腕关节损伤MRI

TheFirstAffiliatedhospitalofChongqingMedicalUniversityPartI腕关节损伤MRI（WristMRI）TheFirstAffiliatedhospitalofChongqingMedicalUniversity基本解剖TheFirstAffiliatedhospitalofChongqingMedicalUniversity尺桡骨远端位置关系变化•Gelberman等平行线法：尺骨头关节面的平行线与桡骨乙状切迹最远端关节面的平行线之间的位置距离差；•阳性变异：尺骨头长于桡骨远端•阴性变异：尺骨头短于桡骨远端TheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversity三角纤维软骨复合体TFCC（triangularfibrocartilagecomplex）•TFCC:由三角纤维软骨（TFC）本身、半月板、背侧和掌侧桡尺韧带、尺侧副韧带及腕尺伸肌腱鞘等构成•冠状位显示最佳TheFirstAffiliatedhospitalofChongqingMedicalUniversitytriangularfibrocartilagecomplex(TFCC)TheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversity尺桡骨远端位置关系•阳性—尺骨头长：TFC变薄，TFCC撕裂，尺侧撞击•阴性—尺骨头短：TFC增厚，KienbocksDiseaseTheFirstAffiliatedhospitalofChongqingMedicalUniversity韧带TheFirstAffiliatedhospitalofChongqingMedicalUniversity腕管（Carpaltunnel）•内侧：豆/钩骨•外侧：桡侧腕屈肌•背侧：背侧腕骨•掌侧：屈肌支持带•内部：屈肌腱正中神经TheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversityNerveInnervation(dorsal)TheFirstAffiliatedhospitalofChongqingMedicalUniversityGuyon’scanal•尺动脉和尺神经被周围支持带包绕而成•小的肿块即可引起严重尺神经卡压TheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversity常见病变•三角纤维软骨复合体（TFCC）损伤•韧带肌腱损伤•腕骨骨折及并发症•腕管综合症TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC撕裂•TFCC撕裂：关节盘（TFC）撕裂或TFCC其他结构的损伤如远端桡尺关节不稳（DRUJ)失稳等•临床症状常为尺侧疼痛、无力，旋转受限伴有弹响。TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC撕裂—Palmer分型1.创伤性和退化性两大类2.评价指标有•TFC整体轮廓•损伤部位•形态特征•信号强度变化TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC撕裂—palmer分型Ⅰ类创伤性A.中心穿孔B.尺侧撕裂伴有远端尺骨骨折不伴有远端尺骨骨折C.远端撕裂D.桡侧撕裂伴有桡骨乙状切迹骨折不伴有桡骨乙状切迹骨折Ⅱ类退变性A.TFCC撕脱B.TFCC撕脱、月骨和、或尺侧软骨软化C.TFCC穿孔、月骨和/或尺侧软骨软化、月三角韧带穿孔D.TFCC穿孔、月骨和/或尺侧软骨软化、月三角韧带穿孔、尺腕关炎TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC桡侧撕裂•结合年龄、临床症状和尺桡骨位置关系鉴别外伤性或退行性TFC撕裂TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC桡侧撕裂MRI关节造影TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFC桡侧撕裂MR造影TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC尺侧撕裂•尺侧附件形态改变•TFC尺侧高信号TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC尺侧撕裂TheFirstAffiliatedhospitalofChongqingMedicalUniversityTFCC尺侧撕裂TheFirstAffiliatedhospitalofChongqingMedicalUniversity尺骨撞击综合症（UlnarImpactionSyndrom，UIS)•由于尺骨头、尺骨茎突与TFCC发生撞击和腕尺侧过重负荷引起的一组症候群。•1941年Milch最先描述由于桡骨远端骨折后长度缩短、尺骨撞击腕部导致月骨和三角骨缺血坏死，引起腕尺侧疼痛并命名之。