肩關(guān)節(jié)常見疾病mri診斷-ⅰ

1、MR imaging of the common shoulder abnormalities肩關(guān)節(jié)常見疾病MRI診斷,(PartⅠ),Wang chaoyan2013/05/27,Background 背景,Shoulder disorders mainly involve rotator cuff diseases and shoulder instability. For rotator cuff diseases, r

2、outine shoulder MR imaging as the first choice can solve most of the problems in practice. For shoulder instability and related glenoid labrum lesions, shoulder MR arthrography is the first selection for evaluation肩關(guān)

3、節(jié)常見病變主要為肩袖相關(guān)病變和肩關(guān)節(jié)不穩(wěn)定。對于肩袖相關(guān)病變，肩關(guān)節(jié)MRI 常規(guī)掃描可作為首選；對于肩關(guān)節(jié)不穩(wěn)定和盂唇病變，則一般首選肩關(guān)節(jié)MRI 造影進行評價。,常見疾病名稱,Rotator cuff tendons disease肩袖肌腱病Rotator cuff tear肩袖撕裂Subscapularis rupture肩胛下肌斷裂Acromioclavicular joint disease肩鎖關(guān)節(jié)病The sub-ac

4、romial shoulder impingement syndrome肩峰下撞擊綜合征SLAP病變（上盂唇前后向撕裂）Bankart病變HAGL病變（盂肱下韌帶肱骨部撕脫）Labrum cyst 盂唇囊腫Adhesive capsulitis joints粘連性關(guān)節(jié)囊炎Shoulder joint osteoarthrosis肩關(guān)節(jié)骨關(guān)節(jié)病,一、 Rotator cuff tendons disease 肩袖肌腱病,Eti

5、ology pathology 病因病理：Excessive use, lead to degeneration and tear of rotator cuff 過度使用導(dǎo)致肩袖的退行性變和撕裂Most often in impingement最常繼發(fā)于撞擊綜合征Can occur in patients with collagen vascular disease可發(fā)生于膠原血管病患者Can be acute, but mo

6、re often repeated attacks on the basis of the already suffer from tendon disease可急性發(fā)生，但更常在已患有肌腱病的基礎(chǔ)上反復(fù)發(fā)作Tendon thickening, hardening; Partial or total disruption; Some tear on slippery bursa, articular surface or in the

7、 stroma肌腱增厚、硬化；部分或完全中斷；部分撕裂可在滑囊面、關(guān)節(jié)面或間質(zhì)中Collagen degeneration, but there is no inflammatory cells, chronic tendon can appear in fatty infiltration膠原變性，但沒有炎性細(xì)胞，慢性肌腱撕裂中可出現(xiàn)脂肪浸潤,NEER in installment of rotator cuff tendon le

8、sions 肩袖肌腱病變的NEER分期,Ⅰ period: rotator cuff, especially hills tendon edema and hemorrhage肩袖特別是崗上肌腱水腫和出血Tendonitis or inflammatory lesions, it is better to send in less than 25 years old young man. reversible肌腱炎或炎性病變，最好發(fā)于小

9、于25歲的青年人,可逆.Ⅱ period: inflammation further progress and more fibrous tissue formation炎癥進一步進展及更多的纖維組織形成Happens at 25～45 years old.好發(fā)于25-45歲。Ⅲ period: rotator cuff tear.肩袖撕裂。 Often occur in more than 45 years old. 常發(fā)于45歲

10、以上。,☆Best location: being is 1 cm, from the hills muscle to the greater tuberosity attachment points (no vascular distribution).最好發(fā)部位：崗上肌距大結(jié)節(jié)附著點1cm處（無血管分布）。,MRI manifestations of rotator cuff tendons disease 肩袖肌腱病的MRI表

11、現(xiàn),On all pulse sequence, signals are increased在所有脈沖序列上，信號均增高Tendon thickening, signal not usually homogeneous肌腱常常增厚、信號不均勻Partial tear, visible water signal in the tendons, but only partial tendon involvement 部分撕裂，在

