臨床檢查(cha)(cha)是診(zhen)斷(duan)(duan)傷科疾病(bing)最基(ji)本的(de)(de)(de)(de)手段,是發現病(bing)人客觀體(ti)征以判斷(duan)(duan)其病(bing)變的(de)(de)(de)(de)有無或(huo)部位、性質的(de)(de)(de)(de)重(zhong)要(yao)(yao)方(fang)法。一般要(yao)(yao)求在前面(mian)(mian)了(le)解(jie)病(bing)史之后再進行(xing)(xing);但對(dui)急癥可以一面(mian)(mian)了(le)解(jie)病(bing)史,一面(mian)(mian)進行(xing)(xing)檢查(cha)(cha)。對(dui)病(bing)情復雜或(huo)診(zhen)斷(duan)(duan)困難者,還要(yao)(yao)定期反復檢查(cha)(cha)。檢查(cha)(cha)時要(yao)(yao)與健肢(zhi)(zhi)正常(chang)的(de)(de)(de)(de)解(jie)剖(pou)和運動功(gong)能進行(xing)(xing)對(dui)比。應從病(bing)變以外的(de)(de)(de)(de)區域開(kai)始,先檢查(cha)(cha)健肢(zhi)(zhi)或(huo)癥狀(zhuang)較輕的(de)(de)(de)(de)肢(zhi)(zhi)體(ti),讓病(bing)人理解(jie)檢查(cha)(cha)動作,對(dui)小兒(er)更應如此。
1、望診 傷(shang)科望診,應借助于視力(li)或觸摸,側重注意觀察患(huan)者站立或坐位的(de)姿勢、步態與(yu)肢體(ti)長短、形態、關節活(huo)動,皮膚色澤,有無潰瘍、瘢痕、壞死(si)、竇道、屢管或靜脈曲張,肌肉萎(wei)縮、松弛(chi)、痙攣、或震(zhen)顫(zhan),創(chuang)(chuang)口的(de)大小、深(shen)淺,創(chuang)(chuang)緣是否整齊(qi),創(chuang)(chuang)面污染程(cheng)度以及有無活(huo)動性出血等。體(ti)表任(ren)何部(bu)位遭受(shou)暴力(li)作(zuo)用的(de)征象(xiang)應予記錄。
2、摸診
(1)切診(zhen) 亦(yi)稱脈(mo)(mo)(mo)(mo)(mo)診(zhen)。是觀察(cha)整體變化的(de)(de)方法之(zhi)(zhi)一(yi)。傷科(ke)切診(zhen)主(zhu)要從脈(mo)(mo)(mo)(mo)(mo)搏的(de)(de)有(you)無、脈(mo)(mo)(mo)(mo)(mo)位的(de)(de)高低、搏動的(de)(de)頻率、節律、強弱(ruo)、大(da)(da)小等方面來觀察(cha)。脈(mo)(mo)(mo)(mo)(mo)浮主(zhu)表,脈(mo)(mo)(mo)(mo)(mo)沉(chen)(chen)主(zhu)里,脈(mo)(mo)(mo)(mo)(mo)弦(xian)主(zhu)痛(tong)。故體表受傷,傷勢較(jiao)輕,可(ke)有(you)俘弦(xian)之(zhi)(zhi)脈(mo)(mo)(mo)(mo)(mo);內臟損(sun)(sun)傷,傷勢較(jiao)重(zhong),可(ke)出現沉(chen)(chen)弦(xian)之(zhi)(zhi)脈(mo)(mo)(mo)(mo)(mo);一(yi)時疼痛(tong),偶可(ke)出現結代之(zhi)(zhi)脈(mo)(mo)(mo)(mo)(mo),隨著痛(tong)止(zhi)脈(mo)(mo)(mo)(mo)(mo)律可(ke)恢復正(zheng)常;脈(mo)(mo)(mo)(mo)(mo)數主(zhu)熱(re),正(zheng)邪(xie)俱盛則脈(mo)(mo)(mo)(mo)(mo)洪大(da)(da);正(zheng)邪(xie)俱慮則脈(mo)(mo)(mo)(mo)(mo)細(xi)微(wei);故骨(gu)關(guan)節急性(xing)(xing)化膿性(xing)(xing)(炎(yan)疾(ji))感(gan)染、創(chuang)傷血瘀化熱(re),熱(re)毒熾盛,而正(zheng)氣亦(yi)盛之(zhi)(zhi)癥,脈(mo)(mo)(mo)(mo)(mo)多數而洪大(da)(da);若(ruo)骨(gu)關(guan)節結核(he)陰虛(xu)內熱(re)之(zhi)(zhi)癥,脈(mo)(mo)(mo)(mo)(mo)多數而微(wei)細(xi);大(da)(da)出血患者可(ke)見(jian)芤脈(mo)(mo)(mo)(mo)(mo);創(chuang)傷性(xing)(xing)休克可(ke)出現脈(mo)(mo)(mo)(mo)(mo)微(wei)欲絕的(de)(de)危象(xiang);損(sun)(sun)傷肢體遠端(duan)可(ke)出現脈(mo)(mo)(mo)(mo)(mo)搏微(wei)弱(ruo)或消失(shi),是動脈(mo)(mo)(mo)(mo)(mo)受壓或損(sun)(sun)傷的(de)(de)征象(xiang)。損(sun)(sun)傷性(xing)(xing)疾(ji)病(bing)常見(jian)的(de)(de)脈(mo)(mo)(mo)(mo)(mo)象(xiang)有(you)下(xia)列幾(ji)種:
浮脈 輕取(qu)應(ying)指,重按之后(hou)反(fan)覺其(qi)搏動力量稍減而不空,舉之泛(fan)泛(fan)而有余(yu)。新傷瘀腫疼痛者多見(jian),亦見(jian)于休克或(huo)虛脫之癥。
沉脈 輕(qing)按不應指,重按覺有(you)搏動。多見(jian)于內傷其(qi)血,腰及脊柱損傷后(hou)期,或見(jian)于因損傷所致肝腎精氣不足(zu)的久(jiu)病患者。
遲脈 脈搏緩慢(man),呼吸1次脈跳不足4次。多見(jian)于(yu)損(sun)傷(shang)后(hou)期瘀血(xue)凝滯,氣血(xue)未充,復為寒邪所(suo)感等癥。
數(shu)脈(mo) 脈(mo)搏快(kuai),呼吸1次脈(mo)跳在6次以上(shang)。數(shu)而有力,多為實熱(re);數(shu)而無力者,多屬(shu)血(xue)虛或(huo)(huo)失血(xue)過多;損傷感染或(huo)(huo)新傷發熱(re)時亦(yi)見數(shu)脈(mo)。
細(xi)脈(mo) 脈(mo)細(xi)如線,應指顯然,按之(zhi)無(wu)力。多見于嚴重損傷出血之(zhi)病(bing)人,久病(bing)體虛、氣血不足者亦可出現細(xi)脈(mo)。
洪脈(mo) 脈(mo)動有力,脈(mo)體(ti)寬大,如波濤洶涌(yong),來盛(sheng)去弱。一(yi)般表示邪(xie)毒內侵,經絡熱(re)盛(sheng)或多見(jian)于傷(shang)后血瘀生(sheng)熱(re)之癥。
弦(xian)脈 脈形直長(chang),如按琴弦(xian),主(zhu)諸痛(tong)。常(chang)見于損傷引(yin)起的劇(ju)烈疼痛(tong),如胸(xiong)脅部損傷;弦(xian)而有力者稱為緊(jin)脈,多見于外感寒勝之腰(yao)背痛(tong)等癥。
芤脈 脈形(xing)浮大而中空,重(zhong)按無力。多見于創傷出血過多者,為(wei)(wei)血虛不能固氣,亦為(wei)(wei)休克脈象之一。
滑脈(mo) 指脈(mo)搏(bo)往來流利(li),如珠走盤,應指圓滑。多見于(yu)胸部挫傷血實(shi)氣(qi)壅時及婦女妊娠期。
澀脈 指脈形不流利(li),細而遲緩,往(wang)來艱澀,如輕刀刮竹。血虧津少(shao)不能濡潤經絡,氣(qi)滯血瘀的陳傷多見此脈。
(2)捫診(zhen) 即觸診(zhen)。通過(guo)對損(sun)傷(shang)局部的(de)(de)認真觸摸(mo),可(ke)以查明損(sun)傷(shang)部位的(de)(de)形態、硬度、溫(wen)(wen)度等有無改變,借以了(le)解腫脹、畸形、筋肉(rou)的(de)(de)硬度、皮膚的(de)(de)溫(wen)(wen)度,患肢的(de)(de)功能狀(zhuang)況等,從而判斷傷(shang)情。觸摸(mo)的(de)(de)方法,要由輕漸重(zhong),由淺而深,沿著肌間隙才能觸摸(mo)清(qing)楚(chu)骨骼、在(zai)捫診(zhen)檢(jian)查時應(ying)該注意下列幾(ji)個方面:
觸(chu)摸動(dong)(dong)(dong)(dong)脈(mo)搏(bo)動(dong)(dong)(dong)(dong) 能了解傷(shang)肢遠端有無血(xue)運障礙,對于(yu)骨折(zhe)、脫位合并動(dong)(dong)(dong)(dong)脈(mo)損(sun)傷(shang)有重(zhong)要意(yi)義,是檢查與治療骨關(guan)節損(sun)傷(shang)必不可(ke)少的步驟。通(tong)常觸(chu)摸動(dong)(dong)(dong)(dong)脈(mo)搏(bo)動(dong)(dong)(dong)(dong)的部位有:肘前(qian)部摸肱動(dong)(dong)(dong)(dong)脈(mo),手(shou)腕部觸(chu)橈動(dong)(dong)(dong)(dong)脈(mo),國窩(wo)部捫(men)國動(dong)(dong)(dong)(dong)脈(mo),足踝前(qian)部測(ce)足背動(dong)(dong)(dong)(dong)脈(mo),內踝后(hou)方(fang)切脛后(hou)動(dong)(dong)(dong)(dong)脈(mo)。還可(ke)以(yi)用手(shou)指(zhi)按壓指(zhi)(趾)甲,觀察肢體末端的血(xue)運情況。
觸摸皮(pi)膚(fu)溫度 局部(bu)皮(pi)膚(fu)溫度高者,多表示急性(xing)損傷后瘀腫(zhong)嚴重或(huo)有急性(xing)炎(yan)癥(zheng)。局部(bu)溫度不高或(huo)發涼者多為陳舊性(xing)損傷或(huo)慢性(xing)勞損所(suo)致。傷肢遠(yuan)端疼痛(tong)、冰冷、脈搏消失、皮(pi)膚(fu)蒼白或(huo)紫紺是(shi)循環(huan)障礙的(de)表現。
觸摸壓痛(tong)(tong)點 首先要應(ying)用(yong)解(jie)剖學的(de)知識,將傷(shang)肢(zhi)體(ti)表可(ke)觸及到的(de)骨(gu)(gu)凸、凹陷、筋(jin)肉等與健肢(zhi)作對比,邊(bian)觸摸邊(bian)思考。尋找壓痛(tong)(tong)點,區(qu)分(fen)疼(teng)(teng)(teng)痛(tong)(tong)的(de)輕重、深淺(qian),過敏或遲鈍,局限(xian)或廣(guang)泛(fan),有無(wu)放射疼(teng)(teng)(teng)及其部位(wei),以鑒別損(sun)傷(shang)的(de)性(xing)質(zhi)與種類。長骨(gu)(gu)干(gan)完全骨(gu)(gu)折時(shi),傷(shang)處(chu)(chu)多有環狀壓痛(tong)(tong),沿骨(gu)(gu)干(gan)縱軸(zhou)擠壓與叩擊時(shi),可(ke)出現骨(gu)(gu)折處(chu)(chu)疼(teng)(teng)(teng)痛(tong)(tong);骨(gu)(gu)盆及肋骨(gu)(gu)骨(gu)(gu)折時(shi),從前后或左右擠壓骨(gu)(gu)盆或胸廓(kuo),可(ke)引起骨(gu)(gu)折處(chu)(chu)疼(teng)(teng)(teng)痛(tong)(tong);壓痛(tong)(tong)部位(wei)較深、范圍較小、呈銳(rui)痛(tong)(tong)或刺痛(tong)(tong),則表示(shi)(shi)筋(jin)的(de)撕裂(lie)或骨(gu)(gu)質(zhi)損(sun)傷(shang);壓痛(tong)(tong)部位(wei)淺(qian)、范圍大、程度輕,則表示(shi)(shi)筋(jin)肉的(de)慢性(xing)損(sun)傷(shang);壓痛(tong)(tong)深并向肢(zhi)體(ti)遠(yuan)端放射者,多系(xi)神經(jing)根(gen)受壓(如椎間盤突出癥等)。
