肩关节MRI诊断~9E717

MRI在肩关节损伤中的应用价值TheApplicationofMRIinShoulderInjury08级硕士研究生张海捷概述：肩关节是典型的球窝关节。肱骨头大，关节盂小，关节囊薄而松弛，是全身最为灵活的关节。因此，关节周围的肌肉、韧带对其固定起了重要的作用，也决定了肩关节损伤的固有特点。MRI具有无创、无辐射，对软组织（肌肉、肌腱、韧带、软骨）病变有良好显示能力的特点，可作为肩关节损伤非常有效的检查手段。IntroduceShoulderAnatomyTheMRIofShoulderinjure1.RotatorCuffTears(肩袖损伤)2.Shoulderimpingementsyndromes(肩撞击综合症)3.LabralTears（盂唇撕裂）4.BicepsProblems（肱二头肌病变）ShoulderAnatomyBones&JointsoftheShoulderShoulderMusclesShoulderTendonsShoulderLigamentsGlenoidLabrumShoulderBurseaShoulderAnatomy——Bones&JointsoftheShoulder三块骨锁骨肩峰喙突关节盂肩胛骨肱骨肩关节正面观ShoulderAnatomy——Bones&JointsoftheShoulder肩峰喙突关节盂肱骨头肩关节侧面观ShoulderAnatomy——Bones&JointsoftheShoulder胸锁关节肩锁关节肩胛胸关节盂肱关节四个关节ShoulderAnatomy——ShoulderMuscles(SuperficialMuscles)前方结节间沟胸大肌ShoulderAnatomy——ShoulderMuscles(SuperficialMuscles)后方斜方肌斜方肌ShoulderAnatomy——ShoulderMuscles(SuperficialMuscles)下方背阔肌背阔肌ShoulderAnatomy——ShoulderMuscles(SuperficialMuscles)上方三角肌三角肌ShoulderAnatomy——ShoulderMuscles(DeepMuscles)前面观锁骨下肌胸小肌ShoulderAnatomy——ShoulderMuscles(DeepMuscles)后面观肩胛提肌大菱形肌小菱形肌ShoulderAnatomy——ShoulderMuscles(DeepMuscles)侧面观前锯肌前锯肌ShoulderAnatomy——ShoulderMuscles(DeepMuscles)最内侧冈上肌冈下肌小圆肌肩胛下肌ShoulderAnatomy——ShoulderTendons肱二头肌长头键肱二头肌短头键肱二头肌ShoulderAnatomy——ShoulderTendons肩胛下肌大圆肌背阔肌胸大肌肱二头肌长头肌腱冈上肌ShoulderAnatomy——ShoulderLigaments四条韧带(CCL):喙锁韧带(CAL):喙突峰韧带(THL):肱横韧带(GlenohumeraL.):盂肱韧带肩锁韧带(CHL):喙肱韧带ShoulderAnatomy——GlenoidLabrum冈上肌关节唇冈下肌小圆肌关节囊肱二头肌长头肩胛下肌上肱盂韧带中肱盂韧带下肱盂韧带ShoulderAnatomy——ShoulderBursaeMRIanatomyAxialObliqueSagittalObliqueCoronalMRIanatomy（Axial）1.尖峰2.锁骨3.冈上肌1.冈上肌2.三角肌MRIanatomy（Axial）1.冈上肌2.三角肌3.肱骨头4.喙突5.冈下肌肌腱6.上盂唇MRIanatomy（Axial）1.冈下肌2.三角肌3.肱骨头4a.关节盂4b.喙突5.冈上肌肌腱6a.肩胛下肌6b.肩胛下肌肌腱7a.前盂唇7b.后唇盂8.喙肱肌与肱二头肌短头MRIanatomy（Axial）1.冈下肌2.三角肌3.肱骨头4.关节盂5.肱二头肌长头6a.肩胛下肌6b.肩胛下肌肌腱7a.前盂唇7b.后唇盂8.喙肱肌与肱二头肌短头1.冈下肌2.小圆肌3.三角肌4.肱骨头5.关节盂6.肩胛下肌7a.前盂唇7b.后唇盂8.肱二头肌长头.9.喙肱肌与肱二头肌短头MRIanatomy（Axial）1.冈下肌2.小圆肌3.三角肌4.肱骨头5.关节盂6.肩胛下肌7a.前盂唇7b.后盂唇8.肱二头肌长头.9.喙肱肌与肱二头肌短头1.小圆肌2.三角肌3.关节盂4a.大结节4b.小结节5.肱二头肌长头6.胛下肌7.喙肱肌与肱二头肌短头MRIanatomy（Axial）1.小圆肌2.三角肌3关节盂4.肱骨近端5.肱二头肌长头.6.喙肱肌与肱二头肌短头1a.肱三头肌长头1b.肱三头肌外侧头2.三角肌3.喙肱肌与肱二头肌短头4.肱骨近端5.肱二头肌长头MRIanatomy（ObliqueCoronal）1.喙突2.锁骨远端3.喙肱肌和肱二头肌短头4.三角肌5.肩胛下肌6.喙锁韧带7.斜方肌MRIanatomy（ObliqueCoronal）1.喙突2.锁骨3.三角肌4.肱二头肌长头键5.肩胛下肌6.冈上肌7.斜方肌1.关节盂2.锁骨远端3.尖峰4.肱骨头5.肩胛下肌6.三角肌7.肱二头肌长头8.冈上肌9.冈上肌肌腱10.上盂唇MRIanatomy（ObliqueCoronal）1.关节盂2.尖峰3.肱骨头4.肩胛下肌5.三角肌6.肱二头肌长头7.冈上肌8.斜方肌9.冈上肌肌腱10.上盂唇MRIanatomy（ObliqueCoronal）1.关节盂2.肩峰3.肱骨头4.肩胛下肌5.小圆肌6.三角肌7.冈下肌8.冈上、下肌肌腱1.关节盂2.肩峰3.肱骨头4.冈下肌5.三角肌MRIanatomy（ObliqueCoronal）1.关节盂2.肩峰3.肱骨头4.肩胛下肌5.三角肌1.肩峰2.冈下肌3.