【作者】 傅渊源；

【导师】 李义凯；

【作者基本信息】 南方医科大学 ， 中西医结合临床， 2011， 博士

【摘要】 目的：1.研究常见肩部劳损性疾病软组织压痛点的分布规律、解剖学基础、体表骨性标志与压痛点以及穴位与压痛点之间的相关性及其临床意义,以期为临床诊疗,特别是体表定位提供解剖学依据。2.研究肩胛冈、肩峰角、肩胛切迹的解剖学特征、解剖学分型、定位和其临床意义,以期为肩部疾病的诊治提供解剖形态学基础。3.研究肩胛上神经的走行特点,为肩胛上神经卡压综合征的临床诊治提供解剖形态学基础及为肩背痛及肩胛上神经损伤性疼痛的临床诊治提供解剖学依据。材料与方法：1.临床研究：对90例肩部劳损性疾病患者的肩部压痛点分布规律及其体表定位进行研究,作局部压痛点指压检查和解剖定位以及肩峰撞击试验,并进行视觉模拟评分(VAS)疼痛量化评分。2.临床研究：对90例肩部劳损性疾病患者,分别按照以现代人体解剖学体表标志为基础的解剖学压痛点和以传统经络腧穴分布为基础的压痛穴位点进行描述,分析两者的对应关系。3.基础研究：对200例成人干燥肩胛骨的肩胛冈以及肩峰角的形状、走形及定位方法等解剖学特征及其临床意义进行研究。4.基础研究：对200例成人干燥肩胛骨的肩胛切迹形状、走形及对以肩峰角为标志来确定肩胛切迹的定位方法进行解剖学分型研究。5.解剖学研究：在7具成人防腐及1具新鲜肩部尸体标本上,对肩胛上神经的走行、毗邻结构以及之间的相互关系进行细致观察,研究肩胛上神经的走行及分布规律。结果：1.肩部常见劳损性软组织压痛点主要分布于上斜方肌、冈下肌、肩峰下、喙突、肱骨结节间沟、喙突与肱骨小结节间、肱骨小结节以及肩胛骨外侧缘等处,且以上斜方肌、冈下肌、喙突、肱骨小结节和肩峰下等处的压痛最明显。肩峰下病变均有肩袖下撞击痛。2.肩部常见软组织压痛点的分布及体表定位与穴位有一定的对应关系,肩井、臑俞、肩髎、天宗和肩髃等穴位有与之相对应的局部解剖结构。肩部痛点的确定基本取决于肩部体表解剖的掌握及相应解剖学知识的理解。3.肩胛冈部位表浅,走形恒定。长度为(118.67士5.06)mm,基底长度为(82.04士5.58)mm,冈中隆凸宽度为(12.92士3.79)mm,冈中隆凸高度为(18.34士3.99)mm；肩峰角多为钝角,突起明显,位置恒定,主要分为三型,肩峰角(119.9士8.53)°,其中C型占68.00%,肩峰角(124.6士6.49)°；L型占22.50%,肩峰角(104.8士5.54)°；双角型占9.50%。4.肩胛骨的肩胛切迹可分为U型、大弧型、V型、O型及部分骨化型等5型为主,其中以U型居多(52.50%)；肩胛切迹宽度为10.52士4.27mm,深度为6.12士2.24mm。肩胛切迹到肩胛冈的垂线交点到肩峰角的距离为43.13士4.82mm,从交点至肩胛切迹的深度为31.43士4.0lmm。5.肩胛上神经走行时与骨面相贴,其中向内侧发出2-3肌支进入冈上肌。主干继续向下走行绕过冈盂切迹进入冈下窝,向内侧发出3-4肌支进入冈下肌。结论：1.各种肩部软组织劳损性疾病压痛点的分布有其规律,且与一些穴位有一定的联系。以肩部体表骨性标志及相应的局部解剖学结构为基础的软组织压痛点定位法,具有定位准确、快速的优点。喙突、肩胛冈、肩峰角、结节间沟等肩部骨性标志对准确确定肩部软组织压痛点具有重要的定位作用；了解并掌握肩部软组织压痛点的分布规律及其解剖学基础,对于肩部劳损性疾病的诊疗具有重要的临床意义。2.对肩部疼痛明显,但肩部检查无明确压痛点,特别是肩部外展活动受限的患者,一定要进行肩峰下撞击试验,以明确患者的疼痛是来自于肩峰下组织结构的病变,还是来自于肩部其它软组织结构的病变。肩峰下撞击痛可用于判断有无肩峰下病变。3.肩部的体表解剖学标志是确定以解剖学为基础压痛点的重要依据,解剖压痛点和压痛穴位有一定的对应关系。例如：肩井对应上斜方肌、天宗对应冈下肌、肩髃对应肩峰下、臑俞对应肩胛骨外缘等。临床应以肩部体表解剖学为基础,结合经络穴位理论来确定压痛点。4.肩胛冈上缘及肩峰角走形恒定,部位表浅,定位清析,而且简单易明,可作为肩部疾病的诊治定位标志;从肩峰角沿肩胛冈上缘水平向内约4 cm,再垂直向上约3 cm即为肩胛切迹,此为封闭治疗肩胛上神经卡压综合征之最佳位置。然而,使用针刀治疗此综合征时,必须熟悉局部解剖结构、清楚骨性标志、掌握施刀位置及操作手感,否则容易伤及其组织下之血管和神经。5.肩胛上神经卡压综合征是指肩胛上神经在经肩胛上切迹处受卡压引起的冈上肌、冈下肌麻痹,萎缩及肩周疼痛和运动受限的一系列症状,是肩部疼痛的原因之一。肩胛上神经在肩胛骨区的走行和该区域复杂的解剖关系是造成肩胛上神经易发生卡压及受到损伤而产生肩背痛的解剖学基础。更多还原

【Abstract】 1. Objectivea) Studies on the tenderness points of common shoulder soft tissue injury in distribution rule, anatomy foundation, the sign of osseous surface as well as the acupuncture points and the tenderness points relevance and the clinical significance, expected in clinical diagnosis & treatment, especially to provide an anatomical basis for body surface localization.b) Studies on scapular spine, acromial angle, scapular notch anatomical characteristics, anatomical morphology, localization and its clinical significance, to provide an anatomical basis of the diagnosis and treatment of shoulder disorder.c) Studies on the alignment character of suprascapular nerve to provide an anatomical basis for the diagnosis and treatment of suprascapular nerve compression syndrome, providing anatomical basis of clinical diagnosis and treatment of shoulder pain and suprascapular nerve injury.2. Materials & Methodsa) Clinical research:To study the shoulder tenderness points distribution rule and the body surface localization in 90 cases shoulder-strain patients by local finger pressing