肩關節(jié)磁共振診斷

1、肩關節(jié)磁共振診斷肩關節(jié)磁共振診斷肩關節(jié)磁共振診斷 骨性出口與肩峰 肩袖 關節(jié)囊和盂唇 骨性結構和關節(jié)面 肱二頭肌 其他MR掃描技術-T1 and T2 FS-斜冠狀面-T1 and T2 FS-斜矢狀面 -T2 FS and GRE-橫斷面骨性出口和肩峰 骨性弓狀結構包圍肩袖肌腱 機械性碰撞導致肩袖肌腱退變 前肩峰是導致肩袖碰撞最重要的結構Anterior Acromion Most Important Structure Leading to Impingement 正常骨性出口正常骨性出口前前 后后喙突鎖骨肩峰肩峰形態(tài)Type I肩峰形態(tài)Type II肩峰形態(tài)Type III肩峰下傾正常肩

2、峰軸位形態(tài)肩峰前下傾表現(xiàn)斜矢狀面上觀察肩峰軸位形態(tài)肩峰下傾在冠狀面上觀察肩峰向外側的下傾表現(xiàn)正常肩峰軸位表現(xiàn)外側下傾骨性肩峰發(fā)育骨性肩峰發(fā)育骨化中心常在骨化中心常在22-25歲閉合歲閉合軸位像前肩峰正常表現(xiàn)骨性肩峰發(fā)育異常（軸位）骨性肩峰發(fā)育異常（軸位）肩峰發(fā)育異?？赡茉斐刹环€(wěn)定，并導致三角肌收縮過程中肩肩峰發(fā)育異?？赡茉斐刹环€(wěn)定，并導致三角肌收縮過程中肩峰與肩袖碰撞峰與肩袖碰撞骨性肩峰發(fā)育（矢狀面）骨性肩峰發(fā)育（矢狀面）肩胛小骨骨贅形成肩胛小骨骨性肩峰骨性肩峰肩鎖關節(jié)肩峰“雙肩鎖關節(jié)”征肩峰骨贅形成肩峰骨贅形成-骨贅-內有骨髓信號-三角肌腱（類似骨贅表現(xiàn)）-低信號（內無骨髓信號）肩肩 峰峰

3、形態(tài)分型（I，II，III） 前/外側下傾型肩峰 下緣骨贅形成肩鎖關節(jié)肩鎖關節(jié)-退變，關節(jié)囊增厚-較少引起肩袖卡壓喙肩關節(jié)喙肩關節(jié)-正常喙肩韌帶厚度3 mm-韌帶增厚可導致前肩袖碰撞喙突碰撞喙突碰撞-正常喙肱距離為 11 mm-喙肱間距狹窄可導致肩胛下區(qū)域碰撞骨性出口和肩峰骨性出口和肩峰 肩峰 形態(tài)分類，下傾型肩峰，骨贅，肩峰發(fā)育異常 肩鎖關節(jié) 退變，關節(jié)囊肥厚(是否存在團塊樣表現(xiàn)？) 喙肩韌帶(是否增厚?) 喙肱間距 (肩胛下區(qū)是否有碰撞?)肩肩 袖袖肩胛下肌肩胛下肌; 岡上肌岡上肌 岡下肌岡下肌; 小圓肌小圓肌; 肩袖（矢狀面）肩袖（矢狀面）岡上肌， 岡下肌，小圓肌，肩胛下肌肩袖（矢狀面）

4、肩袖（矢狀面）岡上肌， 岡下肌，小圓肌，肩胛下肌肩袖（矢狀面）肩袖（矢狀面）覆蓋肱骨頭的連續(xù)低信號表現(xiàn)肩袖（軸位）肩袖（軸位）岡上肌腱肩袖（軸位）肩袖（軸位）Rotator Cuff (Axial Plane)-評價肩胛下肌的最好平面Primary Plane for Evaluating Subscapularis岡下肌位于肩胛下肌對應的關節(jié)后側區(qū)域-Infraspinatus Located Posteriorly肩袖（冠狀面）肩袖（冠狀面）Rotator Cuff (Coronal)評估岡上肌腱的最佳層面評估岡上肌腱的最佳層面肌肉肌腱連接部位于12點方向肩袖（冠狀面）肩袖（冠狀面）岡下肌

