肩关节磁共振诊断课件.ppt

1、医院-社区一体化糖尿病教育项目肩关节磁共振诊断肩关节磁共振诊断肩关节磁共振诊断 骨性出口与肩峰 肩袖 关节囊和盂唇 骨性结构和关节面 肱二头肌 其他MR扫描技术-T1 and T2 FS-斜冠状面-T1 and T2 FS-斜矢状面-T2 FS and GRE-横断面骨性出口和肩峰 骨性弓状结构包围肩袖肌腱 机械性碰撞导致肩袖肌腱退变 前肩峰是导致肩袖碰撞最重要的结构Anterior Acromion Most Important Structure Leading to Impingement 正常骨性出口正常骨性出口前前 后后喙突锁骨肩峰肩峰形态Type I肩峰形态Type II肩峰形态T

2、ype III肩峰下倾正常肩峰轴位形态肩峰前下倾表现斜矢状面上观察肩峰轴位形态肩峰下倾在冠状面上观察肩峰向外侧的下倾表现正常肩峰轴位表现外侧下倾骨性肩峰发育骨性肩峰发育骨化中心常在骨化中心常在22-25岁闭合岁闭合轴位像前肩峰正常表现骨性肩峰发育异常（轴位）骨性肩峰发育异常（轴位）肩峰发育异常可能造成不稳定，并导致三角肌收缩过程中肩肩峰发育异常可能造成不稳定，并导致三角肌收缩过程中肩峰与肩袖碰撞峰与肩袖碰撞骨性肩峰发育（矢状面）骨性肩峰发育（矢状面）肩胛小骨骨赘形成肩胛小骨骨性肩峰骨性肩峰肩锁关节肩峰“双肩锁关节”征肩峰骨赘形成肩峰骨赘形成-骨赘-内有骨髓信号-三角肌腱（类似骨赘表现）-低信号

3、（内无骨髓信号）肩肩 峰峰 形态分型（I，II，III）前/外侧下倾型肩峰 下缘骨赘形成肩锁关节肩锁关节-退变，关节囊增厚-较少引起肩袖卡压喙肩关节喙肩关节-正常喙肩韧带厚度3 mm-韧带增厚可导致前肩袖碰撞喙突碰撞喙突碰撞-正常喙肱距离为 11 mm-喙肱间距狭窄可导致肩胛下区域碰撞骨性出口和肩峰骨性出口和肩峰 肩峰 形态分类，下倾型肩峰，骨赘，肩峰发育异常 肩锁关节 退变，关节囊肥厚(是否存在团块样表现？)喙肩韧带(是否增厚?)喙肱间距(肩胛下区是否有碰撞?)肩肩 袖袖肩胛下肌肩胛下肌;冈上肌冈上肌 冈下肌冈下肌;小圆肌小圆肌;肩袖（矢状面）肩袖（矢状面）冈上肌，冈下肌，小圆肌，肩胛下肌肩

4、袖（矢状面）肩袖（矢状面）冈上肌，冈下肌，小圆肌，肩胛下肌肩袖（矢状面）肩袖（矢状面）覆盖肱骨头的连续低信号表现肩袖（轴位）肩袖（轴位）冈上肌腱肩袖（轴位）肩袖（轴位）Rotator Cuff(Axial Plane)-评价肩胛下肌的最好平面Primary Plane for Evaluating Subscapularis冈下肌位于肩胛下肌对应的关节后侧区域-Infraspinatus Located Posteriorly肩袖（冠状面）肩袖（冠状面）Rotator Cuff(Coronal)评估冈上肌腱的最佳层面评估冈上肌腱的最佳层面肌肉肌腱连接部位于12点方向肩袖（冠状面）肩袖（冠状面）

5、冈下肌腱位置偏后斜行走向肩胛下肌位置偏前多根肌腱组成肩袖病变肩袖病变 Tendonopathy肌腱病变 Tear撕裂 Partial Thickness,Full Thickness,Complete 部分撕裂，全层撕裂，完全撕裂 Musculotendinous Retraction肌肉肌腱回缩 Fatty Atrophy脂肪肥厚 HADD/Calcific Tendonitis钙化性肌腱炎肌腱病变-Increased T1-signal;Thick tendonT1W信号增高，肌腱增厚-Intermediate T2-signal(No Fluid Signal)T2W中等信号，无液体信号

6、关节囊部分撕裂（关节面）关节囊部分撕裂（关节面）Partial Thickness Tear(Articular)Extensive Intermediate T1-SignalT1W延续性中等信号表现T2:Fluid Signal T2：出现液性信号 Partial Thickness 部分撕裂Undersurface Tear肌腱表面下撕裂部分撕裂（关节囊面）部分撕裂（关节囊面）Partial Thickness Tear(Bursal)-Fluid Signal Extending into the Bursal Surface of the Supraspinatus Tendon 液

