肩關(guān)節(jié)磁共振診斷

1、肩關(guān)節(jié)磁共振診斷,,肩關(guān)節(jié)磁共振診斷,骨性出口與肩峰肩袖關(guān)節(jié)囊和盂唇骨性結(jié)構(gòu)和關(guān)節(jié)面肱二頭肌其他,MR掃描技術(shù),-T1 and T2 FS-斜冠狀面,-T1 and T2 FS-斜矢狀面,-T2 FS and GRE-橫斷面,骨性出口和肩峰,骨性弓狀結(jié)構(gòu)包圍肩袖肌腱機(jī)械性碰撞導(dǎo)致肩袖肌腱退變前肩峰是導(dǎo)致肩袖碰撞最重要的結(jié)構(gòu)Anterior Acromion Most Important Structure Lea

2、ding to Impingement,正常骨性出口,前,后,,喙突,,鎖骨,,肩峰,,肩峰形態(tài),Type I,,肩峰形態(tài),Type II,,肩峰形態(tài),Type III,,,肩峰下傾,正常肩峰軸位形態(tài),肩峰前下傾表現(xiàn),,,斜矢狀面上觀察肩峰軸位形態(tài),肩峰下傾,在冠狀面上觀察肩峰向外側(cè)的下傾表現(xiàn),正常肩峰軸位表現(xiàn),外側(cè)下傾,,,骨性肩峰發(fā)育,骨化中心常在22-25歲閉合,軸位像前肩峰正常表現(xiàn),,骨性肩峰發(fā)育異常（軸位）,,,肩峰發(fā)育異?？?/p>

3、能造成不穩(wěn)定，并導(dǎo)致三角肌收縮過(guò)程中肩峰與肩袖碰撞,骨性肩峰發(fā)育（矢狀面）,肩胛小骨骨贅形成,肩胛小骨,,,骨性肩峰,,肩鎖關(guān)節(jié),,肩峰,“雙肩鎖關(guān)節(jié)”征,肩峰骨贅形成,-骨贅-內(nèi)有骨髓信號(hào),-三角肌腱（類似骨贅表現(xiàn)）-低信號(hào)（內(nèi)無(wú)骨髓信號(hào)）,,,,肩 峰,形態(tài)分型（I，II，III）前/外側(cè)下傾型肩峰下緣骨贅形成,肩鎖關(guān)節(jié),-退變，關(guān)節(jié)囊增厚-較少引起肩袖卡壓,,,喙肩關(guān)節(jié),,,-正常喙肩韌帶厚度<3 mm,-韌帶增

4、厚可導(dǎo)致前肩袖碰撞,喙突碰撞,-正常喙肱距離為 11 mm,,-喙肱間距狹窄可導(dǎo)致肩胛下區(qū)域碰撞,,骨性出口和肩峰,肩峰形態(tài)分類，下傾型肩峰，骨贅，肩峰發(fā)育異常肩鎖關(guān)節(jié)退變，關(guān)節(jié)囊肥厚(是否存在團(tuán)塊樣表現(xiàn)？)喙肩韌帶(是否增厚?)喙肱間距 (肩胛下區(qū)是否有碰撞?),肩 袖,肩胛下肌; 岡上肌 岡下肌; 小圓肌;,肩袖（矢狀面）,,,,,,岡上肌， 岡下肌，小圓肌，肩胛下肌,肩袖（矢狀面）,岡上肌， 岡下肌，小圓肌，肩胛

5、下肌,肩袖（矢狀面）,覆蓋肱骨頭的連續(xù)低信號(hào)表現(xiàn),,,肩袖（軸位）,,岡上肌腱,肩袖（軸位）Rotator Cuff (Axial Plane),-評(píng)價(jià)肩胛下肌的最好平面Primary Plane for Evaluating Subscapularis,,岡下肌位于肩胛下肌對(duì)應(yīng)的關(guān)節(jié)后側(cè)區(qū)域-Infraspinatus Located Posteriorly,,,肩袖（冠狀面）Rotator Cuff (Coronal),評(píng)

6、估岡上肌腱的最佳層面,,肌肉肌腱連接部位于12點(diǎn)方向,,肩袖（冠狀面）,岡下肌腱位置偏后斜行走向,,肩胛下肌位置偏前多根肌腱組成,,,,肩袖病變,Tendonopathy肌腱病變Tear撕裂Partial Thickness, Full Thickness, Complete部分撕裂，全層撕裂，完全撕裂Musculotendinous Retraction肌肉肌腱回縮Fatty Atrophy脂肪肥厚HADD/ Ca

