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本期唯醫FM將為您陸續放送美國骨科醫師協會（AAOS）精編教程性書籍《AAOS Essentials of Musculoskeletal Care 5th》。
中國醫師協會骨科醫師分會（CAOS）已獲授權出版中文版書籍，並已組織國內多個著名醫院的醫生完成了全文翻譯，紙質版即將刊印，電子英文原版也會陸續在唯醫網發布。歡迎老師們登陸唯醫網進行學習。本期為大家放送教程節選內容：半月板撕裂。
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膝關節內紊亂 Internal derangement of knee
交鎖膝 Locked knee
軟骨撕裂 Torn cartilage
膝關節內側和外側半月板是纖維軟骨盤結構，其作用是股骨髁和脛骨平臺之間的減震器。這種墊狀結構便於應力從股骨髁到脛骨平臺的有效傳導。半月板撕裂破壞了膝關節的正常力學機制，由於負重外力集中造成膝關節不同程度的症狀和退行性骨關節炎的發生（圖1，表1）。半月板撕裂可以伴隨韌帶的損傷，如前交叉韌帶撕裂。
The medial and lateral menisci are fibrocartilaginous pads that function as shock absorbers betweenthe femoral condyles and tibial plateaus. These gasket-like structuresfacilitate the effi cient transfer of forces from the femoral condyles to the tibial plateau. Meniscal tears disrupt the normal mechanics of the knee;therefore, various degrees of symptoms result and the knee is predisposed todegenerative arthritis because of the concentration of weightbearing forces (Figure 1, Table1). Meniscal tears occur alone or in association with ligament injuries such as anterior cruciate ligamenttears.
圖1 常見的半月板撕裂的圖示 A：放射狀撕裂。B：瓣狀撕裂。C：鳥嘴樣撕裂。D：不完全的縱向撕裂。E：完全的縱向撕裂。F：桶柄狀撕裂。G：移位的桶柄狀撕裂。H：移位的瓣狀撕裂。I：雙重瓣狀撕裂。
Figure 1 Illustration of common patterns of meniscal tears. A: Radial tear. B: Flaptear. C: Parrot beak tear. D: Incomplete longitudinal tear. E: Complete longitudinal tear. F: Bucket-handle tear. G: Displaced bucket-handle tear. H: Displaced flap tear. I: Double flap tear.
表1 半月板撕裂的分型
撕裂類型
特點
垂直縱向
常見，特別是合併前交叉韌帶損傷時；撕裂位於半月板邊緣時可以做修補
桶柄樣垂直縱向
撕裂向缺口處移位
放射狀
從中央向周圍的撕裂；因為環狀纖維的完整性破壞從而無法修補
瓣狀
開始是輻射狀的，然後逐漸向環形發展；可能導致機械性交鎖
橫裂
常發生於老年人群與半月板囊腫伴發
複合型
合併多種撕裂類型；常見於老年患者
(引自Lieberman JR, ed: Comprehensive Orthopaedic Review.Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009, vol 2,p 1133.)
創傷性撕裂的患者通常主訴有膝蓋扭傷史。患有半月板退行性損傷的老年患者常沒有外傷史或者輕微外傷史，通常會主訴某種運動時出現隱秘的疼痛症狀，如由下蹲起立時。患者通常在急性損傷後可以行走，並且能夠繼續參與體育運動。
Patients with traumatic tears typically report a twisting injury to the knee. Older patients with degenerative tears may have a history of minimal or no trauma and recall aseemingly insidious painful episode that happened during an activity such assimply rising from a squatting position. Patients usually can ambulate after anacute injury and frequently are able to continue to participate in athletics.
