肩旋轉袖斷裂


概說

肩旋轉袖斷裂是肩胛關節附近最常見的肌腱創傷,患者多數年過40,年青人較為少見。年青人若患上肩旋轉袖斷裂 ,屬於是嚴重創傷,、大都是重複提舉手臂過頭工作或運動創傷所致。


肩旋轉袖斷裂可分為多個類別。部份撕裂會使肩峰下滑液囊和肩關節面相通。完全肩旋轉袖斷裂的病徵癥,會因撕裂的範圍、形狀及位置的不同而不一樣。若撕裂面積大於五厘米或涉及兩條肌腱以上,便會被界定為「大型」撕裂的個案。



解剖結構

肩旋肌肌腱由四條肌肉組成,像衣袖一樣直接包圍肱骨最近側的部份。當中部份肌腱與肩盂肱骨關節囊相融合。肩旋肌肌鍵與近側肱骨大粗隆(側面)或小粗隆(前面)相連,活動使肱骨頭(肩膀的球狀部位) 緊靠著肩胛骨的肩臼窩部份,穩定肩關節。


肩旋肌肌肉,肌腱與肩胛帶肌肉能維持肩盂肱骨關節的良好活動和協調肩關節活動(包括外展、內收、屈曲、伸展、內旋及外旋等)。



肩旋肌肌腱:肩胛下肌(a) 棘上肌(b) 棘下肌(c)



肩旋轉袖完全撕裂,其下的肱骨頭會暴露於肩峰下滑液囊下


成因

肩旋轉袖斷裂是成人常見的肩痛原因,可令患者有嚴重殘障。撕裂的情況多數在棘上肌的肌腱出現,亦有機會牽涉其他肌腱。


肩旋轉袖斷裂有多種原因:

1. 創傷引致撕裂,例如成人的肩關節前方脫位,或肩旋肌肌腱之前已出現問題,肩關節移位時便觸發撕裂。 有時即使輕微的創傷,例如提舉「重物」,亦會導致肩旋肌撕裂,尤其當患者的肩旋肌肌腱早已出現病變,例如退化、發炎等等。


2. 另一方面,肩旋轉袖斷裂亦可源於日積月累的損傷或撕裂,尤其在長期過度運用肌肉及肌腱;需要重複提臂過頭活動的職業,便有過度運用肩旋肌肉及肌腱的危機。患者在某種創傷後,或在毫無任何特別創傷的觸發下,肩膀會持續疼痛多月的原因。



徵狀

痛楚一般在肩關節前方或側面出現。大部份患者都訴說每當進行提臂過頭活動時會感到疼痛。穿胸圍的動作涉及伸展及內旋肩關節,女性患者就此會遇上問題。也有肩旋肌腱大型撕裂的患者,不能把肩關節外展,出現「假痙攣」的現象。


肩旋轉袖斷裂的徵狀包括:

肩膀的棘上肌或棘下肌無力

外展或提升臂部時感到疼痛 (肩關節夾擊綜合症的徵狀)

手臂由完全提升的位置下垂時感到痛楚

提升或外旋臂部時感覺無力

把肩膀移到某些位置時會感到骨頭摩擦作響


觸發上述徵狀可以是急性的原因 ─ 往往在臂部受到創傷或跌倒受創後即時出現。不過,產生徵狀的原因亦可源於長期進行重複提臂過頭的活動,或是長期的、日積月累的肩旋轉肌腱袖損傷和撕裂所致。


最初,患者只會在進行某些動作,例如提高手臂時感到輕微疼痛,一般在服食止痛藥和休息後,便會消除。及後,徵狀會愈加強烈,即使患者正在休息或沒有進行任何活動時,會感到痛楚。晚上睡覺時,若靠著受影響的一面肩膀躺下,亦感到痛楚。



診斷方法

若懷疑患上肩旋轉袖斷裂,骨科醫生將首先了解患者病史,然後詳細檢查肩關節,查看是否出現畸形或肌肉無力的徵象。醫生會測試患者有沒有特別的酸痛點,衡量肩關節在不同水平面的主動與被動活動範圍。他們亦會檢查患者臂部是否出現夾擊徵狀、無力和有否出現肩膀關節不穩或其他相關問題。醫生更會視乎臨床診斷情況,檢查患者的頸部,查看是否因頸椎病變而衍生肩膊疼痛。

