1、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,-T1 and T2 FS -斜冠状面,-T1 and T2 FS -斜矢状面,-T2 FS and GRE -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Anterior Acromion Most Important Structure Leading to Impingement,正常骨性出口,前,后,喙突,锁骨,肩峰,肩峰形态,Type I,肩峰形态,Type II,肩峰形态,Type III,肩峰下倾
2、,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
3、卡压,喙肩关节,-正常喙肩韧带厚度3 mm,-韧带增厚可导致前肩袖碰撞,喙突碰撞,-正常喙肱距离为 11 mm,-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） Rotator Cuff (Axial P
4、lane),-评价肩胛下肌的最好平面 Primary Plane for Evaluating Subscapularis,冈下肌位于肩胛下肌对应的关节后侧区域 -Infraspinatus Located Posteriorly,肩袖（冠状面） Rotator Cuff (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 Partial Thickness, Full Thickness, Complete 部分撕裂，全层撕裂，完全撕
5、裂 Musculotendinous Retraction肌肉肌腱回缩 Fatty Atrophy脂肪肥厚 HADD/ Calcific Tendonitis钙化性肌腱炎,肌腱病变,-Increased T1-signal; Thick tendonT1W信号增高，肌腱增厚 -Intermediate T2-signal (No Fluid Signal)T2W中等信号，无液体信号,关节囊部分撕裂（关节面） Partial Thickness Tear (Articular),Extensive Intermediate T1-Signal T1W延续性中等信号表现,T2: Fluid Sig
6、nal T2：出现液性信号 Partial Thickness 部分撕裂Undersurface Tear肌腱表面下撕裂,部分撕裂（关节囊面） Partial Thickness Tear (Bursal),-Fluid Signal Extending into the Bursal Surface of the Supraspinatus Tendon 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） Partial Thickness Tear (Interstitial),-Fluid Signal within the Substance of the Tendon 液性
7、信号存在于肌腱内 -Does Not Touch the Surface 不影响到肌腱表面,肩袖肌间囊肿 Intramuscular Cyst Rotator Cuff,-High Association with 与以下因素有关 P.T. Undersurface Tear创伤性表层下撕裂 2. Small F.T. Tear小的全层撕裂 3. DDX: Paralabral Cyst鉴别诊断：盂唇旁囊肿,肌间囊肿 Intramuscular Cyst Rotator Cuff,Intramuscular Cyst Supraspinatus 冈上肌肌间囊肿 Small Undersurfa
8、ce P.T. Tear 小的创伤后撕裂,全层撕裂 Full Thickness Tear,-Fluid extends through the entire thickness of the tendon (top - bottom) 液性信号延伸至肌腱全层（从顶部到底部） -Mild retraction of musculotendinous junction 肌肉肌腱连接部轻度回缩,-Fluid Signal within SST 冈上肌腱内出现液性信号,-Sag Image: Fluid from Top to Bottom 矢状面：液性信号从顶层到底层,全层撕裂 Full Thic
9、kness Tear,-Gad Arthrogram: Demonstrates Full Thickness Tear -肩关节造影：显示全层撕裂,T1,T2,全层撕裂 Full Thickness Tear,-Intermediate T1-Signal -T1W中等信号,-Musculotendinous Retraction -肌肉肌腱回缩,-Fluid Signal on T2 -T2W出现液性信号 -Full thickness Tear -全层撕裂,全层撕裂 Full Thickness Tear,完全撕裂 Complete Tear 特征：肌肉肌腱回缩 Musculotendi
10、nous retraction,-Greater than 3 cm retraction- poor prognosis for repair -肌肉肌腱出现超过3cm的回缩-预后不佳,脂肪增厚 Fatty Atrophy,-Grade as Mild, Moderate, Severe -分为轻度，中度和重度 -Streaks of High Signal on T1 -T1W出现高信号改变,-Normal muscle bulk -正常冈上肌,-Fatty Atrophy: Does not fill supraspinatus fossa -脂肪增厚：肌肉信号未充填冈上肌窝,脂肪增厚
