浙江大学医学院八年制教学浙江大学医学院八年制教学神经精神与运动神经精神与运动 11 （模块（模块 22 ））

运动系统慢性疾病运动系统慢性疾病肩关节周围炎、腱鞘炎肩关节周围炎、腱鞘炎

股骨头坏死股骨头坏死

浙江大学医学院附属二院骨科浙江大学医学院附属二院骨科吴立东吴立东

BursitisBursitis 滑囊炎滑囊炎

运动系统慢性损伤运动系统慢性损伤

Bursae are sacs lined with a membBursae are sacs lined with a membrane similar to synovium; they usurane similar to synovium; they usually are located about joints or whally are located about joints or where skin, tendon, or muscle moves ere skin, tendon, or muscle moves over a bony prominence. over a bony prominence.

may or may not communicate witmay or may not communicate with a joint.h a joint.

Function: reduce friction, protect Function: reduce friction, protect delicate structures from pressure.delicate structures from pressure.

Bursae are similar to tendon sheaths and the Bursae are similar to tendon sheaths and the synovial membranes of joints and are subjecsynovial membranes of joints and are subject to the same disturbances: (1) acute or chrot to the same disturbances: (1) acute or chronic trauma, (2) acute or chronic pyogenic infnic trauma, (2) acute or chronic pyogenic infection, and (3) low-grade inflammatory condection, and (3) low-grade inflammatory conditions such as gout, syphilis, tuberculosis, or itions such as gout, syphilis, tuberculosis, or rheumatoid arthritis. rheumatoid arthritis.

Two types of bursae: normally present (as ovTwo types of bursae: normally present (as over the patella and olecranon) and adventitioer the patella and olecranon) and adventitious ones (such as develop over a bunion, an ous ones (such as develop over a bunion, an osteochondroma, or kyphosis of the spine). Asteochondroma, or kyphosis of the spine). Adventitious bursae are produced by repeated dventitious bursae are produced by repeated trauma or constant friction or pressure.trauma or constant friction or pressure.

Treatment---the cause of the bursitis Treatment---the cause of the bursitis

Systemic causes, such as gout or Systemic causes, such as gout or syphilis, and local trauma or irritants syphilis, and local trauma or irritants should be eliminated, and, when should be eliminated, and, when necessary, the patient's occupation or necessary, the patient's occupation or posture should be changed. One or posture should be changed. One or more of the following local measures more of the following local measures usually are helpful: rest, hot wet usually are helpful: rest, hot wet packs, elevation, and, if necessary, packs, elevation, and, if necessary, immobilization of the affected part. immobilization of the affected part.

Surgical procedures useful in treating Surgical procedures useful in treating bursitis are (1) aspiration and injection bursitis are (1) aspiration and injection of an appropriate drug, (2) incision anof an appropriate drug, (2) incision and drainage when an acute suppurative d drainage when an acute suppurative bursitis fails to respond to nonsurgical bursitis fails to respond to nonsurgical treatment, (3) excision of chronically itreatment, (3) excision of chronically infected and thickened bursae, and (4) nfected and thickened bursae, and (4) removal of an underlying bony prominremoval of an underlying bony prominence.ence.

Carpal Tunnel SyndromeCarpal Tunnel Syndrome腕管综合症腕管综合症

(another name: tardy median pals(another name: tardy median palsy) results from compression of thy) results from compression of the median nerve within the carpal e median nerve within the carpal tunnel. The syndrome consists prtunnel. The syndrome consists predominantly of tingling and numedominantly of tingling and numbness in the typical median nerve bness in the typical median nerve distribution in the radial three andistribution in the radial three and one-half digits (thumb, index, ld one-half digits (thumb, index, long, radial side of ring). Pain occong, radial side of ring). Pain occurs diffusely in the hand and radiurs diffusely in the hand and radiates up the forearm. Thenar atroates up the forearm. Thenar atrophy usually is seen later in the cophy usually is seen later in the course of the nerve compression. urse of the nerve compression.

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

DiagnosisDiagnosis

Paresthesia over the sensory distribution of the Paresthesia over the sensory distribution of the median nerve is the most frequent symptom; it median nerve is the most frequent symptom; it occurs more often in women and frequently caoccurs more often in women and frequently causes the patient to awaken several hours after guses the patient to awaken several hours after getting to sleep with burning and numbness of thetting to sleep with burning and numbness of the hand that is relieved by exercise. The Tinel sige hand that is relieved by exercise. The Tinel sign may be demonstrated in most patients by pern may be demonstrated in most patients by percussing the median nerve at the wrist. Atrophy tcussing the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar o some degree of the median-innervated thenar muscles has been reported in about half of the muscles has been reported in about half of the patients treated by operation. patients treated by operation.

Acute flexion of the wrist for 60 seconds in somAcute flexion of the wrist for 60 seconds in some but not all patients or strenuous use of the hae but not all patients or strenuous use of the hand increases the paresthesia. Application of a bnd increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient lood pressure cuff on the upper arm sufficient to produce venous distention may initiate the sto produce venous distention may initiate the symptoms. Gellman et al. evaluated the clinical ymptoms. Gellman et al. evaluated the clinical usefulness of commonly administered provocausefulness of commonly administered provocative tests, including wrist flexion, nerve percustive tests, including wrist flexion, nerve percussion, and the tourniquet test, in 67 hands with sion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and electrical proof of carpal tunnel syndrome and in 50 control hands. in 50 control hands.

