肩关节磁共振诊断

肩关节磁共振诊断肩关节磁共振诊断•骨性出口与肩峰•肩袖•关节囊和盂唇•骨性结构和关节面•肱二头肌•其他MR扫描技术-T1andT2FS-斜冠状面-T1andT2FS-斜矢状面-T2FSandGRE-横断面骨性出口和肩峰•骨性弓状结构包围肩袖肌腱•机械性碰撞导致肩袖肌腱退变•前肩峰是导致肩袖碰撞最重要的结构AnteriorAcromionMostImportantStructureLeadingtoImpingement正常骨性出口前后喙突锁骨肩峰肩峰形态TypeI肩峰形态TypeII肩峰形态TypeIII肩峰下倾正常肩峰轴位形态肩峰前下倾表现斜矢状面上观察肩峰轴位形态肩峰下倾在冠状面上观察肩峰向外侧的下倾表现正常肩峰轴位表现外侧下倾骨性肩峰发育骨化中心常在22-25岁闭合轴位像前肩峰正常表现骨性肩峰发育异常（轴位）肩峰发育异常可能造成不稳定，并导致三角肌收缩过程中肩峰与肩袖碰撞骨性肩峰发育（矢状面）肩胛小骨骨赘形成肩胛小骨骨性肩峰肩锁关节肩峰“双肩锁关节”征肩峰骨赘形成-骨赘-内有骨髓信号-三角肌腱（类似骨赘表现）-低信号（内无骨髓信号）肩峰•形态分型（I，II，III）•前/外侧下倾型肩峰•下缘骨赘形成肩锁关节-退变，关节囊增厚-较少引起肩袖卡压喙肩关节-正常喙肩韧带厚度3mm-韧带增厚可导致前肩袖碰撞喙突碰撞-正常喙肱距离为11mm-喙肱间距狭窄可导致肩胛下区域碰撞骨性出口和肩峰•肩峰–形态分类，下倾型肩峰，骨赘，肩峰发育异常•肩锁关节–退变，关节囊肥厚(是否存在团块样表现？)•喙肩韧带(是否增厚?)•喙肱间距(肩胛下区是否有碰撞?)肩袖肩胛下肌;冈上肌冈下肌;小圆肌;肩袖（矢状面）冈上肌，冈下肌，小圆肌，肩胛下肌肩袖（矢状面）冈上肌，冈下肌，小圆肌，肩胛下肌肩袖（矢状面）覆盖肱骨头的连续低信号表现肩袖（轴位）冈上肌腱肩袖（轴位）RotatorCuff(AxialPlane)-评价肩胛下肌的最好平面PrimaryPlaneforEvaluatingSubscapularis冈下肌位于肩胛下肌对应的关节后侧区域-InfraspinatusLocatedPosteriorly肩袖（冠状面）RotatorCuff(Coronal)评估冈上肌腱的最佳层面肌肉肌腱连接部位于12点方向肩袖（冠状面）冈下肌腱位置偏后斜行走向肩胛下肌位置偏前多根肌腱组成肩袖病变•Tendonopathy肌腱病变•Tear撕裂–PartialThickness,FullThickness,Complete–部分撕裂，全层撕裂，完全撕裂•MusculotendinousRetraction肌肉肌腱回缩•FattyAtrophy脂肪肥厚•HADD/CalcificTendonitis钙化性肌腱炎肌腱病变-IncreasedT1-signal;ThicktendonT1W信号增高，肌腱增厚-IntermediateT2-signal(NoFluidSignal)T2W中等信号，无液体信号关节囊部分撕裂（关节面）PartialThicknessTear(Articular)ExtensiveIntermediateT1-SignalT1W延续性中等信号表现T2:FluidSignalT2：出现液性信号PartialThickness部分撕裂UndersurfaceTear肌腱表面下撕裂部分撕裂（关节囊面）PartialThicknessTear(Bursal)-FluidSignalExtendingintotheBursalSurfaceoftheSupraspinatusTendon液性信号延伸至冈上肌腱关节囊面表面肩袖部分撕裂（肌腱内型）PartialThicknessTear(Interstitial)-FluidSignalwithintheSubstanceoftheTendon液性信号存在于肌腱内-DoesNotTouchtheSurface不影响到肌腱表面肩袖肌间囊肿IntramuscularCystRotatorCuff-HighAssociationwith与以下因素有关1.P.T.UndersurfaceTear创伤性表层下撕裂2.SmallF.T.Tear小的全层撕裂3.DDX:ParalabralCyst鉴别诊断：盂唇旁囊肿肌间囊肿IntramuscularCystRotatorCuffIntramuscularCystSupraspinatus冈上肌肌间囊肿SmallUndersurfaceP.T.Tear小的创伤后撕裂全层撕裂FullThicknessTear-Fluidextendsthroughtheentirethicknessofthetendon(top-bottom)液性信号延伸至肌腱全层（从顶部到底部）-Mildretractionofmusculotendinousjunction肌肉肌腱连接部轻度回缩-FluidSignalwithinSST冈上肌腱内出现液性信号-SagImage:FluidfromToptoBottom矢状面：液性信号从顶层到底层全层撕裂FullThicknessTear-GadArthrogram:DemonstratesFullThicknessTear-肩关节造影：显示全层撕裂T1T2全层撕裂FullThicknessTear-IntermediateT1-Signal-T1W中等信号-MusculotendinousRetraction-肌肉肌腱回缩-FluidSignalonT2-T2W出现液性信号-FullthicknessTear-全层撕裂全层撕裂FullThicknessTear完全撕裂CompleteTear特征：肌肉肌腱回缩Musculotendinousretraction-Greaterthan3cmretraction-poorprognosisforrepair-肌肉肌腱出现超过3cm的回缩-预后不佳脂肪增厚FattyAtrophy-GradeasMild,Moderate,Severe-分为轻度，中度和重度-StreaksofHighSignalonT1-T1W出现高信号改变-Normalmusclebulk-正常冈上肌-FattyAtrophy:Doesnotfillsupraspinatusfossa-脂肪增厚：肌肉信号未充填冈上肌窝脂肪增厚FattyAtrophy钙化性肌腱炎CalcificTendonitis-DarkGlobularAreaonallPulseSequences-在所有的脉冲序列上均为低信号-BloomingArtifactonGradientEchoImages-GE图像上可出现伪影肩袖病变RotatorCuffPathology•Tendonopathy肌腱病变•Tear撕裂•PartialThickness,FullThickness,Complete•部分撕裂，全层撕裂，完全撕裂•MusculotendinousRetraction肌肉肌腱回缩•FattyAtrophy脂肪增厚•CalcificTendonitis钙化性肌腱炎关节囊结构和盂唇CapsularStructuresandLabrum•Patientunder35y.o.withGHInstabilityorUnexplainedShoulderPain35岁以下患者出现肩关节不稳定或无法解释的肩部疼痛•MRArthrography•适合进行MR关节造影•LabralLesionsCommon盂唇病变较为常见•SubtleLesions(nondisplaced,resynovialized)-DistentionEffectsofContrast小病变（未移位，滑膜化）-对比剂的遮蔽效应Bankart病变BankartLesion-ConventionalMRI:LossofNormalMorphologyofAnteriorLabrum-常规MR：前盂唇正常形态消失-SubtleLesionsBestDemonstratedonMRArthrography-MR肩关节造影能更好的显示盂唇微小病变Bankart病变BankartLesionHillSach病变HillSachsLesion•Top3AxialImagesThroughHumeralHeadShouldBeRound正常：肱骨头轴位像最上面3幅图像应为圆形•FlatteningorConvexityonTop3Images最上面3幅图像扁平或不规则表现•PosteriorHumeralSulcus:CanMimicAHillSachs后肱骨凹：易与HillSachs病变混淆SLAP病SLAPTears•SuperiorLabrumisDarkonPulseSequencesinCoronalPlane冠状面脉冲序列显示上盂唇出现低信号表现•AnySignalinTriangleofSuperiorLabrum=SLAPSLAP病变：上盂唇在任何序列上出现三角形异常信号•MRArthrographyImprovesSensitivityMR关节造影提升了诊断敏感度肩关节表面和骨性结构OsseousStructuresandArticularSurfaces•HematopoieticBoneMarrow局部红骨髓变•SubcorticalCysticChange皮质下囊变•Trauma(Fracture)创伤（骨折）•Arthritis关节炎•Infection感染•Tumor肿瘤红骨髓变HematopoieticMarrow-Humeralepiphysis:OnlyEpiphysisthatNormallycontainsHematopoieticMarrow肱骨红骨髓变：正常情况下仅骨骺保留红骨髓-Females;Curvilinear;SubcorticalDistribution;Bilateral女性多见；弧形表现；皮质下分布；双侧皮质下囊变SubcorticalCysticChange-CommonlySeenNearSSTInsertionSite冈上肌附着处最为常见-MimicHillSachs与HillSach病易混淆创伤Trauma-24y.o.Female:PersistentPainfulShoulderAfterSkiingAccident女性，24岁，滑雪事故后持续性肩关节疼痛肱骨头无菌性坏死AVNT1T2“DoubleLine”Sign-SeenOnT2Images双线征非特异性骨髓信号异常NonspecificMarrowSignal-DDX:Infection,Tumor,Trauma鉴别诊断：感染，肿瘤，创伤-T1Image:UseMuscleasInternalStandardT1加权：肌肉作为对照-T1SignalDarkerthanMuscle:Pathologic异常信号：T1加权像上病灶信号低于肌肉肿瘤Tumor-OsteosarcomaProximalHumerus肱骨近端骨肉瘤-MasswithCorticalDestruction皮质破坏合并软组织肿块形成-LowSignalT1;HighSignalT2Images关节软骨ArticularCartilage-NormalCartilage正常软骨-IntermediateSignal中等信号-Smooth表面平整-ArticularCartilageDefect软骨缺损-Gap:FillsWithContrast关节造影：显示软骨裂隙肱二头肌病变BicepsTendon•Tendonitis肌腱炎•Tear肌腱撕裂•Dislocation脱位•Intra-articular关节内脱位•Extra-articular关节外脱位肱二头肌病变BicepsTendon肱二头肌病变BicepsTendon-Extra-articularBiceps:BestSeenonAxialImage关节