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

运动系统慢性损伤 Chronic injury of soft tissue

概述Overview 临床常见病，多发病 涉及骨，关节，肌肉，肌腱，韧带，筋膜及其相关的血管神经 分类：软组织，骨，软骨慢性损伤及周围神经卡压

特点Feature 局部慢性，无外伤史 有特定部位压痛点和肿块，可放射痛 局部无明显炎症表现 近期有与疼痛部位相关的过度活动史 部分病人偶导致运动系统慢性损伤的工种，坐姿和工作习惯或职业

治疗 Treatment 限制致伤活动，或纠正不良姿势，维持关节的不负重活动 积极物理治疗，按摩推拿，外敷及熏蒸。 正确合理使用肾上腺皮质激素 非甾体消炎镇痛药的合理使用（短期；外用；缓释剂，肠溶剂，栓剂；肾功能不佳者可选用短半衰期药物） 手术

Strain of lumbar muscles 腰肌劳损 Common cause of lumbar pain Local tenderness, start point or end point of muscles Back pain, relieve after rest or activities Erector spainae muscle spasm

Treatment Self care therapy, change position Physiotherapy, massage Local steroid injection Anti-inflammatory drugs

Supraspinous ligament injury interspinous ligament injury Common cause of back pain Supraspinour ligament injury common in middle thoracic segment Interspinous ligament injury common in lower lumbar segment

No trauma history Bend or hyperextension pain Local tenderness Steroid injection Physiotherapy or massage immobilization

滑囊是位于人体摩擦频繁或压力较大部位的一种缓冲结构。分为恒定滑囊，继发性滑囊或附加滑囊 Bursitis 滑囊炎 滑囊是位于人体摩擦频繁或压力较大部位的一种缓冲结构。分为恒定滑囊，继发性滑囊或附加滑囊

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 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, an osteochondroma, or kyphosis of the spine). Adventitious bursae are produced by repeated trauma or constant friction or pressure.

Treatment---the cause of the bursitis Systemic causes, such as gout or syphilis, 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.

Treatment Aspiration and steroid injection Surgical procedures useful in treating bursitis are (1) incision and drainage when an acute suppurative bursitis fails to respond to nonsurgical treatment, (2) excision of chronically infected and thickened bursae, and (3) removal of an underlying bony prominence

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.

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, 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 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 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. Steroid injection 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 or knot in the palm. The lump may be the thickened area in the first annular part of the flexor sheath, or a nodule or fusiform 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 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 symptom for most patients

Ganglion

Treament Squeeze Aspiration and steroid injection Operation

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.

Steroid injection If prolonged (6 to 12 months), operative treatment may be considered; it is effective in 90% of properly selected patients.

肩周，肌腱，滑囊及关节囊的慢性损伤性炎症，主要表现为活动时疼痛，功能受限 Adhesive Capsulitis （frozen shoulder.） 肩周炎或称冻结肩或五十肩 肩周，肌腱，滑囊及关节囊的慢性损伤性炎症，主要表现为活动时疼痛，功能受限

肩部结构 肩部外层肌肉为三角肌 内层为肩袖，由冈上肌，冈下肌，肩胛下肌和小圆肌及肌腱组成 肱二头肌长头 关节囊 滑囊 肩胛盂和肱骨头

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 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

Rotator cuff肩袖 冈上肌，冈下肌，肩胛下肌和小圆肌 Supraspinatus，infraspinatus，subscapular muscle，teres minor Pain may disappear Dysfunction

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.

Differential diagnosis Cervical spondylosis Rotator cuff tear

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. Physiotherapy Steroid injection NSAIDS drugs

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.

Chondromalacia patella 髌骨软骨软化症

Epiphysitis of tibial tuberosity 胫骨结节骨骺炎 (Osgood-Schlatter disease) (Osteochondrol disease of the tibial tubercle) Common age 12-14 ys

OSGOOD-SCHLATTER DISEASE Disorders of actively growing epiphyses. The disorder may be localized to a single epiphysis or occasionally may involve two or more epiphyses simultaneously or successively. The cause generally is unknown, but evidence indicates a lack of vascularity that may be the result of trauma (quadriceps), infection, or congenital malformation.

