骨骼肌肉系统读片课件

1、骨骼系统读片横轴位冠状位股骨颈斜轴位矢状位病史简介：患者，女，38岁，平素体健，无骨肌系统及免疫系统疾病史，现主诉右髋疼痛，疼痛集中于右侧腹股沟区域，且活动后疼痛加剧。体检：髋关节活动受限，屈曲内旋疼痛加剧，4字试验（+）横轴位冠状位股骨颈斜轴位矢状位横轴位横轴位矢状位前倾角4髋臼前倾角，正常值为4-20横轴位结果：右侧髋关节混合型FAI左侧髋关节Cam型FAI目录页CONTENTS PAGEP1.定义及临床特点P2.发病机制及分型P3.影像学诊断P4.治疗髋臼撞击综合征(femoroacetabularimpingement syndrome FAI)Part1定义及临床特点Part 1Pa

2、rt 2Part 3Part 4定义：（患病率：10-15%） 是引起髋关节退变、导致骨性关节炎的主要病因，主要是髋臼边缘和股骨头颈部的异常接触导致软骨破碎、盂唇分离。临床表现： 逐渐发作的腹股沟区疼痛，屈曲和内旋受限，久坐或活动后疼痛加重。髋关节撞击试验阳性（前方和后方撞击试验）9盂唇内含感觉神经终末组织Part 1Part 2Part 3Part 4The C sign: The patient indicates location of pain by gripping the affected hip, just above the greater trochanter, betwee

3、n the abducted thumb and index finger.The impingement test: With patient supine, the hip and knee of the affected limb are flexed to 90. The leg is then adducted and internally rotated in this position. Occurrence of sudden exacerbation of pain, typically in the groin, is considered a positive test.

4、10Part 1Part 2Part 3Part 411Part2发病机制及分型Part 1Part 2Part 3Part 4正常：股骨头-颈交界处存在凹陷的切迹，平行股骨头颈的长轴做股骨头边缘的切线，此切迹不会隆起超过切线范围；正常股骨颈稍前倾；髋臼覆盖球面的1/4.13Part 1Part 2Part 3Part 414发病机制：当股骨头或髋臼因先天或后天因素发生形态学改变导致几何吻合不良时，股骨和髋臼边缘发生异常接触，导致盂唇和关节软骨的损伤，从而诱发FAI。FAI分型判断诊断流程图Part 1Part 2Part 3Part 415易感因素：Legg-Calve-Perthes di

5、seasecongenital hip dysplasia（先天性髋发育不良） slipped capital femoral epiphysis（股骨头骨骺滑脱症）avascular necrosis of the femoral head（股骨头缺血坏死） malunited femoral neck fractures（股骨颈骨折畸形愈合）acetabular protrusion（髋臼前突）a elliptical femoral head（椭圆形股骨头）prominence of the femoral head neck junction（股骨头颈交界处隆起）a retrovert

6、ed acetabulum（髋臼后倾）Part 1Part 2Part 3Part 416发病机制示意图Part 1Part 2Part 3Part 4分型17多见于活动较多的青年男性（20-30岁）；股骨头颈交界处骨性结构异常所致（发育性异常、股骨头骨软骨炎、骨折畸形愈合、股骨头缺血坏死）；股骨后倾及髋内翻亦可多见于中年女性；一般是由髋臼过度覆盖所致（髋臼后倾、过伸、前突或髋臼缘骨化）；常伴发“对冲”损伤（即髋臼后下部关节软骨损伤）Cam-Pincer型（占86%）Cam型凸轮型Pincer型钳夹型混合型Part 1Part 2Part 3Part 418Part3影像学诊断Part 1Pa

7、rt 2Part 3Part 420X线多种投照体位及测量指标CT清晰显示骨性结构异常（包括髋臼后倾、股骨头颈交界处隆起）经过髋臼上部的横断面图（髋臼前倾角）；斜矢状面图（角）MRI发现关节软骨病变及盂唇撕裂伤平扫和关节造影（直接和间接）横断、冠状及矢状面T1WI+脂肪抑制或PDWI；斜矢状面（角）和薄层放射状扫描（盂唇形态）影像学检查手段 Impingement Syndrome: An Imaging-based Diagnosis? NO;参考Femoroacetabular Impingement: Caution Is Warranted in Making Imaging-base