DiagnosisDiagnosis The most sensitive test was the wrist flexion The most sensitive test was the wrist flexion

test, whereas nerve percussion was the most test, whereas nerve percussion was the most specific and the least sensitive. They also found specific and the least sensitive. They also found that with the wrist in neutral position, the mean that with the wrist in neutral position, the mean pressure within the carpal tunnel in patients pressure within the carpal tunnel in patients with carpal tunnel syndrome was 32 mm Hg. with carpal tunnel syndrome was 32 mm Hg. This pressure increased to 99 mm Hg with 90 This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The the wrist at 90 degrees of extension. The pressures in the control subjects with the wrist pressures in the control subjects with the wrist in neutral position were 25 mm Hg, 31 mm Hg in neutral position were 25 mm Hg, 31 mm Hg with the wrist in flexion, and 30 mm Hg with with the wrist in flexion, and 30 mm Hg with the wrist in extension. the wrist in extension.

Sensibility testing in peripheral nerve Sensibility testing in peripheral nerve compression syndromes was investigatcompression syndromes was investigated, found that threshold tests of sensibed, found that threshold tests of sensibility correlated accurately with symptoility correlated accurately with symptoms of nerve compression and electrodims of nerve compression and electrodiagnostic studies. agnostic studies.

Electrodiagnostic studies are reliable confirmatElectrodiagnostic studies are reliable confirmatory tests. Ultrasonography has been used to shoory tests. Ultrasonography has been used to show the movement of the flexor tendons within thw the movement of the flexor tendons within the carpal tunnel, but it does not clearly show soft e carpal tunnel, but it does not clearly show soft tissue planes. Early reports of magnetic resonantissue planes. Early reports of magnetic resonance imaging (MRI) in carpal tunnel syndrome are ce imaging (MRI) in carpal tunnel syndrome are promising. A major advantage of MRI is its high promising. A major advantage of MRI is its high soft tissue contrast, which gives detailed images soft tissue contrast, which gives detailed images of both bones and soft tissues. Care should be taof both bones and soft tissues. Care should be taken not to confuse this syndrome with nerve coken not to confuse this syndrome with nerve compression caused by a cervical disc herniation, mpression caused by a cervical disc herniation, thoracic outlet structures, and median nerve cothoracic outlet structures, and median nerve compression proximally in the forearm and at the mpression proximally in the forearm and at the elbow. elbow.

TreatmentTreatment

If mild symptoms have been present anIf mild symptoms have been present and there is no thenar muscle atrophy, thd there is no thenar muscle atrophy, the injection of hydrocortisone into the cae injection of hydrocortisone into the carpal tunnel may afford relief. Great care rpal tunnel may afford relief. Great care should be taken not to inject directly intshould be taken not to inject directly into the nerve. Injection also can be used ao the nerve. Injection also can be used as a diagnostic tool in patients without bs a diagnostic tool in patients without bony or tumorous blocking of the canal; ony or tumorous blocking of the canal;

65% of these cases probably are caused by a 65% of these cases probably are caused by a nonspecific synovial edema, and these seem nonspecific synovial edema, and these seem to respond more favorably to injection. to respond more favorably to injection. Injection also helps to eliminate the possibility Injection also helps to eliminate the possibility of other syndromes, especially cervical disc or of other syndromes, especially cervical disc or thoracic outlet syndrome. Some patients thoracic outlet syndrome. Some patients prefer to receive injections two or three times prefer to receive injections two or three times before a surgical procedure is carried out. If before a surgical procedure is carried out. If the response is positive and there is no the response is positive and there is no muscle atrophy, conservative treatment with muscle atrophy, conservative treatment with splinting and injection is reasonable.splinting and injection is reasonable.

TreatmentTreatment

If signs and symptoms are persistent aIf signs and symptoms are persistent and progressive, especially if they inclund progressive, especially if they include thenar atrophy, division of the deep de thenar atrophy, division of the deep transverse carpal ligament is indicated.transverse carpal ligament is indicated. The results of surgery are good in mos The results of surgery are good in most instances, and benefits seem to last it instances, and benefits seem to last in most patients. n most patients.

Although thenar atrophy may disappear, it Although thenar atrophy may disappear, it resolves slowly, if at all. As noted earlier, resolves slowly, if at all. As noted earlier, when symptoms of median nerve compreswhen symptoms of median nerve compression develop during treatment of an acute sion develop during treatment of an acute Colles fracture, the constricting bandages Colles fracture, the constricting bandages and cast should be loosened and the wrist and cast should be loosened and the wrist should be extended to neutral position. Wshould be extended to neutral position. When median nerve palsy develops after a Chen median nerve palsy develops after a Colles fracture and has gone unrecognized folles fracture and has gone unrecognized for several weeks, surgery is indicated withor several weeks, surgery is indicated without further delay.out further delay.

Stenosing TenosynovitisStenosing Tenosynovitis狭窄性腱鞘炎狭窄性腱鞘炎

more often in the hand and wrist tmore often in the hand and wrist than anywhere else in the body. han anywhere else in the body.

A peritendinitis may affect these tA peritendinitis may affect these tendons, causing pain, swelling, anendons, causing pain, swelling, and crepitus.d crepitus.

When the long flexor tendons are involved,When the long flexor tendons are involved, trigger thumb, trigger finger, or snapping trigger thumb, trigger finger, or snapping finger occurs. The stenosis occurs at a poifinger occurs. The stenosis occurs at a point where the direction of a tendon changent where the direction of a tendon changes, for here a fibrous sheath acts as a pulley,s, for here a fibrous sheath acts as a pulley, and friction is maximal. Although the ten and friction is maximal. Although the tenosynovium lubricates the sheath, friction osynovium lubricates the sheath, friction can cause a reaction when the repetition ocan cause a reaction when the repetition of a particular movement is necessary, as in f a particular movement is necessary, as in winding a fine coil of wire or stacking launwinding a fine coil of wire or stacking laundry.dry.

