Re:【专题讨论】Rotator Cuff Tears 从解剖到力学，从诊断到鉴

ie wrote:是"晚上疼痛"，还是"卧位疼痛"，这可是重要的区别。要先把这两点分清。临床中经常发现患者晚上无论仰卧位还是侧卧,至深夜时都会不时出现肩部胀痛,而白天卧床休息时则没有那么明显的胀痛. 可否解释一二? 谢了!好像有些干扰楼主的讨论。抱歉。“患者晚上无论仰卧位还是侧卧,至深夜时都会不时出现肩部胀痛,而白天卧床休息时则没有那么明显的胀痛.”--那么，还是不能完全区别是夜间疼痛还是卧位疼痛，一般白天卧床休息的时间比较短，所以，”白天卧床休息时则没有那么明显的胀痛"。－－但卧位时间长了，比如“至深夜时"，疼痛就会明显，也许还是卧位时间太长导致的？不知道患者是什么病，不清楚疼痛的具体部位，只能就事论事非常好喔，学习中。谢谢！不是很懂英文，可否翻译一下，让更多的朋友学习楼主，你的这个东东，写的非常好啊，对我们学习很有帮助，一定要好好学学，非常喜欢这样的形式，有图片，由专业英文，及讲解，我觉得是我很喜欢的学习方式，thanks a million for you .这个先好好的学习了，再次感谢！实在太忙了，要搬家，一堆事情，换手机，多普达838，呵呵，600RMB, 2 years' contract漂亮的机子。（缩略图，点击图片链接看原图）doctorjh wrote:肩袖损伤分三度，每一期的病理变化不一样，临床症状也有所不同。伤病还是要早发现，早治疗。分类的方法各有不同，可以使创伤的机理，可以使根据严重程度：Types of tears:— Interstitial (framing)— Partial thickness (bursal side or articularside)— Full thickness• Associated with other intraarticular injuries up to 74% of the time.• Size of tearso Smallo Mediumo Large• Most often occur near insertion on, greater tuberosity(critical zone)• Full thickness tears rare讨论完解剖，诊断，创伤机理，下面我们来复习一下肩关节的力学吧：首先，有4个关节必须要考虑， GH,SC,AC,ST见图：(图小，点击放大) screen.width-333)this.width=screen.width-333" width=640 height=154 title="Click to view full shoulder joints.gif (839 X 203)" border=0 align=absmiddle>Glenohumeral joint• "Shoulder joint;" synovial, multiaxial ball and socket (golf ball on a tee)Great mobility at the cost of stabilityStatic stabilizers: -the bony structures, -labrum, -GH ligaments, -joint capsuleDynamic stabilizers: -the rotator -scapular stabilizers (ie, teres major, rhomboids, serratus anterior, trapezius, levator scapula)Largest ROM and movement in the body- Reasons for this characteristic include:• Shallow joint• Lax joint capsule• Limited ligamentous supportGlenohumeral Motion• Glenoid shallow socket on scapula and faces anterior, lateral and superior- Glenoid labrum-rim of fibrocartilage• Deepens socket-increases contact area up to 75%- Joint Capsule• Ligamentous Stability- Anterior-glenohumeral ligaments-Posterior-only joint capsuleImportant ligaments• Glenohumeral ligament (4 sections)- Superior Glenohumeral (SGHL)- Middle Glenohumeral (MGHL)— Inferior Glenohumeral ligament (IGHL): Main static stabilizer of the glenohumeral joint• Anterior Band Inferior Glenohumeral Ligament• Posterior Band Inferior Glenohumeral LigamentGlenohumeral Joint Movements1) Flexion2) Extension3) Abduction4) Adduction5) Horizontal abduction(flexion/extension)6) Horizontal adduction7) Internal rotation8) External rotation9) Scaption(见图) screen.width-333)this.width=screen.width-333" width=297 height=160 title="Click to view full SCAPTION.gif (297 X 160)" border=0 align=absmiddle>Open packed position:在这个位置,关节是松的,是open的.- 55 deg abd, 30 deg horiz add• Close packed position:反之.- End range abduction and ERCapsular pattern: ER>ABD>IR 如果是这个模式的功能障碍,提示是关节囊的问题.When arm is neutral, ligaments are loose, allowing IR and ER• As arm is externally rotated, the capsule becomes tighter• When arm is abducted inferior ligamentous tissue becomes tighter, more so with ER• In extreme abduction/ER, ligaments become tight around joint giving stability补充几个关于dynamic stabilizers:Deltoid— Large stabilizing component, regardless ofposition of humerus• Long head of biceps— Effective because of proximity to joint• Most effective when shoulder is extended• Long head of triceps— Effective because of proximity to joint• Most effective when shoulder is flexedGlenohumeral Kinematics with Abduction• Convex on concave rule: Roll and glide occur opposite, so with abduction, the humeral head rolls superior and glides inferior• Questioned in recent research- Humeral head will glide away from the tightest portion of the capsule(usually posterior)• Conjunct inferior glide and ER occur with normal abduction• Adduction is reverse of abductionMechanics of Abduction• As angle approaches 90, greater tuberosity abuts the coracoacromial archacromionand coracoacromial ligament• Soft tissue becomes compressed• If arm is externally rotated, greater tuberosity can clear arch• 30 deg ROM becomes availablePhases 1 of abduction • 0-60 degrees• Clavicle externally rotates and scapula upwardly rotates and protracts.