[정형외과] 관절와순 전후방 병변 (SLAP, superior labrum ant. post.)

지난번에 견관절의 불안정성에 대해 살펴보았읍니다.

Bankart 병변이라고 하는 관절와순의 파열에 대해 살펴보았는데

자세한것은 여기를 클릭

이번엔 이와 무척 유사하지만 발생기전이 다른 또다른 관절와순의 파열에 대해 알아 보겠읍니다..

 

 

 

 아래 그림은 외상에 의한 관절와순 파열(Bankart 병변)의 발생 기전입니다.

 

 

관절와순은 다음과 같이 생겼는데 SLAP은 관절와순의 꼭대기에

이두박건의 장건이 붙는다는 차이가 있읍니다.

 

 

SLAP은 대부분 어깨위로 작업을 하는 노동자나 운동선수에서 자주 발생하는데

이는 이두박건의 장건(긴힘줄)이 반복적 지속적으로 관절와순을 잡아당겨

천천히 파열이 유도되므로서 발생하게 됩니다.

 

 

 

Biceps tendon(이두박건의 장건)이 관절와순의 꼭대기에 붙어있는 모습입니다.

 

즉, Bankart 병변은 급격한 외상에 의해 생기고

SLAP은 지속적 반복적 동작에 의해 발생하게 되는데

사실 모든예가 그러한것은 아니고

두 질병모두 겹치는 영역을 가지고 있읍니다.

 

 

 

SLAP의 분류입니다.

흔히 볼수 있는 1, 2, 3, 4 type입니다.

 

 

알아보기 힘드니 모식도로 보겠읍니다.

1번이 가장 많고 그 다음이 2번 순입니다.

 

 

다음은 확장 type입니다.

 

 

 

MR 소견입니다.

 

조영전에는 병변이 뚜렷이 보이질 않습니다.

 

 

조영제를 넣고 검사하면 위와 같이 뚜렷한 병변을 볼 수 있읍니다.

 

 

 

 

치료는 초기에는 보존적 치료를 하나 증상이 심하고 파열양상이 큰경우에는

관절경을 이용하여 수술을 시행하게 됩니다.

 

다음은 실제 관절경 소견입니다.

 

type IV SLAP 병변입니다.

 

다듬고 난후에 보이는 병변입니다..

 

 

 

 

 

수술은 다음 모식도와 같이 시행합니다.

 

 

 

 

 

실제 관절경 수술장면

 

 

아주 심한 경우에서의 관절경적 수술장면

 

 

중요한 것은 정확한 진단과 이에 따른 정확한 치료입니다.

 

 

 

 

 

수술후 재활에 대한 문의가 있으셔서 복잡한 테이블과 간단한 설명을 덧붙입니다.

 

1. 복잡한 테이블

 

Repair Protocol for Superior Labral Anterior Posterior (SLAP) Lesion[*]

 

 

Phase I—Immediate Postsurgical
Weeks 0-2 Postoperative (Type II and IV) Goals (by end of 2 wk)
   1.     P/AAROM with following restrictions     FL <120 degrees    ER/IR <30 degrees
   2.     Table slides in FL/pendulums
   3.     Scapular mobility exercises
   4.     Passive elbow FL
   5.     Active hand, wrist ROM and gripping exercises
   6.     Submaximal pain-free isometrics     IR/ER    ABD/ADD
 
    Scapular retraction/depression
   1.     Independent with HEP
   2.     PROM 120 degrees maximum     FL/scaption
   3.     PROM 30 degrees maximal     ER/IR
   4.     Full hand, wrist AROM
   5.     Active elbow EXT to 30 degrees, full passive elbow FL
 
    Precautions 
    1.     Sling compliance
    2.     No active biceps contraction
    3.     Full active elbow EXT
 
 
Phase II—Graded AROM/Strengthening
Weeks 3-6 Postoperative Goals (by end of 6 wk)
   1.     Glenohumeral joint mobilizations (grades I and II)
   2.     Progressing PROM to tolerance
   3.     Progress AAROM/AROM
   4.     Progress scapular mobility exercises (side lying)
   5.     Elbow FL—no resistance
   6.     UBE with low resistance
   7.     Initiate T-band ER/IR isometrics in neutral (sidestepping)
   8.     Rhythmic stabilization progression
   9.     PNF diagonals with light/moderate manual resistance
 