DE QUERVAIN DISEASEDE QUERVAIN DISEASE Stenosing tenosynovitis of the abductor pollicStenosing tenosynovitis of the abductor pollic

is longus and extensor pollicis brevis tendons is longus and extensor pollicis brevis tendons When the extensor pollicis brevis and the abductor pWhen the extensor pollicis brevis and the abductor p

ollicis longus tendons in the first dorsal compartmenollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss t are affected, the condition is named after the Swiss physician, De Quervain, who described his experienphysician, De Quervain, who described his experience in 1895. ce in 1895.

Women are affected 10 times more frequently than Women are affected 10 times more frequently than men. The cause is almost always related to overuse, men. The cause is almost always related to overuse, either in the home or at work, or is associated with reither in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usualheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Somely are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable. times a thickening of the fibrous sheath is palpable.

diagnosisdiagnosis

The Finkelstein test usually is pThe Finkelstein test usually is positive: "on grasping the patienositive: "on grasping the patient's thumb and quickly abductint's thumb and quickly abducting the hand ulnarward, the pain g the hand ulnarward, the pain over the styloid tip is excruciatiover the styloid tip is excruciating." Although Finkelstein states ng." Although Finkelstein states that this test is "probably the mthat this test is "probably the most pathognomonic objective siost pathognomonic objective sign," it is not diagnostic; the patign," it is not diagnostic; the patient's history and occupation, thent's history and occupation, the roentgenograms, and other pe roentgenograms, and other physical findings must also be cohysical findings must also be considered.nsidered.

TreatmentTreatment

Conservative treatment, consisting Conservative treatment, consisting of rest on a splint and the injection of rest on a splint and the injection of a steroid preparation into the of a steroid preparation into the tendon sheath, is most successful tendon sheath, is most successful within the first 6 weeks after onset. within the first 6 weeks after onset.

When pain persists, surgery is the When pain persists, surgery is the treatment of choice (treatment of choice (complete relief complete relief ). ).

TRIGGER FINGER AND THUMBTRIGGER FINGER AND THUMB弹响指和弹响拇弹响指和弹响拇

Stenosing tenosynovitis, leading to inability to Stenosing tenosynovitis, leading to inability to extend the flexed digit ("triggering") usually is sextend the flexed digit ("triggering") usually is seen after 45 years of age. een after 45 years of age.

Patients may note a lump or knot in the palm. Patients may note a lump or knot in the palm. The lump may be the thickened area in the firsThe lump may be the thickened area in the first annular part of the flexor sheath, or a nodule t annular part of the flexor sheath, or a nodule or fusiform swelling of the flexor tendon just dior fusiform swelling of the flexor tendon just distal to it. The nodule can be palpated by the exastal to it. The nodule can be palpated by the examiner's fingertip and will move with the tendominer's fingertip and will move with the tendon. The tendon nodule usually is at the entry of tn. The tendon nodule usually is at the entry of the tendon into the proximal annulus at the levehe tendon into the proximal annulus at the level of the metacarpophalangeal joint.l of the metacarpophalangeal joint.

Treatment of trigger digits usuTreatment of trigger digits usually is nonoperative in the uncally is nonoperative in the uncomplicated patient who presenomplicated patient who presents a short time after onset of syts a short time after onset of symptoms. Nonoperative methodmptoms. Nonoperative methods include stretching, night splis include stretching, night splinting, and combinations of heanting, and combinations of heat and ice. Corticosteroid injectit and ice. Corticosteroid injection is effective after one injection is effective after one injection on

Surgical release reliably relieveSurgical release reliably relieves the problem for most patientss the problem for most patients

Lateral epicondylitisLateral epicondylitis肱骨外上髁炎肱骨外上髁炎

Lateral epicondylitis (tennis elbow), Lateral epicondylitis (tennis elbow), a familiar term used to described a ma familiar term used to described a myriad of symptoms about the lateral ayriad of symptoms about the lateral aspect of the elbow, occurs more freqspect of the elbow, occurs more frequently in nonathletes than athletes, uently in nonathletes than athletes, with a peak incidence in the early fiftwith a peak incidence in the early fifth decade and a nearly equal gender ih decade and a nearly equal gender incidence. ncidence.

Activities that require repetitive supiActivities that require repetitive supination and pronation of the forearm nation and pronation of the forearm with the elbow in near full extension. with the elbow in near full extension.

Tenderness is present over the lateral eTenderness is present over the lateral epicondyle approximately 5 mm distal anpicondyle approximately 5 mm distal and anterior to the midpoint of the condyld anterior to the midpoint of the condyle. Pain usually is exacerbated by resistee. Pain usually is exacerbated by resisted wrist dorsiflexion and forearm supinatd wrist dorsiflexion and forearm supination, and there is pain when grasping objion, and there is pain when grasping objects. Plain roentgenograms usually are ects. Plain roentgenograms usually are negative; occasionally calcific tendinitis negative; occasionally calcific tendinitis may be present. MRI demonstrates tendmay be present. MRI demonstrates tendon thickening with increased T1 and T2 on thickening with increased T1 and T2 signals but generally is not indicated. signals but generally is not indicated.

