肩關節傷害 shoulder injury 蔡燿鴻醫師 yao-hung tsai 嘉義長庚醫院...

肩關節傷害

SHOULDER INJURY

蔡燿鴻醫師YAO-HUNG TSAI嘉義長庚醫院骨科系一般骨科主任長庚大學助理教授

SHOULDER ANATOMY Three bones - the scapula (shoulder blade), the hu

merus (upper arm bone), and the clavicle (collarbone)

Rotator cuff

Shoulder joint stability

Dynamic FactorsRotator CuffScapular RotatorsLong Head BicepsLigament DynamizationProprioception

Factors of Stability Static Factors

Labrum Capsuloligamentous Rotator Interval Articular

VersionConformity Integrity

Obligate Translations Negative Intraaarticular Pressure Adhesion-Cohesion Rotator Cuff

Factors of Stability Dynamic Factors

Rotator Cuff Primary Function -Stabilize humeral head Secondary Function -Increased stability Dynamic Joint Compression - Glenohumeral moti

on Stabilizes against inferior translation

Dynamic Compression

Factors of Stability

Dynamic Factors Scapular Rotators

Stable glenoid platform

Maximize rotator cuff efficiency for articular compression

Scapulohumeral Rhythm


Dynamic Factors Long Head Biceps

Secondary Stabilizer

Pagnani JBJS, 1995

Secondary Stabilizer


Static Factors Labrum

Deepens Glenoid by 50% Loss of Cartilage Labral-Com

plex Decreased glenoid depth by 80

% Decrease Stability ratio by 65%

Lazarus JBJS, 1996


Static Factors Capsulo-ligamentous Structures

Mid-range laxity Prevent excessive translation

at extremes of motion

Factors of StabilityStatic Factors

Capsular Injury Intrasubstance Humeral avulsion of glenohumera

l ligments (HAGL) Anterior labroligmentous perioste

al sleeve avulsion(ALPSA)


Static Factors IGHL

Primary restraint to anterior and posterior translation of the abducted arm

Primary restraint to inferior translation of the abducted arm

O’Brien, AJSM 1990 Warner, AJSM 1992


Static Factors Rotator Interval

Primary restraint to inferior translation in adduction

Fields, Arthroscopy 1998 Cole, ASES 1999


Static Factors Anterosuperior Labrum

Incomplete lesion with no significant effect on GH translation

Complete lesion of superior labrum leads to significant increases in AP and SI GH translation

Pagnani, JBJS 1995


Static Factors Articular Geometry

Nearly spherical and very conforming Surface area: HH:Glenoid 3:1 Bony loss leads to lack of articular constraint

Soslowsky, CORR 1992

Bony Bankart Articular Retroversion Hill-Sachs

SHOULDER PAINDIFFERENTAIAL DIAGNOSIS

Cervical radiculopathy Cardiac ischemia Pricarditis Thoracic outlet syndrome Intraabdominal conditions Carpal tunnel syndrome Peripheral nerve entrapment Tumor

ACUTE SHOULDER INJURIES Clavicle fracture Acromioclavicle(AC joint) dislocation Humerus fracture Shoulder fracture dislocation Scapular fracture Brachial plexus injury Axillary nerve or suprascapular nerve injur

y

ACUTE SHOULDER INJURIES Traumatic rotator cuff tears Glenohumeral dislocation Anterior dislocation

(1) Bankart lesion- Labrum tear

(2) Capsule tear or subscapularis tear Posterior dislocation Biceps tendon rupture

CHRONIC SHOULDER INJURIES Overuse injury -Repetitive motion Anterior instability or subluxation:

Capsule laxity, Bankart lesion Superior labrum anteroposterior (SLAP) le

sion Rotator cuff tendinitis or tear Biceps tendinitis Deltoid or Trapezius muscle sprain

五十肩

冰凍肩 , 粘黏性關節膜發炎肩旋轉肌腱炎

Rotator Cuff Tendinitis 嚴重活動限制原因：骨液膜、旋轉肌、兩頭肌發炎退化病度：關節膜、水腫、纖維化肌肉萎縮 → 外轉受限制的嚴重

肩旋轉肌腱斷裂臨床：慢性發生、或外傷之後，中風＞ 40 y/o 外展，伸展，外轉－限制 Night Pain （晚上痛）

肩旋轉肌腱炎 & 斷裂的治療

保守方式1. 復健治療 - 熱敷、靜擺運動 2. 指尖爬牆運動3. 藥物治療

手術治療→ 關節鏡修補擴創術

Arthroscopic assistedmini-open rotator cuff repair

肩旋轉肌腱炎 & 斷裂的治療

手術治療→ 關節鏡修補擴創術 good to excellent 78%

肩旋轉肌腱斷裂的併發症 Open and Mini-open Surgery Complications1. Repair failure – rupture 40% of large tear, 10 to 20% of small tear2. Deltoid detachment3. Axillary nerve injury – 3.5 to 5cm from acromion edge Arthroscopic Surgery Complication1. Transient parasthesia – 5%2. Axillary and suprascapular nerve injury – post. Portal3. Axillary and musculocutaneous nerve – ant. Portal Postoperative Stiffness – 5 to 10 % Infection – 1.5%

肩關節不穩定 (Shoulder Instability) 肩關節囊破裂或是肩臼窩骨 (Glenoid) 及肱骨頭

骨折，造成肩關節有鬆動感。投手重覆做投擲及伸展動作，也會讓關節囊的肌

纖維過度伸長造成鬆弛。肩臼窩上的軟骨 (Labrum) 破裂也會引起肩關節

不穩定。

肩關節不穩定與半脫位原因1. 車禍外傷造成肩脫臼2. 運動時過度伸展傷害，重覆投擲動作3. 先天肩韌帶過度鬆弛

Laxity 症狀 - 大多輕微，平常在做外後旋轉時才會感

到肩膀不舒服嚴重時會有重覆性脫臼現象 Apprehension test

肩關節不穩定診斷身體理學和肌力檢查X 光片 : 檢視有無骨折脫位軟組織超音波檢查核磁共振攝影 (MRI)