    1.     Independent with HEP
    2.     Gradually restore full PROM
    3.     Discontinue sling as pain decreases and proximal stability increases (wk 3-4)
    4.     Restore correct shoulder girdle mechanics (scapulohumeral rhythm)
    5.     Full active elbow FL (pain-free)
    6.     Full EXT by 4-6 wk depending on physician input
    7.     Able to comb hair (if dominant arm)
    8.     Sleep uninterrupted
 
    Precautions 
    1.     No lifting
    2.     No ER with ABD >90 degrees
 
 
Weeks 7-9 Postoperative Goals (by end of 9 wk)
   1.     Continue progressing PROM—more aggressive mobilizations if needed (progress joint mobilizations grades III and IV as needed)
   2.     Elbow FL with light weights (1-5 lb)
   3.     UBE—increase intensity
   4.     Progress isotonics as able (T-band/light weight)
   5.     Progress rhythmic stabilization/PNF diagonals
   6.     Progress closed-chain exercises (especially wall push-ups)
 
    1.     Independent with HEP
    2.     AROM WNL
    3.     Able to reach behind back for wallet
    4.     Able to lift plate into eye-level cabinet
 
    Precautions 
    1.     No lifting >5 lb
 
 
Weeks 10-11 Postoperative Goals (by end of 11 wk)
   1.     Progress above exercises as tolerated
    2.     T-band ER/IR 45 to 90 degrees increase speed/intensity (must be pain-free and demonstrate correct hanics)
    3.     Closed-chain scapular stability exercises (quadruped, tripod, side lying)
    4.     Progress proprioceptive training to include progressive weight bearing exercises on unstable surfaces
 
    1.     MMT elbow FL 4/5
    2.     MMT shoulder FL 4/5
    3.     MMT shoulder ABD 4/5
    4.     MMT shoulder ER 4/5
    5.     MMT shoulder IR 4/5
    6.     Able to lift 3 lb into overhead cabinet
    7.     Maintain scapulohumeral rhythm with strengthening and functional activities
    8.     Able to tuck shirt and fasten bra
 
    Precautions
 
    No unilateral lifting over head >5 lb
 
 
Phase III—Advanced Strengthening for Return to Sport
Weeks 12-15 Postoperative Goals (by end of 15 wk)
   1.     Progress isotonics increasing resistance/repetitions (exercises, throwing, lunges)
   2.     Plyoball exercises if appropriate     Chest pass
 
   Overhead throw
   Sideway throw
   one-handed ball on wall
   3.     Progress shoulder strengthening (lateral pull-downs, rows)
   4.     Isokinetic strengthening as needed
 
   1.     MMT shoulder musculature 5/5
   2.     Able to place ≥10 lb in overhead cabinet
 
 
Weeks 16 to 24 Postoperative Goals (by end of 6 mo)
   1.     Initiate interval throwing (per physician input)
   2.     Initiate sport-specific/functional training
   3.     Isokinetic testing if requested
 
   1.     Return to sport/activity of choice
   2.     Independent with exercise progression
 
 

