肩关节常见疾病MRI诊断-Ⅰ

(PartⅠ)Wangchaoyan2013/05/27Shoulderdisordersmainlyinvolverotatorcuffdiseasesandshoulderinstability.Forrotatorcuffdiseases,routineshoulderMRimagingasthefirstchoicecansolvemostoftheproblemsinpractice.Forshoulderinstabilityandrelatedglenoidlabrumlesions,shoulderMRarthrographyisthefirstselectionforevaluation肩关节常见病变主要为肩袖相关病变和肩关节不稳定。对于肩袖相关病变，肩关节MRI常规扫描可作为首选；对于肩关节不稳定和盂唇病变，则一般首选肩关节MRI造影进行评价。Rotatorcufftendonsdisease肩袖肌腱病Rotatorcufftear肩袖撕裂Subscapularisrupture肩胛下肌断裂Acromioclavicularjointdisease肩锁关节病Thesub-acromialshoulderimpingementsyndrome肩峰下撞击综合征SLAP病变（上盂唇前后向撕裂）Bankart病变HAGL病变（盂肱下韧带肱骨部撕脱）Labrumcyst盂唇囊肿Adhesivecapsulitisjoints粘连性关节囊炎Shoulderjointosteoarthrosis肩关节骨关节病Etiologypathology病因病理：Excessiveuse,leadtodegenerationandtearofrotatorcuff过度使用导致肩袖的退行性变和撕裂Mostofteninimpingement最常继发于撞击综合征Canoccurinpatientswithcollagenvasculardisease可发生于胶原血管病患者Canbeacute,butmoreoftenrepeatedattacksonthebasisofthealreadysufferfromtendondisease可急性发生，但更常在已患有肌腱病的基础上反复发作Tendonthickening,hardening;Partialortotaldisruption;Sometearonslipperybursa,articularsurfaceorinthestroma肌腱增厚、硬化；部分或完全中断；部分撕裂可在滑囊面、关节面或间质中Collagendegeneration,butthereisnoinflammatorycells,chronictendoncanappearinfattyinfiltration胶原变性，但没有炎性细胞，慢性肌腱撕裂中可出现脂肪浸润Ⅰperiod:rotatorcuff,especiallyhillstendonedemaandhemorrhage肩袖特别是岗上肌腱水肿和出血Tendonitisorinflammatorylesions,itisbettertosendinlessthan25yearsoldyoungman.reversible肌腱炎或炎性病变，最好发于小于25岁的青年人,可逆.Ⅱperiod:inflammationfurtherprogressandmorefibroustissueformation炎症进一步进展及更多的纤维组织形成Happensat25～45yearsold.好发于25-45岁。Ⅲperiod:rotatorcufftear.肩袖撕裂。Oftenoccurinmorethan45yearsold.常发于45岁以上。☆Bestlocation:beingis1cm,fromthehillsmuscletothegreatertuberosityattachmentpoints(novasculardistribution).最好发部位：岗上肌距大结节附着点1cm处（无血管分布）。Onallpulsesequence,signalsareincreased在所有脉冲序列上，信号均增高Tendonthickening,signalnotusuallyhomogeneous肌腱常常增厚、信号不均匀Partialtear,visiblewatersignalinthetendons,butonlypartialtendoninvolvement部分撕裂，在肌腱中可见水样信号，但只是部分肌腱受累Tendonfull-thicknesstear,liquidintotendonfractures,withvaryingdegreesoftendonretraction肌腱全层撕裂，液体进入肌腱裂隙中，伴不同程度的肌腱回缩Tendonfull-thicknesstearofthechronicpatientstomergemusclefatatrophy肌腱全层撕裂的慢性患者可合并肌肉脂性萎缩Thincontrastsketchbelowoutlineoftherotatorcuff(whitearrow)薄的造影剂勾画出肩袖的下面轮廓（白长箭头），Normaljointcapsule(blackarrow),正常关节囊（黑箭头），axillaryfossae(whitetrianglearrows).腋隐窝（白三角箭头）。Fig1Subdeltoid–subacromialbursitis.肩峰下滑囊炎。CoronalobliqueMRimagesoftheshouldershowfluidinthedilatedsubdeltoid–subacromialbursa(arrowhead).常规MRI斜冠状位示肩峰下滑囊积液(箭头)；1A:SET1W;1B:TSET2W.Fig2Acromialmorphology.