肩袖损伤ppt讲课稿.ppt

,*,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,肩袖损伤2015ppt,4,1,3,2,5,肩胛骨,3.,喙突,4.,肱骨头,5.,关节盂,1.,锁骨,2.,肩峰,肩关节解剖之骨骼,4,1,3,2,5,肩胛骨,3.,喙突,4.,肱骨头,5.,关节盂,1.,锁骨,2.,肩峰,肩关节骨骼,肩袖解剖,肩袖解剖,组成和功能,冈上肌,(,肩胛上神经,):,上臂外展并固定肱骨头于肩盂上,并防止肱骨头上移,冈下肌,(,肩胛上神经,):,上臂下垂位时使上臂外旋,小圆肌,(,腋神经,):,臂外旋,肩胛下肌,(,肩胛下神经,):,臂下垂位时内旋肩关节,病因,退变学说,血运学说,撞击学说,创伤学说,冈上肌止点附近血供来源于大结节骨膜滋养血管，肌腹血供来源于肩胛上动脉，而止点近端,1 cm,处有明显的乏血管区,肩峰发育异常、肩锁关节增生肥大、高位肱骨大结节、,肩峰下骨赘形成,肩峰下撞击综合征,分类,按损伤程度：,挫伤,不完全断裂,完全断裂,分类,按断裂口方向,横行,纵行,按肌腱断裂范围,小型撕裂,：单一肌腱撕裂范围小于肌腱横径,1/2,大型撕裂,：单一肌腱撕裂范围大于肌腱横径,1/2,广泛撕裂,：范围累及两个及两个以上的肩袖肌腱，伴有肩袖组织的退缩缺损,临床表现,临床表现,外伤史：,急性损伤、重复性或累积性损伤史,疼痛与压痛：,多位于肩前方,活动或增加负荷后加重,被动外旋或过度内收时加重,夜间症状加重,功能障碍：,上举和外展功能受限,肌肉萎缩：,3,周,继发性关节挛缩：,3,月,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？,Gazzola S,Bleakney RR.Current imaging of the rotator cuffJ.Sports Med Arthrosc,2011,19(3):300-9.,cystic change of the greater tuberosity,1,读,X,片,Gazzola 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),Type I calcication with a uffy,eecy appearance with poorly dened borders,with acute symptoms and termed the resorptive phase.,Type II calcication,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 calcic tendinitisJ.Clin Orthop.1961;20:61-72.,calcic tendinopathy,2,可疑诊断,1,关于肩周炎 肩周炎,=,冻结肩（,实用骨科学,第,3,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。,国外报道,Frozen shoulder 40-60 years of age,incidence 2-5%1.,3 phases2,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 side,2),frozen phase,4-12 months,stiffness reaches its maximum,thawing phase,5-12 months,range of motion returns to normal,2,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.,针对肩袖损伤的体查,1,冈上肌 肩外展功能,1 empty can test,1)90 degrees abduction,2)30 degrees horizontal abduction(in the plane of the scapula),3)thumbs pointing downward,2 full can test,1)90 degrees in the horizontal plane,2)rotated 45degrees externally,3)with the thumb pointing upward,painful arc test,60-120,1)shoulder in external rotation,2)palm facing up,4,resisted isometric abduction,1)the arm in neutral rotation,2)abducts the arm to 90 degrees,1 external rotation strength test=Pattes test,1)the patients elbow in 90 degrees,2)in the plane of the scapula,2,冈下肌和小圆肌 肩外旋功能,2 external rotation lag sign,1)elbow passively flexed to 90 degrees,2)maximal external rotation,3 drop sign,1)almost full external rotation,2)elbow flexed at 90 degrees,4 weakness with external rotation,1)elbows flexed to 90 degrees,2)the thumbs up,3)shoulders rotated internally 20 degrees,3,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 