Phase I—Immediate Postsurgical
Weeks 0-2 Postoperative (Type II and IV)	Goals (by end of 2 wk)
1.    P/AAROM with following restrictions    FL <120 degrees    ER/IR <30 degrees    2.    Table slides in FL/pendulums    3.    Scapular mobility exercises    4.    Passive elbow FL    5.    Active hand, wrist ROM and gripping exercises    6.    Submaximal pain-free isometrics    IR/ER    ABD/ADD    Scapular retraction/depression	1.    Independent with HEP    2.    PROM 120 degrees maximum    FL/scaption    3.    PROM 30 degrees maximal    ER/IR    4.    Full hand, wrist AROM    5.    Active elbow EXT to 30 degrees, full passive elbow FL    Precautions    1.    Sling compliance    2.    No active biceps contraction    3.    Full active elbow EXT
Phase II—Graded AROM/Strengthening
Weeks 3-6 Postoperative	Goals (by end of 6 wk)
1.    Glenohumeral joint mobilizations (grades I and II)    2.    Progressing PROM to tolerance    3.    Progress AAROM/AROM    4.    Progress scapular mobility exercises (side lying)    5.    Elbow FL—no resistance    6.    UBE with low resistance    7.    Initiate T-band ER/IR isometrics in neutral (sidestepping)    8.    Rhythmic stabilization progression    9.    PNF diagonals with light/moderate manual resistance	1.    Independent with HEP    2.    Gradually restore full PROM    3.    Discontinue sling as pain decreases and proximal stability increases (wk 3-4)    4.    Restore correct shoulder girdle mechanics (scapulohumeral rhythm)    5.    Full active elbow FL (pain-free)    6.    Full EXT by 4-6 wk depending on physician input    7.    Able to comb hair (if dominant arm)    8.    Sleep uninterrupted    Precautions    1.    No lifting    2.    No ER with ABD >90 degrees
Weeks 7-9 Postoperative	Goals (by end of 9 wk)
1.    Continue progressing PROM—more aggressive mobilizations if needed (progress joint mobilizations grades III and IV as needed)    2.    Elbow FL with light weights (1-5 lb)    3.    UBE—increase intensity    4.    Progress isotonics as able (T-band/light weight)    5.    Progress rhythmic stabilization/PNF diagonals    6.    Progress closed-chain exercises (especially wall push-ups)	1.    Independent with HEP    2.    AROM WNL    3.    Able to reach behind back for wallet    4.    Able to lift plate into eye-level cabinet    Precautions    1.    No lifting >5 lb
Weeks 10-11 Postoperative	Goals (by end of 11 wk)
1.    Progress above exercises as tolerated    2.    T-band ER/IR 45 to 90 degrees increase speed/intensity (must be pain-free and demonstrate correct mechanics)    3.    Closed-chain scapular stability exercises (quadruped, tripod, side lying)    4.    Progress proprioceptive training to include progressive weight bearing exercises on unstable surfaces	1.    MMT elbow FL 4/5    2.    MMT shoulder FL 4/5    3.    MMT shoulder ABD 4/5    4.    MMT shoulder ER 4/5    5.    MMT shoulder IR 4/5    6.    Able to lift 3 lb into overhead cabinet    7.    Maintain scapulohumeral rhythm with strengthening and functional activities    8.    Able to tuck shirt and fasten bra    Precautions    No unilateral lifting over head >5 lb
Phase III—Advanced Strengthening for Return to Sport
Weeks 12-15 Postoperative	Goals (by end of 15 wk)
1.    Progress isotonics increasing resistance/repetitions (exercises, throwing, lunges)    2.    Plyoball exercises if appropriate    Chest pass    Overhead throw    Sideway throw    One-handed ball on wall    3.    Progress shoulder strengthening (lateral pull-downs, rows)    4.    Isokinetic strengthening as needed	1.    MMT shoulder musculature 5/5    2.    Able to place ≥10 lb in overhead cabinet
Weeks 16 to 24 Postoperative	Goals (by end of 6 mo)
1.    Initiate interval throwing (per physician input)   2.    Initiate sport-specific/functional training    3.    Isokinetic testing if requested	1.    Return to sport/activity of choice    2.    Independent with exercise progression

 

 

 

테이블이 복잡하시지요 ?

 

2. 간단한 설명

 

단순 SLAP의 경우  pillow sling을 3주 착용하고

3주부터 6주까지 각도제한없는 능동보조 전방거상 운동(unlimited active-assisted forward elevation)를 실시합니다

 

SLAP이 광범위한 Bankart 병변과 같이 있었을 경우에는

보조기를 6주 착용하고 진자운동과 능동보조 관절운동(Pendulum and active-assisted range-of-motion exercises)을

3주부터 시작하여 4주차에는 내전운동(Internal rotation behind the back )까지 시작하게 됩니다.

하지만 internal rotation with the arm elevated (the cross-body adduction position) 자세는 6주까지는 금지합니다

6주이후에 근력운동을 시작하게 됩니다.