Shoulder Arthroscopy

肩關節不穩定治療方法復健運動為主，加強肩部肌肉韌度，若有疼痛先

讓手臂休息，可服用非類固醇藥物減輕痛和腫脹手術治療 - 在全身麻醉下，測試肩關節鬆弛度，

再以肩關節鏡探視關節內情形

肩關節不穩定治療方法若是軟骨及前關節囊有裂傷，可用特殊帶線骨釘

進行縫合；若發現肩旋轉肌斷裂，就必須做肌腱修補縫合術

Arthroscopic Versus Open Repair

Arthroscopic repair – 4 to 7 % recurrence rate Bankart lesion with glenoid bone defect & Hill-

Sach lesion – 67% recurrence Bankart lesion without bone defect – 4% recurr

ence Robert SN, ASES 1999 – recurrence of 3 types of

repair in Australian rule football players1. Arthroscopic transglenoid repair – 70%2. Arthroscopic tack repair – 38%3. Open capsular repair – 30%

肩關節不穩定治療方法關節囊過於伸張鬆弛 - 水中熱收縮電燒儀 Heat range – 65 to 70 度 C 20 to 30% collagen shrinkage

Acromioclavicular joint 肩鎖關節 The AC joint allows the ability to raise the arm above the head. This joint functions as a pivot point, acting like a strut to help

with movement of the scapula resulting in a greater degree of arm rotation.

Acromioclavicular joint dislocation The most common cause of an AC joint separation is

falling on the shoulder Symptoms range from mild tenderness felt over the

joint after a ligament sprain to the intense pain of a complete separation. Bruising

Acromioclavicular joint dislocation

Grades Treatment – Nonsurgical Possible OA

Acromioclavicular joint dislocation

Surgery – CC screws, Weaver & Dunn procedure OA surgery

Adhesive Capsulitis 40 to 60 Y/O – No prior significant trauma Frozen shoulder Cause unknown – autoimmune inflammation Nonsurgical – NSAID, steroid injection Rehabilitation Surgery - Manipulation

under Anesthesia Arthroscopic release

Shoulder Joint Replacement

Shoulder osteoarthritis Shoulder AVNHumeral 4 part fracture

Shoulder Arthroplasty Procedure

Shoulder Arthroplasty Complicatons1. Anesthesia 2. infection – 4%3. Loosening or Wear 4. Instability or Dislocation– 18%5. Fracture6. Rotator cuff tear7. nerve or blood vessel injury – 2% - brachial ple

xus or axillary nerve Rehabilitation

Biceps Rupture Middle-aged people and is usually due to years of

wear and tear on the shoulder. Younger athletes sometimes occurs during

weightlifting or from actions that cause a sudden load on the arm, such as hard fall with the arm outstretched.

Biceps Tendonitis & Rupture Tendonitis and lift heavy thing Snap sound Symptom – pain and bump Impingement

Biceps Rupture TreatmentNonsurgical -- reduces supination stre

ngth by about 20 percent.

Biceps Rupture Surgery

Calcific Tendonitis 40 – 50 Y/o Cause

1. Degenerative calcification

2. Reactive calcification.

Calcific Tendonitis Treatment Nonsurgical –NSAID, Steroid injection, R

ehalilitation, Shockwave – 80% success Surgery – Open or Arthroscopic resection,

acromiplasty

Impingement Syndrome Repetitive activities that involve using the arm

above shoulder level cause some impingement Continuously working with the arms raised

overhead, repeated throwing activities Impingement causes irritation or damage to the

rotator cuff

Impingement Syndrome Dynamic CausesA. External Impingement Cuff weakness Tight posterior capsule Shoulder instability Scapular dysfunction Use wheelchair and crutches

B. Internal Impingement – anterior and posterior Subscapularis weakness Type II SLAP lesion Scapular dysfunction Stiffness Poor scapulohumeral rhythm

Impingement Syndrome Diagnosis – PE, Impingement test, MRI, Sonography Treatent – Nonsurgical Surgery Arthroscopy or open1. Subacromial bursectomy2. Acromioplasty Results – 80 to 95% good

to excellent Complication – pain (4%)

Superior Labral Anterior Posterior Lesion

Cause 1. Direct injury - falling on an outstretched

hand. 2. Overuse. 3. Instability


Classification1. Type I 9.5-21% 2. Type II, 41-55%3. Type III, 6-33%4. Type IV, 3-15%

Diagnosis – 1. PE: Speed’s test2. O’Brien test 3. Jobe relocation test4. MRI


Treatment – Nonsurgical first Surgery – Arthroscopic repair for type II 85

% good to excellent result Type III and IV - debridement

Snapping Scapula Syndrome Scapulothoracic bursitis under the shoulder bl

ade Muscles under the scapula-atrophied from wea

kness or inactivity Scapular fracture

Snapping Scapula Syndrome Rehabilitation Surgery

Sternoclavicular Joint Dislocation

TraumaDegenerative arthritis

Sternoclavicular Joint Dislocation

ClassificationNonsurgical

Sternoclavicular Joint Dislocation Surgery for posterior dislocation – Resectio

n arthroplasty and graft

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肩關節傷害 shoulder injury 蔡燿鴻醫師 yao-hung tsai 嘉義長庚醫院...

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