12、肌腱中可見水樣信號，但只是部分肌腱受累Tendon full-thickness tear, liquid into tendon fractures, with varying degrees of tendon retraction肌腱全層撕裂，液體進入肌腱裂隙中，伴不同程度的肌腱回縮Tendon full-thickness tear of the chronic patients to merge muscle fat at

13、rophy肌腱全層撕裂的慢性患者可合并肌肉脂性萎縮,Oblique coronary a normal MRI imaging斜冠狀位 正常MRI造影,,Thin contrast sketch below outline of the rotator cuff (white arrow)薄的造影劑勾畫出肩袖的下面輪廓（白長箭頭），Normal joint capsule (black arrow),正常關(guān)節(jié)囊（黑箭頭），a

14、xillary fossae (white triangle arrows).腋隱窩 （白三角箭頭）。,Fig 1 Subdeltoid–subacromial bursitis.肩峰下滑囊炎。Coronal oblique MR images of the shoulder show fluid in the dilated subdeltoid–subacromial bursa (arrow head).常規(guī)MRI斜冠狀位示肩

15、峰下滑囊積液(箭頭)；1A: SE T1W; 1B: TSE T2W. Fig 2 Acromial morphology.肩峰形態(tài)。A. Shape of the Acromion. Type I, flatⅠ型，肩峰下表面為一平面；Type II, curvedⅡ型，肩峰下表面為弧形凹面；Type III, hooked Ⅲ型，肩峰下表面前部呈鉤狀突； B. Sagittal oblique image shows a Ty

16、pe II acromion and a degenerative spur at the anteroinferior edge of the acromion (arrow). MRI造影斜矢狀位示肩峰前下緣的骨刺(箭)，Ⅱ型肩峰,Fig 3 Tendinitis.肩袖變性。 Coronal oblique MR images of the shoulder show the supraspinatus tendon is dif

17、fuse thickening, with intrasubstance intermediate signal on T1-weighted and T2-weighted MR images(arrow).常規(guī)MRI斜冠狀位示岡上肌腱增粗，連續(xù)性好，T1W和T2W信號均增高(箭),4A,Fig 4: Bursal-sided partial thickness tear of the subscapularis.岡上肌腱上表面部分撕

18、裂.4A:Oblique coronal T2-weighted image shows partial disrupture of the bursal-sided tendon fibers (arrow). The articular-sided fibers are intact. 常規(guī)MRI 斜冠狀位FS T2W 示岡上肌腱止點處上表面部分撕裂，局部見液性高信號(箭)，伴肩峰下滑囊積液，下表面完整.4B:partial thi

19、ckness tear of the subscapularis. Oblique coronal T2-weighted MR image shows partial discontinuity of the articular-sided tendon fi bers (arrow).The bursal-sided fi bers are intact.岡上肌腱下表面部分撕裂。常規(guī)MRI 斜冠狀位FS T2W示岡上肌腱止點處下表面

20、撕裂( 箭) ，信號增高，但上表面完整,4B,4C,4D,Fig4C: Intratendinous partial thickness tear of the subscapularis. 岡上肌腱腱內(nèi)部分撕裂。Oblique coronal T2-weighted MR image shows abnormal intratendinous fluid accumulation (arrows). The bursal-sided

21、and articular-sided fi bers are intact常規(guī)MRI 斜冠狀位FS T2W示岡上肌腱止點處腱內(nèi)限局液性高信號影( 箭) ，肌腱上下表面均完整.Fig4D: Articular-sided partial thickness tear of the subscapularis.岡上肌腱下表面部分撕裂。 Oblique coronal T1-weighted MR arthrographic image s

22、hows partial discontinuity of the articular-sided fi bers (arrows), with contrast material leaking into the substance of the tendon, and intact bursal-sided fi bers. MRI造影斜冠狀位示高信號對比劑進入岡上肌腱下表面(箭)，但未進入肩峰下滑囊,Fig 5:Differen

23、t MRI techniques for labral tear.盂唇撕裂對比。 Fig5A : An axial routine MR image shows intact anteroinferior labrum. 常規(guī)MRI 軸位示盂唇未見撕裂征象；Fig5B: An axial MR arthrographic image demonstrates tear of the anteroinferior labrum (arr