back,2,internal rotation lag sign,3 belly press,4 bear hug test,4,针对肩峰下撞击综合症的体查,Hawkins-Kennedy test,关于,MRI,肩袖解剖,解剖足印（,footprint,）,关于,MRI,正常肩袖的,MRI,斜冠状面,正常肩袖的,MRI,斜矢状面,正常肩袖的,MRI,横断面,损伤肩袖的,MRI,魔法角,magic angle phenomenon,the fibers are at 55 degrees to the main magnetic field on T1,Erickson SJ,Prost RW,Timins ME.The“magic angle”effect:background physics and clinical relevance.Radiology.1993;188:23-25.,MRI,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,肩袖走行及连续性,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.,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 the,muscles 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 the,supraspinatus belly.Assessment by MRI in 55 patients with,rotator cuff pathology.Acta Orthop Scand.1996;67:264-268.,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 ,5cm,DeOrio JK,Coeld 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,2,部分撕裂,肩袖损伤的治疗,手术,VS,保守,parameters in decision making for the surgery of the cuff1.75 years,2,撕裂大小,Shimizu2 recommend early cuff repair after conrming 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,肌腱的缝法,开放手术骨质端的固定,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.,不可修复肩袖损伤的判定,According to Gerber et al.,imaging ndings that suggest an irreparable rotator cuff tear include 1,）,static superior subluxation of a glenohumeral joint with an,acromiohumeral interval of 7 mm or less on an anteroposterior radiograph with the arm in neutral rotation,Gerber C,Wirth SH,Farshad M(2011)Treatment options for massive rotator cuff tears.J Should Elb Surg 20:S20S29.,and 2)fatty inltration of the rotator cuff muscles at stage three or greater.,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 bursectomy,3 partial repair,4 arthroscopic tuberoplasty,5 tendon transfers,1)latissimus dorsi transfers-superolateral rotator cuff tears,2)pectoralis major transfers-irreparable tears of the subscapularis muscle,3)deltoid ap,4)trapezius muscle transfer,latissimus 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.,Rotator Cuff,肩袖损伤,撞击,通常在老年患者,(65+),勾状的肩峰和肩袖撞击导致疼痛和附加的肩袖撕裂,肩袖损伤,通常地这种情况导致冈上肌损伤,然后是冈下肌,很少情况下会损伤小圆肌,除非在极其严重的情况下,肩胛下肌损伤极其少见,处理也很困难,部分撕裂也非常常见,这种情况,也是治疗的人选,Rotator Cuff,肩袖损伤,四种主要的肩袖撕裂类型：,1,）新月形撕裂,2,）,U,形撕裂,3,）,L,形和倒,L,形撕裂,4,）巨大回缩性不可移动性撕裂,Rotator Cuff,肩袖损伤,新月形撕裂,IS,冈下肌,SS,冈上肌,Rotator Cuff,肩袖损伤,U,形撕裂,IS,冈下肌,SS,冈上肌,Rotator Cuff,肩袖损伤,L,形撕裂,IS,冈下肌,Sub,肩胛下肌肌腱,RI,肩袖间隙,SS,冈上肌,CHL,喙肱韧带,Rotator