1、.,肩關(guān)節(jié)磁共振診斷,.,肩關(guān)節(jié)磁共振診斷,骨性出口與肩峰 肩袖 關(guān)節(jié)囊和盂唇 骨性結(jié)構(gòu)和關(guān)節(jié)面 肱二頭肌 其他,.,MR掃描技術(shù),-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(jié)構(gòu)包圍肩袖肌腱 機(jī)械性碰撞導(dǎo)致肩袖肌腱退變 前肩峰是導(dǎo)致肩袖碰撞最重要的結(jié)構(gòu) Anterior Acromion Most Important Structure Leading to Impingement,.,.,.,正常骨性出口,前,后,喙突,鎖骨,肩峰,.,肩峰形態(tài),Type I,.,肩峰形態(tài),Type II

2、,.,肩峰形態(tài),Type III,.,肩峰下傾,正常肩峰軸位形態(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(cè)的下傾表現(xiàn),正常肩峰軸位表現(xiàn),外側(cè)下傾,.,骨性肩峰發(fā)育,骨化中心常在22-25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）,肩峰發(fā)育異常可能造成不穩(wěn)定，并導(dǎo)致三角肌收縮過程中肩峰與肩袖碰撞,.,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,肩鎖關(guān)節(jié),肩峰,“雙肩鎖關(guān)節(jié)”征,.,肩峰骨贅形成,-骨贅 -內(nèi)有骨髓信號,-三角肌腱（類似骨贅表現(xiàn)） -低信號（內(nèi)無骨髓信號）,.,肩 峰,形態(tài)分型（I，II，III） 前/

3、外側(cè)下傾型肩峰 下緣骨贅形成,.,肩鎖關(guān)節(jié),-退變，關(guān)節(jié)囊增厚 -較少引起肩袖卡壓,.,喙肩關(guān)節(jié),-正常喙肩韌帶厚度3 mm,-韌帶增厚可導(dǎo)致前肩袖碰撞,.,喙突碰撞,-正常喙肱距離為 11 mm,-喙肱間距狹窄可導(dǎo)致肩胛下區(qū)域碰撞,.,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(guān)節(jié) 退變，關(guān)節(jié)囊肥厚(是否存在團(tuán)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 袖,肩胛下肌; 岡上肌 岡下肌; 小圓肌;,.,肩袖（矢狀面）,岡上肌， 岡下肌，小圓肌，肩胛下肌,.,肩袖（矢狀面）,岡上肌， 岡下肌，小圓肌，肩胛下肌,.,肩袖（矢狀面）,覆

4、蓋肱骨頭的連續(xù)低信號表現(xiàn),.,肩袖（軸位）,岡上肌腱,.,肩袖（軸位） Rotator Cuff (Axial Plane),-評價(jià)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(yīng)的關(guān)節(jié)后側(cè)區(qū)域 -Infraspinatus Located Posteriorly,.,肩袖（冠狀面） Rotator Cuff (Coronal),評估岡上肌腱的最佳層面,肌肉肌腱連接部位于12點(diǎn)方向,.,肩袖（冠狀面）,岡下肌腱 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,Tendonopathy肌腱病變 T

5、ear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，無液體信號,.,關(guān)節(jié)囊部分撕裂（關(guān)節(jié)面） Partial Thickness Tear (Art

6、icular),Extensive Intermediate T1-Signal T1W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(guān)節(jié)囊面） Partial Thickness Tear (Bursal),-Fluid Signal Extending into the Bursal Surface of the Supraspinatus Tendon 液性信號延伸至岡上肌腱關(guān)節(jié)囊面表面,.,肩袖部分撕裂（肌腱內(nèi)型） Partial Thickness