7、性信号延伸至冈上肌腱关节囊面表面肩袖部分撕裂（肌腱内型）肩袖部分撕裂（肌腱内型）Partial Thickness Tear(Interstitial)-Fluid Signal within the Substance of the Tendon液性信号存在于肌腱内-Does Not Touch the Surface不影响到肌腱表面肩袖肌间囊肿肩袖肌间囊肿Intramuscular Cyst Rotator Cuff-High Association with与以下因素有关1.P.T.Undersurface Tear创伤性表层下撕裂2.Small F.T.Tear小的全层撕裂3.DDX:

8、Paralabral Cyst鉴别诊断：盂唇旁囊肿肌间囊肿肌间囊肿 Intramuscular Cyst Rotator CuffIntramuscular Cyst Supraspinatus冈上肌肌间囊肿Small Undersurface P.T.Tear小的创伤后撕裂全层撕裂全层撕裂 Full Thickness Tear-Fluid extends through the entire thickness of the tendon(top-bottom)液性信号延伸至肌腱全层（从顶部到底部）-Mild retraction of musculotendinous junction肌

9、肉肌腱连接部轻度回缩-Fluid Signal within SST冈上肌腱内出现液性信号-Sag Image:Fluid from Top to Bottom矢状面：液性信号从顶层到底层全层撕裂全层撕裂 Full Thickness Tear-Gad Arthrogram:Demonstrates Full Thickness Tear-肩关节造影：显示全层撕裂T1T2全层撕裂全层撕裂 Full Thickness Tear-Intermediate T1-Signal-T1W中等信号-Musculotendinous Retraction-肌肉肌腱回缩-Fluid Signal on T2

10、-T2W出现液性信号-Full thickness Tear-全层撕裂全层撕裂全层撕裂 Full Thickness Tear完全撕裂完全撕裂 Complete Tear特征：肌肉肌腱回缩特征：肌肉肌腱回缩 Musculotendinous retraction-Greater than 3 cm retraction-poor prognosis for repair-肌肉肌腱出现超过3cm的回缩-预后不佳脂肪增厚脂肪增厚 Fatty Atrophy-Grade as Mild,Moderate,Severe-分为轻度，中度和重度-Streaks of High Signal on T1-T

11、1W出现高信号改变-Normal muscle bulk-正常冈上肌-Fatty Atrophy:Does not fill supraspinatus fossa-脂肪增厚：肌肉信号未充填冈上肌窝脂肪增厚脂肪增厚 Fatty Atrophy钙化性肌腱炎钙化性肌腱炎 Calcific Tendonitis-Dark Globular Area on all Pulse Sequences-在所有的脉冲序列上均为低信号-Blooming Artifact on Gradient Echo Images-GE图像上可出现伪影肩袖病变肩袖病变Rotator Cuff Pathology Tendon

12、opathy 肌腱病变 Tear 撕裂 Partial Thickness,Full Thickness,Complete 部分撕裂，全层撕裂，完全撕裂 Musculotendinous Retraction肌肉肌腱回缩 Fatty Atrophy 脂肪增厚 Calcific Tendonitis 钙化性肌腱炎关节囊结构和盂唇关节囊结构和盂唇Capsular Structures and Labrum Patient under 35 y.o.with GH Instability or Unexplained Shoulder Pain35岁以下患者出现肩关节不稳定或无法解释的肩部疼痛 MR

13、 Arthrography 适合进行MR关节造影 Labral Lesions Common 盂唇病变较为常见 Subtle Lesions(nondisplaced,resynovialized)-Distention Effects of Contrast小病变（未移位，滑膜化）-对比剂的遮蔽效应Bankart病变病变 Bankart Lesion-Conventional MRI:Loss of Normal Morphology of Anterior Labrum-常规MR：前盂唇正常形态消失-Subtle Lesions Best Demonstrated on MR Arthro

14、graphy-MR肩关节造影能更好的显示盂唇微小病变Bankart病变病变 Bankart LesionHill Sach病变病变Hill Sachs Lesion Top 3 Axial Images Through Humeral Head Should Be Round正常：肱骨头轴位像最上面3幅图像应为圆形 Flattening or Convexity on Top 3 Images最上面3幅图像扁平或不规则表现 Posterior Humeral Sulcus:Can Mimic A Hill Sachs后肱骨凹：易与Hill Sachs病变混淆SLAP病病 SLAP Tears

