第三节腕、手部筋伤.ppt

第三节 腕、手部筋伤湖南中医药大学第一湖南中医药大学第一(dy)附属医附属医院院骨伤科教研室骨伤科教研室第一页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 骨与关节(gunji)概论概论(giln)第二页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第三页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 肌腱(jjin)与腱膜第四页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第五页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第六页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第七页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第八页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第九页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 神经(shnjng)与血管第十页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第十一页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第十二页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第十三页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第十四页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第十五页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 腕部的功能位：背伸腕部于30，没有尺桡偏移。手指并拢握拳，将前臂和拳平放于桌面上，食指的纵轴与前臂的纵轴在一直线上。手的功能位：手握茶杯的姿势是发挥(fhu)手的最大功能位置。其中腕关节背伸30掌指关节屈曲30-45，指关节半屈曲位，而拇指微屈对掌位，各手指分开，第2-5手指指尖指向舟骨结节。第十六页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 一、腕部扭挫伤(cushng)一、概念：外力作用造成的腕关节部的韧带、筋 膜等筋伤。二、病因病理三、临床表现与诊断(zhndun)1.外伤史2.伤后腕部肿胀疼痛，活动时加剧；局部压痛拒按，活动受限3.由于受力部位与方向的不同，可在相应或相反部位出现症状第十七页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 4.鉴别诊断：骨折(gzh)与脱位 下尺桡关节错缝；桡骨远端骨折；腕舟骨骨折第十八页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、治疗（一）手法治疗（二）固定方法（三）练功疗法（四）药物治疗 瘀滞证活血(hu xu)化瘀，消肿止痛活血(hu xu)止痛汤加减 寒湿阻络证除湿散寒，祛风通络薏苡仁汤加减（五）其他疗法：针灸与理疗第十九页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、桡尺远侧关节(gunji)损伤一、概念(ginin)：第二十页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第二十一页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、病因病理(bngl)三、临床表现与诊断1.外伤史2.伤后桡尺掌侧或背侧肿胀疼痛，压痛；前臂旋前或旋后受限，偶有弹响；腕部无力3.桡尺远端前后被动活动增加，指压尺骨小头有浮动感或沙沙作响4.X片多无异常第二十二页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、鉴别诊断(zhndun)1.舟骨骨折第二十三页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 2.月骨无菌性坏死(hui s)第二十四页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 五、治疗(zhlio)（一）手法治疗（二）固定方法（三）练功疗法（四）药物治疗（五）其他疗法：针灸与理疗 第二十五页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 三、腕管综合征一、概念：腕管综合征是指由于正中神经在腕管中受到卡压，而引起的以手指麻木乏力(f l)为主的症候群。腕管是指腕部掌横韧带与腕骨所构成的骨纤维管。第二十六页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 腕管内有手指的九根指屈肌腱及正中神经共10个内容物，正中神经位于(wiy)肌腱与腕横韧带之间。