髋关节MagneticResonanceImagingoftheH.ppt

Magnetic Resonance Imaging of the Hip,* 髋关节是人体最大也是最稳定的关节 * 关节囊强健、运动肌群发达 * 多轴面球窝关节,站立- 1/3 BW 单脚站立- 2-2.5x BW 行走- 1.5 - 5.5x BW 爬楼梯 - 3x BW 跑- 4.5x BW,屈 - 110-1200 伸 - 10-150 外展 - 30-500 内收 - 300 外旋 - 40-600 内旋 - 30-400,MRI常规扫描技术,表面线圈（以获得最佳SNR）,透视下确定穿刺点：仰卧、轻度曲膝、髋内旋。于髋前外侧平转子间线中点进针，针道平行于股骨颈，靶点为股骨颈中段皮质旁，滴注碘剂确定位置。 Gd-DTPA稀释液（1:200）10ml关节腔内注射。,MR关节造影,COR,OB AXI,AXI,SAG,髋关节的正常解剖, 骨 软组织,球窝关节（杵臼关节）,髋臼（Acetabulum),正常髋臼应较好覆盖股骨头 覆盖不充分或过度均可致异常： 不充分：髋发育不良（早期骨关节炎） 过度：髋关节内陷、髋臼前突（RA，OA） 过度：股骨髋臼撞击症,股骨头（Femoral head）,圆韧带 也叫做股骨头韧带 起自股骨头凹，附着于髋臼切迹和髋臼横韧带 较薄弱 为股骨头供血,髋关节韧带,1：股骨头韧带 2：髋臼横韧带,1,2,髂骨股骨韧带 也称为 Y形韧带 起自髂前下棘基底部，止于转子间线 加强关节囊前部纤维 是髋关节最强壮的韧带 防止站立时髋过伸,耻骨股骨韧带 起自耻骨支前部，止于转子间窝前面 加强下部和前部关节囊的纤维 在外展和伸髋时拉紧 防止髋关节过度外展,坐骨股骨韧带 起自髋臼的坐骨部，旋转止于股骨颈和大转子的基底部 防止髋关节过伸 在屈髋时韧带松弛,腘绳肌腱 （Hamstring）,上外: 半膜肌 下内: 半腱肌和股二头肌长头共同构成的结合腱,近端腘绳肌腱复合体的正常解剖。 A：坐骨粗隆（*）层面显示股二头肌和半腱肌结合腱位于后内侧（弯箭），半膜肌腱位于前外侧（直箭）。 B：股骨近端1/3层面，显示半腱肌肌腹（空箭）和半膜肌腱（箭头）。 *为短收肌。低信号的大收肌腱（实箭）位于结合腱前部。,髋关节滑囊,作用：减少肌肉与骨间摩擦 转子囊：位于臀大肌下方，在臀大肌越过大转子处减少二者间摩擦 臀小肌下滑囊 臀中肌下滑囊 坐骨滑囊：承重结构 臀股滑囊：分离臀大肌和股外侧肌,大转子（Greater Trochanter）,前：臀小肌附着 外侧：臀中肌附着 后上：臀中肌附着 后：转子囊（臀大肌下滑囊）,Anterior: g. minimus attachment Lateral: g. medius attachment Posterosuperior: g. medius attachment Posterior: trochanteric bursa,G. Medius： 臀中肌 G. Minimus: 臀小肌 P: 梨状肌 Oi: 闭孔内肌,Oe：闭孔外肌 SGMiB: 臀小肌下滑囊 SGMeB: 臀中肌下滑囊 TrB：转子囊,髋臼唇（Acetabular Labrum ）,由纤维软骨组织构成 大部分无血供，仅靠近关节囊处血管丰富 向后上延伸部最厚 向下与髋臼横韧带融合,三角形 69.2% 圆形 15.8% 扁平状12.5% 缺如 2.5%,髋臼唇异常的假象,前上唇正常的唇内沟 沟的边缘锐利 尸检和病人术中未发现（可能与未使用对比剂有关）,前上唇内沟,3条标准: 关节造影时对比剂未通过整个髋臼唇 边缘光滑锐利 沟的形态较浅 (50%),后下唇内沟,髋关节的病变,骨病变 软组织病变,应力性损伤（Stress injury）,源于对正常骨的压力过大（重复、过度压力作用下骨的再塑型） 运动员和新兵常见 股骨颈、股骨干骺端常见，骨盆受累极少 MRI为最敏感的检查手段,疲劳性骨折,特定部位 骶骨：体操，保龄球,股骨颈： 长跑，芭蕾，滑雪 耻骨：击剑，障碍跳，长跑,五级分类法,0级：正常 1级：轻微骨膜水肿，仅在FS T2WI或STIR可见 2级：T2WI骨膜水肿、骨髓信号增高，T1WI可有轻微改变 3级：骨膜水肿和骨髓信号明显异常，T1WI、T2WI均可见 4级：明确骨折，可见垂直于骨皮质和骨小梁的骨折线,Right femoral neck fatigue fracture. a,b: Coronal T1-weighted and T2-weighted fat-saturation images of the right hip reveals abnormal linear signal extending from the medial cortex of the right femoral neck (white arrows) representing fatigue fracture with associated marrow edema (*).,不全性骨折（Insufficiency fracture),为正常力作用于潜在薄弱骨所致 易发生于女性、骨质疏松、甲旁亢、使用激素、风湿性关节炎、放疗、糖尿病、佝偻病、成骨不全、肾移植等 最常发生于骶骨、耻骨、髋臼上区域及股骨颈 MRI表现与疲劳骨折类似 发生于股骨头软骨下者与AVN难以鉴别,Supraacetabular insufficiency fracture. Coronal images of the hip reveal an abnormal linear low signal on T1- weighted image (a) paralleling the roof of the acetabulum with corresponding marrow edema on the T2-weighted fat-saturation image (b) consistent with an insufficiency