肩峰形态。A.ShapeoftheAcromion.TypeI,flatⅠ型，肩峰下表面为一平面；TypeII,curvedⅡ型，肩峰下表面为弧形凹面；TypeIII,hookedⅢ型，肩峰下表面前部呈钩状突；B.SagittalobliqueimageshowsaTypeIIacromionandadegenerativespurattheanteroinferioredgeoftheacromion(arrow).MRI造影斜矢状位示肩峰前下缘的骨刺(箭)，Ⅱ型肩峰Fig3Tendinitis.肩袖变性。CoronalobliqueMRimagesoftheshouldershowthesupraspinatustendonisdiffusethickening,withintrasubstanceintermediatesignalonT1-weightedandT2-weightedMRimages(arrow).常规MRI斜冠状位示冈上肌腱增粗，连续性好，T1W和T2W信号均增高(箭)4AFig4:Bursal-sidedpartialthicknesstearofthesubscapularis.冈上肌腱上表面部分撕裂.4A:ObliquecoronalT2-weightedimageshowspartialdisruptureofthebursal-sidedtendonfibers(arrow).Thearticular-sidedfibersareintact.常规MRI斜冠状位FST2W示冈上肌腱止点处上表面部分撕裂，局部见液性高信号(箭)，伴肩峰下滑囊积液，下表面完整.4B:partialthicknesstearofthesubscapularis.ObliquecoronalT2-weightedMRimageshowspartialdiscontinuityofthearticular-sidedtendonfibers(arrow).Thebursal-sidedfibersareintact.冈上肌腱下表面部分撕裂。常规MRI斜冠状位FST2W示冈上肌腱止点处下表面撕裂(箭)，信号增高，但上表面完整4B4C4DFig4C:Intratendinouspartialthicknesstearofthesubscapularis.冈上肌腱腱内部分撕裂。ObliquecoronalT2-weightedMRimageshowsabnormalintratendinousfluidaccumulation(arrows).Thebursal-sidedandarticular-sidedfibersareintact常规MRI斜冠状位FST2W示冈上肌腱止点处腱内限局液性高信号影(箭)，肌腱上下表面均完整.Fig4D:Articular-sidedpartialthicknesstearofthesubscapularis.冈上肌腱下表面部分撕裂。ObliquecoronalT1-weightedMRarthrographicimageshowspartialdiscontinuityofthearticular-sidedfibers(arrows),withcontrastmaterialleakingintothesubstanceofthetendon,andintactbursal-sidedfibers.MRI造影斜冠状位示高信号对比剂进入冈上肌腱下表面(箭)，但未进入肩峰下滑囊Fig5:DifferentMRItechniquesforlabraltear.盂唇撕裂对比。Fig5A:AnaxialroutineMRimageshowsintactanteroinferiorlabrum.常规MRI轴位示盂唇未见撕裂征象；Fig5B:AnaxialMRarthrographicimagedemonstratestearoftheanteroinferiorlabrum(arrow).MRI造影轴位示前方盂唇撕裂(箭)5A5BPDWIT2WIMRarthrogramPDWI（质子加权像）：supraspinatustendonobviouslyobviouslyirregular(longarrow);岗上肌肌腱明显不规则（长箭头所示）；T2WI：foundsimilarsignal,inlinewiththetearoftheparts(longarrow);发现相似信号符合部分撕裂（长箭头所示）；MRarthrogram（关节造影）：contrastagentintotheshouldersleevematerial,butnotfallingdowntotheshoulderpeakcapsule(arrow),inaddition,asmallpartofcontrastagents,insertedneartheshouldersleeve(longarrow).造影剂进入肩袖实质内，但未沿伸到肩峰下滑囊（三角箭头所示），另外一小部分相连的造影剂插入邻近肩袖（长箭头所示）。PDWIT2WIMRarthrogramPDWI：rotatorcuffessence,lackoflimitations(longarrow);肩袖实质局限性缺失（长箭头所示）；T2WI：tearmouthincreasedsignal(longarrow);撕裂口信号增高（长箭头所示）；MRarthrogram：contrastfillinggapsofrotatorcuff(longarrow),undertheshoulderpeak-deltoidincapsule(arrow).造影剂充填肩袖缺口（长箭头所示）、肩峰下-三角肌下滑囊（三角箭头所示）。Calcificationfeaturestendonitis钙化性肌腱炎：tendonthickening,andoftenac