11、Fatty Atrophy,钙化性肌腱炎 Calcific Tendonitis,-Dark Globular Area on all Pulse Sequences -在所有的脉冲序列上均为低信号 -Blooming Artifact on Gradient Echo Images -GE图像上可出现伪影,肩袖病变 Rotator Cuff Pathology,Tendonopathy 肌腱病变 Tear 撕裂 Partial Thickness, Full Thickness, Complete 部分撕裂，全层撕裂，完全撕裂 Musculotendinous Retraction肌肉肌腱回
12、缩 Fatty Atrophy 脂肪增厚 Calcific Tendonitis 钙化性肌腱炎,关节囊结构和盂唇 Capsular Structures and Labrum,Patient under 35 y. o. with GH Instability or Unexplained Shoulder Pain35岁以下患者出现肩关节不稳定或无法解释的肩部疼痛 MR Arthrography 适合进行MR关节造影 Labral Lesions Common 盂唇病变较为常见 Subtle Lesions (nondisplaced, resynovialized) -Distention
13、 Effects of Contrast小病变（未移位，滑膜化）-对比剂的遮蔽效应,Bankart病变 Bankart Lesion,-Conventional MRI: Loss of Normal Morphology of Anterior Labrum -常规MR：前盂唇正常形态消失,-Subtle Lesions Best Demonstrated on MR Arthrography -MR肩关节造影能更好的显示盂唇微小病变,Bankart病变 Bankart Lesion,Hill Sach病变 Hill Sachs Lesion,Top 3 Axial Images Throu
14、gh Humeral Head Should Be Round正常：肱骨头轴位像最上面3幅图像应为圆形 Flattening or Convexity on Top 3 Images最上面3幅图像扁平或不规则表现 Posterior Humeral Sulcus: Can Mimic A Hill Sachs后肱骨凹：易与Hill Sachs病变混淆,SLAP病 SLAP Tears,Superior Labrum is Dark on Pulse Sequences in Coronal Plane冠状面脉冲序列显示上盂唇出现低信号表现 Any Signal in Triangle of S
15、uperior Labrum = SLAPSLAP病变：上盂唇在任何序列上出现三角形异常信号 MR Arthrography Improves SensitivityMR关节造影提升了诊断敏感度,肩关节表面和骨性结构 Osseous Structures and Articular Surfaces,Hematopoietic Bone Marrow 局部红骨髓变 Subcortical Cystic Change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 Hematopoietic Marrow
16、,-Humeral epiphysis: Only Epiphysis that Normally contains Hematopoietic Marrow 肱骨红骨髓变：正常情况下仅骨骺保留红骨髓 -Females; Curvilinear; Subcortical Distribution; Bilateral 女性多见；弧形表现；皮质下分布；双侧,皮质下囊变 Subcortical Cystic Change,-Commonly Seen Near SST Insertion Site 冈上肌附着处最为常见 -Mimic Hill Sachs 与Hill Sach病易混淆,创伤 Tra
17、uma,-24 y.o. Female: Persistent Painful Shoulder After Skiing Accident 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 AVN,T1,T2,“Double Line” Sign- Seen On T2 Images 双线征,非特异性骨髓信号异常 Nonspecific Marrow Signal,-DDX: Infection, Tumor, Trauma 鉴别诊断：感染，肿瘤，创伤 -T1 Image: Use Muscle as Internal Standard T1加权：肌肉作为对照 -T1 Signal
18、 Darker than Muscle: Pathologic 异常信号：T1加权像上病灶信号低于肌肉,肿瘤 Tumor,-Osteosarcoma Proximal Humerus 肱骨近端骨肉瘤 -Mass with Cortical Destruction 皮质破坏合并软组织肿块形成 -Low Signal T1; High Signal T2 Images,关节软骨 Articular Cartilage,-Normal Cartilage 正常软骨 -Intermediate Signal 中等信号 -Smooth 表面平整,-Articular Cartilage Defect 软
19、骨缺损 -Gap: Fills With Contrast 关节造影：显示软骨裂隙,肱二头肌病变 Biceps Tendon,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 Biceps Tendon,肱二头肌病变 Biceps Tendon,-Extra-articular Biceps: Best Seen on Axial Image 关节外肱二头肌腱：轴位显示最佳 -In Bicipital Groove; Transverse Ligament 肌腱位