第二十七页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、病因病理病因内容物增多：劳损，创伤，骨病等；容积减小：挤压创伤等病理病因腕管压力卡压正中神经或肌腱三、诊断要点1.病史与职业2.症状：三个半手指感觉异常3.体征：肌萎缩；肌力减弱4.特殊体征：叩诊试验(shyn)；屈腕试验(shyn)；压脉带试验(shyn)；出汗试验(shyn)第二十八页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 4.肌电图5.X线第二十九页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、鉴别(jinbi)诊断1.颈肋第三十页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 2.颈椎病与颈椎间盘突出症3.多发性神经炎：袜套状感觉麻木区4.脊髓肿瘤五、治疗要点 继发性腕管综合征应治疗原发疾病。原发性腕管综合征则按以下方法治疗：.固定(gdng)：适用于初期患者，固定(gdng)12周。.封闭：注意勿误伤正中神经。第三十一页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine .手法：不宜过多，轻度按压拔伸及旋转。.药物治疗(zhlio).非手术治疗无效，可采用手术治疗。第三十二页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、腕部尺神经管综合征一、概念(ginin)：任何原因使尺神经管内神经受压而引起症状者，称为腕部尺神经管综合征。后壁：腕横韧带(rndi)前壁：腕掌侧韧带内侧壁：豌豆骨外侧壁：钩骨钩第三十三页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、病因病理三、诊断要点1.病史与职业2.压迫平面 一型：尺神经受压（深浅支）运动与感觉(gnju)受累 二型：尺神经深支受压运动受累3.体征：爪形手4.肌电图第三十四页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、鉴别诊断(zhndun)1.腕管综合征2.颈神经根炎五、治疗要点第三十五页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 五、腕关节盘损伤(snshng)一、腕关节盘解剖(jipu)第三十六页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、病因病理：遭受扭动、旋转(xunzhun)暴力。易被误诊。三、诊断要点1.外伤史2.症状3.体征4.造影检查第三十七页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、治疗（一）手法治疗（二）固定方法（三）练功疗法（四）药物治疗 瘀滞证活血化瘀，消肿止痛活血止痛汤加减 虚寒证温经通络当归四逆汤加减 肾亏证补益(by)肝肾补肾壮筋汤加减（五）其他疗法：封闭疗法；手术治疗第三十八页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 六、腱鞘(jinqio)囊肿一、概念：腱鞘囊肿是发生在关节或腱鞘附近的囊性肿物，又称滑液囊肿。其内含(ni hn)物多为无色透明或微白色、淡黄色的浓稠胶冻状粘液。第三十九页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、病因病理长期持续的腕部劳损，造成局部软组织退行性病变，出现囊肿。三、诊断要点好发于青年女性。以腕背最常见，次为踝背。局部肿块，起势快，增长缓慢，多无自觉症状及不适。易复发(f f)。局部可触及一有韧性、外形光滑、张力较大的 肿块，有囊样感或波动感。第四十页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 三、治疗方法手法治疗 药物(yow)治疗针刺破挤法(四)手术治疗第四十一页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 七、桡骨(rog)茎突狭窄性腱鞘炎一、应用解剖桡骨(rog)茎突处有一浅沟，有拇长展肌腱及拇短伸肌腱经此走行。第四十二页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、病因病理 多为手腕过度劳动，造成局部纤维管狭窄、炎症，使肌腱滑动困难，而产生临床症状。三、诊断要点.多见于中年妇女。.桡骨茎突及舟状窝的桡侧疼痛及压痛，凡是有拇指外展或内收动作参与的活动(hu dng)，均可因疼痛加剧而受到影响。第四十三页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine .握拳尺偏动作时疼痛加重（芬克斯坦试验(shyn)阳性）。第四十四页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、治疗方法 急性期可采用纸板或夹板固定于腕略桡偏位23周，配合药物外敷。若未自愈或进入(jnr)慢性期，可采用手法、封闭、小针刀及手术等方法治疗。第四十五页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 八、指屈肌腱鞘炎一、概述1.又称“弹响指”或“板机指”。2.