5、腱位置偏后斜行走向肩胛下肌位置偏前多根肌腱組成肩袖病變肩袖病變 Tendonopathy肌腱病變 Tear撕裂 Partial Thickness, Full Thickness, Complete 部分撕裂，全層撕裂，完全撕裂 Musculotendinous Retraction肌肉肌腱回縮 Fatty Atrophy脂肪肥厚 HADD/ Calcific Tendonitis鈣化性肌腱炎肌腱病變-Increased T1-signal; Thick tendonT1W信號增高，肌腱增厚-Intermediate T2-signal (No Fluid Signal)T2W中等信號，無液體

6、信號關節(jié)囊部分撕裂（關節(jié)面）關節(jié)囊部分撕裂（關節(jié)面）Partial Thickness Tear (Articular)Extensive Intermediate T1-SignalT1W延續(xù)性中等信號表現(xiàn)T2: Fluid Signal T2：出現(xiàn)液性信號 Partial Thickness 部分撕裂Undersurface Tear肌腱表面下撕裂部分撕裂（關節(jié)囊面）部分撕裂（關節(jié)囊面）Partial Thickness Tear (Bursal)-Fluid Signal Extending into the Bursal Surface of the Supraspinatus Ten

7、don 液性信號延伸至岡上肌腱關節(jié)囊面表面肩袖部分撕裂（肌腱內型）肩袖部分撕裂（肌腱內型） Partial Thickness Tear (Interstitial)-Fluid Signal within the Substance of the Tendon液性信號存在于肌腱內-Does Not Touch the Surface不影響到肌腱表面肩袖肌間囊腫肩袖肌間囊腫Intramuscular Cyst Rotator Cuff-High Association with與以下因素有關1.P.T. Undersurface Tear創(chuàng)傷性表層下撕裂2. Small F.T. Tear小的

8、全層撕裂3. DDX: Paralabral Cyst鑒別診斷：盂唇旁囊腫肌間囊腫肌間囊腫 Intramuscular Cyst Rotator CuffIntramuscular Cyst Supraspinatus岡上肌肌間囊腫Small Undersurface P.T. Tear小的創(chuàng)傷后撕裂全層撕裂全層撕裂 Full Thickness Tear-Fluid extends through the entire thickness of the tendon (top - bottom)液性信號延伸至肌腱全層（從頂部到底部）-Mild retraction of musculoten

9、dinous junction肌肉肌腱連接部輕度回縮-Fluid Signal within SST岡上肌腱內出現(xiàn)液性信號-Sag Image: Fluid from Top to Bottom矢狀面：液性信號從頂層到底層全層撕裂全層撕裂 Full Thickness Tear-Gad Arthrogram: Demonstrates Full Thickness Tear-肩關節(jié)造影：顯示全層撕裂T1T2全層撕裂全層撕裂 Full Thickness Tear-Intermediate T1-Signal-T1W中等信號-Musculotendinous Retraction-肌肉肌腱回縮-

10、Fluid Signal on T2-T2W出現(xiàn)液性信號-Full thickness Tear-全層撕裂全層撕裂全層撕裂 Full Thickness Tear完全撕裂完全撕裂 Complete Tear特征：肌肉肌腱回縮特征：肌肉肌腱回縮 Musculotendinous retraction-Greater than 3 cm retraction- poor prognosis for repair-肌肉肌腱出現(xiàn)超過3cm的回縮-預后不佳脂肪增厚脂肪增厚 Fatty Atrophy-Grade as Mild, Moderate, Severe-分為輕度，中度和重度-Streaks o