20、于二头肌沟内，外有横韧带保护,肱二头肌病变 Biceps Tendon,肱二头肌腱脱位 Biceps Tendon Dislocation,-Extra-articular: Transverse Ligament Torn; Subscapularis Intact 关节外脱位：横韧带撕裂；肩胛下肌完整 -Intra-articular: Subscapularis Torn or Avulsed 关节内脱位：肩胛下肌撕裂或撕脱,-Biceps Tendon Intra-articular Dislocation: 肌腱关节内脱位：Subscapularis Tendon Avulsed 肩
21、胛下肌腱撕脱,肱二头肌腱脱位 Biceps Tendon Dislocation,肱二头肌腱脱位 Biceps Tendon Dislocation,肱二头肌腱炎/撕裂 Biceps Tendonitis/ Tear,-Thick Tendon; Increased Signal 肌腱增厚；信号增加 -Longitudinal Splits 纵向撕裂,盂唇旁囊肿 Paralabral Cyst,High Association with Labral Tears and GH Instability与盂唇撕裂和盂肱关节不稳定密切相关Analogous to Meniscal Cysts of
22、the Knee类似于膝关节半月板囊肿 T2 Images- Multi-lobulated Fluid CollectionsT2加权像-多房液性信号 Location: Posterior, Superior, Inferior部位：盂唇后，上，下部 Can Cause Neurovascular Entrapment可导致神经血管卡压,肩胛上神经卡压 Suprascapular Nerve Entrapment,-Suprascapular Notch 肩胛上切迹 -Denervation of Supra- and Infraspinatus Muscles 冈上肌和冈下肌去神经化,-
23、Spinoglenoid Notch 冈盂切迹 -Denervation of Infraspinatus Muscle 冈下肌去神经化,冈上肌/冈下肌去神经化 Denervation Supra/Infraspinatus,-Entrapment of the Suprascapular Nerve in Suprascapular Notch 肩胛上切迹囊肿导致肩胛上神经卡压 -MR Findings: Early- Denervation edema (High Signal on T2) MR表现： 早期-去神经水肿（T2加权高信号）Late- Fatty Replacement (H
24、igh Signal on T1)晚期：脂肪替代（T1加权高信号）,冈下去神经化 Denervation Infraspinatus,-Entrapment of Suprascapular Nerve in Spinoglenoid Notch 冈盂切迹囊肿导致肩胛上神经卡压 -Early Denervation Edema of Infraspinatus Muscle 冈下肌去神经水肿,四边孔综合征 Quadrilateral Space Syndrome,旋肱后动脉和腋神经在四边孔处受压后所引起的一系列临床症候群。其主要表现是腋神经支配的肩臂外侧的感觉障碍和三角肌功能受限。 由于当肩关
25、节外展外旋时，组成四边孔的肌肉均受牵拉，从三个方向对四边产生挤压而致本症发生。 -Axillary Nerve Compression Neuropathy 腋神经受压症状 -Poorly Localized Shoulder Pain in ABER Position ABER位局部严重肩痛 -Atrophy of Teres Minor and Deltoid Muscles 小圆肌和三角肌萎缩 Etiologies: Fibrous Bands- Seen with Repetitive Overhead Activity; Paralabral Cyst; Mass 病因：反复过伸过头
26、运动导致的纤维束带；盂唇旁囊肿；肿块,-Chronic Fatty Atrophy of Teres Minor and Deltoid 小圆肌和三角肌慢性萎缩和脂肪化 -High Signal on T1 Images T1加权高信号表现,四边孔综合征 Quadrilateral Space Syndrome,Systematic Approach to the Shoulder 肩关节读片要领,Osseous Outlet and Acromion Acromial Type, Anterior/Lateral Down Sloping, Spur, Os Acromiale; AC Jo
27、int; C-A Ligament 骨性出口和肩峰 肩峰类型，前/后下斜型，骨赘，肩峰小骨，肩锁关节，喙肩韧带 Rotator Cuff Tendonopathy, Partial Thickness, Full Thickness, Complete Tear; Fatty Atrophy, Retraction 肩袖 -肌腱病变，部分撕裂，全层撕裂，完全撕裂，脂肪性萎缩，韧带回缩,Capsule and Labrum Labral Tear; Anterior; SLAP; Posterior 关节囊和盂唇 盂唇撕裂；前盂唇病变；SLAP；后盂唇病变 Osseous Structures and Articular Surfaces Trauma; Arthritis; Infection; Tumor 骨性结构和关节面 创伤；关节炎；感染；肿瘤 Biceps Tendon Tendonopathy; Tear; Dislocation 肱二头肌腱 肌腱病变；撕裂；脱位,Systematic Approach to the Shoulder 肩关节读片要领,
