肩关节检查法

null肩关节检查方法肩关节检查方法首都医科大学附属北京友谊医院骨科 李强 教授全面检查全面检查疼痛的部位和范围（颈项部） 有无远端放射痛（上臂前部） 涉及的肌力情况（三角肌） 有无病理症（退变的夹杂症）全面检查（病理症）全面检查（病理症）炎症：类风湿性关节炎 神经性疼痛：周围神经疾病；中枢神经疾病 血管性病变：动脉血栓，静脉炎 肿瘤：压迫臂丛的肿瘤病史采集 HISTORY TAKING INTERVIEW病史采集 HISTORY TAKING INTERVIEW疼痛的部位 肩锁关节；大结节；结节间沟；前方肌肉的疼痛 疼痛的性质 锐痛（急性）；钝痛（慢性） 有无夜间痛 （炎性） 疼痛是否与活动有关： 有关：撞击症，肩袖损伤 肩关节检查 PHYSICAL EXAMINATION 肩关节检查 PHYSICAL EXAMINATION 望诊 触诊 活动度 特殊检查望 诊 INSPECTION望 诊 INSPECTION脱衣暴露至腰部 两侧对比检查 观察病人穿脱衣过程，评估患肩功能 依照先后方再前方的顺序观察病人肩部情况，注意有无肌肉 萎缩 （陈旧性肩袖损伤常伴 有冈上肌/冈下肌萎缩）。 望 诊望 诊Proximal tear of the long head of the biceps 肱二头肌长头近端断裂Torticollis斜颈Anterior shoulder dislocation. 前脱位望 诊望 诊Winged scapulaSeparation of the acromioclavicular joint望 诊望 诊Sprengle deformity高位肩胛 触 诊 PALPATION触 诊 PALPATION肩锁关节 肩峰下间隙（滑囊炎） 大结节 （肩袖损伤） 结节间沟（肱二头肌腱） 喙突触 诊 PALPATION触 诊 PALPATIONPrinciples for palpation of the shoulder. Bilaterally and comparatively, the examiner should palpate the bony contours and elements which might be involved in the impingement syndrome.触 诊 PALPATION触 诊 PALPATIONCross-body adduction test (arm crossed). This test is positive when it revives the acromioclavicular pain which the patient complains of.触 诊 PALPATION触 诊 PALPATIONPrinciple for palpation for cuff tears. Palpation is carried out on the anterior edge of the acromion. The presence of the bursa between the deltoid and the cuff should be noted.肩关节活动肩关节活动体位 立位检查 卧位检查（某些肩关节稳定性检查） 活动性质 被动活动 主动活动被动活动被动活动Examination of passive external rotation, elbow to body, looking for asymmetry. Loss of rotation suggests capsule stiffness if x-rays are normal. An increase in passive external rotation will suggest a tear in the subscapularis.主动活动主动活动Analysis of scapulohumeral rhythm. In this patient the scapula pivots before glenohumeral abduction takes place giving this aspect of raising of the shoulder肩关节活动肩关节活动主动活动受限，被动活动不受限 主动活动受限，被动活动也受限 主动活动不受限，被动活动部分受限肩袖破裂 冰冻肩 创伤肩关节不稳定特殊检查特殊检查常规检查 肩袖检查 不稳定检查 肱二头肌检查常规检查常规检查quick test of combined motion- Apley’s scratch test(快速联合运动) Codman sign Palm sign test/Finger sign test 常规检查常规检查Apley’s scratch test 摸背试验 患者用手分别从同侧肩上方向后摸对侧肩上方向后摸对侧肩胛上缘或用手从同侧肩下方向后摸对侧肩胛下缘。判断肩关节内旋及外旋功能。 常规检查常规检查Codman sign 病人坐位，检查者站于其背后，一手握住其肘部，旋转肱骨和肩关节；同时，另一手放在病人肩上，拇指在后，四指在前，用食指在肩峰下方前后依次触摸按压，若在某处出现压痛点，则为本征阳性。常见于肩周炎、冈上肌损伤、冈下肌或小圆肌的损伤或肌腱断裂、肩胛下肌损伤以及肱二头肌腱鞘炎。 常规检查常规检查Palm sign test/Finger sign test 目的：明确患者疼痛位置 肩袖损伤相关检查肩袖损伤相关检查非特异性检查 特异性检查非特异性检查非特异性检查Impingement symptoms 撞击症 Painful arc Drop arm test 坠臂试验Impingement symptoms 撞击症Impingement symptoms 撞击症Neer impingement sign The examiner performs maximal passive abduction in the scapula plane, with internal rotation, whilst stabilising the scapula. 肩关节前屈30度，完全伸展+内旋 大结节与肩峰之间的撞击 对阳性患者，给予1%利多卡因5ml,肩峰下注射，数分钟后再次进行撞击试验。 Neer impingement signNeer impingement signPositive Pain located to the sub-acromial space or anterior edge of acromion False positive Internal impingement Macdonald et al (2000) - Bankart 25% - SLAP 46.1 % Sensitivity = 88.7% Specificity = 30.5% Reliability = 98% Impingement symptoms 撞击症Impingement symptoms 撞击症Hawkins-Kennedy test The patient is examined in sitting with their arm at 90° and their elbow flexed to 90°, supported by the examiner to ensure maximal relaxation. The examiner then stabilises proximal to the elbow with their outside hand and with the other holds just proximal to the patient's wrist. They then quickly move the arm into internal rotation. 