肩關(guān)節(jié)常見(jiàn)疾病MRI診斷-Ⅰ

1、(Part)Wang chaoyanWang chaoyan2013/05/272013/05/27Shoulder disorders mainly involve rotator cuff diseases and shoulder instability. For rotator cuff diseases, routine shoulder MR imaging as the first choice can solve most of the problems in practice. For shoulder instability and related glenoid labr

2、um lesions, shoulder MR arthrography is the first selection for evaluation肩關(guān)節(jié)常見(jiàn)病變主要為肩袖相關(guān)病變和肩關(guān)節(jié)不穩(wěn)定。對(duì)于肩袖相關(guān)病變，肩關(guān)節(jié)MRI 常規(guī)掃描可作為首選；對(duì)于肩關(guān)節(jié)不穩(wěn)定和盂唇病變，則一般首選肩關(guān)節(jié)MRI 造影進(jìn)行評(píng)價(jià)。Rotator cuffRotator cuff tendons diseasetendons disease肩袖肌腱病Rotator cuffRotator cuff teartear肩袖撕裂SubscapularisSubscapularis rupture rupture肩胛下肌

3、斷裂AcromioclavicularAcromioclavicular joint disease joint disease肩鎖關(guān)節(jié)病The sub-The sub-acromialacromial shoulder impingement syndrome shoulder impingement syndrome肩峰下撞擊綜合征SLAPSLAP病變（上盂唇前后向撕裂）BankartBankart病變HAGLHAGL病變（盂肱下韌帶肱骨部撕脫）Labrum cyst Labrum cyst 盂唇囊腫Adhesive Adhesive capsulitiscapsulitis joints

4、 joints粘連性關(guān)節(jié)囊炎Shoulder joint Shoulder joint osteoarthrosisosteoarthrosis肩關(guān)節(jié)骨關(guān)節(jié)病Etiology pathology Etiology pathology 病因病理：Excessive use, lead to degeneration and tear of rotator Excessive use, lead to degeneration and tear of rotator cuff cuff 過(guò)度使用導(dǎo)致肩袖的退行性變和撕裂Most often in impingementMost often in i

5、mpingement最常繼發(fā)于撞擊綜合征Can occur inCan occur in patients with collagen vascular diseasepatients with collagen vascular disease可發(fā)生于膠原血管病患者Can be acute, but more often repeated attacks on the Can be acute, but more often repeated attacks on the basis of the already suffer from tendon diseasebasis of the

6、already suffer from tendon disease可急性發(fā)生，但更常在已患有肌腱病的基礎(chǔ)上反復(fù)發(fā)作Tendon thickening, hardening; Partial or total Tendon thickening, hardening; Partial or total disruption; Some tear on slippery bursa, articular disruption; Some tear on slippery bursa, articular surface or in the stromasurface or in the stro

7、ma肌腱增厚、硬化；部分或完全中斷；部分撕裂可在滑囊面、關(guān)節(jié)面或間質(zhì)中Collagen degeneration, but there is no inflammatory Collagen degeneration, but there is no inflammatory cells, chronic tendon can appear in fatty infiltrationcells, chronic tendon can appear in fatty infiltration膠原變性，但沒(méi)有炎性細(xì)胞，慢性肌腱撕裂中可出現(xiàn)脂肪浸潤(rùn) period: rotator cuff, esp

8、ecially hills tendon period: rotator cuff, especially hills tendon edema and hemorrhageedema and hemorrhage肩袖特別是崗上肌腱水腫和出血Tendonitis Tendonitis or inflammatory lesions, it is better to send in or inflammatory lesions, it is better to send in less than 25 years old young man. reversibleless than 25 ye

9、ars old young man. reversible肌腱炎或炎性病變，最好發(fā)于小于25歲的青年人,可逆. period: inflammation further progress and period: inflammation further progress and more fibrous tissue formationmore fibrous tissue formation炎癥進(jìn)一步進(jìn)展及更多的纖維組織形成Happens at 25Happens at 2545 years old.45 years old.好發(fā)于25-45歲。 period: rotator cuff t

10、ear.period: rotator cuff tear.肩袖撕裂。 Often occur Often occur in more than 45 years old.in more than 45 years old. 常發(fā)于45歲以上。Best location: being is 1 cm, from the hills muscle to the greater Best location: being is 1 cm, from the hills muscle to the greater tuberosity attachment points (no vascular di

