小兒骨科的臨床基礎

小兒骨科的臨床基礎第1頁/共34頁病史現(xiàn)病史出生史（產(chǎn)傷骨折、臂叢神經(jīng)麻痹、腦癱等）發(fā)育史（侏儒、甲低、肌營養(yǎng)不良等）家族史（多指、多發(fā)骨軟骨瘤病等）第2頁/共34頁體格檢查望（整體外觀，冠狀面、矢狀面、水平面）患兒的面容（痛苦面容，21三體面容等）表皮的色澤和皮膚生長情況患兒身材比例肢體對稱情況肢體長短情況肢體活動情況肢體畸形情況軀干部活動情況軀干部畸形情況患兒的步態(tài)第3頁/共34頁體格檢查觸皮膚彈性皮膚變色情況局部腫脹情況，溫度變化包塊（位置、大小、質(zhì)地、界限、溫度、皮色、與周邊關系、活動度、壓縮性）壓痛（位置，最大壓痛點）反?；顒印⒐遣烈?、骨擦感緊張攣縮感痙攣感肌力（0~5級）第4頁/共34頁肌力0級：無任何收縮1級：只可觸及收縮，沒有任何活動。2級：可于水平方向移動，不能對抗重力。3級：僅能對抗重力，不能對抗阻力。4級：能對抗一定程度的阻力5級：肌力正常LovettandMartin’s肌力分級法TexasScottishRiteHospital肌力分級法第5頁/共34頁

NormalTimesofAppearanceandDisappearanceofInfantileReflexesandReactions

Palmar(hand)graspreflexPresentinneonatesandveryyounginfants;normallydisappearsbetweenages2and4moPlantar(foot)graspreflexPresentinneonatesandinfants;usuallydisappearsbetweenages9and12moMoro'sreflexPresentatbirth;graduallydisappearsbyages3-6mo：CNSStartlereflexAppearsatbirth;presentthroughoutlifeVerticalsuspensionpositioningReflexnormallydisappearsafterage4moPlacingreactionNormallypresentatbirthinfull-termneonates;upperlimbplacingusuallydisappearsbyages2-4moandlowerlimbplacingbyages1-2mo;bothresponsesmaypersistuptoage12moorolderWalkingorsteppingreflexNormallypresentatbirth;usuallydisappearsbyages1-2moCrossedextensionreflexPresentatbirth;normallydisappearsbyages1-2moWithdrawalreflexPresentatbirth;disappearsbetweenages1and2moPositivesupportresponse/leg-straighteningreflexPresentatbirth;normallydisappearsatabout4moExtensorthrustreflexPresentatbirth;normallypresentupto2moGalant'sreflex(trunkincurvation)Presentatbirth;disappearsatabout2-2?moRotationreflexTimeofdisappearancevariesTonicneckreflexesAsymmetricreflexpresentatbirth,normallydisappearsby4-6mo;symmetricreflexusuallypresentby5-8mo,oftendiminishedorabsentby12moLandau'sreflexNormallypresentfrom6moto24-30moParachutereactionAppearsatabout6mo;remainsthroughoutlifeNeckrightingreflexNormallypresentfrombirthtoabout6moBodyrightingreflexAppearsaround6mo;candisappearanytimeafter5yrorpersistthroughoutlifeOralreflexesUsuallydisappearat3-4mo;maybepresentlongerduringsleep第6頁/共34頁深反射肱二頭肌反射肱三頭肌反射膝反射踝反射第7頁/共34頁淺反射Babibski反射提睪反射Hoffmann反射括約肌反射腹壁反射第8頁/共34頁MuscleSegmentalInnervationPeripheralNerveTrapeziusCranialXI;C(2)3-4SpinalaccessorynerveLevatoranguliscapulaeC3-4Nervestolevatoranguliscapulae

