膝关节评估917.ppt
膝关节评估膝部韌帶拉傷膝部韌帶拉傷内侧副轫带内侧副轫带(MCL)/(MCL)/外侧副轫带外侧副轫带(LCL)LCL)内翻压力测试内翻压力测试(Varus Stress test)(Varus Stress test)(圖右)外侧副轫带 外翻压力测试外翻压力测试Valgus Stress testValgus Stress test(圖左)内侧副轫带pGrade 0:无松弛pGrade 1:1cm2膝部韌帶拉傷膝部韌帶拉傷前十字轫带前十字轫带(ACL),(ACL),后十字轫带后十字轫带(PCL)(PCL)u前十字轫带:膝弯屈时放松(030度),伸直时紧张u后十字轫带:膝弯屈时紧张(90度),伸直时放松3PCLACL.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);(ACL);后十字轫带(PCL)(PCL)90-前抽屉试验/后后抽屉试验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抽屉试验的盲点抽屉试验的盲点1.腘旁腱(腿后腱)肌(hamstring)太紧會拉不動 伪伪阴性阴性2.2.当后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)伪阳性伪阳性7 Lachman testu对前十字轫带损伤最敏感对前十字轫带损伤最敏感ACL ACL u膝弯屈2530然后拉动胫骨远离股骨u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前十字轫带旋转轴移动测试(ACL Pivot shift test)(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膝部膝部 Knee UnhappyKnee Unhappy TriadTriad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10u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 Fx11前十字轫带损伤在前十字轫带损伤在X X线表现线表现A Fat-Suppressed Proton-Density weighted Sagittal image u实心条状12MRI下正常前十字轫带T1-weighted MRIT1-weighted MRI13MRI appearances in ACLu在应当出现前十字轫带的位置却看不到代表就是有损伤 uSagittal 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.14MRI appearances in ACL tearT1-weighted MRIProton-density weighted fat-suppressed sagittal image 轫带边缘不规则部份断裂15Diagnosis:Partial tear of the proximal anteromedial band of the ACL半月軟骨损伤半月軟骨损伤 关节活动时卡住 McMurray testMcMurray 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)16meniscus 半月軟骨Apleys testApleys test：下压且旋转：下压且旋转若有明显疼痛在膝盖处表示阳性17臏骨痛臏骨痛(Patellofemeral Pain)(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 Hamsting strain Quadriceps strain Quadriceps strain20宾骨股骨疼痛综合征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 muscles21宾骨股骨疼痛综合征宾骨股骨疼痛综合征治疗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 W坐姿坐姿 22宾骨肌腱炎宾骨肌腱炎(Patellar tendonitis)(Patellar tendonitis)近端:跳跃膝(Jumpers knee)远端:Osgood-Schlatter Dz23InfrapatellarInfrapatellar bursitis 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 ManchesterGrade 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 endsnGrade 4:Large osteophytes,marked narrowing of joint space,severe sclerosis,and definite deformity of bone ends髂胫束综合症髂胫束综合症 (Iliotibial band syndrome)(Iliotibial band syndrome)Ober test27Open and Closed-kinetic Chain ExerciseuClosed-kinetic chain exercise provide a more significant compression force across the knee while activating cocontraction of the quadriceps and hamstring muscles.uOpen-chain exercise at low flexion angles may produce an increase in anterior shear forces,that may cause laxity in the ACL.28Open and Closed-kinetic Chain ExerciseuOpen-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l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.lPatellar TapingCreate a mechanical medial shift of the patella centralizing it with in the trochlea groove and improving patellar tracking.30uTherapeutic ExerciseslHeel slides/Wall slides()lPatellar mobilization31uTherapeutic ExerciseslQuadriceps sets lStraight 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.32Nonioerative treatment of Recurrent Patellar Nonioerative treatment of Recurrent Patellar Instability(Lateral)Instability(Lateral)High EMG activity of the VMO1.Leg press.2.Lateral step-up.3.Isometric quadriceps setting.4.Hip adduction exercise.33General Guidelines for Nonioerative General Guidelines for Nonioerative treatment of Recurrent Patellar Instability treatment of Recurrent Patellar Instability(Lateral)(Lateral)lGradual restoration of flexibility(stretching)for noted deficits.1.Iliotibial band 2.Quadriceps34Two-personTwo-person OberOber stretch stretchCross-over Cross-over latera