fracture.,撕脱骨折,年轻运动员常见 ；14-25 y 占儿童骨盆骨折的13.4% 多为机械性 突然肌肉猛烈收缩 或持续作用于骨突,常见撕脱骨折部位,Avulsion fracture of AIIS Radiography,CT and MRI: bone marrow edema and bony fragments,股骨头缺血坏死 AVN,由于血供中断而导致的骨死亡，属于累及骨骺的骨坏死（而骨梗死累及干骺端或骨干） 好发因素：外伤、皮质激素使用、酗酒、血红蛋白病（镰状细胞贫血）、化疗、血管炎（狼疮）、胰腺炎,股骨头的血供,1、圆韧带动脉artery of ligamentum teres位于股骨头圆韧带内 2、股骨干滋养动脉升支madullary cavity blood supply 3、旋股内侧medial femoral circumfllex artery和外侧动脉lat.fem.circumfl.art.，该组动脉损伤是造成 股骨头坏死的主要原因。,历史和演变,1888年Konig首先描述本病，命名为剥脱性骨软骨炎 1925年Haenish报告了第一例成人自发性股骨头缺血坏死 1940年动脉闭塞被认为是AVN的原因 激素应用后出现的AVN由Pietrograndi于 1957年首次报道,特 点,股骨头承重面（前外侧）最易受累 只发生于黄骨髓（血供少），红骨髓血供丰富 其实质为骨组织缺氧，健康人少见 老年人发生率降低脂肪细胞小，胶样骨髓 非外伤性AVN通常为双侧的，发生于年轻人 AVN发病率有上升趋势（外源性激素应用，创伤增加）,病 因,血管内 骨外血管因素动脉，旋股外侧动脉 骨内血管因素 动脉各种栓子 静脉减压病，静脉回流受阻 血管外 骨内因素 关节囊因素外侧骨骺血管（LEVs）,结 局,轻微AVN： 通常无症状，可偶然发现。累及范围小，未邻近关节面可自愈 严重AVN： 坏死骨与正常骨间出现修复，死骨难吸收或部分吸收，坏死与修复并存 力学破坏：死骨与活骨接触面小梁的力学破坏加剧了AVN,Anteroposterior view of the pelvis in a patient with bilateral avascular necrosis of the femoral head. Mild flattening to the superior aspect of the left femoral head indicates stage 3 disease. The right femoral head has a normal contour, indicating stage 2 disease. When avascular necrosis is bilateral, it usually occurs in each hip at different times, and the staging of disease in each hip can be, and often is, at different stages.,Axial CT in a patient without avascular necrosis of the femoral head shows prominent and thickened but normal trabeculae (arrow) within the femoral head. Note the delicate, sclerotic, raylike branchings emanating in a radial fashion from the central dense band. This is the asterisk sign.,Planar bone scan of the pelvis in a patient with bilateral avascular necrosis of the femoral head shows marked increased uptake of radiopharmaceutical in both hips.,Coronal T1-weighted MRI in a patient showing hypointense signal within the proximal femoral neck and intertrochanteric regions representing hematopoietic marrow. Increased signal is present within the greater trochanters and femoral capital epiphysis representing normal fatty marrow .,Double line sign in AVN of the femoral head. Coronal T2-weighted fat-saturation image of the left hip reveals a geographic subchondral lesion of low signal intensity surrounded by a “double line” (white arrow) composed of an inner high-signal band and an outer low-signal rim.,F，19岁，双髋痛1年,M，46岁，双髋痛，左侧明显,Mitchell分级,A: T1WI高，T2WI中等脂肪 B: T1WI高，T2WI高血 C: T1WI低，T2WI高水 D: T1WI低，T2WI低纤维,Ohzono et al. incorporated the concept of location of the lesion, with prognostic value.,Ficat and Arlet