15、Superior Labrum is Dark on Pulse Sequences in Coronal Plane冠状面脉冲序列显示上盂唇出现低信号表现冠状面脉冲序列显示上盂唇出现低信号表现 Any Signal in Triangle of Superior Labrum=SLAPSLAP病变：上盂唇在任何序列上出现三角形异常信号病变：上盂唇在任何序列上出现三角形异常信号 MR Arthrography Improves SensitivityMR关节造影提升了诊断敏感度关节造影提升了诊断敏感度肩关节表面和骨性结构肩关节表面和骨性结构Osseous Structures and Arti

16、cular Surfaces Hematopoietic Bone Marrow 局部红骨髓变局部红骨髓变 Subcortical Cystic Change皮质下囊变皮质下囊变 Trauma(Fracture)创伤（骨折）创伤（骨折）Arthritis 关节炎关节炎 Infection 感染感染 Tumor 肿瘤肿瘤红骨髓变红骨髓变 Hematopoietic Marrow-Humeral epiphysis:Only Epiphysis that Normally contains Hematopoietic Marrow肱骨红骨髓变：正常情况下仅骨骺保留红骨髓-Females;Curvi

17、linear;Subcortical Distribution;Bilateral女性多见；弧形表现；皮质下分布；双侧皮质下囊变皮质下囊变 Subcortical Cystic Change-Commonly Seen Near SST Insertion Site冈上肌附着处最为常见-Mimic Hill Sachs与Hill Sach病易混淆创伤创伤 Trauma-24 y.o.Female:Persistent Painful Shoulder After Skiing Accident女性，女性，24岁，滑雪事故后持续性肩关节疼痛岁，滑雪事故后持续性肩关节疼痛肱骨头无菌性坏死肱骨头无菌

18、性坏死 AVNT1T2“Double Line”Sign-Seen On T2 Images双线征非特异性骨髓信号异常非特异性骨髓信号异常Nonspecific Marrow Signal-DDX:Infection,Tumor,Trauma鉴别诊断：感染，肿瘤，创伤-T1 Image:Use Muscle as Internal StandardT1加权：肌肉作为对照-T1 Signal Darker than Muscle:Pathologic异常信号：T1加权像上病灶信号低于肌肉肿瘤肿瘤 Tumor-Osteosarcoma Proximal Humerus 肱骨近端骨肉瘤-Mass w

19、ith Cortical Destruction 皮质破坏合并软组织肿块形成-Low Signal T1;High Signal T2 Images关节软骨关节软骨 Articular Cartilage-Normal Cartilage 正常软骨-Intermediate Signal 中等信号-Smooth 表面平整-Articular Cartilage Defect软骨缺损-Gap:Fills With Contrast关节造影：显示软骨裂隙肱二头肌病变肱二头肌病变Biceps Tendon Tendonitis 肌腱炎 Tear 肌腱撕裂 Dislocation 脱位 Intra-a

20、rticular 关节内脱位 Extra-articular 关节外脱位肱二头肌病变肱二头肌病变Biceps TendonBiceps Tendon肱二头肌病变肱二头肌病变Biceps TendonBiceps Tendon-Extra-articular Biceps:Best Seen on Axial Image关节外肱二头肌腱：轴位显示最佳关节外肱二头肌腱：轴位显示最佳-In Bicipital Groove;Transverse Ligament肌腱位于二头肌沟内，外有横韧带保护肌腱位于二头肌沟内，外有横韧带保护肱二头肌病变肱二头肌病变Biceps TendonBiceps Tend

21、on肱二头肌腱脱位肱二头肌腱脱位Biceps Tendon Dislocation-Extra-articular:Transverse Ligament Torn;Subscapularis Intact关节外脱位：横韧带撕裂；肩胛下肌完整-Intra-articular:Subscapularis Torn or Avulsed关节内脱位：肩胛下肌撕裂或撕脱-Biceps Tendon Intra-articular Dislocation:肌腱关节内脱位：Subscapularis Tendon Avulsed肩胛下肌腱撕脱肱二头肌腱脱位肱二头肌腱脱位Biceps Tendon Disl

22、ocation肱二头肌腱脱位肱二头肌腱脱位Biceps Tendon Dislocation肱二头肌腱炎肱二头肌腱炎/撕裂撕裂Biceps Tendonitis/Tear-Thick Tendon;Increased Signal肌腱增厚；信号增加-Longitudinal Splits纵向撕裂盂唇旁囊肿盂唇旁囊肿Paralabral Cyst High Association with Labral Tears and GH Instability 与盂唇撕裂和盂肱关节不稳定密与盂唇撕裂和盂肱关节不稳定密切相关切相关 Analogous to Meniscal Cysts of the Kn

23、ee 类似于膝关节半月板囊肿类似于膝关节半月板囊肿T2 Images-Multi-lobulated Fluid Collections T2加权像加权像-多房液性信号多房液性信号Location:Posterior,Superior,Inferior 部位：盂唇后，上，下部部位：盂唇后，上，下部Can Cause Neurovascular Entrapment 可导致神经血管卡压可导致神经血管卡压肩胛上神经卡压肩胛上神经卡压Suprascapular Nerve Entrapment-Suprascapular Notch肩胛上切迹肩胛上切迹-Denervation of Supra-an