Regardless of the underlying cause, nonoRegardless of the underlying cause, nonoperative treatment is successful in 95% operative treatment is successful in 95% of patients with tennis elbow. Initial nonof patients with tennis elbow. Initial nonoperative treatment includes rest, ice, injeperative treatment includes rest, ice, injections, and physical therapy centered aroctions, and physical therapy centered around treatment such as ultrasound, electrund treatment such as ultrasound, electrical stimulation, manipulation, soft tissuical stimulation, manipulation, soft tissue mobilization, friction massage, stretchie mobilization, friction massage, stretching and strengthening exercises, and coung and strengthening exercises, and counter-force bracing. nter-force bracing.

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

Adhesive CapsulitisAdhesive Capsulitis（（ frozen shoulder.frozen shoulder. ））

肩周炎或称冻结肩肩周炎或称冻结肩

Frozen shoulders in patients who report Frozen shoulders in patients who report no inciting event and with no no inciting event and with no abnormality on examination (other than abnormality on examination (other than loss of motion) or plain loss of motion) or plain roentgenograms were designated as roentgenograms were designated as "primary," and those with precipitant "primary," and those with precipitant traumatic injuries as "secondary." This traumatic injuries as "secondary." This division helps in planning treatment division helps in planning treatment but does not necessarily predict but does not necessarily predict outcome. outcome.

No formal inclusion criteria. There are no univeNo formal inclusion criteria. There are no universally accepted criteria for the diagnosis of frozersally accepted criteria for the diagnosis of frozen shoulder. internal rotation frequently is lost in shoulder. internal rotation frequently is lost initially, followed by loss of flexion and external nitially, followed by loss of flexion and external rotation. rotation.

The incidence of frozen shoulder in the general The incidence of frozen shoulder in the general population is approximately 2%. (an increased ipopulation is approximately 2%. (an increased incidence associated with, including diabetes mencidence associated with, including diabetes mellitus (up to 5 times more), cervical disc disease, llitus (up to 5 times more), cervical disc disease, hyperthyroidism, intrathoracic disorders, and trhyperthyroidism, intrathoracic disorders, and trauma). People between the ages of 40 and 70 are auma). People between the ages of 40 and 70 are more commonly affected. Common to almost all more commonly affected. Common to almost all patients is a period of immobility, the etiologies patients is a period of immobility, the etiologies of which are diverse; of which are diverse;

Primary Frozen ShoulderPrimary Frozen Shoulder Primary frozen shoulder is a vague entity Primary frozen shoulder is a vague entity

that only rarely recurs in the same that only rarely recurs in the same shoulder. The clinical course of primary shoulder. The clinical course of primary (idiopathic) frozen shoulder consists of (idiopathic) frozen shoulder consists of three phases. three phases.

Phase I—Pain. Patients usually have a Phase I—Pain. Patients usually have a gradual onset of diffuse shoulder pain, gradual onset of diffuse shoulder pain, which is progressive over weeks to which is progressive over weeks to months. The pain usually is worse at night months. The pain usually is worse at night and is exacerbated by lying on the and is exacerbated by lying on the affected side. As the patient uses the arm affected side. As the patient uses the arm less, pain leading to stiffness ensues. less, pain leading to stiffness ensues.

Primary Frozen ShoulderPrimary Frozen Shoulder Phase II—Stiffness. Patients seek pain Phase II—Stiffness. Patients seek pain

relief by restricting movement. This relief by restricting movement. This heralds the beginning of the stiffness heralds the beginning of the stiffness phase, which usually lasts 4 to 12 months. phase, which usually lasts 4 to 12 months. Patients describe difficulty with activities Patients describe difficulty with activities of daily living; men have trouble getting to of daily living; men have trouble getting to their wallets and women with fastening their wallets and women with fastening brassieres. As stiffness progresses, a dull brassieres. As stiffness progresses, a dull ache is present nearly all the time ache is present nearly all the time (especially at night), and this often is (especially at night), and this often is accompanied by sharp pain during range accompanied by sharp pain during range of motion at or near the new endpoints of of motion at or near the new endpoints of motion.motion.

Primary Frozen ShoulderPrimary Frozen Shoulder

Phase III—Thawing. This phase lasts for Phase III—Thawing. This phase lasts for weeks or months, and as motion weeks or months, and as motion increases, pain diminishes. Without increases, pain diminishes. Without treatment (other than benign neglect) treatment (other than benign neglect) motion return is gradual in most but may motion return is gradual in most but may never objectively return to normal, never objectively return to normal, although most patients subjectively feel although most patients subjectively feel near normal, perhaps as a result of near normal, perhaps as a result of compensation or adjustment in ways of compensation or adjustment in ways of performing activities of daily living. performing activities of daily living.

Secondary Frozen Secondary Frozen ShoulderShoulder

Unlike patients with idiopathic frozen Unlike patients with idiopathic frozen shoulder, patients with secondary frozen shoulder, patients with secondary frozen shoulder can recall a specific shoulder can recall a specific precipitating event, possibly related to precipitating event, possibly related to overuse or injury. The three phases of overuse or injury. The three phases of classic frozen shoulder may not all be classic frozen shoulder may not all be present and may not follow the present and may not follow the previously outlined chronology; previously outlined chronology; fortunately, treatment for the two fortunately, treatment for the two entities is similar. entities is similar.

DiagnosisDiagnosis tests in patients with a frozen shoulder (includitests in patients with a frozen shoulder (includi

ng plain film roentgenograms) usually are norng plain film roentgenograms) usually are normal, except in those with medical disorders sucmal, except in those with medical disorders such as diabetes or thyroid disease. Bone scans havh as diabetes or thyroid disease. Bone scans have been reported to be positive in some patients. e been reported to be positive in some patients.