TheFirstAffiliatedhospitalofChongqingMedicalUniversity病因和临床症状病因：•先天行尺骨阳性变异、桡骨远端骺早闭•桡骨远端骨折、骨不连、桡骨头切除等•腕旋前和用力抓握造成动力型尺骨阳性变异早期症状：•局限性腕尺侧痛•活动受限•握力下降TheFirstAffiliatedhospitalofChongqingMedicalUniversity病理变化•尺骨头阳性变异即长于桡骨•尺侧腕骨负载增加•TFC退行性变—穿孔、撕裂•尺骨头和月骨软骨变性/晚期坏死•月三角韧带撕裂TheFirstAffiliatedhospitalofChongqingMedicalUniversityMRI表现•①三角纤维软骨退行性变—穿孔、撕裂•②尺骨头和月骨软骨变性,软骨下长T1长T2退变滑液囊肿、骨髓水肿，晚期呈T1W、T2W均低信号坏死区•③月三角韧带撕裂•④尺侧周围软组织肿胀TheFirstAffiliatedhospitalofChongqingMedicalUniversityT1WI：尺骨阳性变异；TFCC尺侧信号增高及月骨、三角骨软骨及软骨下骨长T1信号TheFirstAffiliatedhospitalofChongqingMedicalUniversityT2WI：TFCC尺侧撕裂及月骨、三角骨软骨下骨滑液囊肿TheFirstAffiliatedhospitalofChongqingMedicalUniversity早期UIS：三角骨尺骨缘软骨变性、局限性骨髓水肿TheFirstAffiliatedhospitalofChongqingMedicalUniversityUIS：TFCC撕裂，三角骨、月骨尺侧缘明显滑液囊肿及骨髓水肿，尺侧软组织肿胀TheFirstAffiliatedhospitalofChongqingMedicalUniversityUIS：TFCC尺侧撕裂，三角骨、月骨尺侧缘滑液囊肿，月三角韧带撕裂TheFirstAffiliatedhospitalofChongqingMedicalUniversity尺骨茎突撞击症TheFirstAffiliatedhospitalofChongqingMedicalUniversity常见病变•三角纤维软骨复合体（TFCC）损伤•韧带肌腱损伤•腕骨骨骨折及并发症•腕管综合症TheFirstAffiliatedhospitalofChongqingMedicalUniversity舟月韧带撕裂•韧带中断不连续•T2WI或T2*可见局部高信号•形态改变•完全缺如•舟月关节可见液体•晚期舟月间隙增宽TheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversitySLtearTheFirstAffiliatedhospitalofChongqingMedicalUniversity舟月韧带部分撕裂T2FSE/FS：掌侧韧带变薄TheFirstAffiliatedhospitalofChongqingMedicalUniversity舟月韧带部分撕裂对比剂渗入SLSL韧带纤维化/瘢痕形成TheFirstAffiliatedhospitalofChongqingMedicalUniversity腕背侧部分嵌入性失稳（DISI）•生理情况下舟月韧带维持月骨轻度背伸，舟骨轻度掌屈的平衡状态•舟骨骨折并断端移位明显，存在骨缺损或合并舟月韧带损伤,伴发近排腕骨背伸不稳定(DISI)TheFirstAffiliatedhospitalofChongqingMedicalUniversity腕背侧部分嵌入性失稳（DISI）正中矢状位MRI：•月骨背伸畸形•头状骨近端移位•舟骨掌屈•舟月韧带损伤TheFirstAffiliatedhospitalofChongqingMedicalUniversity舟月骨进行性塌陷（SLAC腕)•病因：原发性舟月骨间韧带的松弛或断裂、舟月骨位置异常•腕关节不稳定最严重的后果之一•病理表现为腕关节面广泛软骨磨损，继发退行性关节炎Ⅰ期：局限于桡骨茎突、舟骨腰部；Ⅱ期：发展至整个舟骨窝；Ⅲ期：舟月骨完全分离TheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversity舟月骨进行性塌陷（SLAC)TheFirstAffiliatedhospitalofChongqingMedicalUniversity月三角韧带撕裂MRI•不常见，诊断困难•T2WI月三角韧带见不连续高信号•韧带缺如，或形态改变•MR关节造影能提高敏感性TheFirstAffiliatedhospitalofChongqingMedicalUniversity掌屈型（VISI）腕关节不稳定月三角韧带撕裂TheFirstAffiliatedhospitalofChongqingMedicalUniversityExtensorTendonGanglionTheFirstAffiliatedhospitalofChongqingMedicalUniversityTheFirstAffiliatedhospitalofChongqingMedicalUniversity常见病变•三角纤维软骨复合体（TFCC）损伤•韧带肌腱损伤•腕骨骨骨折及并发症•腕管综合症TheFirstAffiliatedhospitalofChongqingMedicalUniversity舟骨骨折MRI优势•发现隐性骨折（T1WI、T2WI/FS、STIR）骨折线均呈低信号断端呈长T1长T2信号•早期诊断并发症（骨不连、AVN）TheFirstAffiliatedhospitalofChongqingMedicalUniversity舟骨骨折Th