肌骨超声诊断指南肩部.ppt

肌骨超声技术指南 肩部 欧洲肌骨放射学 Althoughpatient spositioningforshoulderUSvarieswidelyacrossdifferentCountriesandInstitutionsreflectingmultifacetedopinionsandexperiencesofdifferentexaminers westronglyrecommendtoexaminethepatientwhileseatedonarevolvingstool Thispositionallowstheexaminertoreachtheanterior lateralandposterioraspectsoftheshoulderwiththeprobebysimplyaskingthepatienttorotateonthechair 不同的国家和机构给病人进行肩部超声检查时所采取的体位各不相同 体现了不同诊查者不同的观点和经验 但是 我们强烈推荐让病人坐在转凳上进行检查 这个体位能够让诊查者只要让病人转动一下凳子就能够使用探头扫查到肩的前面 侧面和后面 longheadofthebicepstendon二头肌腱长头Placethearminslightinternalrotation directedtowardsthecontralateralknee withtheelbowflexed90 palmup Startbyfindingthelongbicepstendoninbetweenthegreaterandlessertuberosities Useshortandlong morelimitedutility axisplanestoexaminethebiceps 肘部屈曲90 手臂轻度内旋 指向对侧膝部 掌心向上 先在大 小结节之间找到肱二头肌长头腱 采用短轴和长轴 作用有限 切面检查二头肌 Shifttheprobeuptoexaminethebicepsinitsintraarticularcourseanddowntoreachthemyotendinousjunction levelofthepectoralismajortendon 向上移动探头检查二头肌关节内的走行 向下移动探头探测肌 腱连接部 胸大肌肌腱水平 Legend SubS subscapularistendon SupraS supraspinatustendon Arrow longheadofthebicepstendon LT lessertuberosity GT greatertuberosity SH shortheadofthebiceps LH longheadofthebiceps H humeralshaft Arrowheads pectoralismajortendon图例 SubS肩胛下肌肌腱 SupraS冈上肌肌腱 箭号 肱二头肌长头 LT小结节 GT大结节 SH二头肌短头 LH二头肌长头 H肱骨干 箭头 胸大肌肌腱 3subscapularistendonRotatethearmexternallyfixingtheelbowontheiliaccresttoshowthesubscapularistendonanditsinsertiononthelessertuberosity slightsupinationofthehandmaybehelpfultoneutralizethetendencytoliftandabducttheelbowfromthelateralchestwall 3肩胛下肌肌腱将肘部固定于髂嵴处 上肢外旋可显示肩胛下肌肌腱及其小结节附着部 手掌轻度后旋可有助于抵抗肘部上抬和外展离开侧胸壁的力量 Thistendonshouldbeevaluatedalongitslong transverseplanes andshort sagittalplanes axisduringpassiveexternalandinternalrotationwithhangingarm Sweepthetransducerupanddownoverthesubscapularisuntilitsfullwidthisdemonstrated 评价该肌腱应该在手臂上举状态下被动外旋和内旋时沿其长轴切面 横切面 和短轴切面 矢状切面 进行扫查 在肩胛下肌表面上下扫查 直至整块肌肉都能全部显示 Legend Arrow longheadofthebicepstendon dashedline insertionofthesubscapularistendon Co coracoid Del deltoidmuscle LT lessertuberosity SubS subscapularistendon voidarrowheads tendonfasciclesofthesubscapularis whitearrowheads muscletissueinterposedbetweentendonfascicles图例 箭号 肱二头肌长头腱 虚线 肩胛下肌肌腱附着处 Co喙突 Del 三角肌 LT 小结节 SubS 肩胛下肌肌腱 空心箭头 肩胛下肌肌腱束 白色箭头 插入肌腱束之间的肌肉组织 4anteromedialstructuresandcoracoacromialligamentMovingtheprobetowardmedialontransverseplanes lookatthecoracoidprocess thecoracoacromialligament themedialmarginofthetransducerisonthecoracoidprocessandthelateraledgeisshiftedupwardandlaterallytowardstheacromion theconjoinedtendonandtheanterioraspectofthesubacromialsubdeltoidbursa Then checkthesubscapularisrecessandthesubcoracoidbursaforeffusion Externalandinternalrotationmayalsousedtodemonstrateanteromedialimpingement distancebetweencoracoidprocessandlessertuberositymeasuredininternalrotation 