Arthrograms characteristically show a reduced jArthrograms characteristically show a reduced joint volume with irregular margins. Clinical imoint volume with irregular margins. Clinical improvement has been reported after arthrographprovement has been reported after arthrography because of brisement of adhesions from forcey because of brisement of adhesions from forcefully injecting fluid into the joint. A volume of lfully injecting fluid into the joint. A volume of less than 10 ml and lack of filling of the axillary fess than 10 ml and lack of filling of the axillary fold currently are accepted arthrographic findinold currently are accepted arthrographic findings indicative of a frozen shoulder. gs indicative of a frozen shoulder.

TreatmentTreatment Traditionally, frozen shoulder has been Traditionally, frozen shoulder has been

considered a self-limiting condition, lasting 12 considered a self-limiting condition, lasting 12 to 18 months.to 18 months.

Approximately 10% of patients have long-term Approximately 10% of patients have long-term problems. Patients seeking care earlier usually problems. Patients seeking care earlier usually recover more quickly. Dominant shoulder recover more quickly. Dominant shoulder involvement has been reported to be predictive involvement has been reported to be predictive of a good result, whereas occupation and of a good result, whereas occupation and treatment programs are not statistically treatment programs are not statistically significant. Obviously, the best treatment of significant. Obviously, the best treatment of frozen shoulder is prevention (secondary frozen frozen shoulder is prevention (secondary frozen shoulder), but early intervention is of shoulder), but early intervention is of paramount importance; a good understanding paramount importance; a good understanding of the pathological process by the patient and of the pathological process by the patient and the physician also is important.the physician also is important.

TreatmentTreatment

Initial treatment is nonoperative, with Initial treatment is nonoperative, with emphasis placed on control of pain anemphasis placed on control of pain and inflammation. d inflammation.

passive and active range-of-motion expassive and active range-of-motion exercises. Abduction should be avoided iercises. Abduction should be avoided initially to prevent impingement until jnitially to prevent impingement until joint motion becomes more supple. oint motion becomes more supple.

TreatmentTreatment

Although a frozen shoulder usually is self-Although a frozen shoulder usually is self-limiting and resolves in 12 to 18 months, limiting and resolves in 12 to 18 months, many patients do not wish to wait that many patients do not wish to wait that long for resolution of symptoms and long for resolution of symptoms and request active intervention long before 12 request active intervention long before 12 months. With appropriate patient months. With appropriate patient selection, significant improvement can be selection, significant improvement can be obtained in approximately 70% of patients. obtained in approximately 70% of patients.

Closed manipulation under anesthesiaClosed manipulation under anesthesia Open release of contracturesOpen release of contractures

TreatmentTreatment

Arthroscopic releasArthroscopic release is an option when e is an option when closed manipulatioclosed manipulation fails or for patientn fails or for patients who have had prols who have had prolonged, recalcitrant onged, recalcitrant adhesive capsulitis.adhesive capsulitis.

Osteonecrosis of Femoral headOsteonecrosis of Femoral head股骨头无菌性坏死股骨头无菌性坏死

Osteonecrosis of the femoral head is a Osteonecrosis of the femoral head is a progressive disease that generally affeprogressive disease that generally affects patients in the third though fifth dects patients in the third though fifth decades of life; if left untreated, it leads tcades of life; if left untreated, it leads to complete deterioration of the hip joio complete deterioration of the hip joint. It is estimated that as many as 20,00nt. It is estimated that as many as 20,000 new cases of osteonecrosis are diagn0 new cases of osteonecrosis are diagnosed each year in the United States.osed each year in the United States.

定义定义 ARCO+AAOSARCO+AAOS 的标准的标准 ONFHONFH 是股骨头血供中断或受损，引起骨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，关节导致股骨头结构改变，股骨头塌陷，关节功能障碍的疾病功能障碍的疾病

Osteonecrosis of the femoral hOsteonecrosis of the femoral headead

非创伤性：常见病因是酒精中毒，激素非创伤性：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，是骨科常见病，多见于中青年，双侧发病，

约约 80%80% 未有效治疗，未有效治疗， 1-41-4 年内将发生股骨年内将发生股骨头塌陷，缺乏有效防治方法头塌陷，缺乏有效防治方法

多数患者不得不接受多数患者不得不接受 THATHA

诊断诊断 早期诊断早期诊断 ------ 困难困难 高度重视病因，尤其重要高度重视病因，尤其重要 常常是一侧有症状作常常是一侧有症状作 MRMR 检查时，发现检查时，发现

对侧有早期对侧有早期 ONFHONFH 有酗酒，长期应用激素史有酗酒，长期应用激素史 病人自己警惕意识强，主动检查病人自己警惕意识强，主动检查 晚期，晚期， XX 线片表现已很明显，容易诊断线片表现已很明显，容易诊断

病史病史 体格检查体格检查 XX 线片线片 骨功能检查骨功能检查 FBEFBE 骨内压测定，骨内静脉造影，核心活检，骨内压测定，骨内静脉造影，核心活检，

放射性核素扫描放射性核素扫描 ECTECT CTCT MRMR

XX 线片：敏感度差，适宜观察股骨头形态，光圆线片：敏感度差，适宜观察股骨头形态，光圆度，高度，塌陷程度度，高度，塌陷程度

CTCT ，敏感度低，不建议采用，敏感度低，不建议采用 ECTECT ，敏感度高，敏感度高 仔细观察确实有冷区，可发现特早期（仔细观察确实有冷区，可发现特早期（ 00 或或 11

