膝關(guān)節(jié)評(píng)估-9-17課件

膝關(guān)節(jié)評(píng)估膝部韌帶拉傷內(nèi)側(cè)副軔帶(MCL)/外側(cè)副軔帶(LCL)內(nèi)翻壓力測(cè)試(VarusStresstest)(圖右)外側(cè)副軔帶外翻壓力測(cè)試ValgusStresstest(圖左)內(nèi)側(cè)副軔帶Grade0:無(wú)松弛Grade1:<0.5cmGrade2:0.5~1cmGrade3:>1cm2膝部韌帶拉傷

前十字軔帶(ACL),后十字軔帶(PCL)前十字軔帶:膝彎屈時(shí)放松(0~30度),伸直時(shí)緊張后十字軔帶:膝彎屈時(shí)緊張(90度),伸直時(shí)放松3PCLACL.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);后十字軔帶(PCL)90°-前抽屜試驗(yàn)/后抽屜試驗(yàn)0~30°: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)的盲點(diǎn)腘旁腱(腿后腱)肌(hamstring)太緊會(huì)拉不動(dòng)

偽陰性當(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(sagsign)偽陽(yáng)性7Lachmantest對(duì)前十字軔帶損傷最敏感ACL膝彎屈25~30°然后拉動(dòng)脛骨遠(yuǎn)離股骨若輕易被拉開(kāi)表示前十字軔帶斷裂8膝部KneeUnhappy

Triad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10AFat-SuppressedProton-DensityweightedSagittalimage實(shí)心條狀12MRI下正常前十字軔帶T1-weightedMRI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

Sagittalimageshowscomplete(ornear-complete)nonvisualizationoftheACLwithill-definededemaandhemorrhageintheusuallocationoftheACLintheintercondylarnotch.14MRIappearances

inACLtearT1-weightedMRIProton-densityweightedfat-suppressedsagittalimage

軔帶邊緣不規(guī)則部份斷裂15Diagnosis:

PartialtearoftheproximalanteromedialbandoftheACL

半月軟骨損傷關(guān)節(jié)活動(dòng)時(shí)卡住McMurraytest：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)雜音(clicksign)16meniscus半月軟骨Apley’stest：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(PatellofemeralPain)賓骨碾磨測(cè)試(patellofemoralgrindtest)Apprehensiontest（恐懼）

賓骨被向外推時(shí)病病人會(huì)有恐慌表情18HamstingstrainQuadricepsstrain20賓骨股骨疼痛綜合征股內(nèi)斜肌(VMOvastusmedialisobliquemuscle)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,Glutealmuscles21賓骨肌腱炎(Patellartendonitis)近端:跳躍膝(Jumper’sknee)遠(yuǎn)端:Osgood-SchlatterDz23InfrapatellarbursitisPoplitealbursitis(Baker’scyst)24Osteoarthritis:grading

DepartmentofRheumatologyandMedicalIllustration,

UniversityofManchesterGrade0:NofeaturesGrade1:DoubtfulnarrowingofjointspaceandpossibleosteophyticlippingGrade2:DefiniteosteophytesandpossiblenarrowingofjointspaceGrade3:Moderatemultipleosteophytes,definitenarrowingofjointspace,andsomesclerosisandpossibledeformityofboneendsGrade4:Largeosteophytes,markednarrowingofjointspace,severesclerosis,anddefinitedeformityofboneends髂脛束綜合癥(Iliotibialbandsyndrome)Obertest27OpenandClosed-kineticChainExerciseClosed-kineticchainexerciseprovideamoresignificantcompressionforceacrossthekneewhileactivatingcocontractionofthequadricepsandhamstringmuscles.Open-chainexerciseatlowflexionanglesmayproduceanincreaseinanteriorshearforces,thatmaycauselaxityintheACL.28反覆賓骨不穩(wěn)定的治療目標(biāo):

減輕癥狀I(lǐng)ncreasequadricepsstrengthadendurance(VMO>lateralstructures).Useofpassiverestraints(Palumo-typebracing,McConnelltaping)toaugmentstabilityduringtransition.PatellarTapingCreateamechanicalmedialshiftofthepatellacentralizingitwithinthetrochleagrooveandimprovingpatellartracking.30TherapeuticExercisesHeelslides/Wallslides()Patellarmobilization31TherapeuticExercisesQuadricepssetsStraightlegraises(SLR)allplaneswithbraceinfullextensionuntilquadricepsstrengthissufficienttopreventextensionlag.Slowlyraiseit6to10inchesoffthefloor.Holdthispositionfor5secondsandthenrelax.Perform3setsof20repetitions,4to5daysaweek.32NonioerativetreatmentofRecurrentPatellarInstability(Lateral)HighEMGactivityoftheVMOLegpress.Lateralstep-up.Isometricquadricepssetting.Hipadductionexercise.33GeneralGuidelinesforNonioerativetreatmentofRecurrentPatellarInstability(Lateral)Gradualrestorationofflexibility(stretching)fornoteddeficits.IliotibialbandQuadriceps34Two-personOberstretchCross-overlateralfascialstretchSelfoberstretchLeaninglateralfascialstretchQuadricepsself-stretchGeneralGuidelinesforNonioerativetreatmentofRecurrentPatellarInstability(Lateral)Gradualrestorationofflexibility(stretching)fornoteddeficits.3.Hamstring4.Gastrocnemius35TherapeuticExercisesHamstringCurlsHoldthispositionfor5secondsandthenrelax.Perform3setsof20repetitions,4to5daysaweek,continuingfor3to4weeks.Straight–LegRaises(Prone)Tightenthehamstringsoftheinjuredlegandraisethelegtowardtheceilingasfarasyoucan.Holdthepositionfor5seconds.Perform3setsof20repetitions,4to5daysaweek.36TherapeuticExercisesNon-weightbearinggastrosoleus,HamstringstretchesProneextensionhangsforgravity–assistedkneeextensionSupineandlegelevationwithresistance37TherapeuticExercisesMinisquats0~30?

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