浙江大学医学院八年制教学 神经精神与运动1（模块2） 运动系统慢性疾病 肩关节周围炎、腱鞘炎 股骨头坏死 浙江大学医学院附属二院骨科 吴立东
滑囊炎是指滑囊的急性或慢性炎症。滑囊是结缔组织中的囊状间隙，是由内皮细胞组成的封闭性囊，内壁为滑膜，有少许滑液。少数与关节相通，位于关节附近的骨突与肌腱或肌肉、皮肤之间。凡摩擦力或压力较大的地方，都可有滑囊存在，其作用主要是有利于滑动，从而减轻或避免关节附近的骨隆突和软组织间的摩擦和压迫滑囊炎是指滑囊的急性或慢性炎症。滑囊是结缔组织中的囊状间隙，是由内皮细胞组成的封闭性囊，内壁为滑膜，有少许滑液。少数与关节相通，位于关节附近的骨突与肌腱或肌肉、皮肤之间。凡摩擦力或压力较大的地方，都可有滑囊存在，其作用主要是有利于滑动，从而减轻或避免关节附近的骨隆突和软组织间的摩擦和压迫 • Bursae are sacs lined with a membrane similar to synovium; they usually are located about joints or where skin, tendon, or muscle moves over a bony prominence. • may or may not communicate with a joint. • Function: reduce friction, protect delicate structures from pressure.
Bursae are similar to tendon sheaths and the synovial membranes of joints and are subject to the same disturbances: (1) acute or chronic trauma, (2) acute or chronic pyogenic化脓性 infection, and (3) low-grade inflammatory conditions such as gout, syphilis, tuberculosis, or rheumatoid arthritis. • Two types of bursae: normally present (as over the patella and olecranon) and adventitious ones (such as develop over a bunion姆囊炎, an osteochondroma骨软骨瘤, or kyphosis驼背 of the spine). Adventitious bursae are produced by repeated trauma or constant friction摩擦 or pressure.
Treatment---the cause of the bursitis Systemic causes, such as gout痛风 or syphilis梅毒, and local trauma or irritants should be eliminated, and, when necessary, the patient's occupation or posture should be changed. One or more of the following local measures usually are helpful: Rest, hot wet packs, elevation, and, if necessary, immobilization of the affected part.
Surgical procedures useful in treating bursitis are (1) aspiration and injection of an appropriate drug, (2) incision and drainage when an acute suppurative 化脓性bursitis fails to respond to nonsurgical treatment, (3) excision of chronically infected and thickened bursae, and (4) removal of an underlying bony prominence.
Carpal Tunnel Syndrome腕管综合症 (another name: tardy median palsy) results from compression of the median nerve within the carpal tunnel. The syndrome consists predominantly of tingling刺痛 and numbness in the typical median nerve distribution in the radial three and one-half digits (thumb, index, long, radial side of ring). Pain occurs diffusely in the hand and radiates up the forearm. Thenar手掌 atrophy usually is seen later in the course of the nerve compression. innervated
The syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Some studies reported biopsy specimens of the flexor tendon synovium from 21 patients with “idiopathic特发性”carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue结缔组织 undergoing degeneration under repeated mechanical stress.
Diagnosis • Paresthesia感觉异常 over the sensory distribution of the median nerve is the most frequent symptom; it occurs more often in women and frequently causes the patient to awaken several hours after getting to sleep with burning and numbness of the hand that is relieved by exercise. The Tinel sign may be demonstrated in most patients by percussing轻叩 the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar muscles has been reported in about half of the patients treated by operation.
Acute flexion of the wrist for 60 seconds in some but not all patients or strenuous use of the hand increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms. Some studies evaluated the clinical usefulness of commonly administered provocative tests, including wrist flexion, nerve percussion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and in 50 control hands.
Diagnosis • The most sensitive test was the wrist flexion test, whereas nerve percussion was the most specific and the least sensitive. They also found that with the wrist in neutral position, the mean pressure within the carpal tunnel in patients with carpal tunnel syndrome was 32 mm Hg. This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures in the control subjects with the wrist in neutral position were 25 mm Hg, 31 mm Hg with the wrist in flexion, and 30 mm Hg with the wrist in extension.
Sensibility testing in peripheral nerve compression syndromes was investigated, found that threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies.
Electrodiagnostic电生理 studies are reliable confirmatory tests. Ultrasonography超声检查 has been used to show the movement of the flexor tendons within the carpal tunnel, but it does not clearly show soft tissue planes. Early reports of magnetic resonance imaging (MRI) in carpal tunnel syndrome are promising. A major advantage of MRI is its high soft tissue contrast, which gives detailed images of both bones and soft tissues. Care should be taken not to confuse this syndrome with nerve compression caused by a cervical disc herniation, thoracic outlet structures, and median nerve compression proximally in the forearm and at the elbow.
