使用X光膝關節伸直影像評估腦性麻痺兒童髕骨上移之嚴重性

腦性麻痺係指腦部在發展過程中發生傷害，造成非進行性、以運動功能障礙呈現之疾病；通常孩童表現肌肉控制障礙，導致步行或維持姿態之困難，其中蹲姿步態為常見之病理性步態，故而腦性痲痺兒童當需利用特殊擺位之X光攝影檢查作為評估手段，因此，本研究之目的為利用膝關節伸直側位X光攝影技術，以評估腦性麻痺兒童髕骨之位置高低以及與正常兒童之差異。本計畫為回溯性研究，自2006年至2010年共收集65位腦性痲痺病患，男生38位、女生27位，評估兩側英索薩瓦提比值（Insall-Salvati Ratio, ISR）。本研究所使用之X光機為Toshiba KXO-50R，X光影像接受器為Canon CXDI-40G，醫學影像擷取暨傳輸系統（PACS）為臺灣電腦公司之醫療數位影像傳輸協定3.0版（Digital Imaging and Communication in Medicine, DICOM）。之後將取得的資料運用獨立樣本T檢定、變異數分析、迴歸分析及皮爾森相關性分析。研究結果發現腦性痲痺兒童左膝與右膝ISR男生平均值與標準差分別為2.94 ± 0.98 mm、2.82 ± 0.82 mm，女生左膝與右膝ISR平均值與標準差分別為2.54 ± 0.73 mm、2.63 ± 1.03 mm，比正常同齡兒童高；當年齡增加時，其ISR會下降；左右膝關節平均ISR愈大者，其ISR不對稱性愈明顯；患者中共有11例呈現髕骨下緣撕裂性骨折。此結果顯示髕骨在股四頭肌長期張力拉扯及蹲膝步態影響之下，造成膝關節之解剖構造明顯改變，而兩側膝關節伸直姿勢之側面X光攝影為臨床追蹤病情嚴重度之方便檢查。臨床醫師未來可以透過年齡與ISR之迴歸模型方程式，用年齡估算出腦性麻痺兒童膝關節之ISR。此外，腦性麻痺病兒童有必要利用膝關節伸展X光攝影技術求得ISR來作為臨床醫師評估髕骨上移嚴重度之參考。作者建議本檢查採用躺臥姿攝影，若有膝彎曲攣縮者並以沙包將大腿及小腿中段壓低或建議由家長施壓，以達到最大伸展角度，如此可提供臨床醫師膝彎曲攣縮程度之資訊且可使檢查標準化，便於日後比較分析。

關鍵字

腦性麻痺；膝關節X光；髕骨

並列摘要

The purposes of this study are to report the findings obtained from the lateral radiography of the extended knee in children with cerebral palsy and propose a standardized method to perform this examination. Cerebral palsy (CP) is a static encephalopathy that occurred in an immature brain with motor dysfunction. One of the most frequently complained pathology is hamstring contracture with crouch gait. Clinical evaluation of hamstring contracture involves physical examination, gait analysis, and imaging studies of the knees. The lateral radiography is one of the most informative imaging studies for this particular condition. But reports about the radiographic findings or standardized imaging technique were scarce in the literature From January 2006 to December 2010, 65 children (38 boys and 27 girls) who were diagnosed as CP and had knee extension lateral radiography were retrospectively reviewed. The image was acquired with Toshiba KXO-50R or Canon CXDI-40G machine, digital imaging and communication in medicine3.0 (DICOM 3.0) was used for viewing image in picture archiving and communication system (PACS) provided by Taiwan Electronic Data Processing Co. The length of patella and patella tendon were measured with tool kit in Smart Iris V1.2.0.9 Build I. The Insall-Salvati ratio (ISR) is the ratio of the patella tendon length (TL) to the length of the patella (PL). The severity index (SI) of patella alta in a child is the average of ISR of right and left knees. The asymmetry index (ASI) is the ISR difference between two knees divided by SI. Logistic regression was used to evaluate the relation between ISR and age, SI and ASI. A p-value of less than 0.05 indicates a statistically significant difference. The ISR averaged 2.94 ± 0.98 mm in left knee of boys and 2.82 ± 0.82 mm in right knee of boys and 2.54 ± 0.73 mm in left knee of girls and 2.63 ± 1.03 mm in right knee of girls which was much higher than the ISR of normal children reported in literature. The ISR decreased with the increase of age. The more severe the patella alta (higher SI), the greater asymmetry between two knees (higher ASI). There were 11 cases revealed patella lower pole avulsion fracture and 79 cases with knee flexion contracture needed additional stress to extend the knee as possible. The knee extension lateral radiography is easy to perform and provides great amount of clinical information in children with cerebral palsy. A standardized imaging technique is required for objective evaluation. The authors recommend supine position with sand bag or manual stress on mid-thigh and mid-tibia to extend the knee as possible.

並列關鍵字

cerebral palsy ； Insall-Salvati Ratio ； patella ； knee joint X-ray

國際替代計量

使用X光膝關節伸直影像評估腦性麻痺兒童髕骨上移之嚴重性

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