X光及其他造影掃描檢查,例如核磁共震振 (連同/沒有連同關節造影)或超聲波等,都能幫助診斷。


一般而言,普通X光檢查顯示不到肩旋肌撕裂的程度,或只能反映輕微的病變現象,例如的肩峰下贅骨增生(骨刺)或肱骨大粗隆變厚等。


醫生或需要配合額外的造影技術,即核磁共振或超聲波技術,以更有效地評估和記存肩峰下的軟組織結構,包括肩旋肌肌腱的狀況。核磁共振有時候能展現出肩旋肌肌鍵的炎症病變,亦可評估肩旋肌腱撕裂的面積、形狀與位置, 肱二頭肌肌腱的狀況以及肩周肌肉的萎縮的程度,幫助作出診斷,及訂定治療方案。



非手術治療

非手術治療能消除痛楚和改善肩部活動功能,方法包括:

休息及改變日常活動肩關節的動作

使用手掛帶

服食藥物控制痛楚

物理治療,包括強化肩旋肌的運動

在肩峰下滑液囊注射局部麻醉藥及類固醇




肩峰下滑液囊注射


手術治療

如出現下列情況,骨科醫生或會建議患者接受手術:

保守治療無助消退徵狀

急性肩旋肌撕裂,患者感到非常疼痛和肌肉無力

患者活躍運動,而撕裂部位位於主臂側的肩膀

患者的工作或運動需要有用最大的手臂力量來進行的提臂過頭的動作。

骨科醫生將考慮多種因素來決定施行手術的類型,例如裂口的面積大小、形狀和位置等。若只屬「微小」的部份撕裂個案,患者將不需要接受任何正式的修補手術治理,只要切除原本纖維化的肌腱纖維便可(清創手術)。若肩旋肌肌腱最厚的部份遭完全撕裂,醫生會用手術縫合線把裂口兩面縫合起來。若肌腱遭撕離的部位是與近側肱骨嵌入相接的,醫生則會直接把肌腱駁回骨上,幫助癒合。


手術中,若突露的肩峰被認為是「夾擊」肩旋肌肌鍵而導致肩旋轉袖斷裂,骨科醫生會切除肩峰前下方的部份,藉此解決「出口夾擊」的問題。


如發現有肩鎖關節炎或肱二頭肌肌腱撕裂等情況,醫生亦會利用上述的手術模式,一併治理。


常用作修補撕裂的肩旋肌手術分為三大類別:

1. 內窺鏡修補技術

在患處開出數個細小的切口,然後插入光纖內窺鏡和各種「筆型」的內窺鏡手術器具進行手術,讓骨科醫生在視像控制下進行修補工作。他們會運用特別的「線錨」植入患處,把撕裂的肌腱重新連接在肱骨大粗隆之上。


2. 微創修補技術

較新的技術與器具,讓醫生能在微小的切口(只有四至六厘米長)內進行肩旋肌完全修補手術。.


3.開放式修補技術

若裂口範圍較大或較為複雜,需要額外的重建程序,例如肌腱轉移等,往往需要透過傳統的開放切口手術進行。


如肩旋轉袖斷裂的撕裂程度與撕裂收縮後兩端的缺口同樣嚴重的個案,可能已不可以在結構上修補。在適合的情況,醫生會考慮進行肌腱轉移的重建技術,運用肱骨粗隆矯形手術 “tuberoplasty” : ,進行簡單的「清創」手術,也可暫時舒緩徵狀。


遇上一些較嚴重的個案,例如大面積的肩旋轉袖斷裂加上肩關節炎(肩旋肌肌腱撕裂關節病),可考慮置換人工肩關節(關節置換術)。


用縫合線和線錨來修補撕裂的肩旋肌



圖中展示在肩峰整形手術中,前肩突需要切除的部份



圖中展示線錨如何把撕裂的肌腱末端重新連接在肱骨大粗隆之上


復康訓練

復康訓練是整個療程的重要部份。手術後,臂部會被支具穩定,限制活動範圍,以便縫接口復元。限制肩膊活動的時間將視乎撕裂的面積和手術的複雜程度而定。


經指導下,患者會逐步開展運動治療,回復肩部的力量和活動的能力。與此同時,患者應避免修補後的肌腱過份操勞。


物理治療通常由一些輕柔和漸進的動作開始,到合適的階段,便會進階至活動量和抗衡張力較大的運動。骨科醫生、物理治療師及職業治療師會配合力患者訂立合適的復康計劃。


療程約需數個月,患者才可完全康復。患者需要貫徹始終完成計劃療程,才可達致良好的外科治療效果。醫生會評估的康復效果,才能確定患者能安全地重拾提臂過頭的工作及體育活動。



預防方法

若發現肩部過勞或活動時誘發痛楚,應及早正視和治療。定期運動肩關節,保持靈活性,可有助防止肩關節僵梗。


俞江山醫生



Rotator Cuff Tears


Introduction

Rotator cuff tears are the most common tendon injury around the shoulder girdle. Most of the patients who suffer from rotator cuff tears are over the age of 40. It is less common to find this injury among younger people but when they do sustain a tear, it often follows an acute trauma or repetitive overhead work or sports activity.


