1Minorscuffing haemorrhageorlocalinject
16、ionandinflammation AcromialSide A1Minorscuffing haemorrhageorlocalinjectionandinflammation A2Markedscuffing damageoftheundersurfaceoftheacromion CAligament Bareboneareas A3 B0Normal smoothsurface B1Minorscuffing haemorrhageorlocalinjectionandinflammation BursalSide B0Normal smoothsurface B3Fullthicknesstear B4Massivecufftear 撞击症的症状 疼痛发病疼痛成隐匿性进展部位肩前外侧有时放射至肘方式肩关节运动到某一部位夜间疼痛只在患侧卧位时疼 特殊检查 NeerHawkins 影像学检查 撞击综合症 治疗 保守治疗休息避免做可能使肩关节疼痛的动作前后部肩袖肌力练习 撞击综合症 治疗 保守治疗肩峰下注射玻璃酸钠 施沛特 2支得保松 布比卡因肩峰前外角下方约2cm不超过2次 撞