觸摸畸形(xing) 檢查時(shi)應注(zhu)意(yi)局部有(you)無高凸、凹陷、成(cheng)角(jiao)、旋轉等畸形(xing)改(gai)變(bian),并結合(he)觸摸骨(gu)(gu)性標志有(you)無異(yi)常。可以幫助判斷有(you)無骨(gu)(gu)折、脫位(wei)。如(ru)肘關節后脫位(wei)。肱骨(gu)(gu)內(nei)上(shang)髁(ke)、外(wai)上(shang)髁(ke)與(yu)尺骨(gu)(gu)鷹嘴三(san)個骨(gu)(gu)突(tu)標志發(fa)生(sheng)異(yi)常改(gai)變(bian)。骨(gu)(gu)折后,可摸到(dao)移位(wei)的斷端高凸活成(cheng)角(jiao)等畸形(xing)。
觸(chu)摸局部腫(zhong)(zhong)脹(zhang)與(yu)(yu)包塊 皮(pi)膚顏(yan)色、溫度正常(chang)(chang)(chang),或(huo)(huo)有(you)皮(pi)下出(chu)血(xue)(xue)(xue)(xue),按(an)之(zhi)(zhi)即起或(huo)(huo)按(an)之(zhi)(zhi)腫(zhong)(zhong)硬(ying),多系損骨(gu)(gu)傷筋后內(nei)出(chu)血(xue)(xue)(xue)(xue)及(ji)(ji)組織反應(ying)性水腫(zhong)(zhong)所引起,常(chang)(chang)(chang)見于骨(gu)(gu)折(zhe)、傷筋早(zao)期(qi)(qi),為(wei)氣滯血(xue)(xue)(xue)(xue)瘀,經(jing)絡阻塞;溫度正常(chang)(chang)(chang),皮(pi)色正常(chang)(chang)(chang)或(huo)(huo)發紫,按(an)之(zhi)(zhi)不(bu)即起,或(huo)(huo)傷肢(zhi)下墜過(guo)久,按(an)之(zhi)(zhi)有(you)硬(ying)韌(ren)感(gan),多系長期(qi)(qi)臥床或(huo)(huo)骨(gu)(gu)折(zhe)固定(ding)后,筋肉組織彈性減弱,肌(ji)力(li)減退,血(xue)(xue)(xue)(xue)液(ye)回流受到(dao)影響所致(zhi),為(wei)氣血(xue)(xue)(xue)(xue)不(bu)能通達于四肢(zhi),氣虛血(xue)(xue)(xue)(xue)滯,常(chang)(chang)(chang)見于骨(gu)(gu)折(zhe)恢復期(qi)(qi)的功能鍛煉過(guo)程(cheng)中(zhong)。若觸(chu)及(ji)(ji)包塊,應(ying)了(le)解(jie)(jie)其部位(wei)、大小、形(xing)狀、硬(ying)度及(ji)(ji)與(yu)(yu)周圍組織器官的關系,還(huan)(huan)應(ying)注意腫(zhong)(zhong)塊的邊界是否清楚(chu)(chu),推(tui)之(zhi)(zhi)能否移動等。如腱鞘囊腫(zhong)(zhong),包塊多呈圓形(xing),邊界清楚(chu)(chu),推(tui)之(zhi)(zhi)可動、質軟。脛骨(gu)(gu)結(jie)節(jie)(jie)骨(gu)(gu)軟骨(gu)(gu)炎(yan)時(shi),在脛骨(gu)(gu)結(jie)節(jie)(jie)處觸(chu)及(ji)(ji)一質地堅硬(ying)、形(xing)狀不(bu)一的明顯凸(tu)起,且有(you)推(tui)之(zhi)(zhi)不(bu)動的壓(ya)痛(tong)。在觸(chu)摸時(shi)用力(li)應(ying)輕柔(rou),以免增加病人疼痛(tong)。對腫(zhong)(zhong)瘤不(bu)要過(guo)多的擠壓(ya),防治瘤細胞的轉移。觸(chu)摸時(shi)還(huan)(huan)應(ying)區(qu)別腫(zhong)(zhong)塊的解(jie)(jie)剖層次(ci),是在骨(gu)(gu)骼還(huan)(huan)是在肌(ji)腱、肌(ji)肉等組織中(zhong)。
3、運動檢查 首(shou)先(xian)要熟(shu)悉正(zheng)(zheng)(zheng)(zheng)常(chang)關(guan)(guan)(guan)節的(de)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)特(te)點及(ji)活動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)幅(fu)(fu)度(du)(du),以了解其運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)是否(fou)正(zheng)(zheng)(zheng)(zheng)常(chang)。例如(ru)球窩關(guan)(guan)(guan)節可(ke)(ke)主動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)進(jin)行屈伸、內收外展和內外旋轉運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong);屈戌關(guan)(guan)(guan)節僅(jin)可(ke)(ke)做屈伸活動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)。如(ru)果一(yi)(yi)個關(guan)(guan)(guan)節的(de)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)幅(fu)(fu)度(du)(du)不足,或某一(yi)(yi)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)方向的(de)活動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)幅(fu)(fu)度(du)(du)超(chao)過了正(zheng)(zheng)(zheng)(zheng)常(chang)范(fan)圍(wei),均(jun)應(ying)視為(wei)異常(chang)。在肢(zhi)體沒有關(guan)(guan)(guan)節處出現(xian)類似關(guan)(guan)(guan)節活動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)稱為(wei)假關(guan)(guan)(guan)節活動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong),這是骨(gu)折(zhe)的(de)主要特(te)征。關(guan)(guan)(guan)節的(de)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)范(fan)圍(wei),一(yi)(yi)般(ban)是被(bei)(bei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)大于主動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong),但還(huan)可(ke)(ke)因(yin)年齡、性(xing)別、生活方式及(ji)熟(shu)練(lian)(lian)程(cheng)(cheng)度(du)(du)而(er)(er)不同(tong)。相(xiang)(xiang)鄰(lin)關(guan)(guan)(guan)節的(de)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)范(fan)圍(wei)也(ye)可(ke)(ke)受(shou)影(ying)響或起(qi)補償作用,檢(jian)查(cha)時(shi)應(ying)考慮(lv)到這些特(te)點而(er)(er)做出正(zheng)(zheng)(zheng)(zheng)確(que)(que)判斷(duan)。檢(jian)查(cha)時(shi),一(yi)(yi)般(ban)是被(bei)(bei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)大于主動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong),但還(huan)可(ke)(ke)因(yin)年齡、性(xing)別、生活方式及(ji)熟(shu)練(lian)(lian)程(cheng)(cheng)度(du)(du)而(er)(er)不同(tong)。相(xiang)(xiang)鄰(lin)關(guan)(guan)(guan)節的(de)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)范(fan)圍(wei)也(ye)可(ke)(ke)受(shou)影(ying)響或起(qi)補償作用,檢(jian)查(cha)時(shi)應(ying)考慮(lv)到這些特(te)點而(er)(er)做出正(zheng)(zheng)(zheng)(zheng)確(que)(que)判斷(duan)。檢(jian)查(cha)時(shi),一(yi)(yi)般(ban)先(xian)做主動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong),后做被(bei)(bei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong),并(bing)對比(bi)其運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)范(fan)圍(wei)相(xiang)(xiang)差度(du)(du)數,借以區別是關(guan)(guan)(guan)節本身病(bing)變引起(qi)或神經(jing)肌(ji)肉(rou)麻(ma)痹所(suo)致(zhi)。如(ru)關(guan)(guan)(guan)節僵直時(shi),主、被(bei)(bei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)均(jun)有障礙;周圍(wei)神經(jing)損傷時(shi),或疾(ji)病(bing)引起(qi)肌(ji)肉(rou)癱瘓(huan)者,不能做主動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong),而(er)(er)被(bei)(bei)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)運(yun)動(dong)(dong)(dong)(dong)(dong)(dong)(dong)(dong)一(yi)(yi)般(ban)良好。
