b6 exam2 note

• 膝蓋9種疾病
• hip8種疾病
• 足踝16種疾病
• 骨頭感染3+3種
• 脊椎5種問題
• 肩膀4種疾病
• 先天上肢畸型9種
• 肌肉神經問題4種
• 神經壓迫症3種
• 手臂3種問題
• 腕手12種問題
  
• 骨骼力學
• 步態分析
• 骨折處理
• 腫瘤

Ankle and foot deformity

1.Hallux valgus
A.病因：

• M1M2IM>10
• 1st MTP>20

B.治療

• Distal Chevron(Mitchell) osteotomy(best way)
• Proximal osteotomy+distal soft tissue procudure
• Keller procedure
• Akin procedure
• Scarf osteotomy

2.Hallux rigidus

病因：

• metatarsal head 有osteophyte
• rigidus

治療

• 無arthritis→chielectimy
• 有arthritis→osteotomy or arthrodesis

3.ankle arthritis

病因：

• ankle instability
• AVN of talus
• inflammatory arthritis
• RA
• degenerative arthritis
• traumatic arthritis(最常見)

治療

• shoe insert
• chielectomy
• lower tibia osteotomy
• high tibia osteotomy(不好用)
• total ankle replacement(成效不彰)→用於RA
• ankle arthrodesis
• triple arthrodesis

4.Flat foot

病因：

• hypermobile flatfoot
• adult flatfoot
• acquired flatfoot

分期

• stage1
• stage2
• stage3
• stage4

治療

• tendon transfer
• calcaneal osteotomy
• isolated talonavicular arthrodes
• double arthrodesis
• triple arthrodesis

5.charcot foot

病因：

• DM併發症

分期

• stage1→急性發炎
• stage2→骨頭healing
• stage3→手術在這期執行

治療

6.plantar fasiitis

支持性治療(80%會好)

• NSAID
• shoe inset and heel cup
• achillis and plantar fascia stretch

手術治療

• total or subtotal faciotomy
• extracorporeal shock wave therapy

7.heel pain-haglund's

下肢的血管走向

1.下肢的動脈血來源為external iliac artery。
2.external iliac artery過了inguinal ligament後成為femoral artery。
3.femoral artery在lesser trochanter處會發出deep femoral artery，為大腿的主要供血動脈。
4.deep femoral artery有4個穿通支+兩個動脈

• lateral circumflex femoral artery
• medial circumflex femoral artery=髖關節主要供血

※十字吻合(cruciate anastomosis)

• inferior gluteal artery
• 深股第一穿通支
• 股內旋橫支
• 股外旋橫支

5.femoral artery進入adductor cannal後，分出saphenous artery進入小腿內側，至於femoral artery則是穿出adductor cannal後先分出descending genicular artery，然後femoral A.穿出adductor hiatus，並繞到膕窩形成popliteal artery。

6.popliteal artery在knee發出5個關節支，並在過膕肌下緣後發出2分支

• 內上
• 內下
• 外上
• 外下
• middle→供應關節囊內軟組織。
• anterior tibial A.→有時會再分出circumflex fibula A.會繞回來
• posterior tibial A.

※膝關節的動脈

• 5條genicular A.
• 股外旋動脈下降支
• descending genicular A.
• anterior tibial A.
• circumflex fibula A.

7.posterior tibial artery→fibular artery

下肢的筋膜

1.subcutaneous fasciae

• Membranous layer融合於inguinal ligament下方一指寬
• 在saphenous opening上有cribriform fascia
• 接下來下肢無淺筋膜的膜狀層

2.Deep fascia

大腿

• Fascia lata
• iliotibia tract
• Fascia iliaca

膕窩

• popliteal fascia

小腿

• Crural fascia
• patellar retinaculum

腳踝

• Extensor retinaculum=superior+inferior
• Fibular retinaculum
• Flexor retinaculum

足底

• Medial planter fascia
• Lateral planter fascia
• superficial transverse metatarsal ligament
• plantar aponeurosis
• fibrous digitorum longus

足背

• extensor expansion：
• central band/middle phalange
• lateral band/distal phalange

考試清單

1.上肢解剖學

7個區域

• 手
• wrist
• foearm
• 肘
• 上臂
• 肩
• 胸肩帶

9個項目

• 動脈
• 淺層靜脈
• 深層靜脈
• 神經
• 肌肉
• 骨頭marking
• 動作
• tendon
• 邊界

2.下肢解剖學

6個區域

• 臀
• 大腿
• knee
• 小腿
• 踝
• 腳

9個項目

• 同上肢

3.病理

自體免疫相關

• 乾躁症
• SS
• PM
• DM
• Inclusion body myositis
• AS
• Reiter's syndrome
• PsA
• RA
• JIA
• AOSD
• OA
• ON
• Posttraumatic A.
• Neuropathic A.
• SLE
• Overlap syndrome
• MCTD
• Anti-P. syndrome
• Vasculitis(大中小=6種)