• Humerus is brought outward and upward by the combined work of the supraspinatus, upper trapezius and deltoidPhase 2 of abduction:• 60-120 degrees• Clavicle is maximally elevated• Capsule tightens superiorly, to the middle and then inferiorly as the humerus is abducted• Serratus functions isometrically while the cuff is maximally active• During abduction and use of the arm overhead for an extended period of time, the teres major becomes an active muscle stabilizing the humerus (inferior glide).Phase 3 of abduction:• 120-160 degrees• Functional ROM for most athletes is 70-110 degrees• 160 degrees: the rotator cuff inactive• AC joint also becomes inactive during extreme abduction1. first 30 degrees of shoulder elevation involves a "setting phase": • The movement is largely glenohumeral. • Scapulothoracic movement is small and inconsistent.2. after the first 30 degrees of shoulder elevation: • The glenohumeral and scapulothoracic joints move simultaneously. • Overall 2:1 ratio of glenohumeral to scapulothoracic movement.Scapulohumeral rhythm serves at least two purposes.1. It preserves the length-tension relationships of the glenohumeral muscles;the muscles do not shorten as much as they would without the scapula'supward rotation, and so can sustain their force production through a largerportion of the range of motion.2. It prevents impingement between the humerus and the acromion.Because of the difference in size between the glenoid fossa and thehumeral head, subacromial impingement can occur unless relativemovement between the humerus and scapula is limited. Simultaneousmovement of the humerus and scapula during shoulder elevation limitsrelative (arthrokinematic) movement between the two bones. screen.width-333)this.width=screen.width-333" width=290 height=313 title="Click to view full shoulder-abduction.jpg (290 X 313)" border=0 align=absmiddle>GH Flexion• More straight spin at GH joint vs roll and glide• Similar rhythm to abduction except the scapula comes in sooner (serratus)• Last 30 degrees of flexion requires thoracic extension• Forward elevation: Humeral head rolls posteriorly,slides inferiorly, and spinsinto IR GH External Rotation• Dependent upon the degree of shoulder abduction (more ER at 90 degrees abduction)• GH joint: Classic description states the humeral head will roll posterior and glide anterior• Recent work has found that the humeral head will roll posterior and glide posterior as the anterior capsule tightens up (away from the tight part of the capsule)• Scapula retractsSternoclavicular Joint• Sternum (manibrum) and clavicle• Synovial, sellar joint• Articular discLigaments— Anterior SC ligament— Posterior SC ligament— CC ligament— Interclavicular ligament• Fulcrum for shoulder movements• Only bony attachment of shoulder girdle to skeleton SC Joint Motions• Elevation and depression: 30-40° ROM• Anterior and posterior rotation: 40-50° ROM• Protraction and retraction: 30° ROM• With shoulder elevation, the convex medial portion of the clavicle moves inferiorly • With shoulder depression, the convex surface moves superiorly.• With shoulder protraction, the concave medial portion of the clavicle moves anteriorly.