24、ow).MRI造影軸位示前方盂唇撕裂(箭),5A,5B,54, M,The right oblique coronary: part of the joint surface and the slippery bursa surface of the Rotator cuff is torn 右側(cè)斜冠狀位示肩袖的關(guān)節(jié)面和滑囊面部分撕裂,PDWI,T2WI,MR arthrogram,PDWI（質(zhì)子加權(quán)像）：supraspinatus t

25、endonobviously obviously irregular (long arrow);崗上肌肌腱明顯不規(guī)則（長箭頭所示）；T2WI：found similar signal, in line with the tear of the parts (long arrow);發(fā)現(xiàn)相似信號符合部分撕裂（長箭頭所示） ；MR arthrogram（關(guān)節(jié)造影）：contrast agent into the shoulder sleev

26、e material, but not falling down to the shoulder peak capsule (arrow), in addition, a small part of contrast agents, inserted near the shoulder sleeve (long arrow).造影劑進入肩袖實質(zhì)內(nèi)，但未沿伸到肩峰下滑囊（三角箭頭所示），另外一小部分相連的造影劑插入鄰近肩袖（長箭頭所示）

27、。,58Y，M， The left oblique coronary in rotator cuff full-thickness tear左側(cè)斜冠狀位示肩袖全層撕裂,PDWI,T2WI,MR arthrogram,PDWI： rotator cuff essence, lack of limitations (long arrow);肩袖實質(zhì)局限性缺失（長箭頭所示）；T2WI：tear mouth increased signa

28、l (long arrow);撕裂口信號增高（長箭頭所示） ；MR arthrogram ：contrast filling gaps of rotator cuff (long arrow), under the shoulder peak - deltoid in capsule (arrow).造影劑充填肩袖缺口（長箭頭所示） 、肩峰下-三角肌下滑囊（三角箭頭所示）。,The differential diagnosis o

29、f tendon disease 肌腱病的鑒別診斷,Calcification features tendonitis鈣化性肌腱炎： tendon thickening, and often accompanied by signal decreases肌腱可增厚，并常伴有信號減低Within the tendon cyst肌腱內(nèi)囊腫：tendon thickening, and on T2WI tumor cyst with

30、partial rotator cuff tear肌腱增厚，且在T2WI上見囊腫合并部分肩袖撕裂,二、 Rotator cuff tear肩袖撕裂,In tendon fissure, visible in joint fluid, slippery bursa liquid filling or granulation tissue, on the FSE T2WI or SPAIR sequences is most clear在肌

31、腱裂隙中可見充以關(guān)節(jié)液、滑囊液或肉芽組織，在FSE T2WI SPAIR序列中最清晰Tendon edges appear different degree of contraction and degeneration肌腱邊緣出現(xiàn)不同程度的收縮和退行性變In patients with chronic tendon full-thickness tear can incorporate the fat of muscle atro

32、phy慢性患者的肌腱全層撕裂可合并肌肉的脂性萎縮Merger of synovial sac effusion under the shoulder peak合并肩峰下滑囊積液Occur between the front of the hills muscle tear or rotator cuff tear, easy to merge synovial sac effusion under beak有崗上肌前方撕裂和肩袖間撕

33、裂時易合并喙下滑囊積液,Suspicious patients with rotator cuff tear, imaging examination, should be a comprehensive observation of rotator cuff and the surrounding structure可疑肩袖撕裂的病人行影像學(xué)檢查時需對肩袖及其周圍結(jié)構(gòu)作全面觀察:Note that tear mouth size,

34、affected the scope, edge cases, muscle atrophy and bone change and so on.注意撕裂口大小、肌腱受累范圍、肌腱邊緣情況、肌肉萎縮及骨骼改變等。Partial tendon according to tear thickness or depth into three degrees.部分性肌腱撕裂可按撕裂厚度或深度分三度。 Ⅰ度：﹤3mm；Ⅱ度：3-6mm；Ⅲ