11、stribution).tuberosity attachment points (no vascular distribution).最好發(fā)部位：崗上肌距大結(jié)節(jié)附著點(diǎn)1cm處（無(wú)血管分布）。On all pulseOn all pulse sequence, signals are increasedsequence, signals are increased在所有脈沖序列上，信號(hào)均增高Tendon thickening, signal not usually Tendon thickening, signal not usually homogeneoushomogeneous肌腱常常增

12、厚、信號(hào)不均勻Partial tear, visible water signal in the Partial tear, visible water signal in the tendons, but only partial tendon involvementtendons, but only partial tendon involvement 部分撕裂，在肌腱中可見(jiàn)水樣信號(hào)，但只是部分肌腱受累Tendon full-thickness tear, liquid into tendon Tendon full-thickness tear, liquid into tendon f

13、ractures, with varying degrees of tendon fractures, with varying degrees of tendon retractionretraction肌腱全層撕裂，液體進(jìn)入肌腱裂隙中，伴不同程度的肌腱回縮Tendon full-thickness tear of the chronic Tendon full-thickness tear of the chronic patients to merge muscle fat atrophypatients to merge muscle fat atrophy肌腱全層撕裂的慢性患者可合并

14、肌肉脂性萎縮 Thin contrast sketch below outline of the rotator cuff (white arrow)薄的造影劑勾畫(huà)出肩袖的下面輪廓（白長(zhǎng)箭頭），Normal joint capsule (black arrow),正常關(guān)節(jié)囊（黑箭頭），axillary fossae (white triangle arrows).腋隱窩 （白三角箭頭）。Fig 1 Subdeltoidsubacromial bursitis.肩峰下滑囊炎。Coronal oblique MR images of the shoulder show fluid in the d

15、ilated subdeltoidsubacromial bursa (arrow head).常規(guī)MRI斜冠狀位示肩峰下滑囊積液(箭頭)；1A: SE T1W; 1B: TSE T2W. Fig 2 Acromial morphology.肩峰形態(tài)。A. Shape of the Acromion. Type I, flat型，肩峰下表面為一平面；Type II, curved型，肩峰下表面為弧形凹面；Type III, hooked 型，肩峰下表面前部呈鉤狀突； B. Sagittal oblique image shows a Type II acromion and a degener

16、ative spur at the anteroinferior edge of the acromion (arrow). MRI造影斜矢狀位示肩峰前下緣的骨刺(箭)，型肩峰 Fig 3 Tendinitis.肩袖變性。 Coronal oblique MR images of the shoulder show the supraspinatus tendon is diffuse thickening, with intrasubstance intermediate signal on T1-weighted and T2-weighted MR images(arrow).常規(guī)MRI

17、斜冠狀位示岡上肌腱增粗，連續(xù)性好，T1W和T2W信號(hào)均增高(箭)4AFig 4: Bursal-sided partial thickness tear of the subscapularis.岡上肌腱上表面部分撕裂.4A:Oblique coronal T2-weighted image shows partial disrupture of the bursal-sided tendon fibers (arrow). The articular-sided fibers are intact. 常規(guī)MRI 斜冠狀位FS T2W 示岡上肌腱止點(diǎn)處上表面部分撕裂，局部見(jiàn)液性高信號(hào)(箭)，伴

18、肩峰下滑囊積液，下表面完整.4B:partial thickness tear of the subscapularis. Oblique coronal T2-weighted MR image shows partial discontinuity of the articular-sided tendon fi bers (arrow).The bursal-sided fi bers are intact.岡上肌腱下表面部分撕裂。常規(guī)MRI 斜冠狀位FS T2W示岡上肌腱止點(diǎn)處下表面撕裂( 箭) ，信號(hào)增高，但上表面完整4B4C4DFig4C: Intratendinous parti

19、al thickness tear of the subscapularis. 岡上肌腱腱內(nèi)部分撕裂。Oblique coronal T2-weighted MR image shows abnormal intratendinous fluid accumulation (arrows). The bursal-sided and articular-sided fi bers are intact常規(guī)MRI 斜冠狀位FS T2W示岡上肌腱止點(diǎn)處腱內(nèi)限局液性高信號(hào)影( 箭) ，肌腱上下表面均完整.Fig4D: Articular-sided partial thickness tear of