Treatment • If mild symptoms have been present and there is no thenar muscle atrophy, the injection of hydrocortisone into the carpal tunnel may afford relief. Great care should be taken not to inject directly into the nerve. Injection also can be used as a diagnostic tool in patients without bony or tumorous blocking of the canal;
65% of these cases probably are caused by a nonspecific synovial edema, and these seem to respond more favorably to injection. Injection also helps to eliminate the possibility of other syndromes, especially cervical disc or thoracic outlet syndrome. Some patients prefer to receive injections two or three times before a surgical procedure is carried out. If the response is positive and there is no muscle atrophy, conservative treatment with splinting and injection is reasonable.
Treatment • If signs and symptoms are persistent and progressive, especially if they include thenar atrophy, division of the deep transverse carpal ligament is indicated. The results of surgery are good in most instances, and benefits seem to last in most patients.
Although thenar atrophy may disappear, it resolves slowly, if at all. As noted earlier, when symptoms of median nerve compression develop during treatment of an acute Colles fracture, the constricting bandages and cast should be loosened and the wrist should be extended to neutral position. When median nerve palsy develops after a Colles fracture and has gone unrecognized for several weeks, surgery is indicated without further delay.
Lateral epicondylitis肱骨外上髁炎 • Lateral epicondylitis (tennis elbow), a familiar term used to described a myriad of symptoms about the lateral aspect of the elbow, occurs more frequently in nonathletes than athletes, with a peak incidence in the early fifth decade and a nearly equal gender incidence. • Activities that require repetitive supination and pronation of the forearm with the elbow in near full extension.
Tenderness is present over the lateral epicondyle approximately 5 mm distal and anterior to the midpoint of the condyle. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm supination, and there is pain when grasping objects. Plain roentgenograms usually are negative; occasionally calcific tendinitis may be present. MRI demonstrates tendon thickening with increased T1 and T2 signals but generally is not indicated.
Regardless of the underlying cause, nonoperative treatment is successful in 95% of patients with tennis elbow. Initial nonoperative treatment includes rest, ice, injections, and physical therapy centered around treatment such as ultrasound, electrical stimulation, manipulation, soft tissue mobilization, friction massage, stretching and strengthening exercises, and counter-force bracing. • If prolonged (6 to 12 months), operative treatment may be considered; it is effective in 90% of properly selected patients.
Adhesive Capsulitis （frozen shoulder.） 肩周炎或称冻结肩
Frozen shoulders in patients who report no inciting event and with no abnormality on examination (other than loss of motion) or plain roentgenograms were designated as "primary," and those with precipitant traumatic injuries as "secondary." This division helps in planning treatment but does not necessarily predict outcome.
No formal inclusion criteria. There are no universally accepted criteria for the diagnosis of frozen shoulder. internal rotation frequently is lost initially, followed by loss of flexion and external rotation.
The incidence of frozen shoulder in the general population is approximately 2%. (an increased incidence associated with, including diabetes mellitus (up to 5 times more), cervical disc disease, hyperthyroidism, intrathoracic disorders, and trauma). People between the ages of 40 and 70 are more commonly affected. Common to almost all patients is a period of immobility, the etiologies of which are diverse
Primary Frozen Shoulder • Primary frozen shoulder is a vague entity that only rarely recurs in the same shoulder. The clinical course of primary (idiopathic) frozen shoulder consists of three phases. • Phase I—Pain. Patients usually have a gradual onset of diffuse shoulder pain, which is progressive over weeks to months. The pain usually is worse at night and is exacerbated by lying on the affected side. As the patient uses the arm less, pain leading to stiffness ensues.
Primary Frozen Shoulder • Phase II—Stiffness. Patients seek pain relief by restricting movement. This heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities of daily living; men have trouble getting to their wallets and women with fastening brassieres. As stiffness progresses, a dull ache is present nearly all the time (especially at night), and this often is accompanied by sharp pain during range of motion at or near the new endpoints of motion.
Primary Frozen Shoulder • Phase III—Thawing. This phase lasts for weeks or months, and as motion increases, pain diminishes. Without treatment (other than benign neglect) motion return is gradual in most but may never objectively return to normal, although most patients subjectively feel near normal, perhaps as a result of compensation or adjustment in ways of performing activities of daily living.
Secondary Frozen Shoulder • Unlike patients with idiopathic frozen shoulder, patients with secondary frozen shoulder can recall a specific precipitating event, possibly related to overuse or injury. The three phases of classic frozen shoulder may not all be present and may not follow the previously outlined chronology; fortunately, treatment for the two entities is similar.