8、d Assumptions and Diagnoses. Radiology 2010; 257:47Part 1Part 2Part 3Part 421X 线常用体位侧位Cross-table lateral view45 or 90Dunn viewFrog-leg lateral view骨盆前后位Faux profilePart 1Part 2Part 3Part 422骨盆前后位：拍摄方法：患者仰卧位，双下肢内旋15（抵消股骨的前倾）。X线球管与检查床垂直，至胶片距离为120cm。对准耻骨联合上缘至双侧髂前上棘连线间的中点。意义：髋臼倾斜程度：髋臼顶倾斜角、外侧CE角髋臼深度：判断参

9、照为髂坐线（髋臼过深、髋臼前突）髋臼前突及后壁缺损：前者“8”字征；后者“后壁”征髋关节Faux位：用于评估髋臼的前覆盖拍摄方法：患者站立位，患侧贴近片盒，骨盆与射线角度65，对准患侧髋关节中心。 X线球管至胶片距离为100cm。合格的片子上显示两个股骨头之间的距离等于一个股骨头的宽度。前覆盖的测量指标：前方CE 角。这个角度评价股骨头的前上方覆盖，正常值应大于25 度。此外可以清晰显示后下方关节间隙（评价pincer-FAI对冲伤）Part 1Part 2Part 3Part 423侧位片：主要用于评价Cam型FAICross-table lateral view：患者平卧，患侧下肢伸直内旋

10、15，对侧髋关节和膝关节屈曲80以上。X线球管与桌面平行并与患侧下肢成45角，对准髋关节中心。45or 90Dunn view：患者仰卧位，髋关节屈曲90，外展20，下肢中立位，对准髂前上棘连线与耻骨联合之间的中点，X线球管与桌面垂直并与片盒距离100cm。Frog-leg lateral view：患者仰卧位，患髋外展45并外旋，患侧膝关节屈曲90，患侧足跟紧贴对侧膝关节。十字瞄准器对准髂前上棘连线与耻骨联合之间的中点，X线球管与桌面垂直并与片盒距离100cm。评价股骨头圆度、角Part 1Part 2Part 3Part 424Cam型：X线片测量指标 The cross-table la

11、teral view is very helpful for detecting lack of head sphericity or a decrease in head-neck offset股骨头颈偏距及偏距率（ femoral head-neck offset）: 11.60.7mm（正常）；8或10mm. 测量方法： The cross-table lateral view 测量股骨头前缘和股骨颈前缘的距离the alpha () angle: Abnormal if greater than 50（定量反映股骨头颈交界处凹陷程度的指标）测量方法：在股骨头前方与股骨颈交界处确定一点（

12、股骨头开始失去圆度的点），该点与股骨头中心的连线和股骨头中点与股骨颈中点连线的夹角Part 1Part 2Part 3Part 425ABCA, Pistol-grip deformity with abnormal extension of epiphyseal scar (arrows) in 19-year-old man.B, Axial view of normal hip with normal offset (OS) and normal alpha angle ( 50) in 32-year-old man.C, Decreased femoral headneck offs

13、et (OS) with consecutive increased alpha angle () in 26-year-old man.axial cross-table view of the proximal femur前后位片Part 1Part 2Part 3Part 426Part 1Part 2Part 3Part 427Part 1Part 2Part 3Part 428Pincer型：分为完全覆盖和部分覆盖正常髋关节：IIL（髂坐线），F（髋臼窝线），AI（髋臼指数），LCE（中心边缘角），股骨头挤压指数（E/A+E，正常为25-39）其中AI、LCE及E/A+E是反映髋臼覆

14、盖程度的重要指标LCE角：为股骨头中点与髋臼外侧缘连线和水平线垂线的夹角，正常值为25-39。AI：髋臼顶硬化区的最低点与髋臼外侧缘的连线和水平线的夹角，正常0。挤压指数：是股骨头未被髋臼覆盖部分的宽度与股骨头直径的比值，正常应25%前后位片：髋臼前壁缘位于后壁缘的内侧；正常髋臼窝线位于髂坐线外侧；正常髋臼后壁缘会通过股骨头中点。Part 1Part 2Part 3Part 429髋臼过深：前后位髋臼窝线位于髂坐线内侧股骨头挤压指数及AI降低，LCE增高注意：假髋臼过深征象，仅依靠X线不足以诊断。can be produced on an anteroposterior radiograph

15、that is centered over the hip. centering errorPart 1Part 2Part 3Part 430髋臼前突：前后位股骨头与髂坐线相交挤压指数为0或负数，AI为负，LCE增加AI为0或负时，提示髋臼过深或前突Part 1Part 2Part 3Part 431正常髋臼前缘线在后缘线内侧。cranial acetabular retroversion：髋臼后倾综合征，致髋臼前方过度覆盖前后位-8字征阳性Part 1Part 2Part 3Part 432髋臼后壁过度覆盖：髋臼后壁缘位于股骨头中心的外侧Part 1Part 2Part 3Part 433

