膝关节评估917.ppt
,膝关节评估,膝部韌帶拉傷,内侧副轫带(MCL)/外侧副轫带(LCL)内翻压力测试(Varus Stress test)(圖右)外侧副轫带 外翻压力测试Valgus Stress test(圖左)内侧副轫带Grade 0:无松弛Grade 1:1cm,2,膝部韌帶拉傷前十字轫带(ACL),后十字轫带(PCL),前十字轫带:膝弯屈时放松(030度),伸直时紧张后十字轫带:膝弯屈时紧张(90度),伸直时放松,3,PCL,ACL.,4,最常见原因跑动中急停改变方向造成一巨大扭转力而损伤高处跳下造成膝扭转,前十字轫带-非碰撞接触损伤,后十字轫带损伤,胫骨下陷(sag sign)常见骑摩托车撞击前档板后损伤,5,前十字轫带(ACL);后十字轫带(PCL),90-前抽屉试验/后抽屉试验030:前十字-紧张 90:后十字-紧张前抽屉试验(+)表示胫骨被拉向前超過0.5cm，前十字轫带可能断裂后抽屉试验(+)表示胫骨被向後推離股骨超過0.5cm后十字轫带可能断裂,6,抽屉试验的盲点,腘旁腱(腿后腱)肌(hamstring)太紧會拉不動 伪阴性当后十字轫带损伤时会使胫骨原先就处在后退的位置(sag sign)伪阳性,7,Lachman test,对前十字轫带损伤最敏感ACL 膝弯屈2530然后拉动胫骨远离股骨若轻易被拉开表示前十字轫带断裂,8,前十字轫带旋转轴移动测试(ACL Pivot shift test),给一拉力将胫骨前拉在膝弯屈0-30时,然后给予股骨向内侧的压迫前十字轫带稳定度如果出现卡住 突然半脱位 pivot shift test(+),9,膝部 Knee Unhappy Triad,膝盖扭伤合并内侧副韧带、前十字形韧带和半月软骨损伤的合并性严重损伤需碰撞的运动常见运动伤害机转:外侧碰撞力量在膝盖此时脚掌还紧贴在地面产生一个外转的扭力前十字形韧带损伤可连带外側/內側结构的破坏,10,小的撕脱性骨哲折 在胫骨近端和前十字轫带有关 扭转伤害 Segond Fx,11,前十字轫带损伤在X线表现,A Fat-Suppressed Proton-Density weighted Sagittal image,实心条状,12,MRI下正常前十字轫带,T1-weighted MRI,T1-weighted MRI,13,MRI appearances in ACL,在应当出现前十字轫带的位置却看不到代表就是有损伤 Sagittal image shows complete(or near-complete)nonvisualization of the ACL with ill-defined edema and hemorrhage in the usual location of the ACL in the intercondylar notch.,14,MRI appearances in ACL tear,T1-weighted MRI,Proton-density weighted fat-suppressed sagittal image 轫带边缘不规则部份断裂,15,Diagnosis:Partial tear of the proximal anteromedial band of the ACL,半月軟骨损伤,关节活动时卡住McMurray test：平躺膝弯屈给与内转外转的力外转的力 外侧半月軟骨(Lat.Meniscus(左圖)内转的力 内侧半月軟骨(Med.meniscus(右圖)检查有无杂音(click sign),16,meniscus 半月軟骨,Apleys test：下压且旋转若有明显疼痛在膝盖处表示阳性,17,臏骨痛(Patellofemeral Pain),宾骨碾磨测试(patellofemoral grind test)Apprehension test（恐懼）宾骨被向外推时病病人会有恐慌表情,18,宾骨股骨疼痛综合征,与造成膝关节外側压力大的任何因素相关的生物力学缺损都可能造成疼痛Q angle 角度過大足部過度pronation（flatfoot）髕骨过度外移髕骨过高或过低(Patella alta(高位)or baja(低位),19,Hamsting strain Quadriceps strain,20,宾骨股骨疼痛综合征,股内斜肌(VMO vastus medialis oblique muscle)肌力不足:最重要的稳定肌肉股骨前倾造成股骨过於內转足旋前髋内转肌縮短;造成股骨過於內轉髋外转肌力不足;造成股骨過於內转:Iliopsoas,Gluteal muscles,21,宾骨股骨疼痛综合征,治疗足弓使用特殊鞋垫支撑肌力训练:髁腰肌(Iliopoas)and 股内斜肌 开放/闭锁链运动伸展内侧腘旁腱肌和大腿内收肌群避免 W坐姿,22,宾骨肌腱炎(Patellar tendonitis)近端:跳跃膝(Jumpers knee)远端:Osgood-Schlatter Dz,23,Infrapatellar bursitisPopliteal bursitis(Bakers cyst),24,膝退化性关节炎Figure 1:正常 Figure 2:有骨刺产生,关节腔变窄,Osteoarthritis:gradingDepartment of Rheumatology and Medical Illustration,University of Manchester,Grade 0:No featuresGrade 1:Doubtful narrowing of joint space and possible osteophytic lippingGrade 2:Definite osteophytes and possible narrowing of joint space Grade 3:Moderate multiple osteophytes,definite narrowing of joint space,and some sclerosis and possible deformity of bone endsGrade 4:Large osteophytes,marked narrowing of joint space,severe sclerosis,and definite deformity of bone ends,髂胫束综合症(Iliotibial band syndrome),Ober test,27,Open and Closed-kinetic Chain Exercise,Closed-kinetic