（医学PPT课件）肩关节磁共振诊断

肩关节磁共振诊断,1,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,2,MR扫描技术,-T1andT2FS-斜冠状面,-T1andT2FS-斜矢状面,-T2FSandGRE-横断面,3,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AnteriorAcromionMostImportantStructureLeadingtoImpingement,4,5,6,正常骨性出口,前,后,喙突,锁骨,肩峰,7,肩峰形态,TypeI,8,肩峰形态,TypeII,9,肩峰形态,TypeIII,10,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,11,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,12,骨性肩峰发育,骨化中心常在22-25岁闭合,轴位像前肩峰正常表现,13,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峰与肩袖碰撞,14,骨性肩峰发育（矢状面）,肩胛小骨骨赘形成,肩胛小骨,15,骨性肩峰,肩锁关节,肩峰,“双肩锁关节”征,16,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（内无骨髓信号）,17,肩峰,形态分型（I，II，III）前/外侧下倾型肩峰下缘骨赘形成,18,肩锁关节,-退变，关节囊增厚-较少引起肩袖卡压,19,喙肩关节,-正常喙肩韧带厚度3mm,-韧带增厚可导致前肩袖碰撞,20,喙突碰撞,-正常喙肱距离为11mm,-喙肱间距狭窄可导致肩胛下区域碰撞,21,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?),22,肩袖,肩胛下肌;冈上肌冈下肌;小圆肌;,23,肩袖（矢状面）,冈上肌，冈下肌，小圆肌，肩胛下肌,24,肩袖（矢状面）,冈上肌，冈下肌，小圆肌，肩胛下肌,25,肩袖（矢状面）,覆盖肱骨头的连续低信号表现,26,肩袖（轴位）,冈上肌腱,27,肩袖（轴位）RotatorCuff(AxialPlane),-评价肩胛下肌的最好平面PrimaryPlaneforEvaluatingSubscapularis,冈下肌位于肩胛下肌对应的关节后侧区域-InfraspinatusLocatedPosteriorly,28,肩袖（冠状面）RotatorCuff(Coronal),评估冈上肌腱的最佳层面,肌肉肌腱连接部位于12点方向,29,肩袖（冠状面）,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,30,肩袖病变,Tendonopathy肌腱病变Tear撕裂PartialThickness,FullThickness,Complete部分撕裂，全层撕裂，完全撕裂MusculotendinousRetraction肌肉肌腱回缩FattyAtrophy脂肪肥厚HADD/CalcificTendonitis钙化性肌腱炎,31,肌腱病变,-IncreasedT1-signal;ThicktendonT1W信号增高，肌腱增厚-IntermediateT2-signal(NoFluidSignal)T2W中等信号，无液体信号,32,关节囊部分撕裂（关节面）PartialThicknessTear(Articular),ExtensiveIntermediateT1-SignalT1W延续性中等信号表现,T2:FluidSignalT2：出现液性信号PartialThickness部分撕裂UndersurfaceTear肌腱表面下撕裂,33,部分撕裂（关节囊面）PartialThicknessTear(Bursal),-FluidSignalExtendingintotheBursalSurfaceoftheSupraspinatusTendon液性信号延伸至冈上肌腱关节囊面表面,34,肩袖部分撕裂（肌腱内型）PartialThicknessTear(Interstitial),-FluidSignalwithintheSubstanceoftheTendon液性信号存在于肌腱内-DoesNotTouchtheSurface不影响到肌腱表面,35,肩袖肌间囊肿IntramuscularCystRotatorCuff,-HighAssociationwith与以下因素有关P.T.UndersurfaceTear创伤性表层下撕裂2.SmallF.T.Tear小的全层撕裂3.DDX:ParalabralCyst鉴别诊断：盂唇旁囊肿,36,肌间囊肿IntramuscularCystRotatorCuff,IntramuscularCystSupraspinatus冈上肌肌间囊肿SmallUndersurfaceP.T.Tear小的创伤后撕裂,37,全层撕裂FullThicknessTear,-Fluidextendsthroughtheentirethicknessofthetendon(top-bottom)液性信号延伸至肌腱全层（从顶部到底部）-Mildretractionofmusculotendinousjunction肌肉肌腱连接部轻度回缩,38,-FluidSignalwithinSST冈上肌腱内出现液性信号,-SagImage:FluidfromToptoBottom矢状面：液性信号从顶层到底层,全层撕裂FullThicknessTear,39,-GadArthrogram:DemonstratesFullThicknessTear-肩关节造影：显示全层撕裂,T1,T2,全层撕裂FullThicknessTear,40,-IntermediateT1-Signal-T1W中等信号,-MusculotendinousRetraction-肌肉肌腱回缩,-FluidSignalonT2-T2W出现液性信号-FullthicknessTear-全层撕裂,全层撕裂FullThicknessTear,41,完全撕裂CompleteTear特征：肌肉肌腱回缩Musculotendinousretraction,-Greaterthan3cmretraction-poorprognosisforrepair-肌肉肌腱出现超过3cm的回缩-预后不佳,42,脂肪增厚FattyAtrophy,-GradeasMild,Moderate,Severe-分为轻度，中度和重度-StreaksofHighSignalonT1-T1W出现高信号改变,43,-Normalmusclebulk-正常冈上肌,-FattyAtrophy:Doesnotfillsupraspinatusfossa-脂肪增厚：肌肉信号未充填冈上肌窝,脂肪增厚FattyAtrophy,44,钙化性肌腱炎CalcificTendonitis,-DarkGlobularAreaonallPulseSequences-在所有的脉冲序列上均为低信号-BloomingArtifactonGradientEchoImages-GE图像上可出现伪影,45,肩袖病变RotatorCuffPathology,Tendonopathy肌腱病变Tear撕裂PartialThickness,FullThickness,Complete部分撕裂，全层撕裂，完全撕裂MusculotendinousRetraction肌肉肌腱回缩FattyAtrophy脂肪增厚CalcificTendonitis钙化性肌腱炎,46,关节囊结构和盂唇CapsularStructuresandLabrum,Patientunder35y.o.withGHInstabilityorUnexplainedShoulderPain35岁以下患者出现肩关节不稳定或无法解释的肩部疼痛MRArthrography适合进行MR关节造影LabralLesionsCommon盂唇病变较为常见SubtleLesions(nondisplaced,resynovialized)-DistentionEffectsofContrast小病变（未移位，滑膜化）-对比剂的遮蔽效应,47,Bankart病变BankartLesion,-ConventionalMRI:LossofNormalMorphologyofAnteriorLabrum-常规MR：前盂唇正常形态消失,48,-SubtleLesionsBestDemonstratedonMRArthrography-MR肩关节造影能更好的显示盂唇微小病变,Bankart病变BankartLesion,49,HillSach病变HillSachsLesion,Top3AxialImagesThroughHumeralHeadShouldBeRound正常：肱骨头轴位像最上面3幅图像应为圆形FlatteningorConvexityonTop3Images最上面3幅图像扁平或不规则表现PosteriorHumeralSulcus:CanMimicAHillSachs后肱骨凹：易与HillSachs病变混淆,50,SLAP病SLAPTears,SuperiorLabrumisDarkonPulseSequencesinCoronalPlane冠状面脉冲序列显示上盂唇出现低信号表现AnySignalinTriangleofSuperiorLabrum=SLAPSLAP病变：上盂唇在任何序列上出现三角形异常信号MRArthrographyImprovesSensitivityMR关节造影提升了诊断敏感度,51,肩关节表面和骨性结构OsseousStructuresandArticularSurfaces,HematopoieticBoneMarrow局部红骨髓变SubcorticalCysticChange皮质下囊变Trauma(Fracture)创伤（骨折）Arthritis关节炎Infection感染Tumor肿瘤,52,红骨髓变HematopoieticMarrow,-Humeralepiphysis:OnlyEpiphysisthatNormallycontainsHematopoieticMarrow肱骨红骨髓变：正常情况下仅骨骺保留红骨髓-Females;Curvilinear;SubcorticalDistribution;Bilateral女性多见；弧形表现；皮质下分布；双侧,53,皮质下囊变SubcorticalCysticChange,-CommonlySeenNearSSTInsertionSite冈上肌附着处最为常见-MimicHillSachs与HillSach病易混淆,54,创伤Trauma,-24y.o.Female:PersistentPainfulShoulderAfterSkiingAccident女性，24岁，滑雪事