4、聞診 在傷科(ke)臨床檢(jian)查(cha)中,要特別注意在觸(chu)摸與(yu)運(yun)動檢(jian)查(cha)時(shi)(shi)有(you)(you)無(wu)(wu)響(xiang)音(yin)的(de)(de)(de)出(chu)現。當擺(bai)動或(huo)(huo)觸(chu)摸骨(gu)(gu)折的(de)(de)(de)肢(zhi)體(ti)時(shi)(shi),兩(liang)斷端相(xiang)互摩(mo)擦發(fa)出(chu)的(de)(de)(de)聲音(yin)(或(huo)(huo)摩(mo)擦感),稱(cheng)骨(gu)(gu)擦音(yin)(感),但檢(jian)查(cha)者不(bu)宜主動去尋(xun)找(zhao)骨(gu)(gu)擦音(yin),以(yi)免增加病人痛苦和(he)損傷。有(you)(you)病理改(gai)變(bian)的(de)(de)(de)關(guan)(guan)節或(huo)(huo)肌腱(jian)在活(huo)動時(shi)(shi),可(ke)觸(chu)到摩(mo)擦感或(huo)(huo)聽到彈(dan)(dan)響(xiang)聲;膝關(guan)(guan)節半月板損傷或(huo)(huo)關(guan)(guan)節內游離體(ti)引起的(de)(de)(de)彈(dan)(dan)響(xiang),多(duo)為較(jiao)清脆的(de)(de)(de)響(xiang)聲,關(guan)(guan)節軟骨(gu)(gu)面(mian)不(bu)光滑時(shi)(shi)的(de)(de)(de)摩(mo)擦響(xiang)聲則如碾米樣(yang);狹窄性(xing)(xing)腱(jian)鞘炎在關(guan)(guan)節活(huo)動時(shi)(shi)可(ke)觸(chu)到捻發(fa)感,關(guan)(guan)節周圍肌腱(jian)或(huo)(huo)韌帶在骨(gu)(gu)凸起部位滑動也能產生彈(dan)(dan)響(xiang);正常關(guan)(guan)節可(ke)有(you)(you)生理性(xing)(xing)彈(dan)(dan)響(xiang),但無(wu)(wu)癥狀,臨床上宜加細辨。
5、感覺檢查 檢(jian)查觸覺(jue)(jue)用(yong)一(yi)小(xiao)條棉花在皮膚上(shang)輕劃,應(ying)注(zhu)意失去觸覺(jue)(jue)區的(de)部(bu)位與范圍;檢(jian)查痛覺(jue)(jue)用(yong)銳針(zhen)輕刺,注(zhu)意痛覺(jue)(jue)改變區的(de)部(bu)位;檢(jian)查溫(wen)覺(jue)(jue)用(yong)小(xiao)瓶或試管分別盛十攝氏度(du)或四十五(wu)攝氏度(du)的(de)水進(jin)行。檢(jian)查時應(ying)由上(shang)而下(xia),從一(yi)側(ce)到另一(yi)側(ce),從失去知(zhi)覺(jue)(jue)區移向正常區。根據感覺(jue)(jue)障礙區域,判斷神經損傷的(de)情(qing)況。
6、測量 用軟尺和(he)量角器(qi)測量肢(zhi)體的(de)周徑、長(chang)短和(he)關節(jie)(jie)活(huo)動度(du)(du)數,要與健側對(dui)比檢查,準確的(de)測量對(dui)診斷和(he)治(zhi)(zhi)療均有重要的(de)意義。它可了(le)解肢(zhi)體的(de)長(chang)短、腫脹及萎縮(suo)的(de)程度(du)(du),關節(jie)(jie)活(huo)動幅度(du)(du),對(dui)確定治(zhi)(zhi)療方案和(he)檢查治(zhi)(zhi)療效果(guo)均有重要價值(zhi)。
(1)角(jiao)度(du) 關節(jie)(jie)(jie)的(de)功能可用(yong)量(liang)(liang)角(jiao)器(qi)測定(ding),先將量(liang)(liang)角(jiao)器(qi)的(de)軸對準關節(jie)(jie)(jie)中心(xin),量(liang)(liang)角(jiao)器(qi)的(de)兩臂緊貼肢體(ti)并對準肢體(ti)的(de)軸線(xian),然后記載量(liang)(liang)角(jiao)器(qi)所示的(de)角(jiao)度(du)(沒有量(liang)(liang)角(jiao)器(qi)時,也可借目測記錄),關于健肢的(de)相應關節(jie)(jie)(jie)比較。常用(yong)方法(fa)有兩種:
【鄰肢夾(jia)角法】 以兩個相鄰肢段所(suo)構成(cheng)的夾(jia)角計算,例(li)如肘(zhou)關節(jie)伸直(zhi)時為(wei)一(yi)(yi)百八十(shi)度(du),屈(qu)曲時可成(cheng)四(si)十(shi)度(du),則該(gai)關節(jie)活(huo)動范圍為(wei)一(yi)(yi)百八十(shi)度(du)減去四(si)十(shi)度(du)等(deng)于一(yi)(yi)百四(si)十(shi)度(du)。
中立(li)(li)位(wei)0度(du)法 即(ji)先確定(ding)每一個關節的中立(li)(li)位(wei)為(wei)(wei)0度(du),中立(li)(li)位(wei)一般相當于(yu)休(xiu)息位(wei),例如肘關節完(wan)全伸直時中立(li)(li)位(wei)為(wei)(wei)0度(du),完(wan)全屈曲時則可成(cheng)為(wei)(wei)一百四十度(du)。
對(dui)一易精確測量角度(du)的(de)(de)部(bu)位,關節功能(neng)活動(dong)也可用長度(du)測量,以(yi)記錄其相對(dui)的(de)(de)移動(dong)范圍(wei)。例如,對(dui)頸椎的(de)(de)前屈(qu)可測量下(xia)(xia)頦與(yu)胸骨柄的(de)(de)距離,側屈(qu)時測量耳垂與(yu)肩峰的(de)(de)距離;腰部(bu)前屈(qu)時測量下(xia)(xia)垂的(de)(de)中指(zhi)尖端與(yu)地面的(de)(de)距離等。
(2)長度 先(xian)將兩(liang)側(ce)肢(zhi)體放在(zai)對(dui)稱(cheng)位置上,在(zai)骨凸處作(zuo)一(yi)記號,用軟尺作(zuo)量(liang)側(ce)肢(zhi)體對(dui)比測(ce)量(liang)。
上肢長 肩峰至橈骨莖突(tu)部或中(zhong)指尖。
上臂(bei)長(chang) 肩峰至肱骨(gu)外(wai)上髁處。
前臂(bei)長 肱(gong)骨(gu)外上髁至橈骨(gu)莖突(tu)部。
下肢長 髂前上(shang)棘至足內踝尖,或(huo)股骨大(da)粗隆至外踝尖。
大腿長 髂(qia)前上棘至膝關節內緣。
小腿長 膝關節內(nei)緣(yuan)至內(nei)踝尖。
(3)周(zhou)徑(jing) 取兩肢體(ti)相對應(ying)的同一水平測量(liang),測量(liang)腫(zhong)脹時取最腫(zhong)處,大腿周(zhou)徑(jing)可(ke)在髕骨(gu)上十(shi)到十(shi)五厘米處測量(liang);小腿在最粗處測量(liang)即可(ke)。也可(ke)用(yong)雙手對稱合(he)抱肢體(ti),觀察雙拇指指尖的距(ju)離而測定之。
1、頭部 注意有(you)無傷(shang)(shang)口、血(xue)腫、壓痛或凹陷,并記(ji)錄其大小范圍;五官(guan)有(you)無溢血(xue)、溢液的情況;瞳孔(kong)是(shi)否對稱、縮(suo)小或散大;語言(yan)對答(da)、視覺(jue)、聽覺(jue)、嗅(xiu)覺(jue)是(shi)否正常(chang);鼻骨(gu)、顴骨(gu)及上頜骨(gu)骨(gu)折(zhe)有(you)否顏面畸形(xing)或觸及骨(gu)擦音(yin);下頜骨(gu)折(zhe)、顳頜關節(jie)脫位,常(chang)可引起(qi)咬合困難。外耳(er)道流血(xue)水,常(chang)提示(shi)顱后(hou)(hou)凹骨(gu)折(zhe)。創傷(shang)(shang)后(hou)(hou)出現不同程(cheng)度(du)的神志昏迷、血(xue)壓升高、脈(mo)象洪大而(er)遲緩(huan)、呼吸慢而(er)深,則提示(shi)嚴重的顱腦損傷(shang)(shang)。兩(liang)側瞳孔(kong)不等,散大與固定,則表示(shi)病危(wei)的征象。
2、胸部 應觀察(cha)呼吸情(qing)況(kuang),注(zhu)意胸部有無畸(ji)形、腫塊、擠壓痛、皮下(xia)氣腫及異常的清濁音區。肋骨骨折(zhe)早期,x線拍片不一定能顯(xian)示(shi)骨折(zhe)征象,故應仔細檢查胸壁(bi),其(qi)間接(jie)壓痛更有臨床診(zhen)斷(duan)意義。
3、腹部 應(ying)檢查壓痛、反跳痛、肌緊張的部位、程(cheng)度;腸鳴音是(shi)(shi)否存在(zai),有無(wu)(wu)亢進或(huo)減弱;肝濁音界有無(wu)(wu)縮小或(huo)消失;有無(wu)(wu)腫物(wu),腫物(wu)之大、部位、硬(ying)度,可否移(yi)動(dong),邊緣(yuan)是(shi)(shi)否清楚。胸部損傷出現咖(ka)啡樣(yang)嘔(ou)吐物(wu)時(shi),是(shi)(shi)上消化道 創傷的重要證(zheng)據。疑有內臟破裂或(huo)穿孔時(shi)可做腹腔穿刺(ci),檢查有無(wu)(wu)積(ji)血或(huo)積(ji)液。
4、上肢
(1)肩部
【望(wang)診(zhen)】 借助于視力或觸摸(mo),來觀(guan)察兩肩的外(wai)形是否(fou)對稱,有無畸(ji)形或肌肉萎(wei)縮。正常鎖骨(gu)的外(wai)下方是凹陷的,腫脹(zhang)時(shi)則該處(chu)膨隆。肩關(guan)節(jie)正常時(shi),直尺兩端不能同(tong)時(shi)接觸到肩峰(feng)和肱骨(gu)外(wai)上髁,若三(san)角肌癱(tan)瘓(huan)或肩關(guan)節(jie)脫位時(shi)則出現(xian)方肩畸(ji)形,直尺兩端可同(tong)時(shi)接觸到肩峰(feng)和肱骨(gu)外(wai)上髁,稱為直尺試驗陽性。
【觸診】 首先是尋找壓痛(tong)(tong)(tong)點(dian),肱二(er)頭肌(ji)長疼頭腱(jian)鞘炎(yan),壓痛(tong)(tong)(tong)點(dian)位于(yu)其(qi)(qi)肌(ji)腱(jian)通過的(de)(de)肱骨結(jie)節(jie)(jie)間溝(gou)處(chu);三(san)角(jiao)肌(ji)纖維退變(bian),壓痛(tong)(tong)(tong)點(dian)位于(yu)三(san)角(jiao)肌(ji)的(de)(de)前后緣(yuan),有時(shi)此其(qi)(qi)彼伏出(chu)現多個壓痛(tong)(tong)(tong)點(dian);岡(gang)上肌(ji)肌(ji)腱(jian)損(sun)傷,壓痛(tong)(tong)(tong)點(dian)常位于(yu)該肌(ji)肘(zhou)附(fu)著的(de)(de)肱骨大(da)結(jie)節(jie)(jie)處(chu);三(san)角(jiao)肌(ji)下滑(hua)囊炎(yan),壓痛(tong)(tong)(tong)比較廣泛,位于(yu)三(san)角(jiao)肌(ji)區。肩(jian)鎖(suo)(suo)關(guan)節(jie)(jie)處(chu)壓痛(tong)(tong)(tong)及隆起、肩(jian)峰下陷(xian),檢查者(zhe)用一(yi)手按壓鎖(suo)(suo)骨外端(duan),另手自肘(zhou)部向上托起其(qi)(qi)上臂,若畸形消失,即(ji)說明(ming)肩(jian)鎖(suo)(suo)關(guan)節(jie)(jie)脫位。
