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1、矫形器在创伤后肘关节功能障碍康复中的应用,肘关节易于在创伤或手术后发生僵直粘连,高能量的创伤容易造成肘关节活动的丧失，轻微的创伤也能导致肘关节的僵直。 25%的肱骨远端骨折和15%的单纯肘关节脱位导致关节僵直， 而21%的肘关节脱位合并桡骨小头骨折的患者遗留有肘关节僵直。 多方面证据表明肘关节是一个对创伤非常敏感的关节,A stiff, arthrofibrotic elbow is a very difficult problem for the orthopedic surgeon and physical therapist to handle.,概 述,肘关节易于在创伤或手术后发生僵直
2、粘连 高能量 轻微创伤 25%的肱骨远端骨折 15%的单纯肘关节脱位 21%的肘关节脱位合并桡骨小头骨折,Part 1,多方面证据表明肘关节是一个对创伤非常敏感的关节。肘关节僵直后的康复治疗，无论对临床医生、康复治疗师还是患者来说都是一个非常棘手的问题。,治疗方法,人工训练 麻醉下手法松解 手术治疗肘关节僵直 切开松解 关节镜松解 连续被动活动（continuous postive motion, CPM）,配合矫形器的康复治疗,家中 诊所 医院,developed countries： as high as 11% in the western literature developing c
3、ountres：much higher in underdeveloped countries,stiffness after total knee replacement occurs in about 1% of cases,after ACL reconstruction has shown our rate to be less than 1%-35% in major studies,It is not easy to determine the incidence of arthrofibrosis triggered by fracture,Tibial Plateau,Femo
4、ral Condyle,Fracture Patella,矫形器治疗的特点,非手术康复治疗往往需要相应的矫形器，而且时间可能长达6个月去维持或增加关节的PROM。 对于手术的患者来说，手术前矫形器的应用可减少关节外挛缩因素，同时也能评价患者的依从性。 而对于肘关节僵直手术后患者来说，矫形器的应用往往是必须的。 ROM required for activities of daily living,Part 2,What is a normal range of motion?,normal ROM is usually minus 5 to 143 degrees in women norma
5、l ROM is usually minus 6 to 140 degrees in men.,ROM required for activities of daily living,You use your knee in normal walking from two degrees of flexion to seventy degrees of flexion,the range of knee motion required for activities of daily living,93 degrees of knee flexion is required for rising
6、 from a seated position 106 degrees of knee flexion is required for shoelace tying 135 degrees of flexion is required to properly take a bath,Pandect,etiology (www.umdnj.edu/ntbcweb/tidinfct.htm) pathology diagnosis (www.umdnj.edu/ntbcweb/tiddiag.htm) prevention a small number of inactive fibroblast
7、s were scattered about these adhesions. Randomly arranged collagen bundles and elastic fibers were also observed in grade IV adhesions, in which synovial membrane cells and cartilaginoid cells were detected. In addition, fibroblasts with active secretion were observed, and a considerable amount of r
8、ough endoplasmic reticulum was noted.,Arthrofibrosis is a complication that may occur within a damaged joint, where the joint becomes inflamed and then fills up with internal scar tissue. As the scar tissue matures and tightens, the joint may become stiff. If not treated early the stiffness may beco
9、me permanent.,symtoms and signs,The severity can range from small amounts of scar tissue in certain locations within the knee that may only cause symptoms with certain activities to diffuse scarring that is chronically painful and completely restricts all motion of the knee.,诊断与鉴别诊断 2,clinical check
10、-up restricts knee motion 病灶数目：多为单发，很少多发。可同时患肺、胸膜或淋巴结核。 颈部淋巴结核最常见。 causes pain 局部肿胀：. 压痛和扣击痛。 关节功能：,Grading system,Type 1 - 10 degree extension loss and normal flexion Type 3 - 10 degree extension loss and 25 degree flexion loss with a tight patella Type 4 - 10 degree extension loss, 30 degrees or m
11、ore flexion loss, and patella infera with marked patellar tightness,established by Donald Shelbourne. He categorised arthrofibrosis into four types,Prevention & Treatment,Prevention,There are several well-known risk factors that can lead to arthrofibrosis： 1. Magnitude of the injury: Dislocated knee
12、, multiple ligaments injured 2. Normal or nearly normal knee motion not restored before surgery 3. Acute ligament reconstruction in swollen, painful knee 4. Technical errors in ACL graft placement, fixation, tensioning 5. Concurrent MCL repair or reconstruction 6. Infection 7. Immobilization, castin