骨頭疾病

• Osteoporosis
• Osteomalascia+Ricket
• Paget's disease

※還有林相如教授兩本考訓

4.藥理

• NSAID
• Dantrolene

5.組織學

• 軟骨(3種)
• 肌肉(3種)
• Bone(3種細胞)
• 關節(2種)
• 肌腱
• Connective tissue
• ECM

6.生理學

• 軟骨生成調控
• 骨化機轉bone remodeling
• OC的生成調控
• 鈣與磷的調控
• 肌肉收縮與放鬆

乾躁症，硬皮症，皮肌炎

1.Sjogren's syndrome乾躁症

• 得B-cell lymphoma的機率↑40倍
• 會出現Raynaud's syndrome
• 最常見的腺體外症狀是多發性關節炎(oligoarthritis)
• Primary Sjogren's syndrome=乾燥+腺體外症
• Second Sjogren's syndrome=乾燥+腺體外症+其他自體免疫疾病
• thrombocytopenia，80%hypergammabulinemia，10%leukopenia

Gland function examination

• eye=Shirmer's tear test(試紙)/Rose Bengal staining(染劑)
• 唾液=Scintigraphy(核醫)
• Minor salivary gland biopsy最準→>50 lymphocytes/4mm2

• 要排除HCV，AIDS
• 服用cholinergic agonist=pilocarpine，但是，會有bronchospasm，asthma病人避免服用
• 腺體外疾病可用corticosteriod

2.全身性硬化症(Systemic sclerosis)

• 集中在皮膚及內臟
• 膠原蛋白分泌量過多
• anti-centromere & anti-Scl-70

ESR CRP
PSjogren ↑ ─(↑if infection)
SLE ↑ ─
RA ↑ ↑

上肢的muscle

1.4塊前胸附肢肌

• Pectoralis major
• Pectoralis minor
• Subclavius
• Serratus anterior

2.superficial posterior thoracoappendicular muscle

• Trapezius
• Latissimus Dorsi

3.Deep thoracoappendicular muscle

• Levator scapulae
• Rhomboid major/minor

4.Scapulohumeral muscle

• Deltoid
• Teres Major

Rotaror cuff muscles

• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres minor

5.上臂前區

• Biceps brachii
• Brachialis
• Coracobrachialis

6.上臂後區

• Triceps brachii(long head/lateral head/medial head)
• Anconeus

7.前臂前區

Layer 1.

• Pronator teres
• Flexor carpi radialis
• Palmaris longus
• Flexor carpi ulnaris

Layer 2.

• Flexor digitorum superficialis

Layer 3.

• Flexor pollicis longus
• Flexor digitorum profundus

Layer 4.

• Pronator quadratus

8.前臂後區

Block6 PBL

2個月前跌倒，橈骨骨折，至兩週前疼痛腫脹，且手指無法彎曲

Disease of the skeletal system

1.發育異常

• Achondroplasia軟骨發育異常

2.與基質異常相關

• Osteogenesis imperfecta or Brittle bones
• Mucopolysaccharidoses
• Osteoporosis

3.噬骨細胞異常

• Osteopetrosis
• Paget Disease / Osteitis deformans

4.礦物質恆定異常

• Rickets / Osteomalacia
• Hyperparathyroidism
• renal osteodystrophy

5.骨折

6.骨壞死

7.感染

• Pyogenic osteomyelitis
• Tuberculous osteomyelitis
• Syphilis

8.Tumor/tumot-like lesions

Bone-forming tumors

• Osteoma
• Osteoid osteoma / osteoblastoma
• Osteosarcoma / osteogenic sarcoma

Cartilage-forming tumors

• Osteochondroma
• Chondroma
• Chondroblastoma
• Chondromyxoid fibroma
• Chondrosarcoma

Fibrous and fibro-osseous tumors

• Fibrous cortical defect(nonossifying fibroma)
• Fibrous dysplasia
• Fibrosarcoma and Malignant fibrous histiocytoma

Miscellaneous tumors

• Ewing sarcoma
• Giant cell tumor of bone
• Metastatic tumors to skeleton

Histology of Bone

1.功能及構造
2.Bone formation

Connective Tissue

1.connective tissue proper

• loose(areolar)
• dense--regular
• --irregular

2.connective tissue with special properities

• adipose tissue
• elastic tissue
• hematopoietic tissue
• mucous tissue

3.supporting connective tissues

• cartilage
• bone

Histology of Cartilage

3種軟骨組織

1.Hyaline cartilage
2.Elastic cartilage
3.Fibrocartilage

upper limb的joints

1.joints of the shoulder girdle & shoulder

• coracoacromial ligament
• superior transverse scapular ligament
• inferior transverse scapular ligament
• acromioclavicular joint
• acromioclavicular ligament
• coracoclavicular ligament=trapezoid ligament+conoid ligament
• glenoid lip
• coracohumeral ligament
• glenohumeral ligaments