11、f High Signal on T1 -T1W出現(xiàn)高信號改變-Normal muscle bulk-正常岡上肌-Fatty Atrophy: Does not fill supraspinatus fossa-脂肪增厚：肌肉信號未充填岡上肌窩脂肪增厚脂肪增厚 Fatty Atrophy鈣化性肌腱炎鈣化性肌腱炎 Calcific Tendonitis-Dark Globular Area on all Pulse Sequences-在所有的脈沖序列上均為低信號-Blooming Artifact on Gradient Echo Images-GE圖像上可出現(xiàn)偽影肩袖病變肩袖病變Rotato

12、r Cuff PathologyRotator Cuff Pathology Tendonopathy 肌腱病變 Tear 撕裂 Partial Thickness, Full Thickness, Complete 部分撕裂，全層撕裂，完全撕裂 Musculotendinous Retraction肌肉肌腱回縮 Fatty Atrophy 脂肪增厚 Calcific Tendonitis 鈣化性肌腱炎關節(jié)囊結構和盂唇關節(jié)囊結構和盂唇Capsular Structures and LabrumCapsular Structures and Labrum Patient under 35 y.

13、o. with GH Instability or Unexplained Shoulder Pain35歲以下患者出現(xiàn)肩關節(jié)不穩(wěn)定或無法解釋的肩部疼痛 MR Arthrography 適合進行MR關節(jié)造影 Labral Lesions Common 盂唇病變較為常見 Subtle Lesions (nondisplaced, resynovialized) -Distention Effects of Contrast小病變（未移位，滑膜化）-對比劑的遮蔽效應Bankart病變病變 Bankart Lesion-Conventional MRI: Loss of Normal Morphol

14、ogy of Anterior Labrum-常規(guī)MR：前盂唇正常形態(tài)消失-Subtle Lesions Best Demonstrated on MR Arthrography-MR肩關節(jié)造影能更好的顯示盂唇微小病變Bankart病變病變 Bankart LesionHill Sach病變病變Hill Sachs Lesion Top 3 Axial Images Through Humeral Head Should Be Round正常：肱骨頭軸位像最上面3幅圖像應為圓形 Flattening or Convexity on Top 3 Images最上面3幅圖像扁平或不規(guī)則表現(xiàn) Pos

15、terior Humeral Sulcus: Can Mimic A Hill Sachs后肱骨凹：易與Hill Sachs病變混淆SLAP病病 SLAP Tears Superior Labrum is Dark on Pulse Sequences in Coronal Plane冠狀面脈沖序列顯示上盂唇出現(xiàn)低信號表現(xiàn)冠狀面脈沖序列顯示上盂唇出現(xiàn)低信號表現(xiàn) Any Signal in Triangle of Superior Labrum = SLAPSLAP病變：上盂唇在任何序列上出現(xiàn)三角形異常信號病變：上盂唇在任何序列上出現(xiàn)三角形異常信號 MR Arthrography Improve

16、s SensitivityMR關節(jié)造影提升了診斷敏感度關節(jié)造影提升了診斷敏感度肩關節(jié)表面和骨性結構肩關節(jié)表面和骨性結構Osseous Structures and Articular SurfacesOsseous Structures and Articular Surfaces Hematopoietic Bone Marrow Hematopoietic Bone Marrow 局部紅骨髓變局部紅骨髓變 Subcortical Cystic ChangeSubcortical Cystic Change皮質下囊變皮質下囊變 Trauma (Fracture)Trauma (Fractur

17、e)創(chuàng)傷（骨折）創(chuàng)傷（骨折） Arthritis Arthritis 關節(jié)炎關節(jié)炎 Infection Infection 感染感染 Tumor Tumor 腫瘤腫瘤紅骨髓變紅骨髓變 Hematopoietic Marrow-Humeral epiphysis: Only Epiphysis that Normally contains Hematopoietic Marrow肱骨紅骨髓變：正常情況下僅骨骺保留紅骨髓-Females; Curvilinear; Subcortical Distribution; Bilateral女性多見；弧形表現(xiàn)；皮質下分布；雙側皮質下囊變皮質下囊變 Sub