Different types of rotator cuff tear can be identified. Partial rotator cuff tears can be identified either at the bursal or the articular side. Complete rotator cuff tears can take on different sizes, shapes and locations. A tear is regarded “massive” if it is bigger than 5 cm or involves more than two tendons.



Anatomy

The rotator cuff consists of four muscles that immediately wrap around the most cranial part of the proximal humerus, with some of the tendons blending with the gleno-humeral joint capsule. They are attached to the greater tuberosity (lateral part) or lesser tuberosity (anterior part) of the proximal humerus. The rotator cuff helps to hold the humeral head (ball of the shoulder) against the glenoid fossa of the scapula during motion, thereby stabilising the shoulder joint.


Rotator cuff muscles, together with other shoulder girdle muscles, are essential for proper and co-ordinated motion of the gleno-humeral joint (including abduction, adduction, flexion, extension, internal and external rotation) and scapulo-thoracic articulation (including protraction, retraction, elevation, external rotation and internal rotation).




View of rotator cuff tendons: a) subscapularis; b) supraspinatus and c) infraspinatus



A complete rotator cuff tear, with the underlying humeral head exposed


Cause

Rotator cuff tears are a common cause of shoulder pain among adults. This can in turn cause significant disability. Most tears occur in the tendon of the supraspinatus muscle, but other parts of the cuff may also be involved.


There are different causes for rotator cuff tears. The rotator cuff can be torn as a result of a single traumatic injury. Examples include the anterior dislocation of the shoulder joint in adult patients with or without existing rotator cuff problems. Trivial traumas can be a cause too, especially for patients with existing rotator cuff problems. Activities such as lifting “heavy” objects could lead to acute tearing of rotator cuff tendons in patients with existing rotator cuff problems.


On the other hand, rotator cuff tears can be a result of everyday wear and tear, especially as a result of the overuse of muscles and tendons over a long period. People who engage in repetitive overhead movements are at risk for overuse. Therefore patients with rotator cuff tears may report recurrent or persistent shoulder pain for several months, with or without any specific injury that triggered the onset of the shoulder pain.



Symptoms

The pain is usually in the front or lateral side the shoulder joint. Most of the patients with rotator cuff tears complain of pain when performing overhead activities. Female patients may have difficulties in putting on bras, which require extension and internal rotation of the shoulder joint. Sometimes, patients with massive rotator cuff tears may experience “psuedoparalysis”, meaning failure to actively abduct the shoulder joint.


Signs of patients with rotator cuff tears may include:

wasting of the supraspinatus or infraspinatus muscles in the shoulder;

pain upon abduction or elevation of the arm (impingement sign);

pain when lowering the arm from a fully raised position;

weakness upon elevation or external rotation of the arm;

“crepitus” upon moving the shoulder in certain positions.


Onset of these symptoms and signs may be acute – often immediately after a specific trauma or a fall on the affected arm. On the other hand, onset of symptoms may develop gradually as a result of repetitive overhead activities or following long-term wear and tear.


At first, the pain may be mild and only comes with certain activities, say upon elevation of the arm. It can often be relieved by over-the-counter pain killers or rest. Gradually, these symptoms become more and more disturbing, with pain even at rest or without any specific activity at all. At night time, patients may have shoulder pain when lying on the affected side.



Diagnosis

If a patient suspects that he or she has a rotator cuff tear, an orthopaedic surgeon can first take a medical history and perform a detailed physical examination of the shoulder joint to see whether there is a deformity or wasting of muscles. He or she will feel for any particular tender spots, and measure the active and passive range of motion of the shoulder in different planes of motion.


The surgeon will also check for any signs of impingement, weakness and instability of the shoulder joint and any other shoulder problems. Depending on the patient’s conditions, the surgeon may also examine the neck, because shoulder pain may actually be a result of referred pain from cervical spine problems.


Plain X-rays and other specific imaging studies, including MRI (Magnetic Resonance Imaging with or without an arthrogram) or ultrasound, are also helpful. X-rays of the shoulder with complete rotator cuff tear may show minor changes only, such as a small subacromial spur or sclerosis of the greater tuberosity. For this reason, the surgeon may need additional imaging studies, either an ultrasound or MRI, for better assessment and documentation of the soft tissue structures, including rotator cuff tendons. MRI scans can sometimes show signal changes suggesting of tendinosis of the cuff tendons. It can also assess the size, shape and location of the tear, as well as the degree of atrophy of the corresponding cuff muscles. The condition of the biceps tendon can also be assessed.