7、Tear (Interstitial),-Fluid Signal within the Substance of the Tendon 液性信號存在于肌腱內(nèi) -Does Not Touch the Surface 不影響到肌腱表面,.,肩袖肌間囊腫 Intramuscular Cyst Rotator Cuff,-High Association with 與以下因素有關(guān) P.T. Undersurface Tear 創(chuàng)傷性表層下撕裂 2. Small F.T. Tear 小的全層撕裂 3. DDX: Paralabral Cyst 鑒別診斷：盂唇旁囊腫,.,肌間囊腫 Intramuscul

8、ar Cyst Rotator Cuff,Intramuscular 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 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 musculotendinous junction 肌肉肌腱連接部輕度回縮,.,-Fluid Signal within

9、SST 岡上肌腱內(nèi)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 Full Thickness Tear,.,-Gad Arthrogram: Demonstrates Full Thickness Tear -肩關(guān)節(jié)造影：顯示全層撕裂,T1,T2,全層撕裂 Full Thickness Tear,.,-Intermediate T1-Signal -T1W中等信號,-Musculotendinous Retraction -肌肉肌腱回縮,-Fluid Signal on T2 -T2W出現(xiàn)液性信號 -Full t

10、hickness Tear -全層撕裂,全層撕裂 Full Thickness Tear,.,完全撕裂 Complete Tear 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(yù)后不佳,.,脂肪增厚 Fatty Atrophy,-Grade as Mild, Moderate, Severe -分為輕度，中度和重度 -Streaks of High Signal on T1 -T1W出現(xiàn)高信號改變,.,-Normal

11、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 Fatty Atrophy,.,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 Rotator Cuff Pathology,Tendonopathy 肌腱病變 Tea

12、r 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(guān)節(jié)囊結(jié)構(gòu)和盂唇 Capsular Structures and Labrum,Patient under 35 y. o. with GH Instability or Unexplained Shoulder Pain 35歲以下患者出現(xiàn)肩關(guān)節(jié)不穩(wěn)定或無法解釋的肩部疼痛 MR Arthrography

13、 適合進(jìn)行MR關(guān)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(yīng),.,Bankart病變 Bankart Lesion,-Conventional MRI: Loss of Normal Morphology of Anterior Labrum -常規(guī)MR：前盂唇正常形態(tài)消失,.,-Subtle Lesions Best Demonstrated on MR Arthrogr

14、aphy -MR肩關(guān)節(jié)造影能更好的顯示盂唇微小病變,Bankart病變 Bankart Lesion,.,Hill Sach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(yīng)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) Posterior Humeral Sulcus: Can Mimic A Hill Sachs 后肱骨凹：易與Hill Sachs病變混淆,.,SLAP病 SLAP

15、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) Any Signal in Triangle of Superior Labrum = SLAP SLAP病變：上盂唇在任何序列上出現(xiàn)三角形異常信號 MR Arthrography Improves Sensitivity MR關(guān)節(jié)造影提升了診斷敏感度,.,肩關(guān)節(jié)表面和骨性結(jié)構(gòu) Osseous Structures and Articular Surfaces,Hematopoietic Bone Marrow 局部紅骨髓變

16、 Subcortical Cystic Change皮質(zhì)下囊變 Trauma (Fracture)創(chuàng)傷（骨折） Arthritis 關(guān)節(jié)炎 Infection 感染 Tumor 腫瘤,.,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(zhì)下分布；雙側(cè),.,

17、皮質(zhì)下囊變 Subcortical 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 Trauma,-24 y.o. Female: Persistent Painful Shoulder After Skiing Accident 女性，24歲，滑雪事故后持續(xù)性肩關(guān)節(jié)疼痛,.,肱骨頭無菌性壞死 AVN,T1,T2,“Double Line” Sign- Seen On T2 Images 雙線征,.,非特異性骨髓信號異常 Nonspecif

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

19、al T2 Images,.,關(guān)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(guān)節(jié)造影：顯示軟骨裂隙,.,肱二頭肌病變 Biceps Tendon,Tendonitis 肌腱炎 Tear 肌腱撕裂 Dislocation 脫位 Intra-articular 關(guān)節(jié)內(nèi)脫位 Extra-articular 關(guān)節(jié)外脫位,.,肱二頭肌病變 Biceps Tend