好发于拇指(mzh)、中指、环指。3.女性多见，中老年发病较多。第四十六页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、应用(yngyng)解剖1.掌骨颈的掌侧，有一浅沟与鞘状韧带形成无弹性之纤维骨管即鞘管。2.屈指肌腱通过此管进入手指。第四十七页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第四十八页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 三、病因病理1.病因：手指长期从事握持硬物工作，屈指肌腱 在环状韧带上摩擦(mc)劳损所致。2.病理 .环状韧带、腱鞘增厚；.骨韧带管狭窄；.肌腱膨大；.屈伸手指时，膨大肌腱通过狭窄腱鞘，即产 生弹响。第四十九页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 第五十页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 四、临床表现与诊断要点1.手指关节掌侧酸痛晨起或劳动(lodng)后出现，活动或遇热后缓解；2.手指屈伸受限，强力屈伸时，有弹响伴跳跃感；3.掌指关节掌面可触及一米粒大小的痛性结节。五、治疗1.理筋手法：适用于初期患者，揉按弹拨痛性结节，伸展、屈伸掌指关节。第五十一页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 2.封闭疗法：用2普鲁卡因1ml加醋酸氢化考的松12.5mg作腱鞘内注射。3.小针刀疗法：无菌条件下，用小针刀挑割松解腱鞘，切勿损伤肌腱。4.手术疗法：如上述方法疗效欠佳(qin ji)时，可考虑手术切开狭窄的腱鞘。5.药物治疗第五十二页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 九、指伸、屈肌腱(jjin)损伤一、应用解剖(jipu)1.根据指屈肌腱的解剖和生理特点，可将其分为五个区：前臂区：此区屈肌腱较多，有腱周组织保护，粘连机会较少。如条件合适，可在此区一期缝合肌腱，效果常较好。腕管区：腕管内有9条肌腱及正中神经，空间较小，常合并正中神经损伤。此区只缝合指伸屈肌腱及拇长屈肌腱。第五十三页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 手掌(shuzhng)区：腕横韧带远侧至肌腱进入腱鞘前的区域。手掌(shuzhng)内伸肌腱的桡侧有蚓状肌附丽，肌腱断了可限制其向近端回缩。蚓状肌至腱鞘段，可一期吻合深肌腱并切开部分腱鞘。第五十四页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 腱鞘区：又称无人区，从腱鞘开始(kish)至中节指骨中份指浅屈肌腱附丽处。此段深浅屈肌腱被限制在狭窄的腱鞘内，伤后易发生粘连，处理效果较差。目前一般认为，如系指浅屈肌肌腱单独断裂可不吻合，以免粘连；深浅肌腱同时断裂，主张仅吻合深肌腱，同时切除浅肌腱及吻合附近的腱鞘，但要保留滑车。A2、A4滑车必须保留。第五十五页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 深肌腱抵止区：中节指骨近中份至深肌腱抵止处。该去只有深屈肌腱，断裂后应争取(zhngq)早期修复，直接缝合断端。第五十六页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 2.根据不同部位解剖结构，将其分为五个区。一区：末节指骨背侧基底部至中央肌腱抵止点之间。二区：中央肌腱止点至近节指骨中点。三区：伸肌腱扩张部远侧缘至伸肌支持带远侧缘。四区：伸肌支持带深面。五区：伸肌支持带近侧缘至伸肌起始部。伸肌腱损伤后，只要损伤部位有足够皮肤覆盖，所以的伸肌腱断裂(dun li)均应一期缝合。第五十七页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 二、临床表现与诊断1.伸肌腱(jjin)损伤第五十八页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 2.屈肌腱(jjin)损伤第五十九页，共六十一页。Hunan University of Traditional Chinese Medicine Hunan University of Traditional Chinese Medicine 三、肌腱缝合常用方法间断缝合、抽出缝合、双垂直(chuzh)缝合、编织缝合等四、治疗方法1.手术治疗2.固定方法：肌腱缝合术后宜用夹板或石膏固定三周；非手术治疗闭合性手指末节，用铝板固定六周于远侧指间关节过伸，近侧指间关节屈曲位。3.练功疗法：术后1周轻度被动活动术后2周中度被动活动术后3周轻度主动活动术后4周中度主动活动术后5周积极主动活动4.药物治疗第六十页，共六十一页。内容(nirng)总结第三节 腕、手部筋伤。腕部的功能位：背伸腕部于30，没有尺桡偏移。3.由于受力部位与方向的不同，可在相应或相反部位出现症状。病理病因腕管压力卡压正中神经或肌腱。.固定(gdng)：适用于初期患者，固定(gdng)12周。一、概念：任何原因使尺神经管内神经受压而引起症状者，称为腕部尺神经管综合征。一型：尺神经受压（深浅支）运动与感觉受累。4.手术疗法：如上述方法疗效欠佳时，可考虑手术切开狭窄的腱鞘。4.药物治疗第六十一页，共六十一页。