C4-5DorsalscapularnerveRhomboideusmajorC4-5DorsalscapularnerveRhomboideusminorC4-5DorsalscapularnerveSerratusanteriorC5-7LongthoracicnerveDeltoidC5-6AxillarynerveTeresminorC5-6AxillarynerveSupraspinatusC(4)5-6SuprascapularnerveInfraspinatusC(4)5-6SuprascapularnerveLatissimusdorsiC6-8Thoracodorsalnerve(longsubscapular)PectoralismajorC5-T1LateralandmedialanteriorthoracicPectoralisminorC7-T1MedialanteriorthoracicSubscapularisC5-7SubscapularnervesTeresmajorC5-7LowersubscapularnerveSubclaviusC5-6NervetosubclaviusCoracobrachialisC6-7MusculocutaneousnerveBicepsbrachiiC5-6MusculocutaneousnerveBrachialisC5-6Musculocutaneousnerve第9頁/共34頁BrachioradialisC5-6RadialnerveTricepsbrachiiC6-8(T1)RadialnerveAnconeusC7-8RadialnerveSupinatorbrevisC5-7RadialnerveExtensorcarpiradialislongusC(5)6-7(8)RadialnerveExtensorcarpiradialisbrevisC(5)6-7(8)RadialnerveExtensorcarpiulnarisC6-8RadialnerveExtensordigitorumcommunisC6-8RadialnerveExtensorindicispropriusC6-8RadialnerveExtensordigitiminimipropriusC6-8RadialnerveExtensorpollicislongusC6-8RadialnerveExtensorpollicisbrevisC6-8RadialnerveAbductorpollicislongusC6-8RadialnervePronatorteresC6-7MediannerveFlexorcarpiradialisC6-7(8)MediannervePronatorquadratusC7-T1MediannervePalmarislongusC7-T1MediannerveFlexordigitorumsublimisC7-T1MediannerveFlexordigitorumprofundus(radialhalf)C7-T1MediannerveLumbricales1and2C7-T1MediannerveFlexorpollicislongusC8-T1MediannerveFlexorpollicisbrevis(lateralhead)C8-T1MediannerveAbductorpollicisbrevisC8-T1MediannerveOpponenspollicisC8-T1Mediannerve第10頁/共34頁FlexorcarpiulnarisC7-T1UlnarnerveFlexordigitorumprofundus(ulnarhalf)C7-T1UlnarnerveInterosseiC8-T1UlnarnerveLumbricales3and4C8-T1UlnarnerveFlexorpollicisbrevis(medialhead)C8-T1UlnarnerveFlexordigitiminimibrevisC8-T1UlnarnerveAbductordigitiminimiC8-T1UlnarnerveOpponensdigitiminimiC8-T1UlnarnervePalmarisbrevisC8-T1UlnarnerveAdductorpollicisC8-T1Ulnarnerve第11頁/共34頁MuscleSegmentalInnervationPeripheralNervePsoasmajorL(1)2-4NervetopsoasmajorPsoasminorL1-2NervetopsoasminorIliacusL2-4FemoralnerveQuadricepsfemorisL2-4FemoralnerveSartoriusL2-4FemoralnervePectineusL2-4FemoralnerveGluteusmaximusL5-S2InferiorglutealnerveGluteusmediusL4-S1SuperiorglutealnerveGluteusminimusL4-S1SuperiorglutealnerveTensorfasciaelataeL4-S1SuperiorglutealnervePiriformisS1-2NervetopiriformisAdductorlongusL2-4ObturatornerveAdductorbrevisL2-4ObturatornerveAdductormagnusL2-4Obturatornerve