13、g 8. Chronic joint effusion 9. Quadriceps atrophy, shutdown 10. Poor rehabilitation, noncompliant patient 11. Cyclops lesion 12. Complex regional pain syndrome, reflex sympathetic dystrophy,The traditional treatment approach,manipulation under general anaesthesia ： risks of complication ： fracture o
14、f the bone rupture of tendons injury to the cartilage not been able to bear much weight for quite some time, 主要鉴别的疾病： 结缔组织病 骨关节感染性疾病 骨肿瘤,CPM,Continuous passive motion(CPM) acts to pump blood and edema fluid away from the joint and periarticular tissues . This allows maintenance of normal periar-ticu
15、lar soft tissue ompliance . CPM is thus effective in preventing the development of stiffness if full motion is applied immediately following surgery and continued until swellingthat limits the full motion of the joint no longer develops ：,诊断与鉴别诊断 1,The reason for CPM (continuous passive motion) and
16、early mobilisation is to prevent adhesions forming in the first place. Once formed, if caught early enough they can be broken with manipulation under anaesthesia (MUA) but if this is unsuccessful they may need to be removed surgically.,The goal of treatment,The goal of treatment in a stiff knee is r
17、estoration of normal motion without inflicting additional damage on the joint or adjacent structures,Non-operative measures,rest ice anti-inflammatory agents subsequent physical therapy CPM,Stretching devices,Stretching devices are intended to stretch joints that have reduced range of motion seconda
18、ry to immobilization, surgery, contracture, fracture, dislocation, or a number of additional non-traumatic disorders.,surgical treatment,Open operative procedures quadricepsplasty Arthroscopic aided procedures percutaneous release of adhesions under arthroscopic visualisation,surgical indications,fa
19、iled a controlled non-operative regimen for a period of 3 months despite an intensive physiotherapy program,Arthroscopy,Arthroscopy is a less invasive surgical technique performed through small incisions that give full access to a joint.,FIGURE 1 -filled up with tough, fibrous scar tissue (the white
20、, fluffy/fibrous material),FIGURE 2-arthroscopic resector has uncovered a portion of the smooth, white femoral condylar surface, marked with an F.,FIGURE 3-The normal, internal joint space has been restored and the medial femoral condyle has been completely released from its enveloping scar tissue c
21、ocoon.,No matter how meticulous and thorough a scar tissue resection may be, and even if a full range of knee motion is successfully restored on the operating room table, the biggest challenge is maintaining that range of motion after surgery.,Rehabilitation After Operative Procedures for Arthrofibr
22、osis,Patient Physical Therapy Program,The extension exercise is done first.The amount of weight to be used is determined before the operation. 15-20-25 pounds of weight is placed over the knee with the foot and ankle supported,Then, the flexion exercise is done.The patient is placed in a “figure-fou
23、r” position in bed. A strap or towel is placed, with approximately 15 to 20 pounds of pull allowed on the ankle,cryotherapy： Immediate cryotherapy with ice-packs was started in the recovery room isometric exercises and active knee flexion were initiated as soon as possible after anaesthesia,Post ope
24、rative Care,Post operative pain relief,indwelling epidural catheters： anesthetic nerve block for a day or two post-operatively, so as to allow joint motion without the inhibiting effect of severe pain,Case Report,case1. a 45-year-old male worker,2 years after exteral fixation of femur shaft fracture PE:PROM 20-40,