35、度：﹥6mm。Complete a tendon, according to the gap size is divided into four categories完全性肌腱撕裂據(jù)裂口大小分四類。 ﹤2mm Mild tear輕度撕裂；2-4 Moderate tear中度撕裂； 4-5mm Severe tear重度撕裂；﹥5mm Giant tear巨型撕裂。,The MRI classification o

36、f Rotator cuff tear (Neer) 肩袖撕裂的MRI分級（Neer）,0：Normally, a uniform low signal 正常，呈均勻一致的低信號1：Rotator cuff normal form, on T1WI or PDWI sequences showed diffuse or linear high signal肩袖形態(tài)正常，T1WI或PDWI上呈彌 漫性或線狀高信號2 ：Shoulde

37、r sleeve, is thinning or irregular, and has high signal on T1WI or PDWI sequences肩袖變薄或不規(guī)則， T1WI或PDWI上呈高信號3 ：Rotator cuff signal on T2WI sequence increased and affected tendon layer T2WI上肩袖信號增高且累及肌腱全層,Carrino, think rota

38、tor cuff tear is divided into seven degrees 肩袖撕裂分7級:0級： Tendon is normal肌腱正常；1級： Tendon (T1WI signal or PDWI) increased, the attachment points about 1 cm距附著點1cm肌腱信號（T1WI或PDWI）增高；2級：Tendonitis, increased signal on T2WI

39、, but not involving the top of the shoulder joint (with Neer2 degree)肌腱炎， T2WI上信號增高，但未累及肩關(guān)節(jié)上面（同Neer2級）；3級： Degeneration, one or more high signal on T2WI, and there is no enough to the torn part of diagnostic criteria退行性

40、變， T2WI上一個或多個高信號區(qū)，未達部分撕裂診斷標(biāo)準(zhǔn)；4級：Part of tear, on T2WI sequence, tendon signal increased obviously, and affected tendon above or below部分撕裂， T2WI上肌腱信號明星增高，且累及肌腱上下面；5級：Tendon near full-thickness rupture, but with a little

41、 muscle fiber complete肌腱近乎全層斷裂，但有少許肌纖維完整；6級： Tendon full-thickness rupture, without tendon contracture肌腱全層斷裂，無肌腱攣縮；7級： Tendon full-thickness rupture with tendon contracture.肌腱全層斷裂伴肌腱攣縮。,Oblique coronary 斜冠狀位,Tendoniti

42、s肌腱炎（1級）,TIWI,TIWI,T2WI,Rotator cuff tear肩袖撕裂（2級）,Fig 3 Full thickness tear of the supraspinatus.肩袖全層撕裂。Coronal oblique T2-weighted MR image shows the supraspinatus tendon becomes thicker, with abnormal high signal

43、as intense as fl uid extending from the articular surface to the subacromial bursa surface(arrow) 常規(guī)MRI斜冠狀位FS T2W示岡上肌腱連續(xù)、增厚，其內(nèi)部可見關(guān)節(jié)液樣的高信號，累及肌腱全層(箭),Fig 4 Full thickness tear of the supraspinatus.肩袖全層撕裂。Coronal oblique T

44、2-weighted MR image shows the complete discontinuity and retraction of the tendon (arrow).MRI造影斜冠狀位FS T2W 示岡上肌腱連續(xù)性中斷，斷端回縮( 箭),5A,5B,Fig 5:Full thickness tear of the supraspinatus.肩袖全層撕裂。A：Fig 6A: Coronal oblique T1-weigh

45、ted MR arthrographic image shows the complete discontinuity and retraction of the supraspinatus tendon (arrow), atrophy of the supraspinatus, and upward displacement of the humeral head. MRI造影斜冠狀位，示岡腱連續(xù)性中斷，斷端(箭)回縮，同時伴有肌腱

46、萎縮、肱骨頭上移；B: Sagittal oblique T1-weighted MR arthrographic image shows the discontinuity of the rotator cuff and the presence of high signal contrast material within the subacromial bursa (arrow).MRI 造影斜矢狀位，示肩袖不完整，撕裂累及岡上肌