前期），出现热区，结合病史有助于诊断，但特前期），出现热区，结合病史有助于诊断，但特异性差异性差

MRIMRI ，敏感度特高，早期发现和诊断股骨头坏死，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的敏感性和特异性达 99%99% ，应为首选，应为首选

股骨头核心活检结果最为准确，组织病理学股骨头核心活检结果最为准确，组织病理学

ARCOARCO 国际骨坏死分期的治疗原则国际骨坏死分期的治疗原则 0-2A0-2A 期，可行髓芯减压术期，可行髓芯减压术 2B-3B2B-3B 期适用于截骨术或骨移植术，包括期适用于截骨术或骨移植术，包括

带血运的骨移植带血运的骨移植 3C3C 期及以上，应考虑作人工髋关节置换术期及以上，应考虑作人工髋关节置换术

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

双支撑骨柱移植长期随访疗效双支撑骨柱移植长期随访疗效 10.210.2 年年 2B 83%2B 83% 2C 80%2C 80% 3A 75%3A 75% 3B 65%3B 65% 3C 40%3C 40% 4 28.6%4 28.6%

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

强度强度

股骨头坏死的分期系列疗法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，才能获得较好只要正确地掌握相应方法，才能获得较好疗效疗效

ONFHONFH 病人多较年轻，应首先考虑保存自病人多较年轻，应首先考虑保存自体股骨头体股骨头

0-1A0-1A ：无症状，保守治疗：无症状，保守治疗 药物：活血化瘀中药，葛根素，降脂药等，药物：活血化瘀中药，葛根素，降脂药等，

最好用于最好用于 11 前期者，可能有一定效果前期者，可能有一定效果 高压氧高压氧 血液净化血液净化 磁疗磁疗 震波震波 临床疗效有待于长期观察临床疗效有待于长期观察

0-1A0-1A ：有症状，行细针钻孔减压，有效率：有症状，行细针钻孔减压，有效率60%60% ，可植入自体骨髓细胞或第，可植入自体骨髓细胞或第 22 代骨髓代骨髓干细胞干细胞

目的：股骨头内减压，打通硬化带，促使目的：股骨头内减压，打通硬化带，促使向坏死区增加血液循环向坏死区增加血液循环

1A1A ，， 1B,2A1B,2A 粗通道髓芯减压，效可粗通道髓芯减压，效可 目的：减压，打通硬化带，增加血液循环目的：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，可植入自体骨髓细胞，干细胞，自体骨，同种异体骨，骨诱导活性材料等同种异体骨，骨诱导活性材料等

1C1C ，， 2A2A ，， 2B2B ，， 2C2C 骨移植，效果尚好骨移植，效果尚好 目的，彻底清除坏死骨，充分植骨，重建目的，彻底清除坏死骨，充分植骨，重建

血循环，促进骨修复，恢复股骨头内生物血循环，促进骨修复，恢复股骨头内生物力学强度力学强度

防止塌陷防止塌陷 3A3A ，， 3B3B ，骨移植术，包括带血运的骨移，骨移植术，包括带血运的骨移

植，效果差植，效果差

3C3C 期及以上期及以上 THATHA ，但是无论是骨水泥或非骨水泥固定，但是无论是骨水泥或非骨水泥固定

的的 THATHA ，用于骨坏死的远期疗效差于，用于骨坏死的远期疗效差于 OAOA的的 THATHA ，，

我们应该做的：明确的术前告知我们应该做的：明确的术前告知 精确标准的手术精确标准的手术 术后的康复术后的康复 积极随访指导，病人日常积极随访指导，病人日常

DiagnosisDiagnosis Patients are typically asymptomatic early in the cPatients are typically asymptomatic early in the c

ourse of osteonecrosis and eventually have groin ourse of osteonecrosis and eventually have groin pain on ambulation. A thorough history and physpain on ambulation. A thorough history and physical examination should be done to discover poteical examination should be done to discover potential risk factors and determine the clinical statuntial risk factors and determine the clinical status of the patient. Plain roentgenograms should be s of the patient. Plain roentgenograms should be obtained including anteroposterior and lateral viobtained including anteroposterior and lateral views. Roentgenographic changes seen in osteonecews. Roentgenographic changes seen in osteonecrosis depend on the stage of the disease. Plain filrosis depend on the stage of the disease. Plain films may appear normal in the early stages, but chms may appear normal in the early stages, but changes are noted as the disease progresses, such aanges are noted as the disease progresses, such as increased density or lucency in the femoral heas increased density or lucency in the femoral head.d.

Advances in MRI have maAdvances in MRI have made earlier diagnosis of ode earlier diagnosis of osteonecrosis of the femosteonecrosis of the femoral head possible and allral head possible and allow determination of the ow determination of the exact stage and extent of exact stage and extent of the pathological process the pathological process without use of invasive without use of invasive methods.methods.