7、lcific Tendonitis鈣化性肌腱炎,肌腱病變,-Increased T1-signal; Thick tendonT1W信號(hào)增高，肌腱增厚-Intermediate T2-signal (No Fluid Signal)T2W中等信號(hào)，無(wú)液體信號(hào),,,關(guān)節(jié)囊部分撕裂（關(guān)節(jié)面）Partial Thickness Tear (Articular),Extensive Intermediate T1-SignalT1W延續(xù)性

8、中等信號(hào)表現(xiàn),T2: Fluid Signal T2：出現(xiàn)液性信號(hào) Partial Thickness 部分撕裂Undersurface Tear肌腱表面下撕裂,,,,部分撕裂（關(guān)節(jié)囊面）Partial Thickness Tear (Bursal),-Fluid Signal Extending into the Bursal Surface of the Supraspinatus Tendon 液性信號(hào)延伸至岡上肌腱關(guān)節(jié)囊面

9、表面,,,,肩袖部分撕裂（肌腱內(nèi)型） Partial Thickness Tear (Interstitial),-Fluid Signal within the Substance of the Tendon液性信號(hào)存在于肌腱內(nèi)-Does Not Touch the Surface不影響到肌腱表面,,,肩袖肌間囊腫Intramuscular Cyst Rotator Cuff,-High Association with與

10、以下因素有關(guān)P.T. Undersurface Tear創(chuàng)傷性表層下撕裂2. Small F.T. Tear小的全層撕裂3. DDX: Paralabral Cyst鑒別診斷：盂唇旁囊腫,,,,,肌間囊腫 Intramuscular Cyst Rotator Cuff,,,,Intramuscular Cyst Supraspinatus岡上肌肌間囊腫Small Undersurface P.T. Tear小的

11、創(chuàng)傷后撕裂,,全層撕裂 Full Thickness Tear,,,-Fluid extends through the entire thickness of the tendon (top - bottom)液性信號(hào)延伸至肌腱全層（從頂部到底部）-Mild retraction of musculotendinous junction肌肉肌腱連接部輕度回縮,-Fluid Signal within SST岡上肌腱內(nèi)出現(xiàn)液性

12、信號(hào),-Sag Image: Fluid from Top to Bottom矢狀面：液性信號(hào)從頂層到底層,,,全層撕裂 Full Thickness Tear,-Gad Arthrogram: Demonstrates Full Thickness Tear-肩關(guān)節(jié)造影：顯示全層撕裂,T1,T2,,,全層撕裂 Full Thickness Tear,,-Intermediate T1-Signal-T1W中等信號(hào),-Musc

13、ulotendinous Retraction-肌肉肌腱回縮,,-Fluid Signal on T2-T2W出現(xiàn)液性信號(hào)-Full thickness Tear-全層撕裂,,全層撕裂 Full Thickness Tear,完全撕裂 Complete Tear特征：肌肉肌腱回縮 Musculotendinous retraction,-Greater than 3 cm retraction- poor prognosi

14、s for repair-肌肉肌腱出現(xiàn)超過(guò)3cm的回縮-預(yù)后不佳,,,脂肪增厚 Fatty Atrophy,-Grade as Mild, Moderate, Severe-分為輕度，中度和重度-Streaks of High Signal on T1 -T1W出現(xiàn)高信號(hào)改變,,,-Normal muscle bulk-正常岡上肌,,,-Fatty Atrophy: Does not fill supraspinatus fo

15、ssa-脂肪增厚：肌肉信號(hào)未充填岡上肌窩,脂肪增厚 Fatty Atrophy,鈣化性肌腱炎 Calcific Tendonitis,-Dark Globular Area on all Pulse Sequences-在所有的脈沖序列上均為低信號(hào)-Blooming Artifact on Gradient Echo Images-GE圖像上可出現(xiàn)偽影,,,肩袖病變Rotator Cuff Pathology,Tendon

16、opathy 肌腱病變Tear 撕裂Partial Thickness, Full Thickness, Complete部分撕裂，全層撕裂，完全撕裂Musculotendinous Retraction肌肉肌腱回縮Fatty Atrophy 脂肪增厚Calcific Tendonitis 鈣化性肌腱炎,關(guān)節(jié)囊結(jié)構(gòu)和盂唇Capsular Structures and Labrum,Patient under 35 y

17、. o. with GH Instability or Unexplained Shoulder Pain35歲以下患者出現(xiàn)肩關(guān)節(jié)不穩(wěn)定或無(wú)法解釋的肩部疼痛MR Arthrography適合進(jìn)行MR關(guān)節(jié)造影Labral Lesions Common 盂唇病變較為常見(jiàn)Subtle Lesions (nondisplaced, resynovialized) -Distention Effects of Contrast小病