創傷性撕裂通常在2-3天後出現膝關節積液和僵硬。當急性炎症緩解後，患者重返運動時可出現交鎖、卡壓和彈響等機械性症狀。患者通常主訴沿關節間隙內側或外側疼痛。疼痛會在屈膝和下蹲時加重。在某些情況下，不穩定半月板的片段會嵌頓在關節間隙，造成膝關節交鎖，無法進行完全的被動伸膝活動。患有片段嵌頓的患者常主訴關節交鎖可在輕微活動關節後恢復。更常見的情況是由於關節積液引起的活動受限。機械性的症狀和疼痛的程度時好時壞。
Traumatic tears can be followed by delayed knee effusion and stiffness over 2 to 3 days. Mechanical symptoms such as locking, catching, and popping may develop as the acute inflammation resolves and the patient resumes normal activities. Patients usually report pain along the joint line of the medial or lateral side of the knee. This pain worsens with twisting or squatting activities. In some cases, large, unstable fragments of meniscal tissue become incarcerated in the knee joint and cause alocked knee, one that is unable to achieve full passive extension. Patients with an incarcerated fragment often describe a period of locking that isresolved by gently manipulating the knee. More frequently, motion is limited bya feeling of tightness in the knee secondary to the effusion. The mechanical symptoms and degree of pain tend to wax and wane.
偶爾，患者會主訴膝關節彈響後繼發膝關節後方銳痛。有上述病史的肥胖患者應特別注意是否有內側半月板后角的損傷，即內側半月板的後部附著點。這種特異性損傷會影響半月板功能並導致受累關節間室快速退變。
Occasionally,patients will describe a 「pop」 followed by a sharp pain in the posterior aspect of the knee following an innocuous episode. In patients with obesity, this history should alert the examiner to the presence of a tear of the posterior medial meniscal root, the posterior attachment site of the medial meniscus. This particular injury renders themeniscus nonfunctional and can resultin a more rapidly progressive degeneration of the affected medial compartment.
• 體格檢查
最常見的檢查結果是關節間隙內外側的壓痛。年輕患者當急性創傷性撕裂發生在半月板附著點以內5mm時會出現典型的大量積液和血腫。在退變性撕裂或者撕裂位於缺乏血供中央區域時，積液通常不明顯。膝關節活動會因疼痛、嵌頓片段和積液而受限。在誘發試驗中，外力屈膝旋轉時（足部內旋或者外旋）可引起半月板撕裂一側的關節疼痛。當屈膝旋轉並發疼痛性彈響時，提示McMurray試驗陽性。
The most common finding on physical examination is point tenderness over the medial or lateral joint line. Young patients who have traumatic tears that occur within 5 mm ofthe meniscal attachment sites to the capsule typically present with a large effusionor hemarthrosis. In degenerative tears or tears that involve the avascularcentral body of the meniscus, effusions are typically small or absent. Kneemotion may be limited secondary to pain, an incarcerated fragment, or aneffusion. During provocative testing, forced fl exion and circumduction(internal and external rotation of the foot) frequently elicit pain on the sideof the knee with the meniscal tear. The McMurray test is positive when the flexion-circumduction maneuver is associated with a painful click.
• 輔助檢查
雖然核磁共振檢查對於半月板病變的特異性和敏感性都比較高，但每個半月板損傷患者都應該在核磁共振檢查前行負重位的攝片。攝片是性價比比較高的檢查，其可以反映骨性關節炎的程度，這關係到半月板手術的預後。負重下膝關節屈曲45度正位片對於早期骨性關節炎較敏感，推薦超過40歲的患者拍攝此片（圖2）。
Although MRI isspecifi c and sensitive for meniscal pathology, each patient with a meniscaltear should undergo weight-bearing radiography prior to MRI. Radiography is a cost-effective imaging modality that provides information on the degree ofosteoarthritis, which has been correlated with outcomes after meniscal surgery.A weight-bearing AP view with the knees in 45° of flexion is sensitive for early osteoarthritis and is recommended in patients older than 40 years (Figure 2).
圖2 MRI下半月板撕裂的分級圖示 0=半月板內無信號，1=半月板內點狀信號不與表面貫通，2=半月內板條帶狀信號不與表面貫通，3=半月板條帶狀信號與表面貫通。
Figure2 Illustration of a gradingscale for meniscal tears seen on MRI. 0 = no intrameniscal signal, 1 = focal intrameniscal signal that does not communicate to a meniscal surface, 2 = intrameniscal line/bandthat does not communicate to a meniscal surface, 3 = intrameniscal line/band that communicates with at least one meniscal surface.