TreatmentTreatment

Core decompressioCore decompressionn

Bone Grafting Bone Grafting Vascularized FibulVascularized Fibul

ar Grafting ar Grafting Osteotomies of ProOsteotomies of Pro

ximal Femurximal Femur

Resurfacing Hemiarthroplasty Resurfacing Hemiarthroplasty Total Hip Arthroplasty and Bipolar HemiarthTotal Hip Arthroplasty and Bipolar Hemiarth

roplastyroplasty. . Improved results recently have been reported Improved results recently have been reported

with modern cementing techniques and press-fwith modern cementing techniques and press-fit cementless total hip arthroplasty in patients it cementless total hip arthroplasty in patients with osteonecrosis. With new bearing surfaces with osteonecrosis. With new bearing surfaces becoming available, such as ceramic on ceramibecoming available, such as ceramic on ceramic, metal on metal, and highly cross-linked polyc, metal on metal, and highly cross-linked polyethylene, results may improve even more. The ethylene, results may improve even more. The results of primary total joint replacement for oresults of primary total joint replacement for osteonecrosis are now approaching those reportsteonecrosis are now approaching those reported for osteoarthritis in aged-matched patients.ed for osteoarthritis in aged-matched patients.

Epiphysitis of tibial tuberosityEpiphysitis of tibial tuberosity胫骨结节骨骺炎胫骨结节骨骺炎

(Osgood-Schlatter disease) (Osgood-Schlatter disease) (Osteochondrol disease of the tibia(Osteochondrol disease of the tibial tubercle)l tubercle)

EPIPHYSITIS OF TIBIAL TUBEROSITY EPIPHYSITIS OF TIBIAL TUBEROSITY

(OSGOOD-SCHLATTER DISEASE)(OSGOOD-SCHLATTER DISEASE)

The terms The terms osteochondrosisosteochondrosis and and epiphysitiepiphysitiss designate disorders of actively growing e designate disorders of actively growing epiphyses. The disorder may be localized to piphyses. The disorder may be localized to a single epiphysis or occasionally may inva single epiphysis or occasionally may involve two or more epiphyses simultaneouslolve two or more epiphyses simultaneously or successively. The cause generally is uy or successively. The cause generally is unknown, but evidence indicates a lack of vnknown, but evidence indicates a lack of vascularity that may be the result of trauma,ascularity that may be the result of trauma, infection, or congenital malformation. infection, or congenital malformation.

TreatmentTreatment

Surgery rarely is indicated for Osgood-SchlatteSurgery rarely is indicated for Osgood-Schlatter disease; r disease;

the disorder usually becomes asymptomatic wthe disorder usually becomes asymptomatic without treatment or with simple conservative ithout treatment or with simple conservative measures such as the restriction of activities omeasures such as the restriction of activities or cast immobilization for 3 to 6 weeks. In a revr cast immobilization for 3 to 6 weeks. In a review of the natural history of untreated Osgooiew of the natural history of untreated Osgood-Schlatter disease in 69 knees in 50 patients, fd-Schlatter disease in 69 knees in 50 patients, found that 76% of patients believed they had nound that 76% of patients believed they had no limitation of activity, although only 60 could o limitation of activity, although only 60 could kneel without discomfort. kneel without discomfort.

In a prospective study of 17 patients with OsgIn a prospective study of 17 patients with Osgood-Schlatter disease and 12 adolescents withood-Schlatter disease and 12 adolescents without anterior knee pain, Aparicio et al. noted a out anterior knee pain, Aparicio et al. noted a strong association between Osgood-Schlatter strong association between Osgood-Schlatter disease and patella alta. The increase in patelldisease and patella alta. The increase in patellar height may require an increase in the force ar height may require an increase in the force by the quadriceps to achieve full extension, wby the quadriceps to achieve full extension, which could be responsible for the apophyseal hich could be responsible for the apophyseal lesion. However, it can be argued that the patlesion. However, it can be argued that the patella alta is the result of chronic avulsion of thella alta is the result of chronic avulsion of the bony tuberosity. e bony tuberosity.

Surgery may be considered if symptomSurgery may be considered if symptoms are persistent and severely disabling. s are persistent and severely disabling.

Complications reported of Osgood-SchlComplications reported of Osgood-Schlatter disease whether treated surgically atter disease whether treated surgically or not, including subluxations of the paor not, including subluxations of the patella, patella alta, nonunion of the bony tella, patella alta, nonunion of the bony fragment to the tibia, and premature fufragment to the tibia, and premature fusion of the anterior part of the epiphysision of the anterior part of the epiphysis with resulting genu recurvatum. s with resulting genu recurvatum.

Insertion of Bone PegsInsertion of Bone Pegs

Incise the periosteum longitudinally distal to thIncise the periosteum longitudinally distal to the tuberosity. With an electric saw cut two matche tuberosity. With an electric saw cut two matchstick pegs 4 cm long from the tibia; make the bastick pegs 4 cm long from the tibia; make the base of each peg larger than its tip. Then drill two se of each peg larger than its tip. Then drill two holes through the tibial tuberosity—one near buholes through the tibial tuberosity—one near but not in contact with the proximal tibial physis at not in contact with the proximal tibial physis and slanting proximally and laterally and the othnd slanting proximally and laterally and the other also distal to the physis and slanting proximaler also distal to the physis and slanting proximally and medially. Insert the pegs into these holes ly and medially. Insert the pegs into these holes and resect their projecting ends. and resect their projecting ends.

technique for insertion of bone ptechnique for insertion of bone pegs for Osgood-Schlatter diseaseegs for Osgood-Schlatter disease

AFTERTREATMENT. A cast is AFTERTREATMENT. A cast is applied from groin to toes and is applied from groin to toes and is worn for 2 weeks. A cylinder worn for 2 weeks. A cylinder walking cast is then worn for 4 walking cast is then worn for 4 more weeks.more weeks.

