Transcript 吴立东_八年制讲课

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
Bursitis
滑囊炎
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.
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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.

Surgical procedures useful in treating bursitis are
(1) aspiration and injection of an appropriate
drug, (2) incision and drainage when an acute
suppurative 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 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; 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 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.
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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
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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.
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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.
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Electrodiagnostic studies are reliable confirmatory tests.
Ultrasonography 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
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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.
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.
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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
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Stenosing tenosynovitis of the abductor pollicis longus
and extensor pollicis brevis tendons
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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 ).
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TRIGGER FINGER AND THUMB
弹响指和弹响拇
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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.
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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
Lateral epicondylitis
肱骨外上髁炎
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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.
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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.
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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
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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
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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
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Traditionally, frozen shoulder has been considered a selflimiting 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
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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
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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.
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.
定义
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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
多数患者不得不接受THA
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诊断
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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
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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
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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
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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
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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
…
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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
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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
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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
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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
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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
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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
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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
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骨移植，效果尚好
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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
3A，3B，骨移植术，包括带血运的骨移植，
效果差
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3C期及以上
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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
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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
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Core decompression
Bone Grafting
Vascularized Fibular
Grafting
Osteotomies of
Proximal Femur
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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 crosslinked 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.
Epiphysitis of tibial tuberosity
胫骨结节骨骺炎

(Osgood-Schlatter disease)
(Osteochondrol disease of the tibial
tubercle)
EPIPHYSITIS OF TIBIAL TUBEROSITY
(OSGOOD-SCHLATTER DISEASE)

The terms osteochondrosis and epiphysitis designate
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, infection, or congenital malformation.
Treatment
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Surgery rarely is indicated for Osgood-Schlatter disease;
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. In a review of the natural history of
untreated Osgood-Schlatter disease in 69 knees in 50
patients, found that 76% of patients believed they had
no limitation of activity, although only 60 could kneel
without discomfort.
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In a prospective study of 17 patients with OsgoodSchlatter disease and 12 adolescents without anterior
knee pain, Aparicio et al. noted a strong association
between Osgood-Schlatter disease and patella alta. The
increase in patellar height may require an increase in the
force by the quadriceps to achieve full extension, which
could be responsible for the apophyseal lesion.
However, it can be argued that the patella alta is the
result of chronic avulsion of the bony tuberosity.
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Surgery may be considered if symptoms are
persistent and severely disabling.
Complications reported of Osgood-Schlatter
disease whether treated surgically or not,
including subluxations of the patella, patella alta,
nonunion of the bony fragment to the tibia, and
premature fusion of the anterior part of the
epiphysis with resulting genu recurvatum.
Insertion of Bone Pegs

Incise the periosteum longitudinally distal to the
tuberosity. With an electric saw cut two matchstick pegs
4 cm long from the tibia; make the base of each peg
larger than its tip. Then drill two holes through the
tibial tuberosity—one near but not in contact with the
proximal tibial physis and slanting proximally and
laterally and the other also distal to the physis and
slanting proximally and medially. Insert the pegs into
these holes and resect their projecting ends.

technique for insertion of bone pegs for
Osgood-Schlatter disease
AFTERTREATMENT.
A cast is applied
from groin to toes and is worn for 2 weeks.
A cylinder walking cast is then worn for 4
more weeks.
Excision of Ununited Tibial Tuberosity
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TECHNIQUE: Make a longitudinal incision centered
over the tibial tuberosity. Expose the patellar tendon
and incise it longitudinally. Elevate the tendon laterally
and medially and excise any loose fragments of bone
and enough tibial cortex, cartilage, and cancellous bone
to remove any bony prominence completely. Do not
disturb the peripheral and distal margins of the
insertion of the patellar tendon. Close the wound.
AFTERTREATMENT. A cylinder walking cast is
applied and worn for 2 to 3 weeks. Exercises are then
begun.

excision of
ununited tibial
tuberosity. A,
Tibial tuberosity
has been exposed.
B, Bony
prominence has
been excised.
Legg-Calve-Perthes DISEASE
Perthes病






The cause
The clinical sign
Plain roentgenographic changes
Bone scintigraphy
MRI
Treatment




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.


(1)
(2)
(3)
(4)
(5)
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 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.
After statistical analysis of 116 hips affected with
Perthes disease, Mukherjee and Fabry concluded that
Salter and Thompson's classification is simple and
accurate and can be applied early in the course of the
disease to determine management.
Conclusions
 1. Most patients can be treated by noncontainment
methods and obtain good results (84%).
 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.
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