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1、关于膝关节评估第1页，讲稿共39张，创作于星期三2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Grade 0:无松弛Grade 1:1cm第2页，讲稿共39张，创作于星期三3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
2、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PCLACL.第3页，讲稿共39张，创作于星期三4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前十字轫带 -非碰撞接触损伤非碰撞接触损伤第4页，讲稿共39张，创作于星期三5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 第5页，讲稿共39张，创作于星期三6前十字轫带前十字轫带(ACL);(ACL);后十字轫带后十字轫带(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.
3、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第6页，讲稿共39张，创作于星期三7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 伪阴性伪阴性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)伪阳性伪阳性第7页，讲稿共39张，创作于星期三8 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第8页，讲稿共39张，创作于星期三9前十字轫带旋转轴移动测试前十字轫带旋转轴移动测
4、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(+)第9页，讲稿共39张，创作于星期三10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/內側结构的破坏第10页，讲稿共39张，创作于星期三11u小的撕脱性骨哲
5、折 在胫骨近端和前十字轫带有关 扭转伤害 Segond Fx前十字轫带损伤在前十字轫带损伤在X X线表现线表现第11页，讲稿共39张，创作于星期三12A Fat-Suppressed Proton-Density weighted Sagittal image u实心条状MRI下正常前十字轫带T1-weighted MRI第12页，讲稿共39张，创作于星期三13T1-weighted MRIMRI appearances in ACL第13页，讲稿共39张，创作于星期三14u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 n
6、ear-complete)nonvisualization of the ACL with ill-defined edema and hemorrhage in the usual location of the ACL in the intercondylar notch.MRI appearances in ACL tearT1-weighted MRI第14页，讲稿共39张，创作于星期三15Proton-density weighted fat-suppressed sagittal image 轫带边缘不规则部份断裂Diagnosis:Partial tear of the prox
7、imal anteromedial band of the ACL第15页，讲稿共39张，创作于星期三16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)第16页，讲稿共39张，创作于星期三17meniscus 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第17页，讲稿共39张，创作于星期三18臏骨痛臏骨痛(Patell
8、ofemeral 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第18页，讲稿共39张，创作于星期三19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)第19页，讲稿共39张，创作于星期三20 Hamsting strain Hamsting str
9、ain Quadriceps strain Quadriceps strain第20页，讲稿共39张，创作于星期三21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 muscles第21页，讲稿共39张，创作于星期三22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
10、内收肌群避免 WW坐姿坐姿 第22页，讲稿共39张，创作于星期三23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 Dz第23页，讲稿共39张，创作于星期三24Infrapatellar bursitisInfrapatellar bursitisPopliteal bursitis(Bakers cyst)第24页，讲稿共39张，创作于星期三膝退化性关节炎Figure 1:正常 Figure 2:有骨刺产生,关节腔变窄第25页，讲稿共39张，创作于星期三Os
11、teoarthritis: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,defini
12、te 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第26页，讲稿共39张，创作于星期三27髂胫束综合症髂胫束综合症 (Iliotibial band syndrome)(Iliotibial band syndrome)Ober test第27页，讲稿共39张，创作
13、于星期三28Open 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,t
14、hat may cause laxity in the ACL.第28页，讲稿共39张，创作于星期三29Open 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 exercis
15、e 第29页，讲稿共39张，创作于星期三30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.Patellar TapingCreate a mechanical medial shift of the patella centralizing it with in the
16、 trochlea groove and improving patellar tracking.第30页，讲稿共39张，创作于星期三31uTherapeutic ExerciseslHeel slides/Wall slides()lPatellar mobilization第31页，讲稿共39张，创作于星期三32uTherapeutic ExerciseslQuadriceps sets lStraight leg raises(SLR)all planes with brace in full extension until quadriceps strength is sufficie
17、nt 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.第32页，讲稿共39张，创作于星期三33Nonioerative treatment of Recurrent Patellar Instability(Lateral)High EMG activity of the VMO1.Leg press.2.
18、Lateral step-up.3.Isometric quadriceps setting.4.Hip adduction exercise.第33页，讲稿共39张，创作于星期三34General Guidelines for Nonioerative treatment of Recurrent Patellar Instability(Lateral)lGradual restoration of flexibility(stretching)for noted deficits.1.Iliotibial band 2.QuadricepsTwo-person Ober stretchC
19、ross-over lateral fascial stretchSelf ober stretchLeaning lateral fascial stretchQuadriceps self-stretch第34页，讲稿共39张，创作于星期三35General Guidelines for Nonioerative treatment of Recurrent Patellar Instability(Lateral)lGradual restoration of flexibility(stretching)for noted deficits.3.Hamstring4.Gastrocne
20、mius第35页，讲稿共39张，创作于星期三36uTherapeutic ExerciseslHamstring 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.lStraight Leg Raises(Prone)Tighten the hamstrings of the injured leg and raise the leg toward the ceiling as f
21、ar as you can.Hold the position for 5 seconds.Perform 3 sets of 20 repetitions,4 to 5 days a week.第36页，讲稿共39张，创作于星期三37uTherapeutic ExerciseslNon-weight bearing gastrosoleus,Hamstring stretcheslProne extension hangs for gravity assisted knee extensionlSupine and leg elevation with resistance第37页，讲稿共3
22、9张，创作于星期三38uTherapeutic ExerciseslMini squats 030 lStationary bike(begin with high seat,low tension)lClosed-chain extension(leg press 030)lContinue hamstring stretch,progress to weight-bearing gastrosoleus stretches.lContinue prone lag hangs with progressively heavier ankle weights until full extension is achieved.第38页，讲稿共39张，创作于星期三2023/4/4感谢大家观看第39页，讲稿共39张，创作于星期三