examination, performing subacromial impingement test and assessing the pain with visual analogue scale (VAS).b) Clinical research:To study and compare the shoulder tenderness points body surface localization distribution and the relationship between the acupuncture points in 90 cases shoulder-strain patients.c) Basic research:To study the anatomical characteristic of shape, course, localizing method, in view of clinical significance of scapular spine and acromial angle on 200 adults dry scapulas.d) Basic research:To study the shape of scapular notches, course, and the anatomical classification of locating methods marked by acromial angle on 200 adults dry scapulas.e) Anatomic research:To observe the function of alignment of suprascapular nerve with its nearby neighboring structure in 7 adult anti-corrosive and 1 adult fresh cadavers.3. Results1.1 Shoulder strain soft tissue tenderness points are mainly located in the upper trapezius, infraspinatus muscle, subacromion, coracoid process, intertubercular groove of humerus, the space between coracoid process and lesser tuberosity of humerus, lesser tuberosity of humerus and lateral border of scapula etc. The most tenderness points are found at upper trapezius, infraspinatus, coracoid process, lesser tuberosity of humerus and subacromion etc. Subacromial lesions have subacromial impingement pain;1.2 Shoulder soft tissue tenderness points of distribution and body surface localization have a certain correspondence with acupuncture points; the acupoints JianJing (GB21); NaoShu (SJ10); JianLiao (SJ14); TianZong (SI11) and JianYu (LI15) are corresponding to the local anatomical structure. To determinate the shoulder tenderness points depends on the basic of the corresponding shoulder surface anatomical knowledge and understanding of correlative anatomy;1.3 The scapular spine is superficial and constant in shape. The average length of scapular spine and basement are (118.67±5.06)mm and (82.04±5.58)mm. The average width and height of eminence on scapular spine are (12.92±3.79)mm and (18.34±3.99)mm. The acromial angles are mostly obtuse, protrude significantly, in constant location and are classified into three types. The average angle is (119.9±8.53)°; C-type accounting for 68.00% and the average angle is (124.6±6.49)°; L-type accounting for 22.50% and the average angle is (104.8±5.54)°; Double-angle-type accounting for 9.50%.1.4 The shapes of scapular notches are classified as type U, type large arc, type V, type O and type incomplete ossification and the most common is type U (52.50%). The average width and depth of scapular notches is (10.52±4.27)mm and (6.12±2.24)mm. The distance of acromial angle and vertical intersection point of scapular notch to spine of scapula is (43.12±4.82)mm. The average depth is (31.42±4.01)mm from the intersection point to the scapular notch.1.5 Suprascapular nerve aligns with the scapula bone surface, which issues 2 or 3 medial branch nerves into the supraspinatus muscle. The main trunk continues to go around the glenoid notch and down into the infraspinatus fossa. The medial muscular branches issues 3 or 4 nerves into the infraspinatus muscle. 