前交叉韌帶斷裂（血腫，Lachman試驗陽性）
結晶病（穿刺發現晶體）
游離體（影像學上可以發現游離體，如果是軟骨游離體則不顯影）
內側副韌帶撕裂（側方應力試驗出現疼痛及不穩）
骨性關節炎（負重位攝片發現關節間隙狹窄）
軟骨剝脫（影像學發現，常見於股骨內髁）
股骨髁骨壞死（年齡超過50歲，疼痛，X線片及MRI明顯可見）
髕骨脫位或半脫位（髕骨內側壓痛，恐懼試驗陽性）
鵝足滑囊炎（關節間隙內側遠端壓痛）
隱神經炎（隱神經走形區壓痛）
脛骨平臺骨折（骨性壓痛，X線片明顯可見）
Anterior cruciate ligament tear (hemarthrosis, positive Lachman test)
Crystalline disease (crystals in aspirate)
Loose body (fragment may be evident on radiographs, but purely cartilaginous loose body may not)
Medial collateral ligament tear (pain and instability with valgus stress)
Osteoarthritis (joint space narrowing may be evident on weightbearing radiographs)
Osteochondritis dissecans (evident on radiographs, especially of the medialfemoral condyle)
Osteonecrosis of the femoral condyle (patient older than 50 years, pain,evident on radiographs or MRIs)
Patellar subluxation or dislocation (tender medial patella, apprehension sign)
Pes anserine bursitis (tender distalto medial joint line)
Saphenous neuritis (tender to palpation along the course of the saphenous nerve)
Tibial plateau fracture (bony tenderness, evident on radiographs)
引起半月板從股骨到脛骨應力傳導異常的任何損傷可導致成膝關節負重部位關節軟骨的退變加速。由於半月板血運不佳，大對數的半月板撕裂不能修補必須切除。然而，在某些情況下，特別是外周型撕裂（靠近半月板與關節囊交界）可以修補。如果半月板損傷漏診和漏治會導致撕裂部位的進一步損傷，並失去重建半月板功能的機會。
Any injury that compromises the meniscal capability to effectively transfer force from thefemur to the tibia can result in accelerated degeneration of the articularcartilage of the weight-bearing portion of the knee. Because the meniscus has arelatively poor blood supply, most tears are not amenable to repair and must beexcised. However, in some instances, especially in persons with a peripheraltear (close to the meniscocapsular junction), tears may be reparable. Failureto recognize and treat these injuries can result in further damage to the tornsegment and a lost opportunity to restore the function of the meniscus.
活動受限的膝關節交鎖需要外科手術減輕疼痛和恢復運動。如果沒有機械性的交鎖症狀，特別是退變性撕裂時，初始治療應包括休息、冰敷、加壓包紮和抬高患肢（RICE，rest,ice, compression, elevation）治療。短期的服用鎮痛藥，如對乙醯氨基酚或布洛芬，有助於恢復正常運動。年輕患者的創傷性撕裂應該積極治療和評估。在MRI評估或症狀緩解前，應限制運動。關節鏡手術清創或修補術適用於較大撕裂的年輕患者、關節交鎖患者和保守治療不佳的老年患者。
A locked knee with loss of range of motion should be managed surgically to reduce pain and restore motion. In the absence of mechanical symptoms, and particularly when adegenerative tear is present, initial treatment should consist of rest, ice,compression, and elevation (RICE). A short course of oral analgesics, such asacetaminophen or ibuprofen, may facilitate return to normal activity. Traumatictears in younger patients should be evaluated and treated aggressively. Sports activity should be restricted until MRI evaluation is performed or symptomsresolve. Arthroscopic surgical débridement or repair is indicated in younger patientswith substantial tears, in patients with a locked knee, and in older patientswhose symptoms do not respond to nonsurgical treatment.
初期治療應該選擇RICE治療，以控制軟組織水腫、關節腔積液和疼痛為目的。早期制動通常有利於改善運動和減輕疼痛。桶柄狀撕裂，即撕裂的後方片段向前方翻轉導致關節交鎖，康復治療無效。
Initial treatment should consist of RICE to control soft-tissue edema, joint effusion,and pain. Early controlled movement is generally effective in improving mobility and reducing pain. The type of meniscal injury called a bucket-handle tear, in which the posterior fragment flips anteriorly,can cause locking and is beyond the scope of rehabilitation.