Diagnosis • tests in patients with a frozen shoulder (including plain film roentgenograms) usually are normal, except in those with medical disorders such as diabetes or thyroid disease. Bone scans have been reported to be positive in some patients. • Arthrograms characteristically show a reduced joint volume with irregular margins. Clinical improvement has been reported after arthrography because of brisement of adhesions from forcefully injecting fluid into the joint. A volume of less than 10 ml and lack of filling of the axillary fold currently are accepted arthrographic findings indicative of a frozen shoulder.
Treatment • Traditionally, frozen shoulder has been considered a self-limiting condition, lasting 12 to 18 months. • Approximately 10% of patients have long-term problems. Patients seeking care earlier usually recover more quickly. Dominant shoulder involvement has been reported to be predictive of a good result, whereas occupation and treatment programs are not statistically significant. Obviously, the best treatment of frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of paramount importance; a good understanding of the pathological process by the patient and the physician also is important.
Treatment • Initial treatment is nonoperative, with emphasis placed on control of pain and inflammation. • passive and active range-of-motion exercises. Abduction should be avoided initially to prevent impingement until joint motion becomes more supple.
Treatment • Although a frozen shoulder usually is self-limiting and resolves in 12 to 18 months, many patients do not wish to wait that long for resolution of symptoms and request active intervention long before 12 months. With appropriate patient selection, significant improvement can be obtained in approximately 70% of patients. • Closed manipulation under anesthesia • Open release of contractures
Treatment • Arthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis.
Stenosing Tenosynovitis狭窄性腱鞘炎 • more often in the hand and wrist than anywhere else in the body. • A peritendinitis may affect these tendons, causing pain, swelling, and crepitus捻发音 .
When the long flexor tendons are involved, trigger thumb, trigger finger, or snapping finger occurs. The stenosis occurs at a point where the direction of a tendon changes, for here a fibrous sheath acts as a pulley滑轮 , and friction is maximal. Although the tenosynovium lubricates the sheath, friction can cause a reaction when the repetition of a particular movement is necessary, as in winding a fine coil of wire线圈 or stacking laundry.
DE QUERVAIN DISEASE • Stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons • When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895. • Women are affected 10 times more frequently than men. The cause is almost always related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable.
diagnosis The Finkelstein test usually is positive: "on grasping the patient's thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating." Although Finkelstein states that this test is "probably the most pathognomonic objective sign," it is not diagnostic; the patient's history and occupation, the roentgenograms, and other physical findings must also be considered.
Treatment • Conservative treatment, consisting of rest on a splint and the injection of a steroid preparation into the tendon sheath, is most successful within the first 6 weeks after onset. • When pain persists, surgery is the treatment of choice (complete relief ).
TRIGGER FINGER AND THUMB弹响指和弹响拇 • Stenosing tenosynovitis, leading to inability to extend the flexed digit ("triggering") usually is seen after 45 years of age. • Patients may note a lump块 or knot小结 in the palm. The lump may be the thickened area in the first annular part of the flexor sheath, or a nodule or fusiform纺锭状 swelling of the flexor tendon just distal to it. The nodule can be palpated by the examiner's fingertip and will move with the tendon. The tendon nodule usually is at the entry of the tendon into the proximal annulus at the level of the metacarpophalangeal joint.
Treatment of trigger digits usually is nonoperative in the uncomplicated patient who presents a short time after onset of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and ice. Corticosteroid injection is effective after one injection • Surgical release reliably relieves the problem for most patients
Osteonecrosis of Femoral head股骨头无菌性坏死 • Osteonecrosis of the femoral head is a progressive disease that generally affects patients in the third though fifth decades of life; if left untreated, it leads to complete deterioration of the hip joint. It is estimated that as many as 20,000 new cases of osteonecrosis are diagnosed each year in the United States.
Diagnosis • Patients are typically asymptomatic early in the course of osteonecrosis and eventually have groin pain on ambulation. A thorough history and physical examination should be done to discover potential risk factors and determine the clinical status of the patient. Plain roentgenograms should be obtained including anteroposterior and lateral views. Roentgenographic changes seen in osteonecrosis depend on the stage of the disease. Plain films may appear normal in the early stages, but changes are noted as the disease progresses, such as increased density or lucency in the femoral head.
Advances in MRI have made earlier diagnosis of osteonecrosis of the femoral head possible and allow determination of the exact stage and extent of the pathological process without use of invasive methods.
Treatment • Core decompression • Bone Grafting • Vascularized Fibular Grafting • Osteotomies of Proximal Femur
Resurfacing Hemiarthroplasty • Total Hip Arthroplasty and Bipolar Hemiarthroplasty. • Improved results recently have been reported with modern cementing techniques and press-fit cementless total hip arthroplasty in patients with osteonecrosis. With new bearing surfaces becoming available, such as ceramic on ceramic, metal on metal, and highly cross-linked polyethylene, results may improve even more. The results of primary total joint replacement for osteonecrosis are now approaching those reported for osteoarthritis in aged-matched patients.