L4-5SciaticnerveGracilisL2-4ObturatornerveObturatorexternusL2-4ObturatornerveObturatorinternusL5-S3NervetoobturatorinternusGemellussuperiorL5-S3NervetoobturatorinternusGemellusinferiorL4-S1NervetoquadratusfemorisQuadratusfemorisL4-S1NervetoquadratusfemorisBicepsfemoris(longhead)L5-S1TibialnerveSemimembranosusL4-S1TibialnerveSemitendinosusL5-S2TibialnervePopliteusL5-S1TibialnerveGastrocnemiusL5-S2TibialnerveSoleusL5-S2Tibialnerve第12頁/共34頁PlantarisL5-S1TibialnerveTibialisposteriorL5-S1TibialnerveFlexordigitorumlongusL5-S1TibialnerveFlexorhallucislongusL5-S1TibialnerveBicepsfemoris(shorthead)L5-S2CommonperonealnerveTibialisanteriorL4-S1DeepperonealnervePeroneustertiusL4-S1DeepperonealnerveExtensordigitorumlongusL4-S1DeepperonealnerveExtensorhallucislongusL4-S1DeepperonealnerveExtensordigitorumbrevisL4-S1DeepperonealnerveExtensorhallucisbrevisL4-S1DeepperonealnervePeroneuslongusL4-S1SuperficialperonealnervePeroneusbrevisL4-S1SuperficialperonealnerveFlexordigitorumbrevisL4-S1MedialplantarnerveFlexorhallucisbrevisL5-S1MedialplantarnerveAbductorhallucisL4-S1MedialplantarnerveLumbricales(medial1or2)L4-S1MedialplantarnerveQuadratusplantaeS1-2LateralplantarnerveAdductorhallucisL5-S2LateralplantarnerveAbductordigitiquintiS1-2LateralplantarnerveFlexordigitiquintibrevisS1-2LateralplantarnerveLumbricales(lateral2or3)S1-2LateralplantarnerveInterosseiS1-2Lateralplantarnerve第13頁/共34頁臨床檢查腹壁反射敲擊試驗Barlow試驗Coleman試驗（足外翻）Ely試驗（股直肌）足前進角前彎試驗Galeazzi征Gower試驗髖關節(jié)旋轉實驗Nelaton線Ober試驗Ortolani試驗Patrick試驗Phelps股薄肌試驗Thomas試驗腘窩角Trenderlenburg試驗第14頁/共34頁體格檢查動（肢體活動范圍）屈：關節(jié)彎曲活動，關節(jié)向遠離中立位的方向活動。伸：關節(jié)伸直活動，關節(jié)向靠近中立位的方向活動。過伸：關節(jié)伸展超過中立位的范圍（膝關節(jié)和肘關節(jié)）內(nèi)收：肢體向靠近身體的中線的方向移動外展：肢體向遠離身體的中線的方向移動旋后：前臂或手部的掌面向前或指向身體的前面旋前：前臂或手部的掌面向后或指向身體的后面內(nèi)翻：向內(nèi)翻轉（中立位）外翻：向外翻轉（中立位）內(nèi)旋：向著身體軸線的方向旋轉外旋：遠離身體軸線的方向旋轉第15頁/共34頁Flexion:Actofbendingajoint;amotionawayfromthezerostartingposition.Extension:Actofstraighteningajoint;areturnmotiontothezerostartingposition.Hyperextension:Whenthemotionoppositetoflexionisanextremeorabnormalextension(asmaybeseenwiththekneeorelbowjoint),andthejointextendsbeyondthezerostartingposition.Abduction:Lateralmovementofthelimbsawayfromthemedianplaneofthebody,orlateralbendingoftheheadortrunk.Adduction:Movementofalimbtowardthemedianplaneofthebody.Supination:Actofturningtheforearmorhandsothatthepalmofthehandfacesupwardortowardtheanteriorsurfaceofthebody.Pronation:Turningofthepalmofthehandsothatitfacesdownwardortowardtheposteriorsurfaceofthebody.Inversion:Aninwardturningmotion(seenprimarilyinthesubtalarjointofthefoot).Eversion:Anoutwardturningmotion.Internal(inward)rotation:Processofturningonanaxistowardthebody.External(outward)rotation:Processofturningonanaxisawayfromthebody(oppositemotionofinternalrotation).第16頁/共34頁體格檢查頸椎（屈、伸、左側屈、右側屈、左環(huán)轉、右環(huán)轉）第17頁/共34頁體格檢查腰椎（屈、伸、左側屈、右側屈、左旋轉、右旋轉）第