Treatment Self limited disease Observation, remain eminance of TT Surgery rarely is indicated the disorder usually becomes asymptomatic without treatment or with simple conservative measures such as the restriction of activities or cast immobilization for 3 to 6 weeks

Legg-Calve-Perthes Disease Perthes病 The cause： chronic injury The clinical sign：pain and limp， Thomas sign plain roentgenographic changes Bone scintigraphy MRI Treatment

Lloyd-Roberts、Catterall and Salamon classification classified patients with this disease into groups according to the amount of involvement of the capital femoral epiphysis: group I, partial head or less than half head involvement; groups II and III, more than half head involvement and sequestrum formation; group IV, involvement of the entire epiphysis.

head at risk They noted certain roentgenographic signs described as "head at risk" correlated positively with poor results, especially in patients in groups II, III, and IV. These head-at-risk signs include Lateral subluxation of the femoral head from the acetabulum, Speckled calcification lateral to the capital epiphysis, Diffuse metaphyseal reaction (metaphyseal cysts), A horizontal physis, Gage sign, a radiolucent V-shaped defect in the lateral epiphysis and adjacent metaphysis.

Containment by femoral varus derotational osteotomy for older children in groups II, III, and IV with head-at-risk signs. Contraindications include an already malformed femoral head and delay of treatment of more than 8 months from onset of symptoms. Surgery is not recommended for any group I children or any child without the head-at-risk signs.

Salter and Thompson classification Salter and Thompson advocated determining the extent of involvement by describing the extent of a subchondral fracture in the superolateral portion of the femoral head. If the extent of the fracture (line) is less than 50% of the superior dome of the femoral head, the involvement is considered type A, and good results can be expected. If the extent of the fracture is more than 50% of the dome, the involvement is considered type B, and fair or poor results can be expected.

According to Salter and Thompson, this subchondral fracture and its entire extent can be observed roentgenographically earlier and more readily than trying to determine the Catterall classification. Furthermore, according to these authors, if the femoral head is graded as type B, then probably an operation such as an innominate osteotomy should be carried out

Herring classification

Conclusions 1. Most patients can be treated by noncontainment methods and obtain good results (80%). 2. Satisfactory clinical results frequently can be obtained at long-term follow-up despite an unsatisfactory roentgenographic appearance.

3. The Catterall classification is a valid indicator of results but is not applicable as a therapeutic guide. 4. Head-at-risk signs added little to the Catterall classification as a prognostic indicator or therapeutic guide. 5. All of the fair and poor results were in patients with Catterall III or IV involvement and onset of the disease at age 6 or later.

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 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 atrophy usually is seen later in the course of the nerve compression.

The syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Schuind et al. studied biopsy specimens of the flexor tendon synovium from 21 patients with "idiopathic" carpal tunnel syndrome. The findings were similar in all and were typical of a connective tissue undergoing degeneration under repeated mechanical stress.

Diagnosis Paresthesia over the sensory distribution of the median nerve is the most frequent symptom; 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 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. Gellman et al. 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 studies are reliable confirmatory tests Electrodiagnostic studies are reliable confirmatory tests. Ultrasonography has been used to show the movement of the flexor tendons within the carpal tunnel Early reports of 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 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.

Osteonecrosis of Femoral head 成人股骨头无菌性坏死 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.

定义 ARCO+AAOS的标准 ONFH是股骨头血供中断或受损，引起骨细胞及骨髓成分死亡及随后的修复，继而导致股骨头结构改变，股骨头塌陷，关节功能障碍的疾病

Osteonecrosis of the femoral head 非创伤性：常见病因是酒精中毒，激素 是骨科常见病，多见于中青年，双侧发病，约80%未有效治疗，1-4年内将发生股骨头塌陷，缺乏有效防治方法 多数患者最后不得不接受全髋关节置换术Total Hip Arthroplasty