【運(yun)動檢查】 關節的(de)活動包括肩(jian)肱關節、肩(jian)鎖(suo)關節、胸(xiong)鎖(suo)關節、肩(jian)胛骨與胸(xiong)廓壁之間的(de)活動性連接(jie)四個(ge)(ge)部(bu)分,只要其中(zhong)任何一(yi)個(ge)(ge)關節發生損傷或疾病,就會(hui)影響整個(ge)(ge)肩(jian)部(bu)活動,肩(jian)關節的(de)主要運(yun)動有前屈、后伸,軟收(shou)、外展,上舉和內旋(xuan)、外旋(xuan)及(ji)環轉。
正常(chang)外展(zhan)(zhan)(zhan)時(shi)(shi),上(shang)(shang)肢可(ke)由軀干旁直舉(ju)(平肩(jian)(jian)(jian)后(hou)并外旋)過頭。這個動作(zuo)包括肩(jian)(jian)(jian)肱(gong)關節(jie)和肩(jian)(jian)(jian)胛骨與胸廓(kuo)壁之間的活動,故在檢查肩(jian)(jian)(jian)肱(gong)關節(jie)的外展(zhan)(zhan)(zhan)活動時(shi)(shi),應固定肩(jian)(jian)(jian)胛骨。岡上(shang)(shang)肌(ji)(ji)(ji)肌(ji)(ji)(ji)腱炎或不(bu)完全(quan)撕裂(lie)及三角(jiao)肌(ji)(ji)(ji)下滑囊炎的患者,在肩(jian)(jian)(jian)關節(jie)外展(zhan)(zhan)(zhan)六十度到一(yi)百二(er)十度范(fan)圍(wei)內(nei)時(shi)(shi),因上(shang)(shang)肌(ji)(ji)(ji)肌(ji)(ji)(ji)腱完全(quan)斷裂(lie)者,當肩(jian)(jian)(jian)關節(jie)外展(zhan)(zhan)(zhan)三十度到六十度時(shi)(shi),三角(jiao)肌(ji)(ji)(ji)雖用力收縮(suo),但不(bu)能外展(zhan)(zhan)(zhan)舉(ju)起上(shang)(shang)臂,越用力向上(shang)(shang)抬(tai)舉(ju)肩(jian)(jian)(jian)越高聳(song),此時(shi)(shi),如果(guo)幫助(zhu)患者外展(zhan)(zhan)(zhan)到這個范(fan)圍(wei)以(yi)上(shang)(shang),三角(jiao)肌(ji)(ji)(ji)便(bian)能單獨完成(cheng)其(qi)余的外展(zhan)(zhan)(zhan)幅度。
正常內收時(shi)(shi),手能摸到對側肩部(bu),同(tong)時(shi)(shi)肘部(bu)能貼(tie)緊胸壁。當肩關節(jie)脫位(wei)時(shi)(shi),上述動作(zuo)不能同(tong)時(shi)(shi)完(wan)成(cheng)或(huo)僅(jin)能完(wan)成(cheng)其中一(yi)項,稱為搭肩試驗陽性。
檢查肩(jian)關(guan)節(jie)(jie)(jie)內旋和外旋時,應先將患(huan)者(zhe)上(shang)臂(bei)緊(jin)貼軀干側面,屈肘九十度位才能進行觀察。肩(jian)關(guan)節(jie)(jie)(jie)周圍炎(yan)時,肩(jian)關(guan)節(jie)(jie)(jie)各(ge)方向活動(dong)均(jun)受(shou)(shou)限(xian)制(zhi)(zhi),其中以(yi)外展(zhan)、外旋及后(hou)伸動(dong)作受(shou)(shou)限(xian)最明(ming)(ming)顯,并(bing)引起(qi)疼痛,但在限(xian)度以(yi)內的活動(dong)則(ze)不痛。肩(jian)關(guan)節(jie)(jie)(jie)化膿(nong)性、類分濕(shi)性、結核性關(guan)節(jie)(jie)(jie)炎(yan)時,各(ge)方向的活動(dong)亦明(ming)(ming)顯受(shou)(shou)限(xian)制(zhi)(zhi)且疼痛。
(2)肘部
【望診】 借助于視力或(huo)觸摸(mo),了(le)解(jie)(jie)肘(zhou)關(guan)(guan)節(jie)的情況(kuang)。肘(zhou)關(guan)(guan)節(jie)后脫位及(ji)伸(shen)直型(xing)肱骨髁(ke)上(shang)骨折(zhe)(zhe)時(shi),肘(zhou)部(bu)呈(cheng)靴樣畸形。正常的肘(zhou)關(guan)(guan)節(jie)伸(shen)直時(shi),肱骨內、外(wai)上(shang)髁(ke)與尺骨鷹嘴三點(dian)在(zai)一條(tiao)直線上(shang),稱肘(zhou)直線;屈肘(zhou)九十度時(shi),此三點(dian)則(ze)形成一等腰三角形,稱為(wei)肘(zhou)三角。這種解(jie)(jie)剖關(guan)(guan)系(xi)在(zai)肘(zhou)關(guan)(guan)節(jie)脫位時(shi)發生異常,肱骨髁(ke)上(shang)骨折(zhe)(zhe)時(shi)則(ze)不變。當肘(zhou)關(guan)(guan)節(jie)伸(shen)直時(shi),前臂與上(shang)臂的縱軸呈(cheng)5度到(dao)十五度的外(wai)翻角(女(nv)性一般(ban)較(jiao)大(da)),稱為(wei)攜帶角,此角增大(da)稱為(wei)肘(zhou)外(wai)翻,反向則(ze)稱為(wei)肘(zhou)內翻。肘(zhou)關(guan)(guan)節(jie)積(ji)液或(huo)積(ji)血時(shi),屈肘(zhou)觀察后方,可見(jian)肱三頭(tou)肌腱兩(liang)側脹滿,嚴重腫脹則(ze)呈(cheng)梭(suo)形,肱橈(rao)關(guan)(guan)節(jie)部(bu)位的凹陷(xian)消失。
觸(chu)診 肘部勞損(sun)的壓痛(tong)點,常(chang)在肱骨內、外上髁部。前(qian)臂尺骨嵴在背側皮下可摸到(dao)其(qi)全(quan)長(chang),若(ruo)有壓痛(tong)或異常(chang)突起,常(chang)表(biao)示有病變。
【運(yun)動(dong)檢查】 肱尺(chi)關(guan)(guan)節(jie)的運(yun)動(dong)為(wei)屈伸,上、下尺(chi)橈(rao)(rao)關(guan)(guan)節(jie)的運(yun)動(dong)為(wei)旋(xuan)前旋(xuan)后(hou)(又稱內旋(xuan)外旋(xuan)活動(dong)),肱橈(rao)(rao)關(guan)(guan)節(jie)則(ze)同時參與屈伸和旋(xuan)轉。肘關(guan)(guan)節(jie)的功能位置是屈肘九十度、旋(xuan)中(zhong)位。
檢查關(guan)(guan)節(jie)(jie)的(de)主動(dong)(dong)(dong)伸(shen)(shen)直活(huo)(huo)動(dong)(dong)(dong),應(ying)(ying)采(cai)取肩(jian)外展或(huo)高(gao)舉(ju)位(wei)(wei)(wei)觀(guan)察。主動(dong)(dong)(dong)屈(qu)曲活(huo)(huo)動(dong)(dong)(dong),應(ying)(ying)在上肢下垂位(wei)(wei)(wei)置進行觀(guan)察。若抗力伸(shen)(shen)肘(zhou)、被動(dong)(dong)(dong)屈(qu)肘(zhou)時,肘(zhou)后部(bu)疼痛(tong),可(ke)推知(zhi)(zhi)是該關(guan)(guan)節(jie)(jie)伸(shen)(shen)側(ce)的(de)病變;若抗力屈(qu)肘(zhou)、被動(dong)(dong)(dong)伸(shen)(shen)肘(zhou)時,肘(zhou)前部(bu)疼痛(tong),可(ke)推知(zhi)(zhi)是肘(zhou)關(guan)(guan)節(jie)(jie)屈(qu)側(ce)的(de)病變。肘(zhou)關(guan)(guan)節(jie)(jie)脫位(wei)(wei)(wei)、關(guan)(guan)節(jie)(jie)部(bu)骨折、感染、骨化(hua)性肌炎等,都(dou)可(ke)以引起屈(qu)、伸(shen)(shen)功能的(de)明顯(xian)障礙。在肘(zhou)關(guan)(guan)節(jie)(jie)伸(shen)(shen)直位(wei)(wei)(wei)時,應(ying)(ying)沒有側(ce)方收展活(huo)(huo)動(dong)(dong)(dong),如有,則說明關(guan)(guan)節(jie)(jie)側(ce)方韌帶松弛或(huo)斷裂(lie)。
檢查前臂(bei)(bei)旋轉(zhuan)(zhuan)(zhuan)(zhuan)活動時(shi)(shi),應采取肘關(guan)節屈(qu)曲九十度(du)位(wei)(wei)觀察,可(ke)讓病人兩(liang)手各握一小棍棒,同時(shi)(shi)作前臂(bei)(bei)旋轉(zhuan)(zhuan)(zhuan)(zhuan)加以(yi)對比。上、下(xia)尺(chi)橈(rao)(rao)關(guan)節任何(he)一端有病變,橈(rao)(rao)、尺(chi)骨(gu)(gu)任何(he)一骨(gu)(gu)骨(gu)(gu)折或折后畸形(xing)愈合都會出(chu)現旋轉(zhuan)(zhuan)(zhuan)(zhuan)障(zhang)礙。若被動旋轉(zhuan)(zhuan)(zhuan)(zhuan)前臂(bei)(bei),在正常(chang)時(shi)(shi)橈(rao)(rao)骨(gu)(gu)頭處(chu)亦可(ke)捫(men)到(dao)轉(zhuan)(zhuan)(zhuan)(zhuan)動;當(dang)橈(rao)(rao)個(ge)骨(gu)(gu)骨(gu)(gu)折不連(lian)時(shi)(shi),不能捫(men)在橈(rao)(rao)骨(gu)(gu)小頭的轉(zhuan)(zhuan)(zhuan)(zhuan)動;但橈(rao)(rao)骨(gu)(gu)小頭脫位(wei)(wei)時(shi)(shi),則可(ke)捫(men)到(dao)突出(chu)而轉(zhuan)(zhuan)(zhuan)(zhuan)動的橈(rao)(rao)骨(gu)(gu)小頭半脫位(wei)(wei)時(shi)(shi),前臂(bei)(bei)固定(ding)于旋前位(wei)(wei)置(zhi),而不能旋后。
(3)腕、手部