2.臂關節

• elbow joint

upper limb的重要bone marking

1.scapula

• spine of scapula
• acromion
• acromial angle
• scapular notch
• infraglenoid tubercle
• supraglenoid tubercle
• neck of scapula
• coracoid process

2.Humerus

lower limb的關節

1.hip joint
2.knee joint
3.tibiofibular joint
4.ankle joint(tarsal joint)
5.subtalar joint

Lower limb的幾個重要區域

1.subinguinal space & femoral triangle--anterior thigh

• femoral triangle→邊界：inguinal ligament 、sartorius、adductorlongus；floor：pectineus、iliopsoas；roof：fascia lata、cribriform fascia、"part of sartorius"
• femoral artery穿過中間，頂點底下有deep femoral A&V
• 由外往內→NAV，其中A與V在femoral sheath內，神經沒被包起來
• femoral sheath包覆：femoral artery、femoral vein、femoral canal
• femoral→medial：lacunar ligament，lateral：femoral vein，anterior：inguinal ligament，posterior：pectineus
• subinguinal space被iliopectineal arch分成，前方：vascular lacuna，含A、V、淋巴；後方：muscular lacuna，含N、iliopsoas
• 股神經→分成saphenous nerve、nerve to vastus medialis
• 股三角的出口接到adductor cannal

2.adductor cannal & adductor hiatus

3.Tarsal tunnel

4.obturator cannal--medial thigh

5.greater sciatic foramen--gluteus

6.lesser sciatic foramen--perineum

Lower limb的Muscle

1.Anterior thigh muscle

• pectineus
• iliopsoas=iliacus+psoas major
• sartorius
• quadriceps femoris
• (1)rectus femoris
• (2)vastus lateralis
• (3)vastus medialis
• (4)vastus intermedius

2.Posterior thigh muscles(hamstrings)

• semitendinosus
• semimembranosus
• biceps femoris(long head)

3.Medial thigh muscles

• adductor longus
• adductor brevis
• adductor magnus
• gracilis
• obturator externus

4.Gluteal

淺層

• gluteus maximus
• gluteus minimus
• gluteus medius

深層

• piriformis
• obturator internus
• gemelli superior
• gemelli inferior
• quadratus femoris

5.Anterior compartment of the leg

• tibialis anterior
• extensor digitorum longus
• extensor hallucis longus
• fibularis(peroneus) tertius

6.Lateral compartmnt of the leg

• Fibularis longus
• fibularis brevis

7.Posterior compartment of the leg

淺層

• triceps surae=gastrocnemius+soleus
• plantaris

深層

• popliteus
• flexor digitorum longus
• flexor hallucis longus
• tibialis posterior

8.Foot

第一層

• abductor hallucis
• flexor digitorum brevis
• abductor digiti minimi

第二層

• quadratus plantae
• tendon of flexor hallucis longus
• tendon of flexor digitorum longus
• lumbrical muscles

第三層

• flexor hallucis brevis
• adductor hallucis

第四層

• interossei

Lower limb的重要Bone Markings

1.Hip Bone

• iliac crest
• tubercle of iliac crest
• anterior superior iliac spine
• anterior inferior iliac spine
• posterior superior iliac spine
• poserior inferior iliac spine
• greater sciatic notch
• ischial spine
• lesser sciatic noch
• ischial tuberosity
• iliac fossa
• gluteal surface
• sacropelvic surface
• auricular surface
• iliac tuberosity
• pubic tubercle
• iliopubic emincence
• pecten of the pubis
• obturator groove

2.Thigh Bone

• head of femur
• greater trochanter
• trochanteric fossa
• lesser trochanter
• intertrochanteric line
• intertrochanteric crest
• gluteal tuberosity
• linea aspera
• pectineal line
• popliteal surface
• intercondylar line
• intercondylar fossa
• medial condyle
• lateral condyle
• patellar surface

3.Leg

• anterior intercondylar area
• posterior intercondylar area
• intercondylar eminence
• medial intercondylar tubercle
• tuberculum intercondylare laterale
• tibial tuberosity
• soleal line of tibia
• interosseous margin
• medial malleolus
• malleolar groove

4.Foot

Block6 解剖學Learning Objects--Low limb

需要學習的是6個regions所對應出的6個項目
其中6個regions指的是
1.Femoral(thigh)
2.Gluteal (buttocks)
3.Knee joints
4.Leg
5.Ankle(talocrural)
6.Foot

所對應的6個項目分別是
1.Bone Marking
2.Vessels
3.Superficial--lymphatic drainage
--cutaneous nerves
4.Gait analysis步態分析
5.Muscle
6.重點區域--structures
--entrance