膝关节评节评 估膝部韌帶拉傷 内侧侧副轫带轫带 (MCL)/外侧侧副轫带轫带 (LCL) 内翻压压力测试测试 (Varus Stress test)(圖右)外侧副轫 带外翻压压力测试测试 Valgus Stress test(圖左)内侧副轫 带pGrade 0: 无松弛pGrade 1: 1cm2膝部韌帶拉傷 前十字轫带(ACL), 后十字轫带(PCL)u前十字轫带: 膝弯屈时放松(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3PCLACL.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轫带 - 非碰撞接触损伤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 5前十字轫带轫带 (ACL) ; 后十字轫带轫带 (PCL)90-前抽屉试验/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0.5cm， 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6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2.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7Lachman testu对对前十字轫带损伤轫带损伤 最敏感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8前十字轫带旋转轴移动测试(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(+)9膝部 Knee Unhappy Triad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10u小的撕脱性骨哲折 在胫骨近端和前十 字轫带有关 扭转伤害 Segond Fx11前十字轫带损伤轫带损伤 在X线线表现现A Fat-Suppressed Proton- Density weighted Sagittal image u实心条状12MRI下正常前十字轫带T1-weighted MRIT1-weighted MRI13MRI appearances in ACLu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 near- complete) nonvisualization of the ACL with ill-defined edema and hemorrhage in the usual location of the ACL in the intercondylar notch. 14MRI appearances in ACL tearT1-weighted MRIProton-density weighted fat- suppressed sagittal image 轫带边缘 不规则 部份断裂15Diagnosis : Partial tear of the proximal anteromedial band of the ACL半月軟骨损伤 关节活动时卡住 McMurray 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)16meniscus 半月軟骨Apleys test：下压且旋转若有明显疼痛在膝盖处表示阳性17臏骨痛(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18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)19 Hamsting strain Quadriceps strain20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 muscles21宾骨股骨疼痛综合征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内收肌群避免 W坐姿 22宾骨肌腱炎(Patellar tendonitis) 近端 : 跳跃膝(Jumpers knee) 远端 : Osgood-Schlatter Dz23Infrapatellar bursitisPopliteal bursitis (Bakers cyst)24膝退化性关节炎 Figure 1 : 正常 Figure 2 : 有骨刺产生, 关节腔变窄Osteoarthritis: grading Department 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, definite narrowing of joint space, and some sclerosis and possible deformity of bone endsnGrade 4 : Large osteophytes, marked narrowing of joint space, severe sclerosis , and definite deformity of bone ends髂胫束综合症 (Iliotibial band syndrome )Ober test27Open and Closed-kinetic Chain ExerciseuClosed-kinetic chain exercise provide a more significant compression force across the kneewhile activating cocontraction of the quadriceps and hamstring muscles.uOpen-chain exercise at low flexion anglesmay produce an increase in anterior shear forces, that may cause laxity in the ACL. 28Open 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 exercise 29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. lPatellar TapingCreate a mechanical medial shift of the patella centralizing it within the trochlea groove and improving patellar tracking. 30uTherapeutic ExerciseslHeel slides / Wall slides()lPatellar mobilization3132Nonioerative treatment of Recurrent Patellar Instability (Lateral)High EMG activity of the VMO1.Leg press. 2.Lateral step-up.3.Isometric quadriceps setting.4.Hip adduction exercise. 33General Guidelines for Nonioerative treatment of Recurrent Patellar Instability (Lateral)lGradual restoration of flexibility (stretching) for noted deficits.1.Iliotibial band 2.Quadriceps34Two-person Ober stretchCross-over lateral fascial stretchSelf ober stretchLeaning lateral fascial stretchQuadriceps self-stretchGeneral Guidelines for Nonioerative treatment of Recurrent Patellar Instability (Lateral)lGradual restoration of flexibility (stretching) for noted deficits. 3. Hamstring4. Gastrocnemius3536uTherapeutic ExerciseslNon-weight bearing gastrosoleus, Hamstring stretcheslProne extension hangs for gravity assisted knee extensionlSupine and leg elevation with resistance37uTherapeutic ExerciseslMini squats 030 lStationary bike (begin with high seat, low tension)lClosed-chain extension (leg press 030 ) lContinue hamstring stretch , p