18、變（未移位，滑膜化）-對(duì)比劑的遮蔽效應(yīng),Bankart病變 Bankart Lesion,,,-Conventional MRI: Loss of Normal Morphology of Anterior Labrum-常規(guī)MR：前盂唇正常形態(tài)消失,-Subtle Lesions Best Demonstrated on MR Arthrography-MR肩關(guān)節(jié)造影能更好的顯示盂唇微小病變,,,Bankart病變 Banka

19、rt Lesion,Hill Sach病變Hill Sachs Lesion,,,Top 3 Axial Images Through Humeral Head Should Be Round正常：肱骨頭軸位像最上面3幅圖像應(yīng)為圓形Flattening or Convexity on Top 3 Images最上面3幅圖像扁平或不規(guī)則表現(xiàn)Posterior Humeral Sulcus: Can Mimic A Hill

20、Sachs后肱骨凹：易與Hill Sachs病變混淆,SLAP病 SLAP Tears,,Superior Labrum is Dark on Pulse Sequences in Coronal Plane冠狀面脈沖序列顯示上盂唇出現(xiàn)低信號(hào)表現(xiàn)Any Signal in Triangle of Superior Labrum = SLAPSLAP病變：上盂唇在任何序列上出現(xiàn)三角形異常信號(hào)MR Arthrography

21、 Improves SensitivityMR關(guān)節(jié)造影提升了診斷敏感度,,肩關(guān)節(jié)表面和骨性結(jié)構(gòu)Osseous Structures and Articular Surfaces,Hematopoietic Bone Marrow 局部紅骨髓變Subcortical Cystic Change皮質(zhì)下囊變Trauma (Fracture)創(chuàng)傷（骨折）Arthritis 關(guān)節(jié)炎Infection 感染Tumor 腫瘤,紅骨髓

22、變 Hematopoietic Marrow,-Humeral epiphysis: Only Epiphysis that Normally contains Hematopoietic Marrow肱骨紅骨髓變：正常情況下僅骨骺保留紅骨髓-Females; Curvilinear; Subcortical Distribution; Bilateral女性多見(jiàn)；弧形表現(xiàn)；皮質(zhì)下分布；雙側(cè),,,皮質(zhì)下囊變 Subcortical

23、 Cystic Change,-Commonly Seen Near SST Insertion Site岡上肌附著處最為常見(jiàn)-Mimic Hill Sachs與Hill Sach病易混淆,,,創(chuàng)傷 Trauma,-24 y.o. Female: Persistent Painful Shoulder After Skiing Accident女性，24歲，滑雪事故后持續(xù)性肩關(guān)節(jié)疼痛,,肱骨頭無(wú)菌性壞死 AVN,T1,T2,“D

24、ouble Line” Sign- Seen On T2 Images雙線征,,,非特異性骨髓信號(hào)異常Nonspecific Marrow Signal,-DDX: Infection, Tumor, Trauma鑒別診斷：感染，腫瘤，創(chuàng)傷-T1 Image: Use Muscle as Internal StandardT1加權(quán)：肌肉作為對(duì)照-T1 Signal Darker than Muscle: Pathologic

25、異常信號(hào)：T1加權(quán)像上病灶信號(hào)低于肌肉,,,腫瘤 Tumor,-Osteosarcoma Proximal Humerus 肱骨近端骨肉瘤-Mass with Cortical Destruction 皮質(zhì)破壞合并軟組織腫塊形成-Low Signal T1; High Signal T2 Images,,,,關(guān)節(jié)軟骨 Articular Cartilage,-Normal Cartilage 正常軟骨-Intermediate

26、 Signal 中等信號(hào)-Smooth 表面平整,,,-Articular Cartilage Defect軟骨缺損-Gap: Fills With Contrast關(guān)節(jié)造影：顯示軟骨裂隙,,,,肱二頭肌病變Biceps Tendon,Tendonitis 肌腱炎Tear 肌腱撕裂Dislocation 脫位Intra-articular 關(guān)節(jié)內(nèi)脫位Extra-articular 關(guān)節(jié)外脫位,肱二頭肌病變Bice

27、ps Tendon,肱二頭肌病變Biceps Tendon,-Extra-articular Biceps: Best Seen on Axial Image關(guān)節(jié)外肱二頭肌腱：軸位顯示最佳-In Bicipital Groove; Transverse Ligament肌腱位于二頭肌溝內(nèi)，外有橫韌帶保護(hù),,肱二頭肌病變Biceps Tendon,肱二頭肌腱脫位Biceps Tendon Dislocation,-Extra-

28、articular: Transverse Ligament Torn; Subscapularis Intact關(guān)節(jié)外脫位：橫韌帶撕裂；肩胛下肌完整-Intra-articular: Subscapularis Torn or Avulsed關(guān)節(jié)內(nèi)脫位：肩胛下肌撕裂或撕脫,,,,-Biceps Tendon Intra-articular Dislocation:肌腱關(guān)節(jié)內(nèi)脫位： Subscapularis Tendon A