20、 the subscapularis.岡上肌腱下表面部分撕裂。 Oblique coronal T1-weighted MR arthrographic image shows partial discontinuity of the articular-sided fi bers (arrows), with contrast material leaking into the substance of the tendon, and intact bursal-sided fi bers. MRI造影斜冠狀位示高信號(hào)對(duì)比劑進(jìn)入岡上肌腱下表面(箭)，但未進(jìn)入肩峰下滑囊Fig 5:Differ

21、ent MRI techniques for labral tear.盂唇撕裂對(duì)比。 Fig5A : An axial routine MR image shows intact anteroinferior labrum. 常規(guī)MRI 軸位示盂唇未見(jiàn)撕裂征象；Fig5B: An axial MR arthrographic image demonstrates tear of the anteroinferior labrum (arrow).MRI造影軸位示前方盂唇撕裂(箭)5A5BPDWIT2WIMR arthrogramPDWI（質(zhì)子加權(quán)像）：supraspinatus tendono

22、bviously obviously irregular (long arrow);崗上肌肌腱明顯不規(guī)則（長(zhǎng)箭頭所示）；T2WI：found similar signal, in line with the tear of the parts (long arrow);發(fā)現(xiàn)相似信號(hào)符合部分撕裂（長(zhǎng)箭頭所示） ；MR arthrogram（關(guān)節(jié)造影）：contrast agent into the shoulder sleeve material, but not falling down to the shoulder peak capsule (arrow), in addition, a

23、small part of contrast agents, inserted near the shoulder sleeve (long arrow).造影劑進(jìn)入肩袖實(shí)質(zhì)內(nèi)，但未沿伸到肩峰下滑囊（三角箭頭所示），另外一小部分相連的造影劑插入鄰近肩袖（長(zhǎng)箭頭所示） 。PDWIT2WIMR arthrogramPDWI： rotator cuff essence, lack of limitations (long arrow);肩袖實(shí)質(zhì)局限性缺失（長(zhǎng)箭頭所示）；T2WI：tear mouth increased signal (long arrow);撕裂口信號(hào)增高（長(zhǎng)箭頭所示） ；MR a

24、rthrogram ：contrast filling gaps of rotator cuff (long arrow), under the shoulder peak - deltoid in capsule (arrow).造影劑充填肩袖缺口（長(zhǎng)箭頭所示） 、肩峰下-三角肌下滑囊（三角箭頭所示）。Calcification features tendonitis鈣化性肌腱炎： tendon thickening, and often accompanied by signal decreases肌腱可增厚，并常伴有信號(hào)減低Within the tendon cyst肌腱內(nèi)囊腫：tend

25、on thickening, and on T2WI tumor cyst with partial rotator cuff tear肌腱增厚，且在T2WI上見(jiàn)囊腫合并部分肩袖撕裂In tendon fissure, visible in joint fluid, slippery bursa liquid filling or granulation tissue, on the FSE T2WI or SPAIR sequences is most clear在肌腱裂隙中可見(jiàn)充以關(guān)節(jié)液、滑囊液或肉芽組織，在FSE T2WI SPAIR序列中最清晰Tendon edges appear d

26、ifferent degree of contraction and degeneration肌腱邊緣出現(xiàn)不同程度的收縮和退行性變In patients with chronic tendon full-thickness tear can incorporate the fat of muscle atrophy慢性患者的肌腱全層撕裂可合并肌肉的脂性萎縮Merger of synovial sac effusion under the shoulder peak合并肩峰下滑囊積液Occur between the front of the hills muscle tear or rotat

27、or cuff tear, easy to merge synovial sac effusion under beak有崗上肌前方撕裂和肩袖間撕裂時(shí)易合并喙下滑囊積液 Suspicious patients with rotator cuff tear, imaging examination, should be a comprehensive observation of rotator cuff and the surrounding structure可疑肩袖撕裂的病人行影像學(xué)檢查時(shí)需對(duì)肩袖及其周圍結(jié)構(gòu)作全面觀察:Note that tear mouth size, affected