47、腱和岡下肌腱，肩峰下滑囊內(nèi)(箭)可見高信號對比劑,三、Subscapularis rupture 肩胛下肌斷裂,Patients with secondary to anterior dislocation of shoulder joint, typically more than 40 years繼發(fā)于肩關(guān)節(jié)前脫位，患者一般大于40歲Secondary to the rear of the shoulder joint dislo

48、cation, visible at any age繼發(fā)于肩關(guān)節(jié)后脫位，可見于任何年齡Tendon signal uneven; Tendon in see water signal; Different degree of tendon retraction.肌腱信號不均勻；肌腱中見水樣信號；不同程度肌腱回縮。Plain radiographs, shows the humerus small tubercle fracture平

49、片可見肱骨小結(jié)節(jié)骨折,,斜失 T1WI,軸位MR arthrogram,T1WI：Edge is clear, uniform low signal邊緣清楚，均勻低信號,0級：19Y，F(xiàn)，Arthroscopy has confirmed the normal hills muscle tendon關(guān)節(jié)鏡證實的正常崗上肌肌腱,MR arthrogram：Complete tendon (arrow), no leakage of con

50、trast media, head of biceps tendon is located in the central完整的肌腱（箭頭），無造影劑滲漏，肱二頭肌腱居中,1級：57Y，M， Surgery confirmed that shoulder injury of tendon adhesion手術(shù)證實肩胛下肌腱附著處損傷,斜失 T1WI,軸位MR arthrogram,T1WI：Below the shoulder tendo

51、ns head wear, higher signal, nodules is complete.肩胛下肌腱頭磨損、信號增高，小結(jié)節(jié)完整。,MR arthrogram：Below the shoulder tendon adhesion, substance within the focal increased signal (triangle arrows), head of biceps tendon show the sublux

52、ation.肩胛下肌腱附著處實質(zhì)內(nèi)局灶信號增高（三角箭頭），肱二頭肌腱半脫位。,2級：49Y，M，Below the shoulder tendon adhesion in 3/4 damage with tendon rupture 肩胛下肌腱附著處3/4損傷伴肌腱斷裂,,斜失 T1WI,軸位MR arthrogram,T1WI： Most of below the shoulder tendons (long arrow) is

53、missing, the following small still attached(arrow).肩胛下肌腱大部份（長箭頭）缺失，下面小部分仍附著（箭頭）。,MR arthrogram：Below the shoulder tendons, small part is still attached to the nodules (arrows).肩胛下肌腱下面小部分仍附著于小結(jié)節(jié)（三角箭頭）。,3級：68Y，F(xiàn)， Under th

54、e shoulder tendon is completely torn 肩胛下肌腱完全撕裂,斜失 T1WI,軸位 MR arthrogram,T1WI： Below the shoulder tendons completely missing (long arrow).肩胛下肌腱完全缺失（長箭頭）。,MR arthrogram：Below the shoulder tendons (white arrow) has moderat

55、e retraction.肩胛下肌腱（白箭頭）已中度回縮,2級： 67Y,M. Auxiliary sign 輔助征像: contrast agent into the humerus small nodules 造影劑進入肱骨小結(jié)節(jié),斜失 T1WI MR arthrogram,軸位MR arthrogram,Oblique sagittal :T1WI MR arthrogram ：造影劑進入小結(jié)節(jié)（箭頭）。,Transverse

56、MR arthrogram：造影劑進入小結(jié)節(jié)（箭頭）。,Auxiliary sign輔助征像： subscapularis fatty infiltration肩胛下肌的脂肪浸潤,斜失 T1WI,3級： 68 Y，F(xiàn). subscapularis head part fat atrophy (long arrow), the following muscle is normal.肩胛下肌頭部部分脂肪萎縮（長箭頭），下面肌肉正常。,3級

57、:43Y,M. Subscapularis almost entirely atrophy (arrow), fat instead of muscles.肩胛下肌幾乎完全萎縮（箭頭），脂肪代替肌肉。,斜失 T1WI,Fig 7 Full thickness tear of the subscapularis.肩胛下肌腱全層撕裂。Axial MR arthrographic image shows the complete dis