• With shoulder retraction, the concave medial portion of the clavicle moves posteriorly.Acromioclavicular Joint • Arthrodial (gliding) joint• Articular disc present in some casesLigaments— Coracoclavicular ligaments• Trapezoid ligament• Conoid ligament- Superior & inferior AC ligaments• Function-absorb impacts to shoulder• Links shoulder girdle to clavicle; tied to all motions of the humerusAcromioclavicular Joint Motion— Protraction & retraction (abduction-adduction)— Upward and downward rotation~60° ROM— Elevation and depression~30° ROM• Several motions at the AC joint are opposite to the movements of the SC joint- AC elevation = SC depression-AC depression = SC elevation- Protraction- RetractionAcromioclavicular Joint Stability• Weak bony stability• A-C ligament provides significant stability— It can resist tension at the joint- It can't prevent clavicle from riding up on acromion when force is applied from the side• Coracoclavicular and conoid ligament help prevent clavicle riding up on acromion screen.width-333)this.width=screen.width-333" width=400 height=400 title="Click to view full ac.jpg (400 X 400)" border=0 align=absmiddle> Scapulothoracic Joint • Pseudojoint-does not connect bone to bone, supported by muscles, not ligaments• It is a physiologic joint• Scapula rests on 2 muscles— Serratus Anterior— SubscapularisScapulothoracic Joint Motion• Scapula will move across thorax as a result of motions at S-C and A-C joints• Approx 65% of this ROM occurs because of motion at SC Joint• Approx 35% occurs because of motion at AC Joint• Total ROM of motion for scapulothoracic joint is approx. 60° for 180° of arm abduction or flexionMovements at the Scapulothoracic Joint1) Abduction (Protraction)2) Adduction (Retraction)3) Downward rotation4) Upward rotation5) Elevation6) Depression• Scapular protraction— AC joint acromion moves anteriorly on the clavicle, axis through conoid ligament— SC joint concave clavicle rolls and glides anteriorly— ST joint glides anteriorly around thorax• Scapular retraction— Opposite of protraction• Scapular Upward Rotation• ST joint glides into upward rotation• 0-30 degrees clavicle elevates (rolls superior and glides inferior) and AC glides superiorly until the conoid is taut• 30-60 degrees the clavicle rotates posteriorly (pulled by conoid) to keep up with the AC joint• Downward rotation is the reverse of upward rotation• Scapular elevation- AC joint angular motion of scapula on clavicle with the axis through the trapezoid- SC joint convex clavicle rolls superior, glides inferior— ST joint glides superiorly• Scapular depression— Opposite of elevation Scapulohumeral Rhythm • Scapulohumeral rhythm consists of integrated movements of the glenohumeral, scapulothoracic, AC and sternoclavicular joints and occurs in sequential fashion to allow full functional motion of the shoulder complex.• Scapulohumeral rhythm serves three functional purposes: 1. It allows for greater overall shoulder ROM2. It maintains optimal contact between the humeral head and glenoid fossa3. It assists with maintaining an optimal length-tension relationship of the glenohumeral muscles.• To complete 180° of abduction, the overall ratio of glenohumeral toscapulothoracic, AC and sternoclavicular motion is 2:1. • Inman was the first to explain scapulohumeral rhythm and described it as 2phases the shoulder complex completes to move through full abduction.• First phase (0-90°) entails the scapula setting against the thorax toprovide initial stability as the humerus abducts to 30°. i. From 30-90° of abduction, the glenohumeral joint contributesanother 30° of ROM while the scapula upwardly rotates 30°. ii. The upward rotation results from clavicular elevation through thesternoclavicular and AC joints.• The second phase (90-180°) entails 60° of glenohumeral abductionand 30° of scapula upward rotation. i. The scapula rotation is associated with 5° of elevation at thesternoclavicular joint and 25° of rotation at the acromiclavicluarjoint.讨论完力学,我们以后谈谈体检的问题. 占位.