三角肌MRIanatomy（ObliqueSagittal）1.锁骨远端2.肩峰3a.喙突3b.关节盂4.喙锁韧带5.冈上肌6.冈下肌7.小圆肌8.肩胛下肌9.喙肱肌与肱二头肌短头MRIanatomy（ObliqueSagittal）1.锁骨远端2.肩峰3a.喙突3b.关节窝4.冈上肌5.冈下肌6.小圆肌7.肩胛下肌8.喙肱肌与肱二头肌短头1.锁骨远端2.肩峰3.喙突4.关节窝5.冈上肌6.冈下肌7.小圆肌8.肩胛下肌9.喙肱肌与肱二头肌短头MRIanatomy（ObliqueSagittal）1.锁骨远端2.肩峰3.喙突4.关节窝5.冈上肌6.冈下肌7.小圆肌8.肩胛下肌1.锁骨远端2.肩峰3.肱骨头4.冈上肌5.冈下肌6.小圆肌7.肩胛下肌MRIanatomy（ObliqueSagittal）1.肩峰2.肱骨头3.冈上肌肌腱4.冈下肌5.小圆肌6.肩胛下肌肌腱7.肱二头肌长头MRIanatomy（ObliqueSagittal）1.肩峰2.肱骨头3.冈上肌肌腱4.冈下肌5.小圆肌6.肩胛下肌肌腱7.肱二头肌长头肌腱1.肱骨头2.冈上、下肌肌腱3.肩胛下肌肌腱4.肱二头肌长头肌腱Shoulderinjure1.RotatorCuffTears(肩袖损伤)2.Shoulderimpingementsyndromes(肩撞击综合症)3.LabralTears（盂唇撕裂）4.BicepsProblems（肱二头肌病变）肩袖撕裂（RotatorCuffTears）WHATISRotatorCuff?Therotatorcuffisagroupoftendonsthatconnectsthefourmusclesoftheuppershouldertothebones.Supraspinatus冈上肌Infraspinatus冈下肌Subscapularis肩胛下肌Taresminor小圆肌肩袖撕裂（RotatorCuffTears）肩袖撕裂（RotatorCuffTears）WHATISRotatorCuffTears?AlsoKnownas:tendonTear,supraspinatustendontearThetendonsrunundertheacromionwheretheyareveryvulnerabletobeingdamaged.Thiscanleadtoatearresultinginapainful,weakshoulder.Thepainisalsoverycommonatnight,oftenradiatingdownthearm.Whenthetendonsormusclesoftherotatorcufftear,thepatientisnolongerabletoliftorrotatehisorherarmwiththesamerangeofmotionasbeforetheinjuryand/orhassignificantpainassociatedwithshouldermotion.Aspeopleage,itisnormalfortherotatorcufftendontowearanddegrade,howeveronlyasmallproportionofpeopledeveloppainandweaknessthatrequirestreatment肩袖撕裂（RotatorCuffTears）CAUSES（病因）:1.Intrinsicfactors(内因):aging,ischemia,attrition（年龄，缺血，磨损）2.Extrinsicfactors(内因):trauma,impingement（创伤，撞击）肩袖撕裂（RotatorCuffTears）AlsoKnownas:supraspinatustendontear肩袖撕裂（RotatorCuffTears）RotatorCuffTears肩袖撕裂（RotatorCuffTears）DIAGNOSIS（诊断）:1.UltrasondScanimmediately,accurate,dynamic,costeffective.(便捷，精确，动态，便宜)2.MRIScanmorecostly,lessaccessible,butmoreinformation.(昂贵，较不易执行，但能提供更多更完善的信息)肩袖撕裂（RotatorCuffTears）肩袖撕裂（RotatorCuffTears）Classification（分类）：1.partialthicknesstears（部分撕裂）（1）Articularsurfacetears（关节侧撕裂）（2）Bursalsurfacetears（滑囊侧撕裂）（3）Intrasubstancetears（肌腱内部撕裂）2.fullthickness（完全撕裂）肩袖撕裂（RotatorCuffTears）1.partialthicknesstears（部分撕裂）(1).肌腱表面关节侧、滑囊侧出现局灶性液性裂隙；(2).肌腱局灶性的不连续，并液体信号影填充；(3).局部肉芽组织增生和瘢痕形成可掩盖撕裂的MR表现，此时MR关节内造影可增加检出率；特别在外展、外旋体位下，检出率可达100%;(4).T1WI显示病灶能力较差，T2WI是必须的序列;(5).正常肩袖的厚度为10-12mm,根据撕裂的深度分度：grade1(3mm)，grade2(3–6mm)，grade3(6mm)，50%。部分撕裂：(A)CoronalT2-weightedMRwithfatsaturationarthrogramshowspartialtearwithdiscontinuityofthearticularfibers(arrows);(B)coronalT2-weightedimageshowspartialtearwithdiscontinuityofthebursal