have developed a staging system using radiographic findings, consisting of four stages.,Hungerford and Lennox modified this staging system when MRI became available, adding stage 0 to the classification.,Steinberg et al. expanded this staging system, by dividing stage III lesions into femoral heads with or without collapse or hips with or without acetabular involvement. In addition, they quantified the amount of involvement of the femoral head into mild , moderate , and severe based on radiographs.,一过性骨质疏松（TOH）,Transient Osteoporosis of the Hip，一过性骨髓水肿综合征 累及股骨头、股骨颈的痛性骨髓水肿，可在数月内自发缓解 发病理论学说较多：股骨头缺血未发展为坏死、交感神经营养不良的非创伤型、不全骨折 平片最初表现正常，数月后出现骨量减少 MRI显示累及股骨头、股骨颈的明显骨髓水肿，可延伸至转子间,TOH. Coronal images demonstrate prominent marrow edema, low signal intensity on T1-weighted image (a) and high signal intensity on T2-weighted fat-saturation image (b), in the right femoral head and neck extending to the intertrochanteric line.,M, 22岁，右髋痛,TOH与AVN鉴别,骨髓水肿更明显 无软骨下病变 缺少AVN相关危险因素,软骨病变,常规MR成像较难评估 髋关节的软骨较薄 (1-2mm) 股骨/髋臼软骨难以分离 MR关节造影 可清晰显示软骨异常 特殊成像序列,前上髋臼多见 可表现为分层 碎片 1mm 软骨分层伴髋臼唇撕裂，多与FAI有关,40 yo female with chronic hip pain （Labral detachment and cartilage loss）,髋臼唇损伤,MR关节造影敏感性、特异性均较高 病变包括外伤性和退变性 唇内、脱离,Acetabular labrum,为髋臼软骨的延续 向内与髋臼关节面相连 向外附着于髋关节囊 为髋臼的边缘 作用：围绕股骨头，起到稳定和限制其运动的作用,髋臼唇撕裂的临床表现,多无症状 髋关节铰锁、弹响，髋、腹股沟转子间区域疼痛 关节僵直或活动度减小 危险因素：过度使用、外伤、FAI、运动过度、先天性疾病、不明原因（80%） 前上唇撕裂最多见，后上唇撕裂多见于年轻人,髋臼唇撕裂的分级,Labral tear (Stage IIA). a: Coronal T1-weighted fatsaturation image from a MR arthrogram reveals contrast material extending in a linear fashion into the labrum (arrow) without detachment from the acetabulum.,Superolateral and anterior labral tear (Stage IIIA).,髋臼唇撕裂可伴发软骨病变（30%） 髋臼唇撕裂间接征象：唇旁囊肿,Labral tear with a paralabral cyst. a,b: Sagittal and coronal T1-weighted fat-saturation images from a MR arthrogram reveal a tear (white arrowhead) through the anterosuperior acetabular labrum with an adjacent paralabral cyst (white arrow).,55 yo female with 8 mo h/o pain, worse with stairs,? Sulcus, but next image shows contrast extending through the labrum,股骨髋臼撞击症 Femoroacetabular Impingement FAI,FAI,是最近10年才被提出和逐渐认识的一种髋关节疾病 很多诊断不清的髋关节周围和腹股沟区的疼痛都是由于存在髋臼撞击 发生机制是股骨近端（股骨头和头颈交界区）与髋臼的异常接触应力导致的关节损害，多数情况是因股骨头颈交界区及髋臼缘骨性形态异常所致 大量证据显示，股骨髋臼撞击是引起骨关节炎早期发生的重要原因之一,确切地说，FAI本身不是一种疾病，而是一种异常的力学作用，但它可以导致髋关节的损害。各种髋臼和/或股骨的骨性异常导致髋关节在活动时反复碰撞，从而使髋臼缘的软组织（盂唇和/或软骨）产生损伤。,临床表现,屈髋和内旋时髋部及腹股沟区疼痛。常常是隐匿性起病，也可以因轻微外伤引发，很多患者找不到特殊的诱因。 