【望(wang)診】 借助于視力或(huo)觸(chu)摸,了解腕(wan)(wan)(wan)手部(bu)的情況。手掌(zhang)(zhang)皮膚厚,其(qi)下有(you)纖(xian)維組織與深筋(jin)膜相連,缺(que)乏活(huo)動(dong)性或(huo)彈性;手背(bei)部(bu)皮膚松弛薄弱,活(huo)動(dong)性和彈性較大(da)。手部(bu)感染或(huo)外(wai)傷腫(zhong)(zhong)脹(zhang)時(shi),背(bei)側比掌(zhang)(zhang)側明(ming)顯。伸直(zhi)型橈骨(gu)下端骨(gu)折,骨(gu)折遠段(duan)向背(bei)側移位(wei)時(shi),腕(wan)(wan)(wan)及手部(bu)呈餐(can)叉樣(yang)畸形;劈裂型骨(gu)折嚴(yan)重移位(wei)時(shi),腕(wan)(wan)(wan)掌(zhang)(zhang)背(bei)側徑增大(da)呈槍(qiang)上(shang)刺刀狀畸形;腱鞘囊腫(zhong)(zhong),常(chang)在腕(wan)(wan)(wan)關(guan)(guan)(guan)節(jie)(jie)背(bei)側或(huo)屈(qu)(qu)指腱上(shang)出現圓形、邊緣清楚(chu)的腫(zhong)(zhong)物;類風濕性關(guan)(guan)(guan)節(jie)(jie)炎,早期掌(zhang)(zhang)指關(guan)(guan)(guan)節(jie)(jie)、指間(jian)關(guan)(guan)(guan)節(jie)(jie)呈梭形腫(zhong)(zhong)脹(zhang),晚期呈典(dian)型的尺偏(pian)屈(qu)(qu)曲(qu)(qu)畸形;缺(que)血性肌攣(luan)縮的典(dian)型畸形是掌(zhang)(zhang)指關(guan)(guan)(guan)節(jie)(jie)過伸,而指間(jian)關(guan)(guan)(guan)節(jie)(jie)屈(qu)(qu)曲(qu)(qu),極度屈(qu)(qu)腕(wan)(wan)(wan)時(shi)手指可以伸直(zhi)些,伸腕(wan)(wan)(wan)時(shi)則手指又屈(qu)(qu)曲(qu)(qu)。
【觸(chu)診(zhen)】 腕、手部筋肉組織(zhi)較(jiao)薄,尋(xun)找出(chu)壓痛(tong)點,對確(que)定病灶部位(wei)有(you)重(zhong)要意義(yi)。腕舟骨(gu)(gu)骨(gu)(gu)折時,陽溪穴(xue)處(chu)有(you)壓痛(tong);伸拇(mu)(mu)短肌和外展(zhan)拇(mu)(mu)長肌腱鞘炎時,橈骨(gu)(gu)莖突(tu)部有(you)壓痛(tong);掌、指(zhi)骨(gu)(gu)骨(gu)(gu)折時,則有(you)局部壓痛(tong)和縱(zong)軸(zhou)擠(ji)壓痛(tong)。
【運(yun)動檢查】 正常腕(wan)關節(jie)(jie)可(ke)(ke)作(zuo)背伸、掌(zhang)屈、橈(rao)傾、尺(chi)偏(pian)及旋轉活(huo)(huo)動,各(ge)掌(zhang)指(zhi)(zhi)(zhi)關節(jie)(jie)可(ke)(ke)作(zuo)屈伸、收展活(huo)(huo)動,各(ge)指(zhi)(zhi)(zhi)間關節(jie)(jie)可(ke)(ke)作(zuo)屈、伸活(huo)(huo)動,拇指(zhi)(zhi)(zhi)還可(ke)(ke)作(zuo)對(dui)掌(zhang)活(huo)(huo)動。手的休息姿勢,是腕(wan)關節(jie)(jie)輕度(du)背伸約十五度(du)、拇指(zhi)(zhi)(zhi)靠近(jin)食指(zhi)(zhi)(zhi)旁邊、2到5指(zhi)(zhi)(zhi)的屈曲度(du)逐漸增大,而諸指(zhi)(zhi)(zhi)呈放射狀(zhuang)指(zhi)(zhi)(zhi)向(xiang)舟骨。手的功能位(wei)置是腕(wan)背伸約三(san)十度(du)、尺(chi)偏(pian)約十度(du),拇指(zhi)(zhi)(zhi)在外對(dui)掌(zhang)屈曲位(wei),其余四指(zhi)(zhi)(zhi)屈曲。
測量(liang)兩(liang)(liang)腕(wan)關節的(de)屈伸活動,可(ke)將兩(liang)(liang)手(shou)手(shou)指及兩(liang)(liang)掌(zhang)相貼,兩(liang)(liang)腕(wan)充(chong)分(fen)背伸而對比之,然后再使兩(liang)(liang)手(shou)手(shou)背貼近,兩(liang)(liang)腕(wan)部充(chong)分(fen)掌(zhang)屈而對比之,如果一側(ce)運動受限(xian)制即可(ke)明顯測出。
橈骨莖突(tu)部(bu)腱鞘炎,可見(jian)拇(mu)指(zhi)(zhi)外展、背(bei)伸受限,若(ruo)將其拇(mu)指(zhi)(zhi)握(wo)于掌心,就引起橈骨莖突(tu)部(bu)疼痛,再作尺偏活動則疼痛加重(zhong),稱(cheng)為(wei)握(wo)拳尺偏試驗陽性(xing)。屈指(zhi)(zhi)肌腱狹窄性(xing)腱鞘炎時(shi),手指(zhi)(zhi)屈伸可發生彈跳樣動作,屈曲后不能主(zhu)動伸直,或伸直后又(you)不能主(zhu)動屈曲稱(cheng)為(wei)彈響指(zhi)(zhi)或扳級指(zhi)(zhi)。
(4) 肌腱損傷
1、指(zhi)(zhi)(zhi)深(shen)(shen)屈(qu)(qu)肌(ji)腱和拇(mu)(mu)長屈(qu)(qu)肌(ji)腱的功(gong)能(neng),分(fen)別(bie)是屈(qu)(qu)指(zhi)(zhi)(zhi)和屈(qu)(qu)拇(mu)(mu)的末節,發(fa)生斷裂時末節不能(neng)屈(qu)(qu)曲(qu);指(zhi)(zhi)(zhi)淺屈(qu)(qu)肌(ji)和拇(mu)(mu)短屈(qu)(qu)肌(ji)的功(gong)能(neng),分(fen)別(bie)是屈(qu)(qu)曲(qu)近側指(zhi)(zhi)(zhi)間關節和拇(mu)(mu)指(zhi)(zhi)(zhi)的近節,由(you)于其功(gong)能(neng)可分(fen)別(bie)由(you)指(zhi)(zhi)(zhi)深(shen)(shen)屈(qu)(qu)肌(ji)和拇(mu)(mu)長屈(qu)(qu)肌(ji)所代(dai)替,故發(fa)生斷裂時,手指(zhi)(zhi)(zhi)屈(qu)(qu)曲(qu)動作可仍然(ran)存在。
2、拇(mu)(mu)長(chang)伸(shen)(shen)肌(ji)(ji)(ji)(ji)主要伸(shen)(shen)拇(mu)(mu)指(zhi)(zhi)(zhi)(zhi)(zhi)末(mo)節(jie)(jie)(jie),伸(shen)(shen)拇(mu)(mu)短(duan)肌(ji)(ji)(ji)(ji)伸(shen)(shen)拇(mu)(mu)指(zhi)(zhi)(zhi)(zhi)(zhi)的(de)(de)掌(zhang)(zhang)(zhang)指(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)(guan)節(jie)(jie)(jie),伸(shen)(shen)指(zhi)(zhi)(zhi)(zhi)(zhi)總(zong)肌(ji)(ji)(ji)(ji)是伸(shen)(shen)其余四指(zhi)(zhi)(zhi)(zhi)(zhi)的(de)(de)掌(zhang)(zhang)(zhang)指(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)(guan)節(jie)(jie)(jie)。這(zhe)些(xie)(xie)伸(shen)(shen)肌(ji)(ji)(ji)(ji)癱(tan)(tan)瘓(huan)或(huo)斷(duan)裂時,除食(shi)指(zhi)(zhi)(zhi)(zhi)(zhi)的(de)(de)掌(zhang)(zhang)(zhang)指(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)(guan)節(jie)(jie)(jie),伸(shen)(shen)指(zhi)(zhi)(zhi)(zhi)(zhi)總(zong)肌(ji)(ji)(ji)(ji)是伸(shen)(shen)其余四指(zhi)(zhi)(zhi)(zhi)(zhi)的(de)(de)掌(zhang)(zhang)(zhang)指(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)(guan)節(jie)(jie)(jie)。這(zhe)些(xie)(xie)伸(shen)(shen)肌(ji)(ji)(ji)(ji)癱(tan)(tan)瘓(huan)或(huo)斷(duan)裂時,除食(shi)指(zhi)(zhi)(zhi)(zhi)(zhi)和小(xiao)指(zhi)(zhi)(zhi)(zhi)(zhi)因尚有食(shi)指(zhi)(zhi)(zhi)(zhi)(zhi)固有伸(shen)(shen)肌(ji)(ji)(ji)(ji)和小(xiao)指(zhi)(zhi)(zhi)(zhi)(zhi)固有伸(shen)(shen)肌(ji)(ji)(ji)(ji)可(ke)以(yi)背伸(shen)(shen)處,其余相應關(guan)(guan)節(jie)(jie)(jie)的(de)(de)背伸(shen)(shen)功能(neng)喪失。骨間(jian)肌(ji)(ji)(ji)(ji)和蚓狀肌(ji)(ji)(ji)(ji)屈掌(zhang)(zhang)(zhang)指(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)(guan)節(jie)(jie)(jie)和伸(shen)(shen)指(zhi)(zhi)(zhi)(zhi)(zhi)間(jian)關(guan)(guan)節(jie)(jie)(jie),當此二肌(ji)(ji)(ji)(ji)癱(tan)(tan)瘓(huan)時,可(ke)引起掌(zhang)(zhang)(zhang)指(zhi)(zhi)(zhi)(zhi)(zhi)關(guan)(guan)節(jie)(jie)(jie)伸(shen)(shen)和指(zhi)(zhi)(zhi)(zhi)(zhi)間(jian)關(guan)(guan)節(jie)(jie)(jie)屈的(de)(de)爪形手。若(ruo)伸(shen)(shen)肌(ji)(ji)(ji)(ji)腱(jian)損傷在手指(zhi)(zhi)(zhi)(zhi)(zhi)末(mo)節(jie)(jie)(jie),則末(mo)節(jie)(jie)(jie)彎曲形成錘狀指(zhi)(zhi)(zhi)(zhi)(zhi)畸形。
5.下肢
(1)髖部
【望(wang)診】 借助于視力或(huo)觸摸,來了解(jie)髖(kuan)(kuan)部情況。股骨上端骨折(zhe)典型移(yi)位(wei)(wei)(wei)者(zhe),同側下肢(zhi)呈(cheng)外旋、短(duan)縮(suo)畸形(xing)。髖(kuan)(kuan)關(guan)(guan)節(jie)后脫位(wei)(wei)(wei)者(zhe),肢(zhi)體多呈(cheng)屈(qu)曲、內收、內旋及(ji)短(duan)縮(suo)畸形(xing);髖(kuan)(kuan)關(guan)(guan)節(jie)前(qian)脫位(wei)(wei)(wei),則下肢(zhi)呈(cheng)外展,外旋畸形(xing)。髖(kuan)(kuan)關(guan)(guan)節(jie)感染(ran),下肢(zhi)常(chang)攣縮(suo)在半屈(qu)伸位(wei)(wei)(wei);先(xian)天性髖(kuan)(kuan)關(guan)(guan)節(jie)脫位(wei)(wei)(wei),則臀(tun)部向后凸,腰部代償性前(qian)凸。