24、d Infraspinatus Muscles冈上肌和冈下肌去神经化冈上肌和冈下肌去神经化-Spinoglenoid Notch冈盂切迹冈盂切迹-Denervation of Infraspinatus Muscle冈下肌去神经化冈下肌去神经化冈上肌冈上肌/冈下肌去神经化冈下肌去神经化Denervation Supra/Infraspinatus-Entrapment of the Suprascapular Nerve in Suprascapular Notch肩胛上切迹囊肿导致肩胛上神经卡压肩胛上切迹囊肿导致肩胛上神经卡压-MR Findings:Early-Denervation ed

25、ema(High Signal on T2)MR表现：表现：早期早期-去神经水肿（去神经水肿（T2加权高信号）加权高信号）Late-Fatty Replacement(High Signal on T1)晚期：脂肪替代（晚期：脂肪替代（T1加权高信号）加权高信号）冈下去神经化冈下去神经化Denervation Infraspinatus-Entrapment of Suprascapular Nerve in Spinoglenoid Notch冈盂切迹囊肿导致肩胛上神经卡压冈盂切迹囊肿导致肩胛上神经卡压-Early Denervation Edema of Infraspinatus Mus

26、cle冈下肌去神经水肿冈下肌去神经水肿四边孔综合征四边孔综合征Quadrilateral Space Syndrome旋肱后动脉和腋神经旋肱后动脉和腋神经在四边孔处受压后所引起的一系在四边孔处受压后所引起的一系列临床症候群。其主要表现是腋神经支配的肩臂外侧列临床症候群。其主要表现是腋神经支配的肩臂外侧的感觉障碍和三角肌功能受限。的感觉障碍和三角肌功能受限。由于当肩关节外展外旋时，组成四边孔的肌肉均受牵由于当肩关节外展外旋时，组成四边孔的肌肉均受牵拉，从三个方向对四边产生挤压而致本症发生。拉，从三个方向对四边产生挤压而致本症发生。-Axillary Nerve Compression Neuro

27、pathy腋神经受压症状腋神经受压症状-Poorly Localized Shoulder Pain in ABER PositionABER位局部严重肩痛位局部严重肩痛-Atrophy of Teres Minor and Deltoid Muscles小圆肌和三角肌萎缩小圆肌和三角肌萎缩Etiologies:Fibrous Bands-Seen with Repetitive Overhead Activity;Paralabral Cyst;Mass病因：反复过伸过头运动导致的纤维束带；盂唇旁囊病因：反复过伸过头运动导致的纤维束带；盂唇旁囊肿；肿块肿；肿块-Chronic Fatty A

28、trophy of Teres Minor and Deltoid小圆肌和三角肌慢性萎缩和脂肪化小圆肌和三角肌慢性萎缩和脂肪化-High Signal on T1 ImagesT1加权高信号表现加权高信号表现四边孔综合征四边孔综合征Quadrilateral Space SyndromeSystematic Approach to the Shoulder肩关节读片要领肩关节读片要领 Osseous Outlet and Acromion Acromial Type,Anterior/Lateral Down Sloping,Spur,Os Acromiale;AC Joint;C-A Lig

29、ament骨性出口和肩峰骨性出口和肩峰 肩峰类型，前肩峰类型，前/后下斜型，骨赘，肩峰小骨，肩锁关节，喙后下斜型，骨赘，肩峰小骨，肩锁关节，喙肩韧带肩韧带 Rotator Cuff Tendonopathy,Partial Thickness,Full Thickness,Complete Tear;Fatty Atrophy,Retraction肩袖肩袖-肌腱病变，部分撕裂，全层撕裂，完全撕裂，脂肪性萎缩，肌腱病变，部分撕裂，全层撕裂，完全撕裂，脂肪性萎缩，韧带回缩韧带回缩 Capsule and Labrum Labral Tear;Anterior;SLAP;Posterior关节囊和盂唇关节囊和盂唇盂唇撕裂；前盂唇病变；盂唇撕裂；前盂唇病变；SLAP；后盂唇病变；后盂唇病变 Osseous Structures and Articular Surfaces Trauma;Arthritis;Infection;Tumor骨性结构和关节面骨性结构和关节面 创伤；关节炎；感染；肿瘤创伤；关节炎；感染；肿瘤 Biceps Tendon Tendonopathy;Tear;Dislocation肱二头肌腱肱二头肌腱肌腱病变；撕裂；脱位肌腱病变；撕裂；脱位Systematic Approach to the Shoulder肩关节读片要领肩关节读片要领