ARCO 分期 0期 活检符合坏死，其余检查正常 1期 MR、骨扫描异常 A<15%, B15-30%, C>30% 2期 股骨头斑片状密度不均、硬化与囊肿形成，平片与CT没有塌陷表现，MR及骨扫描异常，髋臼无异常A MR<15%; B 15-30%; C>30% 3期 正侧位片出现新月征 A长度<15%或塌陷<2mm; B新月征长度15-30%或塌陷2-4mm; C>30%或塌陷>4mm 4期 关节面塌陷变扁，关节间隙狭窄，髋臼出现坏死变化，囊性变和骨赘

诊断 早期诊断---困难 高度重视病因，尤其重要 常常是一侧有症状作MR检查时，发现对侧有早期ONFH 有酗酒，长期应用激素史 病人自己警惕意识强，主动检查 晚期，X线片表现已很明显，容易诊断

病史 体格检查 X线片 骨功能检查FBE 骨内压测定，骨内静脉造影，核心活检，放射性核素扫描ECT CT MR

X线片：敏感度差，适宜观察股骨头形态，光圆度，高度，塌陷程度 CT，敏感度低，不建议采用 ECT，敏感度高 仔细观察确实有冷区，可发现特早期（0或1前期），出现热区，结合病史有助于诊断，但特异性差 MRI，敏感度特高，早期发现和诊断股骨头坏死的敏感性和特异性达99%，应为首选 股骨头核心活检结果最为准确，组织病理学

ARCO国际骨坏死分期的治疗原则 0-2A期，可行髓芯减压术 2B-3B期适用于截骨术或骨移植术，包括带血运的骨移植 3C期及以上，应考虑作人工髋关节置换术

骨移植术 带缝匠肌蒂骨瓣 带股直肌蒂骨瓣 带臀中肌蒂骨瓣 带股方肌蒂骨瓣 带股外侧肌蒂骨瓣 单纯游离腓骨移植 带缝匠肌蒂骨瓣 带股直肌蒂骨瓣 带臀中肌蒂骨瓣 带股方肌蒂骨瓣 带股外侧肌蒂骨瓣 单纯游离腓骨移植 吻合血管腓骨移植 带旋髂深血管蒂髂骨瓣 带血管蒂大转子骨-筋膜瓣 股骨头内记忆合金球网植入 双支撑骨柱移植 支撑物加植骨 空心钉植入 钽棒植入 BMP及生物因子植入…

双支撑骨柱移植长期随访疗效10.2年 2B 83% 2C 80% 3A 75% 3B 65% 3C 40% 4 28.6%

保头手术影响因素 病变本身因素 股骨头坏死范围和塌陷程度，部位 技术因素 减压有效与否 坏死骨清除彻底与否 植骨的血运保证与否 机械支撑足够与否：部位，强度，面积 良好的血供+足够大的支撑面积，足够强的支撑强度

股骨头坏死的分期系列疗法 根据年龄，坏死面积，坏死位置，塌陷危险性等进行个体化选择治疗方法 只要正确地掌握相应方法，才能获得较好疗效 ONFH病人多较年轻，应首先考虑保存自体股骨头

0-1A：无症状，保守治疗 药物：活血化瘀中药，葛根素，降脂药等，最好用于1前期者，可能有一定效果 高压氧 血液净化 磁疗 震波 临床疗效有待于长期观察

0-1A：有症状，行细针钻孔减压，有效率60%，可植入自体骨髓细胞或第2代骨髓干细胞 目的：股骨头内减压，打通硬化带，促使向坏死区增加血液循环

1A，1B,2A 粗通道髓芯减压，效可 目的：减压，打通硬化带，增加血液循环 可植入自体骨髓细胞，干细胞，自体骨，同种异体骨，骨诱导活性材料等

1C，2A，2B，2C 骨移植，效果尚好 目的，彻底清除坏死骨，充分植骨，重建血循环，促进骨修复，恢复股骨头内生物力学强度 防止塌陷

3C期及以上 THA，但是无论是骨水泥或非骨水泥固定的THA，用于骨坏死的远期疗效差于OA的THA， 我们应该做的：明确的术前告知 精确标准的手术 术后的康复 积极随访指导，病人日常

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.

Thank you very much for your attention! 谢谢大家! Thank you very much for your attention!