家庭康複方案包括早期的無痛活動，比如屈膝訓練和直腿抬高。另外，採用康復自行車的訓練可以改善膝關節活動度和減輕疼痛。如果疼痛持續超過3-4周，則需正規的康復治療。評估應包括整個下肢的活動度和強度，以及髖部、軀幹周圍的核心肌肉功能。另外，應該開始促進癒合的訓練。
A home exercise program should include early, pain-free movement such as hamstring curls and straight leg raises. In addition, using a stationary bicycle can help reduce pain and increase range of motion. If the pain continues for more than 3 to 4weeks, formal rehabilitation is an option. The evaluation should include athorough assessment of lower extremity flexibility and strength, as well as core muscle function around the hip and trunk. In addition, exercises to promote healing should be initiated.
非甾體抗炎藥可使高血壓病加重，引起胃、腎或肝的併發症，尤其是長期超治療劑量使用。2015年，美國FDA再次強調：非甾體類消炎藥有誘發心臟疾病和中風的可能，並指出：即便在開始使用一種非甾體類消炎藥的數周內也可發生。半月板修補有10%-30%的失敗率，有症狀的再撕裂病例需要再次修復或部分半月板切除。部分半月板部分切除術的持續性疼痛可能繼發於關節的病理性改變，如骨性關節炎或隱神經炎。創傷性關節炎可以成為部分半月板切除術的晚期併發症。骨性關節炎的發生率和進展程度與半月板切除後的半月板殘留量有關。半月板保留越多，應力傳導越好，關節退變率越低。雖然術後感染少見，但是術後深靜脈血栓並不少見，高危患者中考慮使用合適的預防性藥物治療。
NSAIDs canworsen hypertension and cause gastric, renal, or hepatic complications,especially if taken in supratherapeutic doses and for prolonged periods. In 2015, the FDA strengthened its warning linking NSAIDs with therisk of heart attack or stroke, even in the first weeks of use of an NSAID.Meniscal repair has a 10% to 30% failure rate and, in symptomatic cases of retear of incomplete healing, requires subsequentre-repair or partial meniscectomy. Persistent pain after a partial meniscectomycan occur secondary to concomitant pathology, such as osteoarthritis orsaphenous neuritis. Traumatic osteoarthritis can be a late complication in the involved compartment after partial meniscectomy. The rate and degree of osteoarthritic progression can be correlated to the amount of meniscus remaining following resection. The more of the meniscus that remains, the more efficient the load transfer will be, and the slower the rate of joint degeneration. Although postoperative infection is rare, deep vein thrombosis is not uncommon postoperatively, and appropriate chemoprophylaxis should beconsidered in patients at increased risk of thromboembolism.
不是所有的半月板撕裂的患者都需要進一步檢查和外科手術來減輕疼痛。然而，患者有創傷性積液、機械性交鎖症狀、韌帶不穩和可能需要半月板修補的則需要諮詢骨科醫師行早期治療。外傷患者如保守治療效果不佳的比如關節腔內注射激素、非甾體類消炎藥、物理治療，並有持續性關節間隙壓痛和關節腔內積液的，可能需要外科手術幹預並進一步評估。
Not all patients with a meniscal tear identified on advanced imaging require surgical intervention to alleviate pain. However, patients with a traumatic effusion,mechanical symptoms, or ligamentous instability may have a reparable tear and should be referred to an orthopaedic surgeon early in treatment. Patients whose injuries do not respond to nonsurgical management, such as intra-articularsteroid injections, NSAIDs, or physical therapy, and who have persistent joint linetenderness or effusions may benefit from surgical intervention and should bereferred for further evaluation.
翻 譯：蔣 勵 主治醫師 復旦大學附屬華山醫院
一 校：畢 龍 副主任醫師 西京醫院
副主譯：馬建兵 主任醫師 西安交通大學醫學院附屬紅會醫院
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