2/9(金) セミナー参加
◆今日の気持ち
(整形外科 2週目)
・身体所見は難しい…。
・疑った疾患は質問前にきちんと頭に内容入れないとな…。ついつい気持ちが焦ってしまう
・指導医に患者の、入院契機となったのではない疾患について質問したが、自分の準備に深みがなかった。担当患者でなかったことはあったが、問診が浅かった。その病気について知識がないからだが、前医の治療内容について深く聞き出せなかった。知らない分野は難しい…
・肺炎の治療をしていて抗生剤に対しての薬剤性肺障害が出現したとき、きっちり対応しきれいるのか不安に思った…
・妊娠可能女性の妊娠をCT前に聞き損ねる…。あぶないあぶない…
・どこまで検査をするのかは、難しい。手軽に安く検査は終らせたいところだし余計なことはしないにせよ、病理に確信を持って到達できるまでは、設備が許す限りは効率よくやってもよいか。
・疾患を否定する質問、を頭に整理して叩き込まねば
・復習は、ためるとしんどい…
●目指す医師像
まずは、医者
●今の目標
・整形外科を味わいきる
●今日の新患・診断
・恥骨骨折
・頚椎捻挫
・尿管結石
・結膜炎
・骨metaで腸骨骨折
・C5中心性脊髄損傷
●今日の病院滞在時間
当直〜18時半
●今日行ったこと・見たこと・知ったこと
・手についてのモーニングセミナー
・講演「薬剤性肺障害」
・頚椎後彎は20%くらいあり、生理的
・ナート。気持ちが悪くなっても倒れないように、全身状態よくても寝かせてやること
・骨の見方。輪郭・関節・骨の分断線
・仙骨裂孔ブロック
・整形外科的疾患の検査。MRIなど有力な検査ではあるが、先入観が入ることがある。原則としてまずは、過不足ないX線を。
・手の腱診察
本来脱力すれば屈曲するはずの指の中で伸展位をとるものが1本だけあれば腱断裂を疑う。他のDIPが曲がらないようにしてその指を曲がらせるよう指示して屈曲しなければFDS断裂(4つの指のFDPは分離が悪く普通は同時に収縮するから、その方法でFDPを固定できる)。その指のPIPが曲がらないようにして(FDSを固定して)屈曲しなければFDP断裂。特に小児など、痛み強く屈曲を指示通りにできなければDynamic tendesis effect(手首の屈曲で腱を収縮・弛緩させる)を用いる方法も。
FDSは表にあるので切れやすいが、切れていても指は屈曲するので見逃されやすい
腱断裂は放置するとどんどん手首まで筋肉で引き込まれる。屈筋腱なら手首腕を屈曲させて弛緩させ、伸筋腱なら伸展させて弛緩させ、固定して手の外科に送る
PIPから手1/3までのno man's landは癒着を起こしやすい。癒着したら、腱の外のopeで断裂した血行が開腹する3ヶ月後に再手術(待たないと腱が再度切れる可能性高い)。
PIPでの伸筋腱断裂 →ボタンホール
DIPでの伸筋腱断裂 →槌指(マレット・フィンガー)、さらに強まるとスワンネック
伸筋腱断裂は保存(4週)が原則(屈筋なら3週。伸筋は屈筋より弱いので負けてしまうから)。絶対に、入浴などでも、固定ははずさせない。すぐ切れる。それ以上の固定は癒着を引き起こす
腱断裂あとの運動はpassiveでおこない腱に負担をかけないように癒着を防ぐ
・神経断裂
二点識別覚、differentiation, Tinelでチェック
治療は2〜3週以内に
Tinelが末梢に移動することで、神経の回復をチェックできる
・圧迫による神経麻痺 治療は経過観察orビタミンB12
下垂手(drop hand / drop finger)、猿手(母指球筋萎縮)、鷲手(骨間筋、小指球筋萎縮)
・Intrinsic plus position
MPを曲げた状態。固定するならこれ。MPが曲がっていない状態で硬縮した手は何の役にもたたなくなる。曲がっていればいろいろ使える。
・五十肩
あらゆる方向への動きが制限される肩の拘縮と疼痛が主症状。関節内の炎症→短縮?→自然治癒
・肩峰下impingement syndrome
烏口肩峰アーチに腱板・肩峰下包が繰り返し衝突。棘上筋が最も傷害されやすい。
関節包の炎症起こる →臥位にて圧力高くなる →痛み増強
painfull arc sign有痛弧徴候 .. 60度〜120度で痛み(それを越えると痛みなくなる)
→impingement syndromeか肩板断裂 「ひっかかる痛み」
Neer's impingement sign ... 肩甲骨を押さえつつ内旋した腕を前方挙上で痛み
Hawkins's impingement sign ... 前方挙上し90度曲げた腕を肩甲骨を押さえ内旋
どちらも、棘上筋腱と肩峰下胞が肩峰に押し付けられる
・肩板断裂
高齢者なら半数以上はかかっている。よほど不具合がなければ保存療法で十分。
運動時の突然の発症…だからといって断裂ではない。五十肩でも蓄積された影響がちょっとした契機に出現するのはありうるはなし。
・肩の診察
Flection ... Active & Passive
External rotation first position ... 上腕下垂・前腕90度前。外旋をチェック。
(Secondは上腕を横、Thirdは上腕を前)
Internal rotation ... 背面のものが意義あり。肩甲骨下がTh7、上がTh4、を目安に。
Drop arm sign ... 上に他動的に上げた手がストンと落ちる。挙上位保持がきつい、とでることも
棘上筋test(supraspinatus SSP test) ... 上腕を前に出し母指を下に向け、上腕を挙上させる。筋力落ちたら陽性。大結節の圧痛もチェック
棘下筋test(infraspinatus ISP test) ... ER1で負荷をかける
Lift off test ... 背中に付けた手をぱっと離させる。肩甲下筋のチェック
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