一文读懂肩袖损伤的治疗

首先申明肩袖损伤的治疗原则：

1、缓解损伤局部的炎症反应、消除疼痛；

2、重建肩袖的力学平衡机制，促进肩关节功能的恢复，以满足生活和运动需要。

适应症、时机、原则

1、手术适应症：

肩袖完全损伤的患者应采取手术治疗、保守治疗效果不理想时应及时采用手术治疗。

对于肩袖完全损伤的患者除因年迈体弱、对功能要求不高或伴有严重内科疾患不宜手术外，均应争取早期手术。

2、手术时机：

伤后 3 周内手术效果最好，早期手术可恢复肩袖原有张力，防止肌肉萎缩和软组织病变的发展。

3、手术原则：

切除撕裂口边缘坏死腱性组织，恢复肩袖解剖连续性，恢复肩峰下滑动。

手术治疗

肩袖撕裂伤的手术治疗分为开放手术和关节镜下手术。

1、开放手术

切开肩关节皮肤，找到损伤处，行缝合修补。目前开放手术较少使用，多采用微创治疗。

术后需卧床休养，肩关节固定于外展、前屈、外旋位 6 ~ 8 周；避免肩关节过度负重，防止再次发生肩袖损伤；定期复查。

2、关节镜手术

关节镜手术治疗肩袖撕裂有三种方法：

①肩峰下减压成形和肩袖修复术；

②肩关节病灶清创和小切口辅助下肩袖修复术；

③单纯肩关节镜下清创术。

关节镜能够直观显示肩袖断裂的范围、大小、形态，对肩关节退变、滑膜的炎性改变、冈上肌腱、肱二头肌长头部分断裂及肱二头肌腱半脱位、肩关节盂唇分离、盂肱关节软骨面的损伤和滑膜炎等疾患作出诊断并镜下手术治疗。

通过关节镜从肩峰下滑囊可观察滑囊病变及冈上肌腱滑囊面的断裂，其效果是影像学检查及传统的开放手术下观察无法比拟的。

肩袖关节镜修复

1、单排缝合修复

小至中度的肩袖撕裂采用单排法修复。（直径 < 10 mm 为小撕裂，10~30 mm 为中度撕裂）

2. 双排缝合修复

大至大面积撕裂采用双排法修复。（30~50 mm 为大撕裂，> 50 mm 为巨大撕裂）

与开放手术一样，术后需卧床休养，肩关节固定于外展、前屈、外旋位 6~8 周；避免肩关节过度负重，防止再次发生肩袖损伤；定期复查。

关节镜手术最常见的并发症是关节软骨面损伤。

由于软骨损伤后修复困难，在进行关节镜检查和手术时，所用的器械不可强力插入关节间隙或在软骨表面划动，应在直观下进行手术操作。

附1：肩袖损伤双排修复法

附2：肩袖缝合方法

1、新月形肩袖撕裂

2、U 型或 v 型肩袖撕裂

①U 形撕裂在前后方向具有良好的移动性，采用边缘聚合技术原则先进行侧-侧缝合。

②无张力下将边缘修复到骨床。

3、L 型和倒 L 型肩袖撕裂

• 急性 L 型和倒 L 型肩袖撕裂

①先从纵行劈裂的部位修复。

②边缘聚合修复到骨床。

• 慢性 L 型和倒 L 型肩袖撕裂

① L 形撕裂在前后方向具有良好的移动性，而撕裂的单侧（通常是后叶）活动性更好。依据边缘聚合的技术原则先进行侧-侧缝合。

② 无张力下边缘聚合修复到骨床。

4、巨大的、挛缩性、新月形肩袖撕裂

①松解冈上肌和冈下肌间隙，进行双间隙滑动。首次施行前间隙滑动，然后施行后侧间隙滑动。

②松解后，改善冈上肌和冈下肌及小圆肌肌腱的活动（箭头所示）。

③无张力方式缝合至侧面骨床修复冈上肌肌腱，冈下肌和小圆肌肌腱向侧方推移

④余下的缺损使用侧-侧缝合关闭

保守治疗

肩袖部分损伤的患者以保守治疗为主，保守治疗效果不理想时应及时采用手术治疗。

保守治疗主要包括药物治疗、理疗及外展架或石膏固定治疗。

1、药物治疗：

非甾体类药物，消炎止痛等治疗。

2、理疗：

超短波可起到对肩关节局部消炎止痛的作用

3、外展架或石膏固定治疗：

可用石膏/外展架将肩关节固定在外展、前屈、外旋位 3~4 周，以使肩袖断裂部分接近而获得愈合，然后进行肩关节功能练习。

如经 4~6 周严格非手术疗法仍不能恢复肩关节有力、无痛、主动的外展活动，则需考虑手术修补。

治疗过程中，即使效果满意、疼痛减轻，也应注意修养患肩，不得突然发力或过度用力，否则会再发肩袖损伤，甚至加重损伤。

作者：孙小六

图源：文末文献

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