20、on,.,肱二頭肌病變 Biceps Tendon,.,-Extra-articular Biceps: Best Seen on Axial Image 關(guān)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(nèi)，外有橫韌帶保護(hù),肱二頭肌病變 Biceps Tendon,.,肱二頭肌腱脫位 Biceps Tendon Dislocation,-Extra-articular: Transverse Ligament Torn; Subscapularis Intact 關(guān)節(jié)外脫位：橫韌帶撕裂；肩胛下肌完整 -Intr

21、a-articular: Subscapularis Torn or Avulsed 關(guān)節(jié)內(nèi)脫位：肩胛下肌撕裂或撕脫,.,-Biceps Tendon Intra-articular Dislocation: 肌腱關(guān)節(jié)內(nèi)脫位： Subscapularis Tendon Avulsed 肩胛下肌腱撕脫,肱二頭肌腱脫位 Biceps Tendon Dislocation,.,肱二頭肌腱脫位 Biceps Tendon Dislocation,.,肱二頭肌腱炎/撕裂 Biceps Tendonitis/ Tear,-Thick Tendon; Increased Signal 肌腱增厚；信號增加 -

22、Longitudinal Splits 縱向撕裂,.,盂唇旁囊腫 Paralabral Cyst,High Association with Labral Tears and GH Instability 與盂唇撕裂和盂肱關(guān)節(jié)不穩(wěn)定密切相關(guān) Analogous to Meniscal Cysts of the Knee 類似于膝關(guān)節(jié)半月板囊腫 T2 Images- Multi-lobulated Fluid Collections T2加權(quán)像-多房液性信號 Location: Posterior, Superior, Inferior 部位：盂唇后，上，下部 Can Cause Neurova

23、scular Entrapment 可導(dǎo)致神經(jīng)血管卡壓,.,肩胛上神經(jīng)卡壓 Suprascapular Nerve Entrapment,-Suprascapular Notch 肩胛上切跡 -Denervation of Supra- and Infraspinatus Muscles 岡上肌和岡下肌去神經(jīng)化,-Spinoglenoid Notch 岡盂切跡 -Denervation of Infraspinatus Muscle 岡下肌去神經(jīng)化,.,岡上肌/岡下肌去神經(jīng)化 Denervation Supra/Infraspinatus,-Entrapment of the Suprasca

24、pular Nerve in Suprascapular Notch 肩胛上切跡囊腫導(dǎo)致肩胛上神經(jīng)卡壓 -MR Findings: Early- Denervation edema (High Signal on T2) MR表現(xiàn)： 早期-去神經(jīng)水腫（T2加權(quán)高信號） Late- Fatty Replacement (High Signal on T1) 晚期：脂肪替代（T1加權(quán)高信號）,.,岡下去神經(jīng)化 Denervation Infraspinatus,-Entrapment of Suprascapular Nerve in Spinoglenoid Notch 岡盂切跡囊腫導(dǎo)致肩胛上神

25、經(jīng)卡壓 -Early Denervation Edema of Infraspinatus Muscle 岡下肌去神經(jīng)水腫,.,四邊孔綜合征 Quadrilateral Space Syndrome,旋肱后動脈和腋神經(jīng)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(cè)的感覺障礙和三角肌功能受限。 由于當(dāng)肩關(guān)節(jié)外展外旋時(shí)，組成四邊孔的肌肉均受牽拉，從三個(gè)方向?qū)λ倪叜a(chǎn)生擠壓而致本癥發(fā)生。 -Axillary Nerve Compression Neuropathy 腋神經(jīng)受壓癥狀 -Poorly Localized Shoulder Pain in ABER Position ABER位局部嚴(yán)重肩痛 -Atrophy of Teres Minor and Deltoid Muscles 小圓肌和三角肌萎縮 Etiologies: Fibrous Bands- Seen with Repetitiv