1、肌骨超聲技術(shù)指南-肩部(歐洲肌骨放射學(xué))1Although patients positioning for shoulder US varies widely across different Countries and Institutions reflecting multifaceted opinions and experiences of different examiners, we strongly recommend to examine the patient while seated on a revolving stool. This position allows t

2、he examiner to reach the anterior, lateral and posterior aspects of the shoulder with the probe by simply asking the patient to rotate on the chair.不同的國(guó)家和機(jī)構(gòu)給病人進(jìn)行肩部超聲檢查時(shí)所采取的體位各不相同，體現(xiàn)了不同診查者不同的觀點(diǎn)和經(jīng)驗(yàn)，但是，我們強(qiáng)烈推薦讓病人坐在轉(zhuǎn)凳上進(jìn)行檢查。這個(gè)體位能夠讓診查者只要讓病人轉(zhuǎn)動(dòng)一下凳子就能夠使用探頭掃查到肩的前面、側(cè)面和后面。 2long head of the biceps tendon二頭肌腱長(zhǎng)頭Pl

3、ace the arm in slight internal rotation (directed towards the contralateral knee) with the elbow flexed 90, palm up. Start by finding the long biceps tendon in between the greater and lesser tuberosities Use short and long (more limited utility) axis planes to examine the biceps.肘部屈曲90，手臂輕度內(nèi)旋（指向?qū)?cè)膝部

4、），掌心向上。先在大、小結(jié)節(jié)之間找到肱二頭肌長(zhǎng)頭腱，采用短軸和長(zhǎng)軸（作用有限）切面檢查二頭肌。 Shift the probe up to examine the biceps in its intraarticular course and down to reach the myotendinous junction (level of the pectoralis major tendon).向上移動(dòng)探頭檢查二頭肌關(guān)節(jié)內(nèi)的走行，向下移動(dòng)探頭探測(cè)肌-腱連接部（胸大肌肌腱水平）。3Legend: SubS, subscapularis tendon; SupraS, supraspinatu

5、s tendon; Arrow, long head of the biceps tendon; LT, lesser tuberosity; GT, greater tuberosity; SH, short head of the biceps; LH, long head of the biceps; H, humeral shaft; Arrowheads, pectoralis major tendon圖例： SubS 肩胛下肌肌腱； SupraS 岡上肌肌腱；箭號(hào)，肱二頭肌長(zhǎng)頭； LT 小結(jié)節(jié)；GT 大結(jié)節(jié)；SH 二頭肌短頭；LH 二頭肌長(zhǎng)頭；H 肱骨干；箭頭，胸大肌肌腱4563

6、subscapularis tendonRotate the arm externally fixing the elbow on the iliac crest to show the subscapularis tendonand its insertion on the lesser tuberosity (slight supination of the hand may be helpfulto neutralize the tendency to lift and abduct the elbow from the lateral chest wall).3 肩胛下肌肌腱將肘部固定

7、于髂嵴處，上肢外旋可顯示肩胛下肌肌腱及其小結(jié)節(jié)附著部。（手掌輕度后旋可有助于抵抗肘部上抬和外展離開(kāi)側(cè)胸壁的力量） 7This tendon should be evaluated along its long- (transverse planes) and short- (sagittal planes) axis during passive external and internal rotation with hanging arm. Sweep the transducer up and down over the subscapularis until its full width

8、 is demonstrated.評(píng)價(jià)該肌腱應(yīng)該在手臂上舉狀態(tài)下被動(dòng)外旋和內(nèi)旋時(shí)沿其長(zhǎng)軸切面（橫切面）和短軸切面（矢狀切面）進(jìn)行掃查。在肩胛下肌表面上下掃查，直至整塊肌肉都能全部顯示。 8Legend: Arrow, long head of the biceps tendon; dashed line, insertion of the subscapularis tendon; Co, coracoid; Del, deltoid muscle; LT, lesser tuberosity; SubS, subscapularis tendon; void arrowheads, tend

9、on fascicles of the subscapularis; white arrowheads, muscle tissue interposed between tendon fascicles圖例： 箭號(hào)，肱二頭肌長(zhǎng)頭腱；虛線，肩胛下肌肌腱附著處；Co喙突；Del, 三角??；LT, 小結(jié)節(jié)；SubS, 肩胛下肌肌腱；空心箭頭，肩胛下肌肌腱束；白色箭頭，插入肌腱束之間的肌肉組織；910114 anteromedial structures and coracoacromial ligamentMoving the probe toward medial on transverse p

10、lanes, look at the coracoid process, the coracoacromial ligament (the medial margin of the transducer is on the coracoid process and the lateral edge is shifted upward and laterally towards the acromion), the conjoined tendon and the anterior aspect of the subacromial subdeltoid bursa. Then, check t

11、he subscapularis recess and the subcoracoid bursa for effusion. External and internal rotation may also used to demonstrate anteromedial impingement (distance between coracoid processand lesser tuberosity measured in internal rotation).4. 肩部前內(nèi)側(cè)結(jié)構(gòu)和喙肩韌帶在橫切面上，將探頭向內(nèi)側(cè)移動(dòng)，查看肩胛骨喙突、喙肩韌帶（探頭的內(nèi)側(cè)固定在肩胛骨喙突，探頭外側(cè)緣向外