chain exercise provide a more significant compression force across the knee while activating cocontraction of the quadriceps and hamstring muscles.Open-chain exercise at low flexion angles may produce an increase in anterior shear forces,that may cause laxity in the ACL.,28,Open and Closed-kinetic Chain Exercise,Open-chain exercise generate more isolated muscle activities and allow for more specific strengthening training.Closed-chain better than Open-chain exercise in ACL reconstruction Avoid early open-chain exercise,29,反覆宾骨不稳定的治疗,目标:减轻症状Increase quadriceps strength a d endurance(VMO lateral structures).Use of passive restraints(Palumo-type bracing,McConnell taping)to augment stability during transition.Patellar TapingCreate a mechanical medial shift of the patella centralizing it with in the trochlea groove and improving patellar tracking.,30,Therapeutic ExercisesHeel slides/Wall slides()Patellar mobilization,31,Therapeutic ExercisesQuadriceps sets Straight leg raises(SLR)all planes with brace in full extension until quadriceps strength is sufficient to prevent extension lag.Slowly raise it 6 to 10 inches off the floor.Hold this position for 5 seconds and then relax.Perform 3 sets of 20 repetitions,4 to 5 days a week.,32,Nonioerative treatment of Recurrent Patellar Instability(Lateral),High EMG activity of the VMOLeg press.Lateral step-up.Isometric quadriceps setting.Hip adduction exercise.,33,General Guidelines for Nonioerative treatment of Recurrent Patellar Instability(Lateral),Gradual restoration of flexibility(stretching)for noted deficits.Iliotibial band Quadriceps,34,Two-person Ober stretch,Cross-over lateral fascial stretch,Self ober stretch,Leaning lateral fascial stretch,Quadriceps self-stretch,General Guidelines for Nonioerative treatment of Recurrent Patellar Instability(Lateral),Gradual restoration of flexibility(stretching)for noted deficits.3.Hamstring4.Gastrocnemius,35,Therapeutic ExercisesHamstring CurlsHold this position for 5 seconds and then relax.Perform 3 sets of 20 repetitions,4 to 5 days a week,continuing for 3 to 4 weeks.Straight Leg Raises(Prone)Tighten the hamstrings of the injured leg and raise the leg toward the ceiling as far as you can.Hold the position for 5 seconds.Perform 3 sets of 20 repetitions,4 to 5 days a week.,36,Therapeutic ExercisesNon-weight bearing gastrosoleus,Hamstring stretchesProne extension hangs for gravity assisted knee extensionSupine and leg elevation with resistance,37,Therapeutic ExercisesMini squats 030 Stationary bike(begin with high seat,low tension)Closed-chain extension(leg press 030)Continue hamstring stretch,progress to weight-bearing gastrosoleus stretches.Continue prone lag hangs with progressively heavier ankle weights until full extension is achieved.,38,行走测试,39,
