肩袖損傷

當(dāng)我們?cè)谂R床上遇到疑似病人，只有X片而無MRI檢查時(shí)，1我們能從X片中得到什么信息？2我們印象中的可疑診斷有哪些？3針對(duì)性的體查有哪些？

GazzolaS,BleakneyRR.Currentimagingoftherotatorcuff[J].SportsMedArthrosc,2011,19(3):300-9.cysticchangeofthegreatertuberosity1讀X片GazzolaS,BleakneyRR.Currentimagingoftherotatorcuff[J].SportsMedArthrosc,2011,19(3):300-9.normalsubacromialjointspace(≥7mm)(arrow)1superiorsubluxationofthehumeralhead

(arrow)2notchedhumeralneck(arrowhead)TypeIcalci?cationwitha?uffy,?eecyappearancewithpoorlyde?nedborders,withacutesymptomsandtermedtheresorptivephase.TypeIIcalci?cation,morediscreetandofhomogenousdensity,withwell-circumscribedborders,andintheformativephase.DePalmaAF,KruperJS.Long-termstudyofshoulderjointsaffliatedwithandtreatedforcalci?ctendinitis[J].ClinOrthop.1961;20:61-72.calci?ctendinopathy2可疑診斷1關(guān)于肩周炎肩周炎=凍結(jié)肩（《實(shí)用骨科學(xué)》第3版），是由于肩關(guān)節(jié)周圍軟組織病變而引起肩關(guān)節(jié)疼痛和活動(dòng)功能障礙。國(guó)外報(bào)道Frozenshoulder40-60yearsofage,incidence2-5%[1].3phases[2]freezingphase2-9months,painandlossofmotionoftheglenohumeraljointinalldirection，usuallyworstatnightandwhenlyingontheaffectedside2)frozenphase4-12months,stiffnessreachesitsmaximumthawingphase5-12months,rangeofmotionreturnstonormal2肩峰下撞擊綜合癥疼痛，主訴為三角肌下疼痛，并經(jīng)常向下放射至前方的肱二頭肌，夜間疼痛可影響睡眠1HandC,ClipshamK,ReesJL,etal.Long-termoutcomeoffrozenshoulder.JShoulderElbowSurg2008;17:231-6.2ReevesB.Thenaturalhistoryofthefrozenshouldersyndrome.ScandJRheumatol1975;4:193-6.3針對(duì)肩袖損傷的體查1岡上肌肩外展功能4resistedisometricabduction1)thearminneutralrotation2)abductsthearmto90degrees2岡下肌和小圓肌肩外旋功能2externalrotationlagsign1)elbowpassivelyflexedto90degrees2)maximalexternalrotation3dropsign1)almostfullexternalrotation2)elbowflexedat90degrees4weaknesswithexternalrotation1)elbowsflexedto90degrees2)thethumbsup3)shouldersrotatedinternally20degrees3肩胛下肌肩內(nèi)旋、后伸功能2

internalrotationlagsign3bellypress4針對(duì)肩峰下撞擊綜合癥的體查關(guān)于MRI肩袖解剖解剖足印（footprint）關(guān)于MRI正常肩袖的MRI斜冠狀面正常肩袖的MRI斜矢狀面正常肩袖的MRI橫斷面損傷肩袖的MRI魔法角magicanglephenomenonthefibersareat55degreestothemainmagneticfieldonT1EricksonSJ,ProstRW,TiminsME.The“magicangle”effect:backgroundphysicsandclinicalrelevance.Radiology.1993;188:23-25.我們?cè)贛RI上應(yīng)得到的信息1肩袖走行及連續(xù)性2高信號(hào)3脂肪變性4肌肉萎縮5肌肉回縮6三角肌下、肩峰下囊滑液相連

肩袖走行及連續(xù)性脂肪滲透（fattyinfiltration）FuchsB,WeishauptD,ZanettiM,HodlerJ,GerberC.Fattydegenerationofthemusclesoftherotatorcuff:assessmentbycomputedtomographyversusmagneticresonanceimaging.JShoulderElbowSurg1999;8:599-605.肌肉萎縮（muscleatrophy）1切線征[1]（tangentsign）2肩胛比（scapularratio）Scapularratiousestheratioofthesupraspinatusmuscleincrosssectiononthesagittalobliqueimagecomparedwiththesizeofthesupraspinatusfossa,andinsupraspinatusatrophytheratioislessthan50%[2].1ZanettiM,GerberC,HodlerJ.Quantitativeassessmentofthemusclesoftherotatorcuffwithmagneticresonanceimaging.InvestRadiol.1998;33:163-170.2ThomazeauH,RollandY,LucasC,etal.Atrophyofthesupraspinatusbelly.AssessmentbyMRIin55patientswithrotatorcuffpathology.ActaOrthopScand.1996;67:264-268.肩袖損傷的分類1全層撕裂

1）小＜1cm2）中1-3cm3）大3-5cm4）巨大＞5cmDeOrioJK,Co?eldRH.Resultsofasecondattemptatsurgicalrepairofafailedinitialrotator-cuffrepair.JBoneJointSurg.1984;66:563–567.肩袖損傷的分類2部分撕裂肩袖損傷的治療手術(shù)VS保守1年齡Ageisoneofthemostusedparametersindecisionmakingforthesurgeryofthecuff[1].75years2撕裂大小Shimizu[2]recommendearlycuffrepairaftercon?rmingthediagnosisofmassiverotatorcufftears.Partial-thicknessrotatorcufftearisafurtherindicationinthosepatientswithminimalriskoftearextension,minimalpain,anddysfunction[3].1TanakaM,ItoiE,SatoK,etal.Factorsrelatedtosuccessfuloutcomeofconservativetreatmentforrotatorcufftears.UpsJMedSci.2010;115:193-200.2ShimizuC,HoriiM,YamashitaF,etal.Prognosisofmassiverotatorcufftear.Chubuseisai.1990;33:392.3OzbaydarMU,BekmezciT,TonbulM,etal.Theresultsofarthroscopicrepairinpartialrotatorcufftears.ActaOrthopTraumatolTurc.2006;40:49–55.肩袖損傷的治療肌腱的縫法開放手術(shù)骨質(zhì)端的固定肩袖損傷的治療手術(shù)方式的選擇開放手術(shù)VS關(guān)節(jié)鏡手術(shù)美國(guó)的一篇系統(tǒng)評(píng)價(jià)顯示：術(shù)后6個(gè)月的ASES、UCLA、疼痛評(píng)分及再斷裂方面，兩者無顯著差異，只有短期疼痛，關(guān)節(jié)鏡優(yōu)于開放手術(shù)。LindleyK,JonesGL.Outcomesofarthroscopicversusopenrotatorcuffrepair:asystematicreviewoftheliterature.AmJOrthop(BelleMeadNJ),2010,39(12):592-600.不可修復(fù)肩袖損傷的判定AccordingtoGerberetal.,imaging?ndingsthatsuggestanirreparablerotatorcufftearinclude1）staticsuperiorsubluxationofaglenohumeraljointwithanacromiohumeralintervalof7mmorlessonananteroposteriorradiographwiththearminneutralrotationGerberC,WirthSH,FarshadM(2011)Treatmentoptionsformassiverotatorcufftears.JShouldElbSurg20:S20–S29.and2)fattyin?ltrationoftherotatorcuffmusclesatstagethreeorgreater.

不可修復(fù)肩袖損傷的治療latissimusdorsitransfers一篇關(guān)于背闊肌修復(fù)巨大撕裂肩袖損傷的系統(tǒng)評(píng)價(jià)結(jié)果顯示：在45.5個(gè)月的隨訪期內(nèi)