若(ruo)傷肢(zhi)短縮(suo),可作下肢(zhi)長度對比檢查。方法是讓病人仰臥,兩髖膝(xi)關節屈曲并攏,兩足并齊平放床面。如雙膝(xi)出現高(gao)低(di)差即(ji)為陽性,多見于(yu)髖關節后脫位或股、脛骨的短縮(suo)。
若病(bing)人尚能步(bu)行,應注意其步(bu)態和負重能力,是(shi)否(fou)需用(yong)扶拐,兩側(ce)髖(kuan)(kuan)骨、臀皺襞是(shi)否(fou)同(tong)(tong)一高度,有無肌(ji)萎縮,并做(zuo)髖(kuan)(kuan)關(guan)節(jie)承重功能試(shi)驗。以檢查右髖(kuan)(kuan)為(wei)(wei)例,囑病(bing)人抬(tai)起左下肢,若能單獨用(yong)右下肢站立同(tong)(tong)時左臀皺襞、髂(qia)骨翼(yi)均上提為(wei)(wei)陰性(xing);若左臀皺襞、髂(qia)骨翼(yi)下降則為(wei)(wei)陽性(xing)。陳舊性(xing)髖(kuan)(kuan)關(guan)節(jie)脫位和股骨頸骨折,或(huo)臀中(zhong)肌(ji)、臀中(zhong)肌(ji)、臀小肌(ji)麻痹時,此試(shi)驗均為(wei)(wei)陽性(xing)。
【觸(chu)診(zhen)】 髖(kuan)關(guan)節感染、股(gu)(gu)骨(gu)頸骨(gu)折,早期的(de)壓(ya)痛點(dian)多位于腹股(gu)(gu)溝韌帶中點(dian)的(de)外下(xia)方(fang)(fang)一橫(heng)指處(chu);股(gu)(gu)骨(gu)粗隆間骨(gu)折的(de)壓(ya)痛點(dian)則位于大粗隆處(chu);若(ruo)在下(xia)肢伸直(zhi)給足(zu)跟部加(jia)壓(ya)或叩(kou)擊,髖(kuan)關(guan)節部即出現疼痛。髖(kuan)關(guan)節變(bian)(感染、骨(gu)折、脫位等)引起的(de)下(xia)肢縮短,可觸(chu)摸(mo)到大粗隆向(xiang)上移位。常用下(xia)列方(fang)(fang)法測(ce)量:
1、將髂前上棘與(yu)坐骨結節的中心(xin)連一直(zhi)線,正常時股骨大(da)粗(cu)隆(long)的頂點不(bu)高于此線;若大(da)粗(cu)隆(long)上移,則超(chao)過(guo)此線。
2.將兩側股骨大粗隆(long)與髂前上棘的連線向腹部延長,正(zheng)常交點(dian)應在(zai)臍上中線,若一側大粗隆(long)上移時,則交點(dian)在(zai)臍下的對側腹面(mian)。
【運(yun)動檢查】 正(zheng)常髖關節(jie)的運(yun)動,應包括內旋和(he)外旋、內收和(he)外展、屈曲和(he)伸展等。
1)內(nei)旋(xuan)(xuan)(xuan)和外旋(xuan)(xuan)(xuan) ①單側(ce)測量(liang)法:病人(ren)(ren)取仰(yang)臥(wo)位,下(xia)肢伸直,檢查(cha)者(zhe)用手握住傷側(ce)下(xia)肢使之向(xiang)(xiang)內(nei)、向(xiang)(xiang)外旋(xuan)(xuan)(xuan)動(dong)。若髖(kuan)關(guan)節(jie)(jie)(jie)攣縮不(bu)能伸直時(shi)(shi),可將髖(kuan)、膝(xi)(xi)關(guan)節(jie)(jie)(jie)均屈(qu)(qu)曲九十度,把(ba)小腿當作(zuo)杠桿,而將髖(kuan)關(guan)節(jie)(jie)(jie)內(nei)旋(xuan)(xuan)(xuan)、外旋(xuan)(xuan)(xuan)。②雙側(ce)同時(shi)(shi)測量(liang)法:囑病人(ren)(ren)仰(yang)臥(wo),同時(shi)(shi)屈(qu)(qu)曲髖(kuan)、膝(xi)(xi)關(guan)節(jie)(jie)(jie),兩足跟并列不(bu)動(dong),兩膝(xi)(xi)盡量(liang)分開,觀察兩髖(kuan)關(guan)節(jie)(jie)(jie)的(de)外旋(xuan)(xuan)(xuan)度;然后(hou)兩膝(xi)(xi)并攏(long),兩足盡量(liang)分開,觀察兩髖(kuan)關(guan)節(jie)(jie)(jie)的(de)內(nei)旋(xuan)(xuan)(xuan)度。關(guan)節(jie)(jie)(jie)感(gan)染、骨(gu)折,股(gu)骨(gu)頭骨(gu)骺炎(yan)、類風濕性關(guan)節(jie)(jie)(jie)炎(yan)等疾患時(shi)(shi),內(nei)旋(xuan)(xuan)(xuan)與外旋(xuan)(xuan)(xuan)均受限(xian)制并疼痛;而先天(tian)性、陳舊性的(de)髖(kuan)關(guan)節(jie)(jie)(jie)后(hou)脫位,則(ze)可發現(xian)內(nei)旋(xuan)(xuan)(xuan)范圍增大而外旋(xuan)(xuan)(xuan)活動(dong)受限(xian)制。
2)內收(shou)和(he)外(wai)展(zhan)(zhan) ①單側測(ce)量法:病(bing)人取(qu)仰臥位(wei),術者一手(shou)固定(ding)骨盆,另手(shou)握(wo)住(zhu)下(xia)肢(zhi)(zhi)踝(huai)部,然后使下(xia)肢(zhi)(zhi)在伸直位(wei)外(wai)展(zhan)(zhan)、內收(shou),并記(ji)錄其度數。②雙(shuang)(shuang)側同時測(ce)量法;囑(zhu)病(bing)人仰臥,兩下(xia)肢(zhi)(zhi)平伸,檢查者用雙(shuang)(shuang)手(shou)分別托(tuo)握(wo)兩足跟(gen),將兩腿盡(jin)量盡(jin)量交叉(cha),觀察兩側髖(kuan)關節的(de)內收(shou)度;兩將兩腿盡(jin)量分開,觀察兩髖(kuan)關節的(de)外(wai)展(zhan)(zhan)度。髖(kuan)關節后脫位(wei)、髖(kuan)內翻(fan)及(ji)炎癥疾病(bing)時,均有(you)外(wai)展(zhan)(zhan)受限;髂脛束(shu)攣(luan)縮時,則有(you)髖(kuan)內收(shou)受限。
3)屈曲和伸展 病(bing)人取(qu)仰臥(wo)(wo)位,將一(yi)(yi)(yi)側(ce)髖、膝(xi)關(guan)(guan)節(jie)(jie)極度屈曲,使腰(yao)部平(ping)貼床面,另一(yi)(yi)(yi)側(ce)大腿(tui)也能(neng)完全貼床屬正常;若另側(ce)大腿(tui)離開床面,或強令該(gai)大腿(tui)貼床,但腰(yao)部卻挺起以代償,則(ze)說明髖關(guan)(guan)節(jie)(jie)有屈曲攣縮畸形。病(bing)人取(qu)俯臥(wo)(wo)位,檢查者一(yi)(yi)(yi)手固(gu)定(ding)骨盆(pen),另一(yi)(yi)(yi)手握(wo)住踝部,屈膝(xi)九(jiu)十度向后提起下肢(zhi),髖關(guan)(guan)節(jie)(jie)屈曲攣縮時,則(ze)后伸受限,甚至不能(neng)完全俯臥(wo)(wo)。
4)望(wang)遠鏡征:病(bing)人仰臥,檢查者一手(shou)固定(ding)骨盆(pen),另(ling)一手(shou)握住膝部,沿股(gu)骨縱軸上(shang)下推拉,如(ru)髖關節脫位(wei),則(ze)有過多的(de)上(shang)下活(huo)動移位(wei)感。
(2)膝部
【望診】 借(jie)助于(yu)視力或觸摸,了解膝(xi)(xi)部情況。下(xia)肢正(zheng)常生(sheng)理(li)軸線(xian),是髂(qia)前上棘與第1趾蹼(pu)間連線(xian)通過(guo)(guo)髕骨內(nei)緣,兩(liang)膝(xi)(xi)及內(nei)踝部同(tong)時并攏。膝(xi)(xi)內(nei)翻時,兩(liang)踝并攏而(er)雙膝(xi)(xi)分(fen)開(kai)(kai)(o型腿(tui));膝(xi)(xi)外翻時,則雙膝(xi)(xi)并攏而(er)兩(liang)踝分(fen)開(kai)(kai)(x型腿(tui))。測量分(fen)開(kai)(kai)的距離可判斷畸(ji)形的程度。正(zheng)常膝(xi)(xi)關(guan)(guan)節(jie)能輕度超伸(shen)(shen),若過(guo)(guo)度超伸(shen)(shen)即稱為膝(xi)(xi)過(guo)(guo)伸(shen)(shen)(膝(xi)(xi)反張)。此外,還要了解步行姿勢,股四頭(tou)肌癱瘓時,病人用(yong)手將傷(shang)側大(da)腿(tui)向后壓,以伸(shen)(shen)直膝(xi)(xi)關(guan)(guan)節(jie)而(er)行走。膝(xi)(xi)內(nei)翻、外翻及過(guo)(guo)伸(shen)(shen)畸(ji)形,常由(you)佝僂(lou)病、小(xiao)兒麻痹(bi)后遺癥引起。
【觸(chu)診】 觸(chu)摸關節(jie)內(nei)、外(wai)有(you)(you)無腫脹(zhang)或腫物。慢性滑膜炎(yan)(yan)(包(bao)括結核(he)性滑膜炎(yan)(yan))時,觸(chu)之(zhi)(zhi)有(you)(you)柔韌、肥厚感(gan),可(ke)將兩(liang)側對(dui)比。股骨(gu)下端及(ji)脛骨(gu)上端的(de)腫瘤(liu)(骨(gu)肉瘤(liu)或巨細胞瘤(liu)),觸(chu)之(zhi)(zhi)則(ze)有(you)(you)堅硬感(gan)而且推之(zhi)(zhi)不(bu)能移(yi)動(dong)。關節(jie)內(nei)積液的(de)腫脹(zhang)則(ze)有(you)(you)波動(dong)感(gan),用一手(shou)壓(ya)迫髕骨(gu)上囊將液體及(ji)入關節(jie)腔,以另一手(shou)的(de)手(shou)指(zhi)反復的(de)壓(ya)迫髕骨(gu),可(ke)感(gan)覺髕骨(gu)有(you)(you)漂浮(fu)(fu)現(xian)(xian)象,即稱為浮(fu)(fu)髕試驗陽性。髕前滑液囊的(de)積液與關節(jie)腔不(bu)相(xiang)通,故無浮(fu)(fu)髕現(xian)(xian)象。內(nei)外(wai)側副韌帶損傷(shang)脛骨(gu)結節(jie)骨(gu)骺炎(yan)(yan)等均可(ke)找到相(xiang)應的(de)壓(ya)痛點。
【運動檢查】
1)側(ce)向運(yun)動(dong)試驗(yan) 膝關(guan)節的主(zhu)要運(yun)動(dong)是(shi)屈伸(shen)。在伸(shen)直位,膝關(guan)節不能做側(ce)向內收、外展運(yun)動(dong);內、外側(ce)副韌(ren)帶斷裂時,可有(you)被(bei)動(dong)的外展、內收運(yun)動(dong)。