髋关节铰锁（卡住的感觉）、弹响和不稳定感， “死腿征”（dead-leg sign） 病史较长者可表现出关节僵硬、乏力和活动度下降等,Clinical tests to assess femoroacetabular impingement. Anterior impingement sign (left) is positive, with painful forced internal rotation in 90o of flexion. In extreme forms, there is unavoidable passive external rotation of hip during hip flexion (“Drehmanns” sign, center). “Posterior impingement” sign is positive when there is painful forced external rotation in maximal extension (right).,1,2,Theumann 2007,FAI,PINCER,CAM,Cam-type FAI,30-40岁爱好运动男性多见 股骨头/颈交界处隆起、偏移，股骨头呈“非球形” 病因： 先天性髋关节脱位 股骨头骨骺脱位 缺血性坏死 外伤,当髋关节屈曲和内旋，特别在屈曲位内旋时，股骨头或/和头颈交界区与形态正常的髋臼之间产生异常接触 这种异常接触应力将髋臼盂唇推向关节囊方向，盂唇和关节软骨交界的移行区承受不均匀的异常负荷，导致髋臼前上方负重区的软骨损伤或盂唇撕裂 前上方区域是软骨和盂唇损伤是最常见的发生部位,角,于斜轴位上测量角，正常值范围为42-55度,Kawan S et al. Clin Orthop Relat Res (2009) 467:660665,CAM FAIMRI表现,Ganz: 软骨撕裂、髋臼唇完整 Kassarjian: 三联征包括软骨和髋臼唇异常 Leunig: 纤维囊变为FAI早期表现 唇旁囊肿，滑膜疝,Kassarjian A, et al. Triad of MR arthrographic findings in patients with cam-type femoracetabular impingement. Radiology 2005:236:588-592,前上髋臼唇撕裂，软骨变薄，软骨下囊变,FROM: MR Arthrography of Acetabular Cartilage Delamination in Femoroacetabular Cam Impingement,股骨头不圆，剪切力损伤软骨和髋臼唇,CAM-FAI,M/25,髋臼过度覆盖股骨头,髋臼唇撕裂，疝形成 后部半脱位，软骨损伤,PINCER-FAI,Pincer-type FAI,多见于中老年女性人群 髋臼覆盖异常 病因： 深髋 髋臼后倾 前突 外伤 髋臼唇骨化,正常髋臼,交叉征,Cross-over 征 髋臼后倾,Pincer-type FAI,深髋： 测量髋臼内侧缘与髂坐线的距离 男性: 2mm 女性: 6mm 髋臼突入: 股骨头突出于髂坐线内侧,Pincer-type FAI,MRI表现：主要是髋臼唇异常 软骨较少受累 后下髋臼唇可见对冲伤,M/63 右髋痛2月余,FAI,86%的FAI病人同时存在CAM and Pincer,治疗,早期诊断对于治疗极为重要 Cam-FAI: 股骨颈成形术 去除股骨头多余部分 Pincer-FAI: 去除多余的髋臼部分 髋臼边缘反切除术用于髋臼后倾,滑囊炎,G. Medius： 臀中肌 G. Minimus: 臀小肌 P: 梨状肌 Oi: 闭孔内肌,Oe：闭孔外肌 SGMiB: 臀小肌下滑囊 SGMeB: 臀中肌下滑囊 TrB：转子囊,髂腰肌滑囊炎 髂腰肌在髂耻隆起上弹响引起 小转子处的液体积聚 大小不一，可向盆腔扩展 MRI：特定区域的液体积聚，长T1长T2，边界清晰,转子周滑囊炎 臀大肌与大转子间滑囊的反复摩擦或刺激，直接撞击或不适当的机械运动所致 通常见于运动（长跑） 症状和体征:局部疼痛、肿胀、压痛，大转子处捻发音 患者通常主诉髋部异常声响,坐骨滑囊炎 位于坐骨粗隆处 过度摩擦所致疼痛和炎症反应 症状和体征: 坐时疼痛，局部触痛，被动屈髋和主动伸髋时疼痛 通常临床上难以与近端腘绳肌腱炎鉴别,腘绳肌腱 （Hamstring）,Hamstring Pathology,MC site usually involves MT junction Focus on pathology to the PHAC to the ischial tuberosity Most severe injury avulsion Occurs in athletes during excessive eccentric contraction during running or jumping In children, the apophysis involved,Hamstring Pathology,Koulouris G, Connell D. Hamstring muscle complex: an imaging review. Radiographics 2005:25:571-586.,Koulouris G, Connell D. Evaluation of the hamstring muscle complex following acute injury. Skeletal Radiol 2003:32:582-589.,MR findings,Most avulsions involve conjoint tendon with partial tearing of SMB Ragheb et al: 82% of pathology involved all 3 tendons SMB most common to be torn in isolation,Treatment,Early surgical intervention required To avoid complications such as gluteal sciatica from localized scarring