膝關(guān)節(jié)評(píng)估_9-17

1、膝關(guān)節(jié)評(píng)估 膝部韌帶拉傷膝部韌帶拉傷 內(nèi)側(cè)副軔帶內(nèi)側(cè)副軔帶(MCL)/(MCL)/外側(cè)副軔帶外側(cè)副軔帶( (LCL) LCL) 內(nèi)翻壓力測(cè)試內(nèi)翻壓力測(cè)試(Varus Stress test)(Varus Stress test)(圖右)外側(cè)副軔帶 外翻壓力測(cè)試外翻壓力測(cè)試Valgus Stress testValgus Stress test(圖左)內(nèi)側(cè)副軔帶 pGrade 0: 無(wú)松弛 pGrade 1: 1cm 2 膝部韌帶拉傷膝部韌帶拉傷 前十字軔帶前十字軔帶(ACL), (ACL), 后十字軔帶后十字軔帶(PCL)(PCL) u前十字軔帶: 膝彎屈時(shí)放松(030度),伸直時(shí)緊張 u后十

2、字軔帶: 膝彎屈時(shí)緊張(90度),伸直時(shí)放松 3 PCL ACL. 4 最常見(jiàn)原因 跑動(dòng)中急停改變方向造成一巨大扭轉(zhuǎn)力 而損傷 高處跳下造成膝扭轉(zhuǎn) 前十字軔帶 - - 非碰撞接觸損傷 后十字軔帶損傷后十字軔帶損傷 脛骨下陷(sag sign) 常見(jiàn)騎摩托車(chē)撞擊前檔板后損傷 5 前十字軔帶(ACL) ; (ACL) ; 后十字軔帶(PCL)(PCL) 90-前抽屜試驗(yàn)/ /后后抽屜試驗(yàn)030 :前十字- 緊張 90 : 后十字- 緊張 前抽屜試驗(yàn)(+)表示脛骨被拉向前超過(guò)0.5cm， 前十字軔帶可能斷裂 后抽屜試驗(yàn)(+)(+)表示脛骨被向後推離股骨超過(guò)0.5cm 后十字軔帶可能斷裂 6 抽屜試驗(yàn)

3、的盲點(diǎn)抽屜試驗(yàn)的盲點(diǎn) 1.腘旁腱(腿后腱)肌(hamstring)太緊會(huì)拉不動(dòng) 偽偽 陰性陰性 2. 2.當(dāng)后當(dāng)后十字軔帶損傷時(shí)會(huì)使脛骨原先就處在后退的 位置(sag sign) 偽陽(yáng)性偽陽(yáng)性 7 Lachman test u對(duì)前十字軔帶損傷最敏感對(duì)前十字軔帶損傷最敏感ACL ACL u膝彎屈2530然后拉動(dòng)脛骨遠(yuǎn)離股骨 u若輕易被拉開(kāi)表示前十字軔帶斷裂 8 前十字軔帶旋轉(zhuǎn)軸移動(dòng)測(cè)試前十字軔帶旋轉(zhuǎn)軸移動(dòng)測(cè)試(ACL Pivot shift test)(ACL Pivot shift test) 給一拉力將脛骨前拉在膝彎屈0-30時(shí), 然后給 予股骨向內(nèi)側(cè)的壓迫 前十字軔帶穩(wěn)定度 如果出現(xiàn)卡住

4、突然半脫位 pivot shift test(+) 9 膝部膝部 Knee UnhappyKnee Unhappy TriadTriad 膝蓋扭傷合并內(nèi)側(cè)副韌帶、前十字形韌帶和半 月軟骨損傷的合并性嚴(yán)重?fù)p傷 需碰撞的運(yùn)動(dòng)常見(jiàn)運(yùn)動(dòng)傷害 機(jī)轉(zhuǎn): 外側(cè)碰撞力量在膝蓋此時(shí)腳掌還緊貼在地 面產(chǎn)生一個(gè)外轉(zhuǎn)的扭力 前十字形韌帶損傷可連帶外側(cè)/內(nèi)側(cè)結(jié)構(gòu)的破壞 10 u小的撕脫性骨哲折 在脛骨近端和前十 字軔帶有關(guān) 扭轉(zhuǎn)傷害 Segond Fx 11 前十字軔帶損傷在前十字軔帶損傷在X X線表現(xiàn)線表現(xiàn) A Fat-Suppressed Proton- Density weighted Sagittal imag

5、e u實(shí)心條狀 12 MRI下正常前十字軔帶 T1-weighted MRI T1-weighted MRI 13 MRI appearances in ACL u在應(yīng)當(dāng)出現(xiàn)前十字軔帶的位 置卻看不到代表就是有損傷 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. 14 MRI appearan

6、ces in ACL tear T1-weighted MRI Proton-density weighted fat- suppressed sagittal image 軔帶邊緣不規(guī)則部份斷裂 15 Diagnosis : Partial tear of the proximal anteromedial band of the ACL 半月軟骨損傷半月軟骨損傷 關(guān)節(jié)活動(dòng)時(shí)卡住 McMurray testMcMurray test：平躺膝彎屈給與內(nèi)轉(zhuǎn)外轉(zhuǎn)的力 外轉(zhuǎn)的力 外側(cè)半月軟骨(Lat. Meniscus(左圖) 內(nèi)轉(zhuǎn)的力 內(nèi)側(cè)半月軟骨(Med. meniscus(右圖 ) 檢查有無(wú)雜