4 肩部前内侧结构和喙肩韧带在横切面上 将探头向内侧移动 查看肩胛骨喙突 喙肩韧带 探头的内侧固定在肩胛骨喙突 探头外侧缘向外上方转动指向肩峰 联合腱和肩峰下的三角肌下滑囊前部 然后 探测肩胛下肌隐窝和喙突下囊有无积液 内旋和外旋也可用以探测前内侧的创伤部位 内旋可用以测量肩胛骨喙突和肱骨小结节之间的距离 Legend Acr acromion Arrows shortheadofthebiceps Arrowheads coracoacromialligament Co coracoid CoBr coraco brachialis HH humeralhead SubS subscapularistendon SupraS supraspinatus图示 Acr 肩峰 箭 二头肌短头 箭头 喙肩韧带 Co 喙突 CoBr 喙肱肌 HH 肱骨头 SubS 肩胛下肌肌腱 SupraS 冈上肌 supraspinatustendon positioning 1 冈上肌肌腱 定位 1 Placethepatient sarmposteriorly placingthepalmarsideofthehandonthesuperioraspectoftheiliacwingwiththeelbowflexedanddirectedposteriorly Thesupraspinatustendonshouldbeevaluatedalongitslong andshort axis 患者上肢后置 肘部向后屈曲 手掌面置于髂骨翼上部 应沿长轴和短轴观测冈上肌肌腱 supraspinatustendon5冈上肌肌腱Refertotheintraarticularportionofthebicepsasalandmarktoobtainpropertransducerorientationforimagingthesupraspinatus Infact thesetendonsrunparallelonetotheotherandtheintraarticularportionofthebicepsiseasytoberecognizedduetoamoreclearlydefinedfibrillarpattern OneshouldrotatethetransduceruntilthebicepsisdepictedasmoreelongatedaspossibleintheUSimage Then theprobeisshiftedupwardandposteriorlyoverthesupraspinatuswithoutchangingitsorientation Theresultingimageisinaxiswiththesupraspinatus Betweenthesupraspinatusandthedeltoid thenormalsubacromial subdeltoidbursaappearsasathinhypoechoicband 肱二头肌的关节内部分是确定合适的探头方向以显示冈上肌的定位标志 事实上 这些肌腱是相互平行的 而二头肌关节内的部分由于其边界清晰的细纤维结构而易于辨认 操作者应该转动探头使二头肌的超声图像显示得尽可能长 然后 保持探头方向不变 在冈上肌表面向后上方移动探头 最终图像就是冈上肌的长轴 在冈上肌和三角肌之间 正常的肩峰 三角肌下滑囊呈一条薄薄的低回声带 Tiltthetransducergentlyintheareaoverlyingthetendoninsertiontoavoidanisotropy Remembertoscanthelateralpouchofthesubacromialsubdeltoidbursaalongthelateraledgeofthegreatertuberosity Whenlookingforthesupraspinatusonshort axis thenormalcuffmusthavealmostthesamethicknessfromthebicepstendonlandmarkuntil2cmbackwards fromthispointbackwardsthetendonseenistheinfraspinatus 在肌腱附着端轻轻地倾斜探头以消除各向异性假象 记住 要沿着大结节的外侧缘扫查肩峰下三角肌下囊的侧囊 在短轴上寻找冈下肌时 从二头肌腱标记处向后2cm 正常肩袖的厚度一定是不变的 从该点向后看到的肌腱就是冈下肌 Legend Acr acromion asterisk myotendinousjunction Del deltoidmuscle GT greatertuberosity voidarrow head articularcartilage curvedarrow hypoechoicartifactrelatedtoanisotropy straightarrow longheadofthebicepstendon SupraS supraspinatustendon whitearrowhead subacromialsubdeltoidbursa图例 Acr 肩峰 星号 肌 腱连接 Del 三角肌 GT 大结节 空心箭头 关节软骨 弯箭头 各向异性导致的低回声伪像 直箭头 二头肌肌腱 SupraS 冈上肌肌腱 白色箭头 肩峰下三角肌下滑囊 6supraspinatustendon positioning 2 Placethedorsumofthehandovertheoppositebackpocket forcedinternalrotation stressmanoeuvre Thereshouldnotbeanyspacegapbetweentheelbowandthelateralchestwall Usingthisposition thesupraspinatusbecomesamoreanteriorstructureandthetransducershouldbeorientedalmostverticallytobeinaxiswithit Considerthatthetendonfibersaremorestretchedthaninthepositiondescribedatpoint 5 Thismaybepossiblecauseofoverestimationoftearsize Duetoanexcessiveinternalrot