骨与关节影像诊断

骨与关节影像诊断学（二）北京大学第一医院医学影像科王继琛骨关节结核•继发性结核病，血行感染•儿童、青少年多见•脊柱及髋、膝关节好发•临床经过缓慢骨关节结核•长骨干骺端结核•短管状骨骨干结核•关节结核（滑膜型）•脊柱结核骺和干骺端结核•骨质疏松•类圆形限局性骨质破坏•中间可有碎屑死骨•周围骨增生硬化不明显短管状骨骨干结核•四肢短管状骨•儿童多见，病变多发•骨质破坏在骨内呈囊性改变•骨膜增生使骨干增粗•骨气鼓征Spinaventosaina22-year-oldwoman.Anteroposterior(a)andmagnified(b)radiographsshowextensivesoft-tissueswellingwithballooningofthethirdmetacarpalofthelefthand.Findingsoftuberculousarthritisarealsoseenintheadjacentjoint(arrowheads)滑膜型关节结核•青年人髋、膝大关节常见•早期关节周围软组织肿胀，骨质疏松•关节面非持重边缘部先有先有骨质破坏•关节间隙狭窄Tuberculousarthritisina28-year-oldmanwithpain.A-P(a)andmagnified(b)radiographsshowmarginalosseouserosionsofthefemoralhead(arrows)withrelativepreservationofthelefthipjointspace.Thereisalsoevidenceofperiarticularosteopenia.Tuberculousdiseasewasconfirmedwithbonebiopsy脊柱结核•椎体破坏•椎间隙狭窄•椎旁脓肿•脊柱畸形Tuberculousspondylitisina17-year-oldgirlwithlowbackpain.(a,b)A-P(a)andlateral(b)plainradiographsshowlossofvertebralbodyheight(arrowheadina),sclerosisoftheendplates,andanteriorscalloping(arrowheadsinb).(c)SagittalT1imageshowsfocaldecreasedsignalintensity(arrow).SagittalT2-weighted(d)andGd-T1-weighted(e)MRimagesshowincreasedsignalintensity(arrow).TuberculousdiseasewasconfirmedwithbonebiopsyTuberculousspondylitiswithpsoasabscessina21-year-oldwoman.(a)MidsagittalT1-MRimagesshowlossofvertebralbodyheightanddecreasedsignalintensityatT4(arrows).(b)CoronalT2-weightedMRimageoftheupperdorsalspineshowsbilateralparaspinalabscesses(arrows)withinvolvementofT4.(c,d)AxialT2-weighted(c)andparasagittalT2-weighted(d)MRimagesshowalarge,lobulatedparaspinalmasswithhighsignalintensitythatextendstotheposteriorparavertebralregion(arrows).Thediagnosiswasconfirmedwithbiopsyoftheabscess骨肿瘤•良性–骨软骨瘤–骨巨细胞瘤•恶性–原发：骨肉瘤–继发：骨转移瘤骨软骨瘤•起于长骨干骺端，邻近骺线•向外突出的骨性肿块，皮质与正常骨相连•有细长的蒂和宽基底•软骨帽，可发生钙化•骨骺闭合即停止生长Benignosteochondromaofthetibiaina15-yrsboywithlesiongrowth.(a)Initialradiographshowspathognomonicfeaturesofosteochondroma.Thecortical(solidarrows)andmedullary(*)continuitywiththetibiawasseenonradiographs.Thecartilagecapisnotmineralizedandcannotbeseen.(b-d)AxialMRimagesT1obtainedbefore(b)andafter(c)Gdadministrationalsorevealthecortical(arrowheads)andmarrow(*)continuitywiththeunderlyingboneandyellowmarrowinthelesion.Thehyalinecartilagecapis3cmthick(curvedarrows),showsmildperipheralandseptalcontrastmaterialenhancement(straightarrows),andbecomesveryhighsignalintensityonthesagittalSTIRMRimage(d).Lateralradiographobtained2yearslatershowslesiongrowthandmineralizationthatsimulatemalignanttransformationbutrepresentonlygrowthintheimmaturepatient.