7、音(click sign) 16 meniscus 半月軟骨 Apleys testApleys test：下壓且旋轉(zhuǎn)：下壓且旋轉(zhuǎn) 若有明顯疼痛在膝蓋處表示陽(yáng)性 17 臏骨痛臏骨痛(Patellofemeral Pain)(Patellofemeral Pain) 賓骨碾磨測(cè)試(patellofemoral grind test) Apprehension test（恐懼） 賓骨被向外推時(shí)病病人會(huì)有恐慌表情 18 賓骨股骨疼痛綜合征賓骨股骨疼痛綜合征 與造成膝關(guān)節(jié)外側(cè)壓力大的任何因素相關(guān)的生物 力學(xué)缺損都可能造成疼痛 Q angle 角度過(guò)大 足部過(guò)度pronation （flatfoot）

8、髕骨過(guò)度外移 髕骨過(guò)高或過(guò)低(Patella alta(高位) or baja(低位) 19 Hamsting strain Hamsting strain Quadriceps strain Quadriceps strain 20 賓骨股骨疼痛綜合征賓骨股骨疼痛綜合征 股內(nèi)斜肌(VMO vastus medialis oblique muscle) 肌力不足: 最重要的穩(wěn)定肌肉 股骨前傾造成股骨過(guò)於內(nèi)轉(zhuǎn)足旋前 髖內(nèi)轉(zhuǎn)肌縮短;造成股骨過(guò)於內(nèi)轉(zhuǎn) 髖外轉(zhuǎn)肌力不足;造成股骨過(guò)於內(nèi)轉(zhuǎn): Iliopsoas, Gluteal muscles 21 賓骨股骨疼痛綜合征賓骨股骨疼痛綜合征 治療治療 足弓使

9、用特殊鞋墊支撐 肌力訓(xùn)練: 髁腰肌(Iliopoas) and 股內(nèi)斜肌 開(kāi)放/閉鎖鏈運(yùn)動(dòng) 伸展內(nèi)側(cè)腘旁腱肌和大腿內(nèi)收肌群 避免 W W坐姿坐姿 22 賓骨肌腱炎賓骨肌腱炎(Patellar tendonitis)(Patellar tendonitis) 近端 : 跳躍膝(Jumpers knee) 遠(yuǎn)端 : Osgood-Schlatter Dz 23 InfrapatellarInfrapatellar bursitis bursitis Popliteal bursitis (Bakers cyst) 24 膝退化性關(guān)節(jié)炎 Figure 1 : 正常 Figure 2 : 有骨刺產(chǎn)生,

10、 關(guān)節(jié)腔變窄 Osteoarthritis: grading Department of Rheumatology and Medical Illustration, University of Manchester Grade 0 : No features Grade 1 : Doubtful narrowing of joint space and possible osteophytic lipping Grade 2 : Definite osteophytes and possible narrowing of joint space Grade 3 : Moderate mult

11、iple osteophytes, definite narrowing of joint space, and some sclerosis and possible deformity of bone ends nGrade 4 : Large osteophytes, marked narrowing of joint space, severe sclerosis , and definite deformity of bone ends 髂脛束綜合癥髂脛束綜合癥 (Iliotibial band syndrome )(Iliotibial band syndrome ) Ober t

12、est 27 Open and Closed-kinetic Chain Exercise uClosed-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 force

13、s, that may cause laxity in the ACL. 28 Open and Closed-kinetic Chain Exercise uOpen-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 反覆賓骨不

14、穩(wěn)定的治療 l目標(biāo): 減輕癥狀 Increase quadriceps strength a d endurance (VMO lateral structures). Use of passive restraints (Palumo-type bracing, McConnell taping) to augment stability during transition. lPatellar Taping Create a mechanical medial shift of the patella centralizing it with in the trochlea groove

15、and improving patellar tracking. 30 uTherapeutic Exercises lHeel slides / Wall slides() lPatellar mobilization 31 uTherapeutic Exercises lQuadriceps sets lStraight leg raises(SLR) all planes with brace in full extension until quadriceps strength is sufficient to prevent extension lag. Slowly raise i

16、t 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 Nonioerative treatment of Recurrent Patellar Instability (Lateral)Instability (Lateral) High EMG activity of the VMO

17、1.Leg press. 2.Lateral step-up. 3.Isometric quadriceps setting. 4.Hip adduction exercise. 33 General Guidelines for Nonioerative General Guidelines for Nonioerative treatment of Recurrent Patellar Instability treatment of Recurrent Patellar Instability (Lateral)(Lateral) lGradual restoration of flex

18、ibility (stretching) for noted deficits. 1.Iliotibial band 2.Quadriceps 34 Two-personTwo-person OberOber stretch stretch Cross-over Cross-over lateral lateral fascialfascial stretchstretch Self Self oberober stretch stretch Leaning lateral Leaning lateral fascialfascial stretch stretch Quadriceps se

19、lf-stretchQuadriceps self-stretch General 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. 3. Hamstring 4. Gastrocnemius 35 uTherapeutic Exercises lHamstring Curls Hold 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. lStraight Leg Raises(Prone) Tighten the hamstrings of the injured l