16、Pincer-FAI的对冲伤：The resulting loss of joint space can be visualized on a faux profile and is a bad prognostic signPart 1Part 2Part 3Part 434Part 1Part 2Part 3Part 435混合型：Part 1Part 2Part 3Part 436Slipped capital femoral epiphysis and femoral neck fractures:Impingement caused by SCFE has been shown to

17、 cause early damage to the acetabular labrum and adjacent articular cartilage due to the prominent femoral metaphysis in this region.Klein线Part 1Part 2Part 3Part 437髋内翻 Coxa varaThe varus position gives rise to an abnormally located femoral neck that is situated more superiorly than normal given the

18、 decreased caput collum diaphysis angle(normal angles range from 120 to 135).Part 1Part 2Part 3Part 435关节造影： Stage 0 (normal) Homogeneous low signal intensity, a triangular shape, and continuous attachment to the lateral margin of the acetabulum without a notch or a sulcus. Stage IA Area of increase

19、d signal intensity within the center of the triangular-shaped labrum (Fig. 4a, b). Stage IB Similar to stage IA, but the labrum is thickened and there is no recess. Stage IIA Extension of contrast material into the labrum without detachment and the presence of a triangular shape and a recess (Fig. 5

20、). Stage IIB Same as stage IIA, but the labrum is thickened and a recess is not present Stage IIIA The labrum is detached, and there is a triangular shape and a recess. Stage IIIB Same as stage IIIA, but the labrum is thickened and there is no recess.Part 1Part 2Part 3Part 439Stage I AStage II A：盂唇撕

21、裂（黑）及软骨损伤（白）Stage II B：Part 1Part 2Part 3Part 440MR arthrography in FAI. (A) Oblique sagittal fat-saturated T1-weighted MR arthrographic image (600/8) of the hip in a patient with cam FAI. Coronal spin-echo sequence T1-weighted MR image (524/14) showing ossi cation of the acetabular labrum in a pati

22、ent with pincer FAI.Coronal T2-weighted MR image of the hip joint shows cartilage damage (chondral defects) in the superiolateral portion of the hip joint .Part 1Part 2Part 4Part 341斜轴位定位斜轴位2. 股骨颈疝窝：形成原因尚不明确，大部分学者认为与髋关节前方关节囊和股骨头颈部前方皮质之间的长期磨损及关节囊内压增高有关，认为其与Cam型FAI有相关性(33%)。Part 1Part 2Part 3Part 442S

23、econdary Radiographic Changes in Hipsincreasing theimpingement problemfurther deepeningof the acetabuluma reactive ossification1.Part 1Part 2Part 3Part 443X线片成像的优缺点：The gold standard remains the patients pain and not the imaging findings alone.X线片是否有异常的倾斜和旋转：尾骨尖是否正对耻骨联合两侧闭孔及髂骨翼是否对称耻骨联合上缘至尾骨尖的垂直距离是否在

24、正常范围。（ If the sacrococcygeal joint is within approximately 3.2 cm of the symphysis for men or 4.7 cm for women, then the pelvic tilt should be largely neutral. ）Part 1Part 2Part 3Part 444It is worth remembering that the diagnosis of FAI depends on both clinical and imaging evidence. Radiologists sho

25、uld recognize and describe imaging abnormalities that may be associated with FAI, but it may be prudent to avoid any reference to FAI in the report. The incompleteness of data on the natural history of hips with this condition, and the lack of immediate proof of a long-term benet of the surgical tre

26、atment from prospective randomized studies might have led to skepticism in the radiologic and orthopedic communities.治疗Part4Part 1Part 2Part 3Part 41保守治疗保守治疗包括限制活动、改变不良运动习惯及使用非甾体抗炎药等，非手术治疗只能暂时缓解疼痛症状，并不能解除撞击因素，因此不能阻止关节退变的持续进展。2手术治疗手术治疗适应证：年轻，无严重的继发性骨关节炎，解剖结构畸形预计可矫正者，包括股骨头及髋臼畸形。3关节镜治疗关节镜在诊断和治疗FAI髋臼唇撕裂方面具有重要的临床价值其临床应用疗效满意。46Will every patient with radiographic evidence of FAIregardless of symptomsprogress to end-stage hip OA, and should therefore, be referred for joint preserving surgery?It is still