18、cortical Cystic Change-Commonly Seen Near SST Insertion Site岡上肌附著處最為常見-Mimic Hill Sachs與Hill Sach病易混淆創(chuàng)傷創(chuàng)傷 Trauma-24 y.o. Female: Persistent Painful Shoulder After Skiing Accident女性，女性，24歲，滑雪事故后持續(xù)性肩關節(jié)疼痛歲，滑雪事故后持續(xù)性肩關節(jié)疼痛肱骨頭無菌性壞死肱骨頭無菌性壞死 AVNT1T2“Double Line” Sign- Seen On T2 Images雙線征非特異性骨髓信號異常非特異性骨髓信號異常

19、Nonspecific Marrow Signal-DDX: Infection, Tumor, Trauma鑒別診斷：感染，腫瘤，創(chuàng)傷-T1 Image: Use Muscle as Internal StandardT1加權：肌肉作為對照-T1 Signal Darker than Muscle: Pathologic異常信號：T1加權像上病灶信號低于肌肉腫瘤腫瘤 Tumor-Osteosarcoma Proximal Humerus 肱骨近端骨肉瘤-Mass with Cortical Destruction 皮質破壞合并軟組織腫塊形成-Low Signal T1; High Signa

20、l T2 Images關節(jié)軟骨關節(jié)軟骨 Articular Cartilage-Normal Cartilage 正常軟骨-Intermediate Signal 中等信號-Smooth 表面平整-Articular Cartilage Defect軟骨缺損-Gap: Fills With Contrast關節(jié)造影：顯示軟骨裂隙肱二頭肌病變肱二頭肌病變Biceps TendonBiceps Tendon Tendonitis 肌腱炎 Tear 肌腱撕裂 Dislocation 脫位 Intra-articular 關節(jié)內脫位 Extra-articular 關節(jié)外脫位肱二頭肌病變肱二頭肌病變B

21、iceps TendonBiceps Tendon肱二頭肌病變肱二頭肌病變Biceps TendonBiceps Tendon-Extra-articular Biceps: Best Seen on Axial Image關節(jié)外肱二頭肌腱：軸位顯示最佳關節(jié)外肱二頭肌腱：軸位顯示最佳-In Bicipital Groove; Transverse Ligament肌腱位于二頭肌溝內，外有橫韌帶保護肌腱位于二頭肌溝內，外有橫韌帶保護肱二頭肌病變肱二頭肌病變Biceps TendonBiceps Tendon肱二頭肌腱脫位肱二頭肌腱脫位Biceps Tendon Dislocation-Extra

22、-articular: Transverse Ligament Torn; Subscapularis Intact關節(jié)外脫位：橫韌帶撕裂；肩胛下肌完整-Intra-articular: Subscapularis Torn or Avulsed關節(jié)內脫位：肩胛下肌撕裂或撕脫-Biceps Tendon Intra-articular Dislocation:肌腱關節(jié)內脫位： Subscapularis Tendon Avulsed肩胛下肌腱撕脫肱二頭肌腱脫位肱二頭肌腱脫位Biceps Tendon Dislocation肱二頭肌腱脫位肱二頭肌腱脫位Biceps Tendon Dislocat

23、ion肱二頭肌腱炎肱二頭肌腱炎/撕裂撕裂Biceps Tendonitis/ Tear-Thick Tendon; Increased Signal肌腱增厚；信號增加-Longitudinal Splits縱向撕裂盂唇旁囊腫盂唇旁囊腫Paralabral Cyst High Association with Labral Tears and GH Instability 與盂唇撕裂和盂肱關節(jié)不穩(wěn)定密與盂唇撕裂和盂肱關節(jié)不穩(wěn)定密切相關切相關 Analogous to Meniscal Cysts of the Knee 類似于膝關節(jié)半月板囊腫類似于膝關節(jié)半月板囊腫T2 Images- Multi