故后持续性肩关节疼痛,55,肱骨头无菌性坏死AVN,T1,T2,“DoubleLine”Sign-SeenOnT2Images双线征,56,非特异性骨髓信号异常NonspecificMarrowSignal,-DDX:Infection,Tumor,Trauma鉴别诊断：感染，肿瘤，创伤-T1Image:UseMuscleasInternalStandardT1加权：肌肉作为对照-T1SignalDarkerthanMuscle:Pathologic异常信号：T1加权像上病灶信号低于肌肉,57,肿瘤Tumor,-OsteosarcomaProximalHumerus肱骨近端骨肉瘤-MasswithCorticalDestruction皮质破坏合并软组织肿块形成-LowSignalT1;HighSignalT2Images,58,关节软骨ArticularCartilage,-NormalCartilage正常软骨-IntermediateSignal中等信号-Smooth表面平整,-ArticularCartilageDefect软骨缺损-Gap:FillsWithContrast关节造影：显示软骨裂隙,59,肱二头肌病变BicepsTendon,Tendonitis肌腱炎Tear肌腱撕裂Dislocation脱位Intra-articular关节内脱位Extra-articular关节外脱位,60,肱二头肌病变BicepsTendon,61,肱二头肌病变BicepsTendon,62,-Extra-articularBiceps:BestSeenonAxialImage关节外肱二头肌腱：轴位显示最佳-InBicipitalGroove;TransverseLigament肌腱位于二头肌沟内，外有横韧带保护,肱二头肌病变BicepsTendon,63,肱二头肌腱脱位BicepsTendonDislocation,-Extra-articular:TransverseLigamentTorn;SubscapularisIntact关节外脱位：横韧带撕裂；肩胛下肌完整-Intra-articular:SubscapularisTornorAvulsed关节内脱位：肩胛下肌撕裂或撕脱,64,-BicepsTendonIntra-articularDislocation:肌腱关节内脱位：SubscapularisTendonAvulsed肩胛下肌腱撕脱,肱二头肌腱脱位BicepsTendonDislocation,65,肱二头肌腱脱位BicepsTendonDislocation,66,肱二头肌腱炎/撕裂BicepsTendonitis/Tear,-ThickTendon;IncreasedSignal肌腱增厚；信号增加-LongitudinalSplits纵向撕裂,67,盂唇旁囊肿ParalabralCyst,HighAssociationwithLabralTearsandGHInstability与盂唇撕裂和盂肱关节不稳定密切相关AnalogoustoMeniscalCystsoftheKnee类似于膝关节半月板囊肿T2Images-Multi-lobulatedFluidCollectionsT2加权像-多房液性信号Location:Posterior,Superior,Inferior部位：盂唇后，上，下部CanCauseNeurovascularEntrapment可导致神经血管卡压,68,肩胛上神经卡压SuprascapularNerveEntrapment,-SuprascapularNotch肩胛上切迹-DenervationofSupra-andInfraspinatusMuscles冈上肌和冈下肌去神经化,-SpinoglenoidNotch冈盂切迹-DenervationofInfraspinatusMuscle冈下肌去神经化,69,冈上肌/冈下肌去神经化DenervationSupra/Infraspinatus,-EntrapmentoftheSuprascapularNerveinSuprascapularNotch肩胛上切迹囊肿导致肩胛上神经卡压-MRFindings:Early-Denervationedema(HighSignalonT2)MR表现：早期-去神经水肿（T2加权高信号）Late-FattyReplacement(HighSignalonT1)晚期：脂肪替代（T1加权高信号）,70,冈下去神经化DenervationInfraspinatus,-EntrapmentofSuprascapularNerveinSpinoglenoidNotch冈盂切迹囊肿导致肩胛上神经卡压-EarlyDenervationEdemaofInfraspinatusMuscle冈下肌去神经水肿,71,四边孔综合征QuadrilateralSpaceSyndrome,旋肱后动脉和腋神经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拉，从三个方向对四边产生挤压而致本症发生。-AxillaryNerveCompressionNeuropathy腋神经受压症状-PoorlyLocalizedShoulderPaininABERPositionABER位局部严重肩痛-AtrophyofTeresMinorandDeltoidMuscles小圆肌和三角肌萎缩Etiologies:FibrousBands-SeenwithR