4. Conclusions4.1 All kinds of shoulder soft tissue strain injury have their tenderness points distribution rules, and certain correlations with some acupuncture points. The shoulder surface osseous signs and the corresponding topographic anatomical structures as the soft tissue tenderness point locating, can be accurately and vastly located are advantages. Coracoid process, spine of scapula, the angle of acromion, intertubercular groove of humerus, etc have an important role in determining the tenderness points of shoulder soft tissue. To understand the tenderness points of shoulder soft tissue distribution and the anatomical basis for disease diagnosis and treatment of shoulder disorders has an important clinical significance.4.2 Of the shoulder pain is significantly, but no clear shoulder tenderness points, particularly in restricted mobility of shoulder abduction, subacromial impingement test must be performed to clear the pain from the subacromial organizational structure, or from other soft tissue lesions in the shoulder. Subacromial impingement pain can be used to determine the presence of subacromial lesions.4.3 The shoulder surface anatomical landmarks are an important anatomical basis for tenderness points, Anatomical tenderness points and tenderness acupoints have a certain correlation. These tenderness points are well corresponding in general, JianJing (GB21) corresponding upper part of trapezius muscle, TianZong (SI11) corresponding infraspinatus muscle, JianYu (LI15) corresponding subacromial, NaoShu (SJ10) corresponding lateral edge of the scapula. In clinical, the shoulder surface anatomical basis should be combined with the theory of meridian points to determine tenderness points.4.4 Superior border of scapular spine and angle of acromial are constant in shape and its superficial, clear positioning, can be easy to understand, and used as the locating sign for the diagnosis and treatment of shoulder diseases. Scapular notch is located by the method of moving about 4 cm from an acromial angle to the medial along spine of scapula and then turning forward about 3 cm, where the best position for steroid injection treatment of suprascapular nerve entrapment syndrome. However, the use of needle-knife treatment of this syndrome must be familiar with the local anatomy, clear signs of bone, and an expertise in know well the locating and operating of facilities like the needle-knife, otherwise, it can damage the below blood vessels and nerves easily.3.1 Suprascapular nerve entrapment syndrome is the department compression of suprascapular nerve in suprascapular notch, causing the paralysis and atrophy of supraspinatus, infraspinatus muscle; as well as a series of symptoms of shoulder pain and movement limitation, which is one of reason of shoulder pain. Suprascapular nerve located in scapular area takes an important place of complex anatomy in this region. It is the anatomical basis of shoulder pain caused by suprascapular nerve entrapment and or injury.更多还原