24、-lobulated Fluid Collections T2加權像加權像-多房液性信號多房液性信號Location: Posterior, Superior, Inferior 部位：盂唇后，上，下部部位：盂唇后，上，下部Can Cause Neurovascular Entrapment 可導致神經(jīng)血管卡壓可導致神經(jīng)血管卡壓肩胛上神經(jīng)卡壓肩胛上神經(jīng)卡壓Suprascapular Nerve Entrapment-Suprascapular Notch肩胛上切跡肩胛上切跡-Denervation of Supra- and Infraspinatus Muscles岡上肌和岡下肌去神經(jīng)化岡上

25、肌和岡下肌去神經(jīng)化-Spinoglenoid Notch岡盂切跡岡盂切跡-Denervation of Infraspinatus Muscle岡下肌去神經(jīng)化岡下肌去神經(jīng)化岡上肌岡上肌/岡下肌去神經(jīng)化岡下肌去神經(jīng)化Denervation Supra/Infraspinatus-Entrapment of the Suprascapular Nerve in Suprascapular Notch肩胛上切跡囊腫導致肩胛上神經(jīng)卡壓肩胛上切跡囊腫導致肩胛上神經(jīng)卡壓-MR Findings: Early- Denervation edema (High Signal on T2)MR表現(xiàn)：表現(xiàn)：早期早

26、期-去神經(jīng)水腫（去神經(jīng)水腫（T2加權高信號）加權高信號）Late- Fatty Replacement (High Signal on T1)晚期：脂肪替代（晚期：脂肪替代（T1加權高信號）加權高信號）岡下去神經(jīng)化岡下去神經(jīng)化Denervation Infraspinatus-Entrapment of Suprascapular Nerve in Spinoglenoid Notch岡盂切跡囊腫導致肩胛上神經(jīng)卡壓岡盂切跡囊腫導致肩胛上神經(jīng)卡壓-Early Denervation Edema of Infraspinatus Muscle岡下肌去神經(jīng)水腫岡下肌去神經(jīng)水腫四邊孔綜合征四邊孔綜合征

27、Quadrilateral Space Syndrome旋肱后動脈和腋神經(jīng)旋肱后動脈和腋神經(jīng)在四邊孔處受壓后所引起的一系在四邊孔處受壓后所引起的一系列臨床癥候群。其主要表現(xiàn)是腋神經(jīng)支配的肩臂外側列臨床癥候群。其主要表現(xiàn)是腋神經(jīng)支配的肩臂外側的感覺障礙和三角肌功能受限。的感覺障礙和三角肌功能受限。由于當肩關節(jié)外展外旋時，組成四邊孔的肌肉均受牽由于當肩關節(jié)外展外旋時，組成四邊孔的肌肉均受牽拉，從三個方向對四邊產(chǎn)生擠壓而致本癥發(fā)生。拉，從三個方向對四邊產(chǎn)生擠壓而致本癥發(fā)生。 -Axillary Nerve Compression Neuropathy腋神經(jīng)受壓癥狀腋神經(jīng)受壓癥狀-Poorly Loc

28、alized Shoulder Pain in ABER PositionABER位局部嚴重肩痛位局部嚴重肩痛-Atrophy of Teres Minor and Deltoid Muscles小圓肌和三角肌萎縮小圓肌和三角肌萎縮Etiologies: Fibrous Bands- Seen with Repetitive Overhead Activity; Paralabral Cyst; Mass病因：反復過伸過頭運動導致的纖維束帶；盂唇旁囊病因：反復過伸過頭運動導致的纖維束帶；盂唇旁囊腫；腫塊腫；腫塊-Chronic Fatty Atrophy of Teres Minor and Deltoid小圓肌和三角肌慢性萎縮和脂肪化小圓肌和三角肌慢性萎縮和脂肪化-High Signal on T1 ImagesT1加權高信號表現(xiàn)加權高信號表現(xiàn)四邊孔綜合征四邊孔綜合征Quadrilateral Space Sy