(f)Bonescandemonstratesmarkedincreaseduptakeofradionuclide.(g)Photographofthesagittallysectionedspecimencorrelateswiththeimagingappearance,revealingyellowmarrow(*)andthethickhyalinecartilagecap(arrows).Fociofmineralization(x)arealsoseen,asnotedpreviouslyintheMRimages(b-d).骨巨细胞瘤•青壮年（20~40岁）多见，好发于股骨远端、胫骨近端、桡骨远端•病变在骨端，偏心性，皂泡状溶骨破坏•肿瘤呈膨胀性增大，骨皮质变薄•无骨膜反应•一般不破坏关节面BenignmetastasizingGCToftheproximaltibiaina30-year-oldwoman.(a)Anteroposteriorradiographshowsaneccentriclyticmetaepiphyseallesionextendingtosubchondralbonewithanarrowzoneoftransition(arrow).(b)Bonescintigramrevealsincreasedradionuclideuptakeperipherallyandphotopeniacentrally(donutsign).(c)CTscandemonstratesmildexpansionandsclerosisabouttheGCT(arrows)butnosoft-tissuemass.OnacoronalT2WI,theGCTdemonstratespredominantlyintermediatesignalintensitywithseveralhigh-signal-intensityfoci(arrowheads)correspondingtosecondaryABCregions.(e)ChestCTscanshowsmultiplepulmonarynodulesinbothlungs(arrowheads).(f)Photographofthecoronallysectionedwholemountedspecimen(H-Estain)revealsaGCTextendingtosubchondralbonewithABCregions(white*)andsolidareas(black*)成骨肉瘤•青年男性（20岁以下）多见，好发于膝关节周围，长骨干骺端•溶骨型：大片骨质破坏，骨膜反应呈“袖口征”，软组织肿块明显•成骨型：大量瘤骨及骨膜新生骨•多为混合型H骨转移瘤•血行转移，多见于乳癌、肺癌、甲状腺癌、前列腺癌、肾癌等•好发于脊柱、骨盆、颅骨等，且病变常为多发•多为溶骨性破坏，可发生病理性骨折•成骨转移多为前列腺癌等，在骨盆和腰椎松质骨内见到境界不清的斑片状致密影metastasis良、恶性骨肿瘤的鉴别•生长情况•局部骨变化•骨膜增生•周围软组织变化慢性骨关节病•退行性骨关节病•类风湿性关节炎•强直性脊柱炎退行性骨关节病•40岁以上男性多见，脊柱和髋、膝关节好发•关节间隙狭窄•关节面不规则•骨质增生硬化，骨赘形成Case1Case2,T1&T2类风湿性关节炎•多见于中年女性，累及近侧指间关节，多发•软组织肿胀•关节间隙变窄•关节面边缘骨质虫蚀样破坏•关节半脱位•邻近骨骼骨质疏松RAina42-year-oldwoman.(a)PosteroanteriorradiographofthehandsshowsnoevidenceoferosionorjointspacenarrowingCoronalfat-suppressedGdT1WIshowmarkedperiarticularenhancement(arrows)inmultiplePIPandMCPjoints强直性脊柱炎•见于成年男性•病变从骶髂关节开始，早期表现为关节面凹凸不平，边缘模糊，以后关节间隙逐渐狭窄，以致完全消失，形成骨性强直•病变向上发展，侵犯脊柱小关节•椎旁韧带钙化，呈“竹节样”改变全身性骨病佝偻病•长骨干骺端（尤其尺桡关节远端）表现典型•干骺端加宽，呈杯口样凹陷•先期钙化带模糊，出现毛刷样改变•骨骺小，与干骺端距离加大•普遍骨质密度减低其他骨关节疾病骨髓梗死Asymptomaticmedialplica(typeB)32-year-old,hitbyatruck10months.A:3D-GE,lowSIatcartilage;B:T1SE,linearsubcorticalsignalabnormalitywithdeformityofcortex,typicalimpactionfraction;C:T2-FSE;D:Fat-suppressedT1afterintra-articularinjectionofGD,fullthicknesscartilagelossPCL完全撕裂CT在骨关节疾病中的应用