肌骨超聲診斷指南肩部第1頁/共25頁肌骨超聲技術(shù)指南--肩部(歐洲肌骨放射學(xué))第2頁/共25頁Althoughpatient’spositioningforshoulderUSvarieswidelyacrossdifferentCountriesandInstitutionsreflectingmultifacetedopinionsandexperiencesofdifferentexaminers,westronglyrecommendtoexaminethepatientwhileseatedonarevolvingstool.Thispositionallowstheexaminertoreachtheanterior,lateralandposterioraspectsoftheshoulderwiththeprobebysimplyaskingthepatienttorotateonthechair.

不同的國家和機(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。第3頁/共25頁longheadofthebicepstendon

二頭肌腱長頭

Placethearminslightinternalrotation(directedtowardsthecontralateralknee)withtheelbowflexed90°,palmup.Startbyfindingthelongbicepstendoninbetweenthegreaterandlessertuberosities–Useshortandlong(morelimitedutility)axisplanestoexaminethebiceps.

肘部屈曲90°，手臂輕度內(nèi)旋（指向?qū)?cè)膝部），掌心向上。先在大、小結(jié)節(jié)之間找到肱二頭肌長頭腱，采用短軸和長軸（作用有限）切面檢查二頭肌。Shifttheprobeuptoexaminethebicepsinitsintraarticularcourseanddowntoreachthemyotendinousjunction(levelofthepectoralismajortendon).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)探頭探測肌-腱連接部（胸大肌肌腱水平）。第4頁/共25頁Legend:SubS,subscapularistendon;SupraS,supraspinatustendon;Arrow,longheadofthebicepstendon;LT,lessertuberosity;GT,greatertuberosity;SH,shortheadofthebiceps;LH,longheadofthebiceps;H,humeralshaft;Arrowheads,pectoralismajortendon圖例：

SubS肩胛下肌肌腱；SupraS岡上肌肌腱；箭號(hào)，肱二頭肌長頭；LT小結(jié)節(jié)；GT大結(jié)節(jié)；SH二頭肌短頭；LH二頭肌長頭；H肱骨干；箭頭，胸大肌肌腱第5頁/共25頁第6頁/共25頁第7頁/共25頁3subscapularistendon

Rotatethearmexternallyfixingtheelbowontheiliaccresttoshowthesubscapularistendon

anditsinsertiononthelessertuberosity(slightsupinationofthehandmaybehelpful

toneutralizethetendencytoliftandabducttheelbowfromthelateralchestwall).

3肩胛下肌肌腱

將肘部固定于髂嵴處，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側(cè)胸壁的力量）第8頁/共25頁Thistendonshouldbeevaluatedalongitslong-(transverseplanes)andshort-(sagittalplanes)axisduringpassiveexternalandinternalrotationwithhangingarm.Sweepthetransducerupanddownoverthesubscapularisuntilitsfullwidthisdemonstrated.

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。第9頁/共25頁Legend:Arrow,longheadofthebicepstendon;dashedline,insertionofthesubscapularistendon;Co,coracoid;Del,deltoidmuscle;LT,lessertuberosity;SubS,subscapularistendon;voidarrowheads,tendonfasciclesofthesubscapularis;whitearrowheads,muscletissueinterposedbetweentendonfascicles

圖例：箭號(hào)，肱二頭肌長頭腱；虛線，肩胛下肌肌腱附著處；Co喙突；Del,三角肌；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；第10頁/共25頁第11頁/共25頁第12頁/共25頁4anteromedialstructuresandcoracoacromialligament

Movingtheprobetowardmedialontransverseplanes,lookatthecoracoidprocess,thecoracoacromialligament(themedialmarginofthetransducerisonthecoracoidprocessandthelateraledgeisshiftedupwardandlaterallytowardstheacromion),theconjoinedtendonandtheanterioraspectofthesubacromialsubdeltoidbursa.Then,checkthesubscapularisrecessandthesubcoracoidbursaforeffusion.Externalandinternalrotationmayalsousedtodemonstrateanteromedialimpingement(distancebetweencoracoidprocess

andlessertuberositymeasuredininternalrotation).

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，探測肩胛下肌隱窩和喙突下囊有無積液。內(nèi)旋和外旋也可用以探測前內(nèi)側(cè)的創(chuàng)傷部位（內(nèi)旋可用以測量肩胛骨喙突和肱骨小結(jié)節(jié)之間的距離）第13頁/共25頁Legend:Acr,acromion;Arrows,shortheadofthebiceps;Arrowheads,coracoacromialligament;Co,coracoid;CoBr,coraco-brachialis;HH,humeralhead;SubS,subscapularistendon;SupraS,supraspinatus圖示：Acr,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,岡上肌第14頁/共25頁第15頁/共25頁supraspinatustendon:positioning(1)岡上肌肌腱：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。應(yīng)沿長軸和短軸觀測岡上肌肌腱。第16頁/共25頁第17頁/共25頁supraspinatustendon5岡上肌肌腱

Refertotheintraarticularportionofthebicepsasalandmarktoobtainpropertransducerorientationforimagingthesupraspinatus.Infact,thesetendonsrunparallelonetotheotherandtheintraarticularportionofthebicepsiseasytoberecognizedduetoamoreclearlydefinedfibrillarpattern.OneshouldrotatethetransduceruntilthebicepsisdepictedasmoreelongatedaspossibleintheUSimage.Then,theprobeisshiftedupwardandposteriorlyoverthesupraspinatuswithoutchangingitsorientation.Theresultingimageisinaxiswiththesupraspinatus.Betweenthesupraspinatusandthedeltoid,thenormalsubacromial-subdeltoidbursaappearsasathinhypoechoicband.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。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。第18頁/共25頁第19頁/共25頁Tiltthetransducergentlyintheareaoverlyingthetendoninsertiontoavoidanisotropy.Remembertoscanthelateralpouchofthesubacromialsubdeltoidbursaalongthelateraledgeofthegreatertuberosity.Whenlookingforthesupraspinatusonshort-axis,thenormalcuffmusthavealmostthesamethicknessfromthebicepstendonlandmarkuntil2cmbackwards:fromthispointbackwardsthetendonseenistheinfraspinatus.

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第20頁/共25頁Legend:Acr,acromion;asterisk,myotendinousjunction;Del,deltoidmuscle;GT,greatertuberosity;voidarrow-head,articularcartilage;curvedarrow,hypoechoicartifactrelatedtoanisotropy;straightarrow,longheadofthebicepstendon;SupraS,supraspinatustendon;whitearrowhead,subacromialsubdeltoidbursa

圖例：Acr,肩峰；星號(hào)，肌-腱連接；Del,三角??；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第21頁/共25頁第22頁/共25頁6supraspinatustendon:positioning(2)Placethedorsumofthehandovertheoppositebackpocket(forcedinternalrotation,stressmanoeuvre).