2)抽(chou)屜試驗(又稱(cheng)推拉試驗)囑病人屈(qu)膝九十度(du),足平放床(chuang)上,檢查者用一肘部壓住傷肢足背以固定(ding)之。同(tong)時用雙手握住小腿上端作(zuo)前(qian)后(hou)推拉,正(zheng)常可有輕度(du)(在0.5厘米左右)的前(qian)后(hou)活動;若向(xiang)前(qian)活動度(du)過(guo)大(da)與(yu)疼(teng)痛,則(ze)(ze)說(shuo)明(ming)前(qian)十字韌帶斷裂或(huo)松弛(chi);向(xiang)后(hou)活動度(du)過(guo)大(da)與(yu)疼(teng)痛,則(ze)(ze)提示后(hou)十字韌帶斷裂或(huo)松弛(chi)。
3)回(hui)旋(xuan)擠壓試驗 檢查右(you)(you)(you)膝(xi)外(wai)側(ce)半月(yue)(yue)板(ban)(ban)損傷時(shi),檢查者立(li)于(yu)患者右(you)(you)(you)側(ce),用右(you)(you)(you)手握住右(you)(you)(you)足,左手放在(zai)右(you)(you)(you)膝(xi)部以穩定(ding)大腿和感觸異常(chang)音響(xiang)或跳動,先使小腿在(zai)內旋(xuan)位充分(fen)內收、屈曲(qu),然后(hou)外(wai)展(zhan)、伸直,注(zhu)意(yi)在(zai)伸直過程中有(you)(you)無(wu)彈響(xiang)及疼痛;檢查內側(ce)半月(yue)(yue)板(ban)(ban)損傷時(shi),先使小腿在(zai)外(wai)旋(xuan)位充分(fen)外(wai)展(zhan)屈膝(xi),然后(hou)內收伸直。響(xiang)聲清脆者多為(wei)(wei)半月(yue)(yue)板(ban)(ban)損傷,聲音大而伴(ban)有(you)(you)跳動者多為(wei)(wei)盤狀半月(yue)(yue)板(ban)(ban)。
(3)踝、足部
【望診】 借(jie)助(zhu)于(yu)視力或(huo)觸(chu)摸,了解足(zu)踝部(bu)的情況。先讓病(bing)人赤足(zu)行走(zou),觀察(cha)其(qi)步態(tai),并在負(fu)重情況下觀察(cha)其(qi)外形與(yu)站立(li)姿勢。常見的足(zu)部(bu)畸(ji)形有下列(lie)數種:
1)扁平(ping)足(zu) 正常(chang)時,站立后足(zu)弓(gong)(gong)(gong)下(xia)方可插(cha)入(ru)一個手(shou)指;輕(qing)度扁平(ping)足(zu)足(zu)弓(gong)(gong)(gong)下(xia)部手(shou)指不能插(cha)入(ru),但足(zu)弓(gong)(gong)(gong)尚未全(quan)部著地;較重的(de)扁平(ping)足(zu)則足(zu)內(nei)(nei)緣著地,舟狀骨明(ming)顯向內(nei)(nei)隆起(qi)甚至接觸地面,足(zu)呈外翻(fan)外展姿態。檢查其鞋底則內(nei)(nei)側磨(mo)損較多(duo)。柔軟性(xing)的(de)扁平(ping)足(zu),在(zai)不負重的(de)情(qing)況下(xia)足(zu)弓(gong)(gong)(gong)外形尚正常(chang),但站立時足(zu)弓(gong)(gong)(gong)即塌陷;痙攣性(xing)扁平(ping)足(zu)則活動受(shou)限,在(zai)不負重情(qing)況下(xia)亦有明(ming)顯畸形。
2)馬蹄足 在站立時僅(jin)能(neng)前足掌(zhang)著(zhu)地,跟(gen)腱有攣縮;日久則(ze)前足掌(zhang)增大且(qie)有胼胝,足后(hou)跟(gen)部顯小(xiao)。
3)內(nei)(nei)翻足(zu)(zu)(zu) 站(zhan)立或(huo)行走時,僅以足(zu)(zu)(zu)外側負重(zhong),跟腱向內(nei)(nei)偏斜。足(zu)(zu)(zu)外側或(huo)第(di)五趾骨頭下方有(you)胼胝,鞋底(di)或(huo)鞋面外側有(you)磨損。馬蹄足(zu)(zu)(zu)與(yu)內(nei)(nei)翻足(zu)(zu)(zu)多(duo)合并存在,稱為馬蹄內(nei)(nei)翻足(zu)(zu)(zu)。
4)外翻(fan)足(zu) 畸形(xing)與內翻(fan)足(zu)相反(fan),足(zu)內側縱弓(gong)下陷,鞋底(di)內側磨(mo)損。
5)仰趾足(zu)(zu)(又稱跟(gen)足(zu)(zu)) 站立(li)時負重(zhong)以足(zu)(zu)跟(gen)為(wei)主,走路(lu)時足(zu)(zu)前(qian)部不能用(yong)力著地,日久則前(qian)足(zu)(zu)掌變(bian)小,足(zu)(zu)后跟(gen)增大且有(you)胼胝。
6)高弓(gong)足 足弓(gong)較正常高,僅部分病人有癥(zheng)狀。
7)拇(mu)(mu)外翻(常合并(bing)扁平足)足拇(mu)(mu)趾(zhi)(zhi)向外側偏斜,較重者拇(mu)(mu)趾(zhi)(zhi)位(wei)于第2、3趾(zhi)(zhi)下(xia)面將第2趾(zhi)(zhi)頂起。此(ci)時可并(bing)發(fa)2、3趾(zhi)(zhi)錘狀趾(zhi)(zhi)畸形。
【觸診】 壓(ya)(ya)(ya)痛(tong)點在(zai)(zai)跟(gen)腱(jian)(jian)上,可(ke)(ke)能(neng)是(shi)跟(gen)腱(jian)(jian)本(ben)身或(huo)腱(jian)(jian)旁膜的損(sun)(sun)傷(shang)(shang);跟(gen)腱(jian)(jian)止(zhi)點處壓(ya)(ya)(ya)痛(tong),可(ke)(ke)能(neng)是(shi)跟(gen)腱(jian)(jian)后(hou)(hou)滑囊炎;在(zai)(zai)足跟(gen)部后(hou)(hou)下(xia)方(fang)壓(ya)(ya)(ya)痛(tong),可(ke)(ke)能(neng)是(shi)跟(gen)骨(gu)骺炎;壓(ya)(ya)(ya)痛(tong)在(zai)(zai)跟(gen)骨(gu)跟(gen)面正(zheng)中偏(pian)后(hou)(hou),可(ke)(ke)能(neng)是(shi)跟(gen)骨(gu)骨(gu)刺或(huo)脂肪(fang)墊(dian)損(sun)(sun)傷(shang)(shang);壓(ya)(ya)(ya)痛(tong)靠部可(ke)(ke)能(neng)是(shi)跖(zhi)腱(jian)(jian)膜損(sun)(sun)傷(shang)(shang)引起;跟(gen)骨(gu)骨(gu)折的壓(ya)(ya)(ya)痛(tong)點在(zai)(zai)跟(gen)骨(gu)的內側和外(wai)側,踝關節內翻或(huo)外(wai)翻損(sun)(sun)傷(shang)(shang),壓(ya)(ya)(ya)痛(tong)點則(ze)在(zai)(zai)內側或(huo)外(wai)側。
【運動(dong)檢查】 踝關(guan)節(jie)(jie)的活動(dong)主要(yao)是(shi)背(bei)伸和跖屈。足的內(nei)翻及外(wai)(wai)翻動(dong)作。主要(yao)在(zai)跟距關(guan)節(jie)(jie)。前(qian)足部(bu)的內(nei)翻、外(wai)(wai)翻及內(nei)收、外(wai)(wai)展活動(dong)是(shi)在(zai)跟骰及記(ji)舟關(guan)節(jie)(jie)。足趾的屈伸活動(dong)主要(yao)靠跖拇(mu)及跖趾關(guan)節(jie)(jie)。關(guan)節(jie)(jie)部(bu)骨折、脫位、肌腱斷裂(lie)、神(shen)經(jing)損害等,是(shi)足踝部(bu)運動(dong)阻礙的主要(yao)原(yuan)因。
6、脊柱部檢查
(1)頸部
【望診】 借助(zhu)于(yu)視力或觸摸,了(le)解(jie)頸部(bu)的情況(kuang)。首先觀(guan)察(cha)頸部(bu)形(xing)態,頭部(bu)能否(fou)自由(you)轉(zhuan)動,需要(yao)旁視時,是否(fou)要(yao)將身體一齊轉(zhuan)動,能否(fou)主(zhu)持頭部(bu)的重量,是否(fou)需用手扶持下頜。其次(ci)觀(guan)察(cha)頸椎的生理軸(zhou)線。頸椎骨折、脫(tuo)位(wei)、結核等可(ke)出現后凸、側彎或扭轉(zhuan)畸形(xing)。寒性膿(nong)瘍多(duo)由(you)頸椎結核所致,高位(wei)者可(ke)見于(yu)咽后壁,低位(wei)者可(ke)見于(yu)頸旁。先天性斜頸可(ke)見單(dan)側肌肉痙(jing)攣和短縮,甚至影響到顏面及兩肩不對稱。
觸診扭傷(shang)(shang)(shang)或(huo)“落枕”,壓(ya)痛(tong)點多見于(yu)棘(ji)間韌(ren)帶或(huo)兩(liang)側項(xiang)肌(ji)。頸(jing)椎(zhui)棘(ji)突間觸到痛(tong)性硬(ying)結或(huo)索條(tiao),可能是項(xiang)韌(ren)帶鈣化。頸(jing)椎(zhui)病或(huo)頸(jing)椎(zhui)間盤突出癥,壓(ya)痛(tong)多在傷(shang)(shang)(shang)側下部(bu)(bu)頸(jing)椎(zhui)旁(pang)及肩胛(jia)內(nei)上角處,且向傷(shang)(shang)(shang)側上肢放射。頸(jing)椎(zhui)骨折、結核(he)的(de)壓(ya)痛(tong)點位于(yu)患(huan)椎(zhui)棘(ji)突部(bu)(bu)。
【運動(dong)檢(jian)查】 脊(ji)柱頸(jing)(jing)段可(ke)(ke)作前(qian)屈(qu)、后伸(shen)、左(zuo)右側屈(qu)及左(zuo)右旋(xuan)轉(zhuan)等(deng)活(huo)動(dong)。檢(jian)查時要固(gu)定雙肩,使(shi)軀干不參與運動(dong)。環枕關節(jie)和環樞關節(jie)的功能最(zui)重要,如有病變(bian)或固(gu)定時,可(ke)(ke)使(shi)頸(jing)(jing)部(bu)的旋(xuan)轉(zhuan)及屈(qu)伸(shen)功能喪失百分之五(wu)十左(zuo)右,頸(jing)(jing)椎(zhui)結(jie)核,可(ke)(ke)使(shi)頸(jing)(jing)部(bu)前(qian)屈(qu)、后伸(shen)及側屈(qu)受限(xian)制。頸(jing)(jing)椎(zhui)間盤突(tu)出癥則一般向患(huan)側屈(qu)及后伸(shen)受限(xian)。頸(jing)(jing)椎(zhui)骨關節(jie)病變(bian)。則在旋(xuan)轉(zhuan)活(huo)動(dong)時,出現摩擦(ca)音(yin)響或摩擦(ca)感(gan)。
(2)胸(xiong)、腰椎和骶(di)髂(qia)部
可根據情況,選取立位(wei)、坐位(wei)、俯臥(wo)位(wei)、仰(yang)臥(wo)位(wei)、側臥(wo)位(wei)等體位(wei)進行檢查。