Excision of Ununited Tibial TuberosityExcision of Ununited Tibial Tuberosity

TECHNIQUE:TECHNIQUE: Make a longitudinal incision cen Make a longitudinal incision centered over the tibial tuberosity. Expose the patetered over the tibial tuberosity. Expose the patellar tendon and incise it longitudinally. Elevate llar tendon and incise it longitudinally. Elevate the tendon laterally and medially and excise anthe tendon laterally and medially and excise any loose fragments of bone and enough tibial coy loose fragments of bone and enough tibial cortex, cartilage, and cancellous bone to remove rtex, cartilage, and cancellous bone to remove any bony prominence completely. Do not distuany bony prominence completely. Do not disturb the peripheral and distal margins of the inserb the peripheral and distal margins of the insertion of the patellar tendon. Close the wound. rtion of the patellar tendon. Close the wound.

AFTERTREATMENT.AFTERTREATMENT. A cylinder walking cast i A cylinder walking cast is applied and worn for 2 to 3 weeks. Exercises as applied and worn for 2 to 3 weeks. Exercises are then begun. re then begun.

excision of unexcision of ununited tibial tunited tibial tuberosity. uberosity. A,A, Tibial tuberosTibial tuberosity has been eity has been exposed. xposed. B,B, Bo Bony prominencny prominence has been exce has been excised. ised.

Legg-Calve-Perthes DISEASELegg-Calve-Perthes DISEASEPerthesPerthes 病病

The cause The cause The clinical signThe clinical sign Plain roentgenographic changes Plain roentgenographic changes Bone scintigraphyBone scintigraphy MRI MRI Treatment Treatment

classified patients with this disease into gclassified patients with this disease into groups according to the amount of involveroups according to the amount of involvement of the capital femoral epiphysis: ment of the capital femoral epiphysis:

group I, partial head or less than half heagroup I, partial head or less than half head involvement; d involvement;

groups II and III, more than half head ingroups II and III, more than half head involvement and sequestrum formation; volvement and sequestrum formation;

group IV, involvement of the entire epipgroup IV, involvement of the entire epiphysis. hysis.

They noted certain roentgenographic signs descriThey noted certain roentgenographic signs described as "head at risk" correlated positively with poobed as "head at risk" correlated positively with poor results, especially in patients in groups II, III, anr results, especially in patients in groups II, III, and IV. d IV.

These head-at-risk signs includeThese head-at-risk signs include(1)(1) Lateral subluxation of the femoral head from the Lateral subluxation of the femoral head from the

acetabulum, acetabulum, (2)(2) Speckled calcification lateral to the capital epiphySpeckled calcification lateral to the capital epiphy

sis, sis, (3)(3) Diffuse metaphyseal reaction (metaphyseal cysts), Diffuse metaphyseal reaction (metaphyseal cysts), (4)(4) A horizontal physis, A horizontal physis, (5)(5) Gage sign, a radiolucent V-shaped defect in the latGage sign, a radiolucent V-shaped defect in the lat

eral epiphysis and adjacent metaphysis. eral epiphysis and adjacent metaphysis.

Containment by femoral varus derotationContainment by femoral varus derotational osteotomy for al osteotomy for olderolder children in grou children in groups II, III, and IV with head-at-risk signs.ps II, III, and IV with head-at-risk signs.

Contraindications include an already malfContraindications include an already malformed femoral head and delay of treatormed femoral head and delay of treatment of more than 8 months from onsement of more than 8 months from onset of symptoms. t of symptoms.

Surgery is not recommended for any grouSurgery is not recommended for any group I children or any child without the hep I children or any child without the head-at-risk signs. ad-at-risk signs.

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

According to Salter and Thompson, this subchAccording to Salter and Thompson, this subchondral fracture and its entire extent can be obondral fracture and its entire extent can be observed roentgenographically earlier and more served roentgenographically earlier and more readily than trying to determine the Catterall readily than trying to determine the Catterall classification. Furthermore, according to thesclassification. Furthermore, according to these authors, if the femoral head is graded as type authors, if the femoral head is graded as type B, then probably an operation such as an ine B, then probably an operation such as an innominate osteotomy should be carried out. Afnominate osteotomy should be carried out. After statistical analysis of 116 hips affected with ter statistical analysis of 116 hips affected with Perthes disease, Mukherjee and Fabry concluPerthes disease, Mukherjee and Fabry concluded that Salter and Thompson's classification ided that Salter and Thompson's classification is simple and accurate and can be applied earls simple and accurate and can be applied early in the course of the disease to determine may in the course of the disease to determine management. nagement.

Conclusions Conclusions 1. Most patients can be treated by noncontain1. Most patients can be treated by noncontain

ment methods and obtain good results (84%). ment methods and obtain good results (84%). 2. Satisfactory clinical results frequently can b2. Satisfactory clinical results frequently can b

e obtained at long-term follow-up despite an ue obtained at long-term follow-up despite an unsatisfactory roentgenographic appearance. nsatisfactory roentgenographic appearance.

3. The Catterall classification is a valid indicat3. The Catterall classification is a valid indicator of results but is not applicable as a therapeor of results but is not applicable as a therapeutic guide. utic guide.

4. Head-at-risk signs added little to the Cattera4. Head-at-risk signs added little to the Catterall classification as a prognostic indicator or thell classification as a prognostic indicator or therapeutic guide. rapeutic guide.

5.5. All of the fair and poor results were in paAll of the fair and poor results were in patients with Catterall III or IV involvement and tients with Catterall III or IV involvement and onset of the disease at age 6 or later. onset of the disease at age 6 or later.

谢谢大家谢谢大家 !!Thank you very much fThank you very much f

or your attention!or your attention!