Conservative treatment

Conservative treatment can provide pain relief and improve the shoulder’s functions.

The options are:

rest and modifications of day-to-day activities;

the use of an arm sling;

medications for pain control;

physiotherapy, including cuff-strengthening exercises;

injection into the subacromial space with steroid.




Injection into the subacromial bursa


Surgical treatment

Under the following conditions, your orthopaedic surgeon may recommend surgery:

failed conservative treatment with persistent symptoms;

acute rotate cuff tear with severe pain and significant weakness;

tear is in the shoulder of the dominant arm of an active person;

if maximum strength in the arm is needed for overhead work or sports.


The type of surgery chosen by your orthopaedic surgeon depends on a lot of factors, for example, the size, shape and location of the tear. A “minimal” partial tear may not require any formal repair procedure, and a trimming procedure of the fibrillated tendon fibers is adequate (debridement). A complete tear within the thickest part of the tendon is repaired by suturing the two sides of the tendon back together. If the tendon is torn away from its bony insertion site at the proximal humerus, it is repaired directly back to the bone for healing.


During surgery, your orthopaedic surgeon may remove the anteroinferior part of the acromion (acromioplasty) to tackle the issue of “outlet impingement”. It is because a prominent acromion is thought to cause impingement on the cuff tendons and contribute to tear formation.


Other conditions, such as arthritis of the acromioclavicular joint (ACJ) or tearing of the biceps tendon, may also be addressed in this surgery.


Generally, there are three surgical approaches available for the repair of a torn cuff tendon. These include:

1. Arthroscopic repair

A fiber optic scope and appropriate “pen-like” arthroscopic instruments are inserted through several small incisions. This allows the orthopaedic surgeon to perform appropriate surgical repairs under video control. Special implants, known as suture anchors, are used to reattach the torn tendon back onto the greater tuberosity.


2. Mini-open repair

Newer techniques and instruments allow surgeons to perform a complete rotator cuff repair through a small incision, typically 4 cm to 6 cm.


3. Open surgical repair

A traditional open surgical incision is often required if the tear is large or complex or if additional reconstruction, such as a tendon transfer, has to be done.


In some chronic cases with massive rotator cuff tears and severe retraction of the torn tendon ends, anatomical repair may not be possible. Reconstruction with tendon transfer is a possible option for suitable cases. Simple “debridement” with “tuberoplasty” may provide temporary relief of the symptoms. Your orthopaedic surgeon can provide detailed explanations concerning treatment options for this condition.


In some severe cases of massive rotator cuff tears associated with arthritis of the shoulder joint (cuff arthropathy), one option is to replace the shoulder joint with an artificial joint (arthroplasty).



Diagram shows repair of a rotator cuff tear with the use of sutres and a sutre anchor


In a surgical operation called "acromioplasty", a certain amount of the anterior acromial process will be removed


The diagram shows a sutre anchor that allows the re-attachment of the torn tendon end back onto the greater tuberosity



Rehabilitation

Rehabilitation constitutes an essential component of the whole treatment process. After the surgery, the arm is immobilised to allow the tear to heal. The duration of immobilisation depends on the size and complexity of the tear.


A supervised exercise programme will help regain motion and strength of the shoulder joint while, at the same time, avoiding excessive stress to overload the repaired tendon. Usually, the physical therapy programme begins with gentle and passive motion and, at the appropriate time, advances to active exercises that involve resistance. The programme will be individualised by your orthopaedic surgeon, physiotherapist and occupational therapist based on your conditions.


Complete recovery usually takes several months. A strong commitment to rehabilitation is essential in achieving a good surgical outcome. Your orthopaedic surgeon will assess the final outcome to provide advice on when it is safe to return to overhead work and sports activity.



Prevention

One should seek early medical attention if shoulder pain develops because of overuse

Regular exercise to maintain the range of motion of the shoulder joint can help prevent stiffness.



Dr. Yu Kong-san

 
綜論
GeneralGeneral.html
髖關節
HipHip.html
手及腕部
Hand & WristHand_and_wrist.html
膝部及腿部 Knee & LegKnee_and_leg.html
足踝及腳
Foot & AnkleFoot_and_ankle.html
肩膀,手臂及手肘
Shoulder, Arm & ElbowShoulder,_arm_and_elbow.html
小兒骨科
Paediatric Ortho.Paediatric_Orthopaedics.html
創傷及疾病種類
Injuries and DiseasesInjuries_and_Diseases.html
香港骨科專科簡介
Orthopaedics in HKOrthopaedics_in_HK.html
關於我們
About UsAbout_us.html
主頁
Main PageHome.html
頸部及脊椎
Neck & SpineNeck_and_Spine.html