【望診(zhen)】 借助于視力(li)或觸摸(mo),了解(jie)胸椎、腰(yao)椎和骶髂部(bu)(bu)的情況。急性(xing)腰(yao)扭傷(shang)或腰(yao)椎結核患(huan)(huan)者,由(you)于腰(yao)部(bu)(bu)不(bu)能負(fu)重,常以雙手(shou)扶(fu)持腰(yao)部(bu)(bu)行走,坐下時常用兩(liang)手(shou)撐(cheng)在椅子(zi)上。腰(yao)椎間盤突出癥的患(huan)(huan)者行走時,因疼痛的下肢不(bu)敢用力(li)著地(di)而表現為跛(bo)行。從背(bei)面或側(ce)面可(ke)觀(guan)察(cha)脊柱(zhu)有無后凸(tu)、前(qian)凸(tu)及側(ce)彎(wan)畸形,上身多前(qian)傾。
脊柱后凸(tu)(tu)有兩種類(lei)型(xing),一種呈弧(hu)形,又稱圓背(bei),常見(jian)于姿勢性后凸(tu)(tu)、椎體(ti)骨(gu)骺炎、類(lei)風濕性脊柱炎等;另一種呈角狀,或(huo)稱駝背(bei),常見(jian)于脊柱結核,椎體(ti)屈(qu)曲(qu)(qu)型(xing)壓縮性骨(gu)折等。輕(qing)度(du)角狀后凸(tu)(tu)不明(ming)顯者,可(ke)用滑動(dong)(dong)觸診法,手指放在棘突上由上而下迅速滑動(dong)(dong),即可(ke)觸到后凸(tu)(tu)的部位(wei)。前(qian)凸(tu)(tu)增加(jia)常見(jian)于脊椎滑脫(tuo)癥、先天性髖關(guan)節(jie)脫(tuo)位(wei)或(huo)炎癥所(suo)致的髖關(guan)節(jie)屈(qu)曲(qu)(qu)畸形。
脊柱側彎應記明(ming)方向及(ji)部位(wei),是(shi)“C”形(xing)(xing)或反“C”形(xing)(xing),是(shi)“S”形(xing)(xing)或反“S”形(xing)(xing)。側凸不明(ming)顯(xian)者,可用滑動觸(chu)診法,即用中(zhong)指(zhi)放在棘(ji)突上,食、環指(zhi)緊貼在棘(ji)突旁用力由上而下滑動觸(chu)摸,測(ce)定有無彎曲(qu),同時(shi)可觀察(cha)觸(chu)摸后的充(chong)血帶是(shi)否正直。脊柱側彎常兼有縱(zong)軸旋轉(zhuan),外觀棘(ji)突連線(xian)并無彎曲(qu),僅表(biao)現為(wei)兩側肋(lei)骨、腰(yao)(yao)肌的不對稱。當病人向前(qian)彎腰(yao)(yao)時(shi)可看出(chu)兩側肩胛(jia)骨、腰(yao)(yao)肌的高度有明(ming)顯(xian)差(cha)異。
背肌(ji)在脊柱(zhu)兩側隆起(qi),脊柱(zhu)在中央呈(cheng)現(xian)一條(tiao)(tiao)溝狀。經常在彎腰位工作或缺乏鍛煉(lian)者,兩側背肌(ji)萎縮變平,而中央的(de)棘突呈(cheng)現(xian)一條(tiao)(tiao)隆起(qi)。腰痛患者有時會出現(xian)保護性腰肌(ji)緊張或痙攣(luan)。
【觸診】 棘上韌帶(dai)或(huo)棘間韌帶(dai)的損(sun)傷(shang)(shang)(shang),以及(ji)腰肌(ji)扭傷(shang)(shang)(shang)常有(you)(you)明顯固定的淺在壓(ya)(ya)痛點;下腰部及(ji)骶骨(gu)(gu)部某(mou)些(xie)韌帶(dai)損(sun)傷(shang)(shang)(shang),其疼痛可(ke)沿坐骨(gu)(gu)神經向(xiang)下肢(zhi)放射(she)。椎間盤突(tu)出,常于第(di)3、4、5腰椎棘突(tu)旁1.5厘米處(chu)有(you)(you)深在的壓(ya)(ya)痛,同(tong)時(shi)(shi)向(xiang)傷(shang)(shang)(shang)肢(zhi)遠端放射(she)。腰椎的橫(heng)突(tu)上有(you)(you)腰肌(ji)的起(qi)止點,腰肌(ji)急(ji)慢性損(sun)傷(shang)(shang)(shang)時(shi)(shi),常在橫(heng)突(tu)上有(you)(you)不同(tong)程(cheng)度的壓(ya)(ya)痛。椎體(ti)骨(gu)(gu)折(zhe)或(huo)結核,可(ke)有(you)(you)棘突(tu)壓(ya)(ya)痛、縱橫(heng)擠壓(ya)(ya)或(huo)叩擊痛。
【運(yun)動檢查】 脊(ji)(ji)柱的運(yun)動主要在頸段及腰段。腰段的運(yun)動包括前屈、后伸、左右(you)側屈及左右(you)旋(xuan)轉(zhuan)。腰椎間盤突出(chu)癥,向傷側的側屈及前屈受限明顯,然而在其可能活(huo)(huo)動的范圍內(nei),脊(ji)(ji)柱的活(huo)(huo)動曲線是較(jiao)柔和而均勻的。脊(ji)(ji)柱結核或僵直性脊(ji)(ji)椎炎,則各方向運(yun)動均受限制,失去(qu)正常的活(huo)(huo)動屈線,病變部(bu)脊(ji)(ji)椎僵硬。檢查腰、骶部(bu)病變,還常用下列方法:
1)拾(shi)物試驗 通過拾(shi)取一件(jian)放在(zai)地上(shang)的(de)(de)物品,觀(guan)察脊(ji)柱的(de)(de)活動是(shi)否正(zheng)常。腰椎有病變,則下蹲時(shi)必須屈曲兩側膝、髖關節,而(er)腰部仍是(shi)挺直的(de)(de)。
2)直腿(tui)抬高(gao)(gao)試驗 一般(ban)能自(zi)動直腿(tui)高(gao)(gao)舉八十度到九十度,除國部(bu)有(you)拉緊感覺外,無其(qi)它不適者為正(zheng)常(chang)(chang)。直腿(tui)抬高(gao)(gao)不能達到正(zheng)常(chang)(chang)角(jiao)度,且沿坐骨(gu)神經有(you)放(fang)射(she)痛(tong)者為陽(yang)性(xing)。為了鑒別其(qi)陽(yang)性(xing)是否為坐骨(gu)神經受牽扯(che)所引起(qi),可于抬高(gao)(gao)到疼痛(tong)的角(jiao)度放(fang)低5度,放(fang)射(she)痛(tong)消失,再(zai)使(shi)足踝用力背(bei)伸,如放(fang)射(she)痛(tong)加(jia)重,即非腰骶、骶髂部(bu)病(bing)變所引起(qi)。
3)腰(yao)骶(di)(di)關節檢查(cha) 極度屈曲兩(liang)髖與兩(liang)膝(xi)關節,使臀部離開(kai)床面,腰(yao)部被動前屈。下腰(yao)部筋肉組(zu)織(zhi)勞損,或腰(yao)骶(di)(di)椎(zhui)有病變時則感疼(teng)痛。
4)“4”字(zi)試驗 試驗右側(ce)(ce)時(shi),將右側(ce)(ce)足置于左(zuo)膝(xi)上(shang)部,然后醫生左(zuo)手壓(ya)左(zuo)髂前上(shang)棘,右手將右膝(xi)向(xiang)下壓(ya),如右側(ce)(ce)骶髂關節部有病變(bian)時(shi),則出現疼痛為陽(yang)性(xing)。如同側(ce)(ce)髖關節有病變(bian)也呈(cheng)陽(yang)性(xing)。
5)股神經(jing)牽(qian)拉試驗 病人俯臥位,下肢伸直,使傷(shang)側下肢向后過度伸展,在腰3、4椎間盤突出(chu)癥(zheng)時,可沿(yan)股神經(jing)有放射痛,稱為股神經(jing)牽(qian)拉試驗陽性。
6)脊柱被動伸展試驗(yan) 病(bing)人俯臥,將其雙(shuang)腿(tui)上提,觀(guan)察腰部伸展是否(fou)正(zheng)常或有僵直現象等。
X線檢(jian)(jian)查(cha)(cha)(cha),是傷(shang)科疾病(bing)很有價(jia)值(zhi)的(de)(de)診斷(duan)方(fang)法(fa)之一(yi)。X線照(zhao)(zhao)(zhao)(zhao)(zhao)片(pian)至少必(bi)(bi)須拍攝(she)兩個方(fang)位(wei)(wei),即正(zheng)位(wei)(wei)片(pian)和側位(wei)(wei)片(pian)。對某些部(bu)(bu)位(wei)(wei)還(huan)必(bi)(bi)須加(jia)攝(she)特殊(shu)體位(wei)(wei)的(de)(de)照(zhao)(zhao)(zhao)(zhao)(zhao)片(pian),例如了解脊椎(zhui)椎(zhui)弓峽部(bu)(bu),應拍攝(she)左右兩側的(de)(de)斜位(wei)(wei)片(pian);觀察第(di)1頸椎(zhui)或(huo)寰樞關(guan)節,須攝(she)正(zheng)位(wei)(wei)張口(kou)片(pian)。拍攝(she)長管骨(gu)骨(gu)干最(zui)好包括其上(shang)(shang)、下關(guan)節,因(yin)為(wei)在其上(shang)(shang)下部(bu)(bu)關(guan)節處(chu)可能(neng)另有損傷(shang),如尺骨(gu)上(shang)(shang)三(san)分(fen)之一(yi)骨(gu)折(zhe)(zhe)(zhe)可能(neng)合并橈骨(gu)小頭脫位(wei)(wei);脛骨(gu)中下三(san)分(fen)之一(yi)骨(gu)折(zhe)(zhe)(zhe),可兼(jian)有腓骨(gu)上(shang)(shang)部(bu)(bu)骨(gu)折(zhe)(zhe)(zhe)等。兒童四(si)肢靠近骨(gu)骺部(bu)(bu)位(wei)(wei)的(de)(de)損傷(shang),有時不易(yi)辨明(ming)有無骨(gu)折(zhe)(zhe)(zhe)及骨(gu)折(zhe)(zhe)(zhe)段移位(wei)(wei)的(de)(de)情況,需(xu)加(jia)攝(she)健肢相應部(bu)(bu)位(wei)(wei)照(zhao)(zhao)(zhao)(zhao)(zhao)片(pian)作為(wei)對比。對危重病(bing)人應在采取(qu)急救措施后,再進行X線照(zhao)(zhao)(zhao)(zhao)(zhao)片(pian),以(yi)免拍片(pian)時引起(qi)意外。X線檢(jian)(jian)查(cha)(cha)(cha)必(bi)(bi)須與臨床其它檢(jian)(jian)查(cha)(cha)(cha)相結合,才(cai)能(neng)得(de)出正(zheng)確的(de)(de)診斷(duan)。如腕舟(zhou)骨(gu)骨(gu)折(zhe)(zhe)(zhe),初期(qi)在陽溪(xi)穴處(chu)有明(ming)顯壓痛,而(er)X線照(zhao)(zhao)(zhao)(zhao)(zhao)片(pian)上(shang)(shang)可能(neng)未見明(ming)顯骨(gu)折(zhe)(zhe)(zhe)現象(xiang),往往在2周后再行照(zhao)(zhao)(zhao)(zhao)(zhao)片(pian)檢(jian)(jian)查(cha)(cha)(cha),才(cai)能(neng)顯示出骨(gu)折(zhe)(zhe)(zhe)的(de)(de)裂(lie)縫。懷疑有惡性腫(zhong)瘤時,還(huan)應進行活體組織檢(jian)(jian)查(cha)(cha)(cha),測定血(xue)清(qing)中鈣、磷(lin)、堿性磷(lin)酸酶的(de)(de)含量(liang),必(bi)(bi)要時還(huan)需(xu)作尿蛋白檢(jian)(jian)查(cha)(cha)(cha)等。
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上(shang)一篇: 道(dao)醫中醫傷科按摩(mo)學【第(di)七(qi)章(zhang)】第(di)三節 ···