29、vulsed肩胛下肌腱撕脫,肱二頭肌腱脫位Biceps Tendon Dislocation,,,肱二頭肌腱脫位Biceps Tendon Dislocation,肱二頭肌腱炎/撕裂Biceps Tendonitis/ Tear,-Thick Tendon; Increased Signal肌腱增厚；信號(hào)增加-Longitudinal Splits縱向撕裂,,,,,盂唇旁囊腫Paralabral Cyst,High As

30、sociation with Labral Tears and GH Instability 與盂唇撕裂和盂肱關(guān)節(jié)不穩(wěn)定密切相關(guān) Analogous to Meniscal Cysts of the Knee 類似于膝關(guān)節(jié)半月板囊腫T2 Images- Multi-lobulated Fluid Collections T2加權(quán)像-多房液性信號(hào)Location: Posterior, Superior, Inferi

31、or 部位：盂唇后，上，下部Can Cause Neurovascular Entrapment 可導(dǎo)致神經(jīng)血管卡壓,,肩胛上神經(jīng)卡壓Suprascapular Nerve Entrapment,-Suprascapular Notch肩胛上切跡-Denervation of Supra- and Infraspinatus Muscles岡上肌和岡下肌去神經(jīng)化,,-Spinoglenoid Notch岡盂切跡-D

32、enervation of Infraspinatus Muscle岡下肌去神經(jīng)化,,岡上肌/岡下肌去神經(jīng)化Denervation Supra/Infraspinatus,-Entrapment of the Suprascapular Nerve in Suprascapular Notch肩胛上切跡囊腫導(dǎo)致肩胛上神經(jīng)卡壓-MR Findings: Early- Denervation edema (High Signal

33、on T2)MR表現(xiàn)：早期-去神經(jīng)水腫（T2加權(quán)高信號(hào)）Late- Fatty Replacement (High Signal on T1)晚期：脂肪替代（T1加權(quán)高信號(hào)）,,,,岡下去神經(jīng)化Denervation Infraspinatus,-Entrapment of Suprascapular Nerve in Spinoglenoid Notch岡盂切跡囊腫導(dǎo)致肩胛上神經(jīng)卡壓-Early Denervat

34、ion Edema of Infraspinatus Muscle岡下肌去神經(jīng)水腫,,,,四邊孔綜合征Quadrilateral Space Syndrome,旋肱后動(dòng)脈和腋神經(jīng)在四邊孔處受壓后所引起的一系列臨床癥候群。其主要表現(xiàn)是腋神經(jīng)支配的肩臂外側(cè)的感覺(jué)障礙和三角肌功能受限。由于當(dāng)肩關(guān)節(jié)外展外旋時(shí)，組成四邊孔的肌肉均受牽拉，從三個(gè)方向?qū)λ倪叜a(chǎn)生擠壓而致本癥發(fā)生。 -Axillary Nerve Compression Neu

35、ropathy腋神經(jīng)受壓癥狀-Poorly Localized Shoulder Pain in ABER PositionABER位局部嚴(yán)重肩痛-Atrophy of Teres Minor and Deltoid Muscles小圓肌和三角肌萎縮Etiologies: Fibrous Bands- Seen with Repetitive Overhead Activity; Paralabral Cyst; Mass

36、病因：反復(fù)過(guò)伸過(guò)頭運(yùn)動(dòng)導(dǎo)致的纖維束帶；盂唇旁囊腫；腫塊,-Chronic Fatty Atrophy of Teres Minor and Deltoid小圓肌和三角肌慢性萎縮和脂肪化-High Signal on T1 ImagesT1加權(quán)高信號(hào)表現(xiàn),,,,四邊孔綜合征Quadrilateral Space Syndrome,Systematic Approach to the Shoulder肩關(guān)節(jié)讀片要領(lǐng),Osseous

37、 Outlet and AcromionAcromial Type, Anterior/Lateral Down Sloping, Spur, Os Acromiale; AC Joint; C-A Ligament骨性出口和肩峰肩峰類型，前/后下斜型，骨贅，肩峰小骨，肩鎖關(guān)節(jié)，喙肩韌帶Rotator Cuff Tendonopathy, Partial Thickness, Full Thickness, Complete

38、Tear; Fatty Atrophy, Retraction肩袖-肌腱病變，部分撕裂，全層撕裂，完全撕裂，脂肪性萎縮，韌帶回縮,Capsule and LabrumLabral Tear; Anterior; SLAP; Posterior關(guān)節(jié)囊和盂唇盂唇撕裂；前盂唇病變；SLAP；后盂唇病變Osseous Structures and Articular SurfacesTrauma; Arthritis; Infec