12、上方轉(zhuǎn)動(dòng)指向肩峰）、聯(lián)合腱和肩峰下的三角肌下滑囊前部。然后，探測(cè)肩胛下肌隱窩和喙突下囊有無(wú)積液。內(nèi)旋和外旋也可用以探測(cè)前內(nèi)側(cè)的創(chuàng)傷部位（內(nèi)旋可用以測(cè)量肩胛骨喙突和肱骨小結(jié)節(jié)之間的距離）12Legend: Acr, acromion; Arrows, short head of the biceps; Arrowheads, coracoacromial ligament; Co, coracoid; CoBr, coraco-brachialis; HH, humeral head; SubS, subscapularis tendon; SupraS, supraspinatus圖示：Acr

13、, 肩峰；箭，二頭肌短頭；箭頭，喙肩韌帶；Co,喙突；CoBr, 喙肱?。籋H, 肱骨頭；SubS, 肩胛下肌肌腱；SupraS, 岡上肌1314supraspinatus tendon: positioning(1)岡上肌肌腱：定位（1）Place the patients arm posteriorly, placing the palmar side of the hand on the superior aspect of the iliac wing with the elbow flexed and directed posteriorly. The supraspinatus t

14、endon should be evaluated along its long- and short-axis.患者上肢后置，肘部向后屈曲，手掌面置于髂骨翼上部。應(yīng)沿長(zhǎng)軸和短軸觀測(cè)岡上肌肌腱。1516supraspinatus tendon5 岡上肌肌腱Refer to the intraarticular portion of the biceps as a landmark to obtain proper transducer orientation for imaging the supraspinatus. In fact, these tendons run parallel o

15、ne to the other and the intraarticular portion of the biceps is easy to be recognized due to a more clearly defined fibrillar pattern. One should rotate the transducer until the biceps is depicted as more elongated as possible in the US image. Then, the probe is shifted upward and posteriorly over t

16、he supraspinatus without changing its orientation. The resulting image is in axis with the supraspinatus. Between the supraspinatus and the deltoid, the normal subacromial-subdeltoid bursa appears as a thin hypoechoic band.肱二頭肌的關(guān)節(jié)內(nèi)部分是確定合適的探頭方向以顯示岡上肌的定位標(biāo)志。事實(shí)上，這些肌腱是相互平行的，而二頭肌關(guān)節(jié)內(nèi)的部分由于其邊界清晰的細(xì)纖維結(jié)構(gòu)而易于辨認(rèn)。操

17、作者應(yīng)該轉(zhuǎn)動(dòng)探頭使二頭肌的超聲圖像顯示得盡可能長(zhǎng)。然后，保持探頭方向不變，在岡上肌表面向后上方移動(dòng)探頭，最終圖像就是岡上肌的長(zhǎng)軸。在岡上肌和三角肌之間，正常的肩峰-三角肌下滑囊呈一條薄薄的低回聲帶。1718Tilt the transducer gently in the area overlying the tendon insertion to avoid anisotropy. Remember to scan the lateral pouch of the subacromial subdeltoid bursa along the lateral edge of the great

18、er tuberosity. When looking for the supraspinatus on short-axis, the normal cuff must have almost the same thickness from the biceps tendon landmark until 2cm backwards: from this point backwards the tendon seen is the infraspinatus.在肌腱附著端輕輕地傾斜探頭以消除各向異性假象。 記住，要沿著大結(jié)節(jié)的外側(cè)緣掃查肩峰下三角肌下囊的側(cè)囊。在短軸上尋找岡下肌時(shí)，從二頭肌腱

19、標(biāo)記處向后2cm，正常肩袖的厚度一定是不變的：從該點(diǎn)向后看到的肌腱就是岡下肌19Legend: Acr, acromion; asterisk, myotendinous junction; Del, deltoid muscle; GT, greater tuberosity; void arrow-head, articular cartilage; curved arrow, hypoechoic artifact related to anisotropy; straight arrow, long head of the biceps tendon; SupraS, supraspi

20、natus tendon; white arrowhead, subacromial subdeltoid bursa圖例： Acr, 肩峰；星號(hào)，肌-腱連接； Del, 三角肌； GT, 大結(jié)節(jié)；空心箭頭，關(guān)節(jié)軟骨； 彎箭頭，各向異性導(dǎo)致的低回聲偽像；直箭頭，二頭肌肌腱； SupraS, 岡上肌肌腱；白色箭頭，肩峰下三角肌下滑囊20216 supraspinatus tendon: positioning(2)Place the dorsum of the hand over the opposite back pocket (forced internal rotation, stress

21、 manoeuvre). There should not be any space gap between the elbow and the lateral chest wall. Using this position, the supraspinatus becomes a more anterior structure and the transducer should be oriented almost vertically to be in axis with it. Consider that the tendon fibers are more stretched than in the position described at point -5. This may be possible cause of overestimation of tear size. Due to an excessive inter