Cuff,肩袖损伤,巨大回缩性不可移动性撕裂,IS,冈下肌,Sub,肩胛下肌肌腱,RI,肩袖间隙,SS,冈上肌,CHL,喙肱韧带,前面,侧面,/,后面,肩峰下囊是个潜在的空间直到充满了流体在关节镜手术中,肩峰下囊,前面观,侧面,/,后面观,肩袖由四块肌肉和他们的肌腱组成,1.,2,3,4,1.,肩胛下肌,2.,冈上肌,肩袖,3.,冈下肌,4.,小圆肌,肩袖,关节镜下观,Rotator Cuff,Humeral Head,Rotator Cuff,肩袖损伤,肱骨头,肩袖,肱骨头,肩袖,关节囊方向看,肱骨头方向看,Rotator Cuff,肩袖损伤,撞击,通常在老年患者,(65+),勾状的肩峰和肩袖撞击导致疼痛和附加的肩袖撕裂,肩袖损伤,通常地这种情况导致冈上肌损伤,然后是冈下肌,很少情况下会损伤小圆肌,除非在极其严重的情况下,肩胛下肌损伤极其少见,处理也很困难,部分撕裂也非常常见,这种情况,也是治疗的人选,Rotator Cuff,肩袖损伤,四种主要的肩袖撕裂类型：,1,）新月形撕裂,2,）,U,形撕裂,3,）,L,形和倒,L,形撕裂,4,）巨大回缩性不可移动性撕裂,Rotator Cuff,肩袖损伤,新月形撕裂,IS,冈下肌,SS,冈上肌,Rotator Cuff,肩袖修补,Rotator Cuff,肩袖修复,主要考虑因素,主要目标,减少活动疼痛,(SAD),和恢复运动功能,入路,锚钉放置,过线,.,打结,Rotator Cuff,肩袖修复方式,穿骨缝线,带线铆钉,选择锚钉,肩袖损伤,:,TwinFix Ti 5.0 mm:,骨质疏松，需要高固定强度,.,多个缝线,肩关节不稳,(Bankart and SLAP),TwinFix Ti 3.5 mm:,此锚钉可以用于所有手术，包括肩袖损伤,肩关节不稳,(Bankart and SLAP),TwinFix Ti 2.8 mm:,关节盂表面较小，医生需选择较小的锚钉，但是也需要很高的拔出强度,.,选择使用单线孔锚钉，对于缝线的操作比较简单,肩袖损伤及肩关节不稳,TwinFix Ti Suture Anchor Range with Needles,如医生进行开放手术，选择带针的缝线锚钉,.,Rotator Cuff,肩袖修复,应用,3,个入路在这个手术过程中,-,后侧,前侧,侧面的工作入路,.,也同时在前侧建立一个小切口来作为锚钉置入的入路,.,在后侧入路插入关节镜,进行观察,.,Rotator Cuff,肩袖修复,在这个手术操作过程中以,L,形肩袖撕裂为例,.,图中显示为冈上肌的,L,形撕裂,Rotator Cuff,肩袖修复,ELITE,肩关节探勾通过前侧入路来评估撕裂程度,.,同时可应用抓钳来评估撕裂程度,Rotator Cuff,肩袖修复,将关节镜镜头变换至侧面工作入路,.,使用直型的,ELITE CUFF STITCH,缝合传递器械在后侧入路内,穿过撕裂的肩袖组织部位来传递缝线,.,使用缝线组织抓钳通过前侧入路抓取缝线,.,Rotator Cuff,肩袖修复,移去直型的,ELITE CUFF STITCH,缝合传递器械,在后侧入路插入,ELITE,缝线抓钳,从前侧入路处重新抓取缝线,.,Rotator Cuff,肩袖修复,将,2,股缝线移入同一个入路,移去缝线抓钳,在后侧入路外打一个关节镜下滑节,.,通过后侧入路将结移向撕裂处,使用,ELITE,全圈推结器对滑结推向撕裂处,Rotator Cuff,肩袖修复,通过全圈推结器的配合操作,对滑节进行打紧,.,Rotator Cuff,肩袖修复,用,ELITE,勾型剪剪断缝线,可以使用滑动剪线器进行代替使用,Rotator Cuff,肩袖修复,缝线传递的另外方法,用直型缝线传递器械夹带缝线通过后侧入路穿透肩袖,AP,抓钳通过前侧入路穿透肩袖,配合操作,将缝线穿过撕裂部位,.,用缝线抓钳通过后侧入路抓取缝线,对缝线进行打结,Rotator Cuff,肩袖修复,通过辅助的小切口来进行锚钉的放置,这个小切口的位置接近于肩峰的侧缘,Rotator Cuff,肩袖修复,置入第一个锚钉,接近,45,度的操作角度来旋转置入锚钉,埋于关节表面下,置入锚钉时要超过远端的标记,这样才能才能确定锚钉的尾断完全埋于骨表面之下,.,应用垂直的标记线来确定、调整理想的置入部位,Rotator Cuff,肩袖修复,用缝线抓钳将白色的缝线从辅助的入路传递到后侧入路,用,70,度的右弯传递器械夹带白色缝线穿透肩袖，然后用组织缝线抓钳通过前侧入路抓取缝线。,用缝线抓钳通过后侧入路抓取缝线，使穿过肩袖的两股缝线共同从后侧入路拉出,Rotator Cuff,肩袖修复,用缝线抓钳将绿色的缝线从辅助的入路传递到后侧入路,用,70,度的右弯传递器械夹带绿色缝线穿透肩袖，然后用组织缝线抓钳通过前侧入路抓取缝线。,用缝线抓钳通过后侧入路抓取缝线，使穿过肩袖的两股缝线共同从后侧入路拉出,Rotator Cuff,肩袖修复,放置第二个锚钉,又一次使用辅助的小切口入路,接近,45,度的操作角度来旋转置入锚钉,埋于关节表面下,置入锚钉时要超过远端的标记,这样才能才能确定锚钉的尾断完全埋于骨表面之下,.,Rotator Cuff,肩袖修复,用缝线抓钳传递白色缝线,然后用,AP,抓钳通过前侧入路抓取白色缝线，穿透于肩袖。,Rotator Cuff,肩袖修复,用全圈打结器通过合适的入路，对白色的缝线进行打结,Rotator Cuff,肩袖修复,然后用,AP,抓钳穿透肩袖组织,通过前侧入路，抓取其中一根绿色的缝线,Rotator Cuff,肩袖修复,从前侧入路中移去器械，并插入后侧入路,穿透肩袖组织并抓取第二根绿色缝线,用缝线抓钳将两条缝线并入同一个合适的入路,绿色的缝线然后打结,最后确定修补的合适性及稳定性,病例,1,患者，男性，,68,岁。,左肩外伤,3,周余。,手术方式,肩峰成形术,肱二头肌长头腱切断（未固定），,65,岁以上患者一般不需要固定，,肩袖修补,Thank you,谢谢大家,此课件下载可自行编辑修改，仅供参考！感谢您的支持，我们努力做得更好！谢谢,