浙江大学医学院八年制教学

1. 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

2. 运动系统慢性损伤 Chronic injury of locomotor Systems

3. 概述Overview • Common diseases • Bone, joint, muscle, tendon, ligament, fascia, related blood vessels and nerves • Category: soft tissue injury, bone injury, chronic cartilage injury and peripheral nerve entrapment

4. Osteoporosis

5. 特点 Features • Locality, chronic ( be slow in taking effect), without history of trauma • Tenderness or mass in specific areas, radiating pain • Without obvious inflammation in local areas • The injuries are related to overuse recently • Related to some type of work or occupations, posture, working or studying habit, etc

6. Demba Ba

7. Once the best of second spiker

8. Treatment • Limit injurious activities, posture correction, maintaining joint movement without weight bearing • Physiotherapy, medical massage, external application and fumigation • Proper and reasonable use of adrenocortical hormone • Proper and reasonable use of NSAIDs • Surgery

9. 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

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

11. Supraspinous ligament injuryinterspinous ligament injury • Common cause of back pain • Supraspinour ligament injury common in middle thoracic segment • Interspinous ligament injury common in lower lumbar segment

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

13. Bursitis The bursa is a kind of buffer structure located in the part of human body with frequent friction or high pressure. Divided into constant bursa, secondary bursa or additional bursa 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

14. may or may not communicate with a joint. Function: reduce friction, protect delicate structures from pressure.

15. 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

16. 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

17. 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.

18. 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

19. Stenosing Tenosynovitis • more often in the hand and wrist than anywhere else in the body. • A peritendinitis may affect these tendons, causing pain, swelling, and crepitus.

20. 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.

21. DE QUERVAIN DISEASE • Stenosingtenosynovitis of the abductor pollicislongus and extensor pollicisbrevis tendons • When the extensor pollicisbrevis and the abductor pollicislongus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, De Quervain, who described his experience in 1895. • .

22. 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

23. Diagnosis Finkelstein: on grasping the patient's thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating

24. 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 )

25. TRIGGER FINGER AND THUMB弹响指和弹响拇 • Stenosingtenosynovitis, 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.

26. 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

27. Ganglion

28. Treament • Squeeze • Aspiration and steroid injection • Operation

29. Lateral epicondylitis • 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.

30. 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.

31. 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.

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

33. 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

34. Shoulder structure The outer muscle of the shoulder is the deltoid The inner is rotator cuff, which is consisted by the supraspinatus, infraspinatus, subscapularis and teres minor and tendons Long head of biceps Capsule Bursa Glenoid and humerus head

35. 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.

36. 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

37. Rotator cuff • Supraspinatus，infraspinatus，subscapular muscle，teres minor • Pain may disappear • Dysfunction

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. Differential diagnosis • Cervical spondylosis • Rotator cuff tear

44. 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.

45. 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

46. 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

47. Treatment • Arthroscopic release is an option when closed manipulation fails or for patients who have had prolonged, recalcitrant adhesive capsulitis.

48. Chondromalacia patella髌骨软骨软化症

49. 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

50. 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.