大结节与喙肩弓撞击Hawkins-Kennedy testHawkins-Kennedy testPositive Pain located to the sub-acromial space False Positive - Internal impingement Macdonald et al (2000) - Bankart 25% - SLAP 46.1 %   Sensitivity  Specificity Accuracy PPV NPV Calis et al (%) 92.1 25 72.8 75.2 56.2 Ure et al (%) 62 69 NA NA NA 非特异性检查非特异性检查Painful arc. Test Purpose ：A test used to identify subacromial impingement Technique：Patient is positioned in sitting. Clinical asks patient to abduct both arms through the full ROM and back down. Positive：Pain between 60°-120° of abduction. Interpretation：A positive test indicates subacromial impingement. Painful arc. TestPainful arc. Test： 前屈上举肩关节（肩胛骨平面） 先完全上举后，再放下 注意患者肢体有无旋转，以避免或减少疼痛 非特异性检查非特异性检查Drop arm test 肩关节被动外展120度左右 维持位置，慢慢放下双臂 突然下降伴有疼痛即阳性Indications Rotator Cuff Tear Suspected Technique Examiner passively abducts shoulder to 160 degrees Patient attempts to slowly adduct arm to resting position at side Interpretation: Signs of Rotator Cuff Tear Arm drops to side quickly and not smoothly Gentle tap over abducted arm may force arm to give way Efficacy Test Sensitivity: 27% Test Specificity: 88% 特异性检查特异性检查冈上肌检查：Jobe test，外旋延迟试验 冈下肌检查：外旋延迟试验 肩胛下肌检查： Lift-off test Press Belly test 内旋延迟试验 肱二头肌腱损伤（SLAP损伤） O’brien test Speed test 冈上肌检查冈上肌检查Jobe supraspinatus test 外展90度，前屈30度（肩胛骨水平） （拇指向下）内旋时冈上肌肌束力线成一直线 抗阻力出现无力疼痛为阳性 Jobe supraspinatus test Jobe supraspinatus test Jobe’s test. This is to test the muscle. The examiner places the arm in a 90° abduction in the plane of the scapula and in internal rotation. He will then ask the patient to resist the pressure and determine the muscular strength of the supraspinatus. Pain will often prevent this test from being carried out correctly.冈下肌检查冈下肌检查肘关节屈曲90度 不要碰到躯干 外旋90度，前屈30度（排除三角肌影响）对抗阻力 无力为阳性冈下肌检查冈下肌检查外旋迟滞试验 屈肘前伸肩关节30度，被动外旋肩关节，嘱维持住位置，放手后，若有肩袖破裂，外旋的肩关节会回弹。 回弹超过手掌范围为阳性。肩胛下肌检查肩胛下肌检查Lift-off test 主动内旋后伸肩关节 远离躯干 对抗阻力 无力者为阳性 肩胛下肌检查肩胛下肌检查Press belly test the press-belly test be carried out comparatively by pressing on the elbows to quantify the strength of the supraspinatus muscle.肩胛下肌检查肩胛下肌检查内旋迟滞试验 屈肘后伸肩关节，检查者一手扶住病人肘关节，另一手握住病人腕关节，将其向后拉离病人背部，嘱病人维持住位置。 放手回弹超过一个手掌范围为阳性。肩袖损伤的检查肩袖损伤的检查检查冈上肌和冈下肌 敏感性 特异性 Jobe test + 外旋迟滞试验 + 检查肩胛下肌 Lift-off + 内旋迟滞试验 + + 迟滞试验检出率高，但受患者活动度的限制 肱二头肌肩胛盂损伤的检查肱二头肌肩胛盂损伤的检查O’brien test Speed test Yargason sign O’brien testO’brien testO’Brien’s test consists of asking a patient whose arm, elbow in extension, is taken to anterior elevation at 90°, slightly in adduction (15°) and internal rotation (thumb down) then external rotation (thumb up) to resist a superoinferior pressure. The test is positive if pain appears in internal rotation and pronation, then disappears in external rotation and supination.Speed testSpeed testSpeed’s (or Gilcrest’s) test. Anterior elevation in staggered supination revives pain, which is more related to damage to the long head of the biceps. Flexion of the arm against resistance is carried out, elbow in extension and in supination, which will cause pain on the anterior face of the shoulder, at the level of the bicipital groove of the humerus Yargason signYargason sign雅加森征(Yargason sign) 又称“肱二头肌长头紧张试验”。嘱病人屈曲肘关节，并同时使前臂外旋，若肱骨结节间沟处疼痛，则为雅加森征阳性。本征阳性是肱二头肌长头肌腱腱鞘炎的特异征象。 Yargason signYargason signYergason’s test (1931) (Magee, 1987 - Post, 1987): elbow bent at 90°, and steadied against the chest, the forearm in pronation. The patient carries out a supination against resistance. Pain will be a sign of tendinitis. This test has very good specificity (86.1 %) (Calis et al., 2000).null