28、 the scope, edge cases, muscle atrophy and bone change and so on.注意撕裂口大小、肌腱受累范圍、肌腱邊緣情況、肌肉萎縮及骨骼改變等。Partial tendon according to tear thickness or depth into three degrees.部分性肌腱撕裂可按撕裂厚度或深度分三度。 度：3mm；度：3-6mm；度：6mm。Complete a tendon, according to the gap size is divided into four categories完全性肌腱撕裂據(jù)裂口大小分四

29、類。 2mm Mild tear輕度撕裂；2-4 Moderate tear中度撕裂； 4-5mm Severe tear重度撕裂；5mm Giant tear巨型撕裂。0：Normally, a uniform low signal 正常，呈均勻一致的低信號(hào)1：Rotator cuff normal form, on T1WI or PDWI sequences showed diffuse or linear high signal肩袖形態(tài)正常，T1WI或PDWI上呈彌 漫性或線狀高信號(hào)2 ：Shoulder sleeve, is thinning or irregular, and ha

30、s high signal on T1WI or PDWI sequences肩袖變薄或不規(guī)則， T1WI或PDWI上呈高信號(hào)3 ：Rotator cuff signal on T2WI sequence increased and affected tendon layer T2WI上肩袖信號(hào)增高且累及肌腱全層Carrino, think rotator cuff tear is divided into seven degrees 肩袖撕裂分7級(jí):0級(jí)： Tendon is normal肌腱正常；1級(jí)： Tendon (T1WI signal or PDWI) increased, the

31、 attachment points about 1 cm距附著點(diǎn)1cm肌腱信號(hào)（T1WI或PDWI）增高；2級(jí)：Tendonitis, increased signal on T2WI, but not involving the top of the shoulder joint (with Neer2 degree)肌腱炎， T2WI上信號(hào)增高，但未累及肩關(guān)節(jié)上面（同Neer2級(jí)）；3級(jí)： Degeneration, one or more high signal on T2WI, and there is no enough to the torn part of diagnostic

32、 criteria退行性變， T2WI上一個(gè)或多個(gè)高信號(hào)區(qū)，未達(dá)部分撕裂診斷標(biāo)準(zhǔn)；4級(jí)：Part of tear, on T2WI sequence, tendon signal increased obviously, and affected tendon above or below部分撕裂， T2WI上肌腱信號(hào)明星增高，且累及肌腱上下面；5級(jí)：Tendon near full-thickness rupture, but with a little muscle fiber complete肌腱近乎全層斷裂，但有少許肌纖維完整；6級(jí)： Tendon full-thickness rup

33、ture, without tendon contracture肌腱全層斷裂，無(wú)肌腱攣縮；7級(jí)： Tendon full-thickness rupture with tendon contracture.肌腱全層斷裂伴肌腱攣縮。Tendonitis肌腱炎（1級(jí)）TIWITIWIT2WIRotator cuff tear肩袖撕裂（2級(jí)）Fig 3 Full thickness tear of the supraspinatus.肩袖全層撕裂。Coronal oblique T2-weighted MR image shows the supraspinatus tendon becomes t

34、hicker, with abnormal high signal as intense as fl uid extending from the articular surface to the subacromial bursa surface(arrow) 常規(guī)MRI斜冠狀位FS T2W示岡上肌腱連續(xù)、增厚，其內(nèi)部可見(jiàn)關(guān)節(jié)液樣的高信號(hào)，累及肌腱全層(箭)Fig 4 Full thickness tear of the supraspinatus.肩袖全層撕裂。Coronal oblique T2-weighted MR image shows the complete discontin

35、uity and retraction of the tendon (arrow).MRI造影斜冠狀位FS T2W 示岡上肌腱連續(xù)性中斷，斷端回縮( 箭)5A5BFig 5:Full thickness tear of the supraspinatus.肩袖全層撕裂。A：Fig 6A: Coronal oblique T1-weighted MR arthrographic image shows the complete discontinuity and retraction of the supraspinatus tendon (arrow), atrophy of the supr

36、aspinatus, and upward displacement of the humeral head. MRI造影斜冠狀位，示岡腱連續(xù)性中斷，斷端(箭)回縮，同時(shí)伴有肌腱萎縮、肱骨頭上移；B: Sagittal oblique T1-weighted MR arthrographic image shows the discontinuity of the rotator cuff and the presence of high signal contrast material within the subacromial bursa (arrow).MRI 造影斜矢狀位，示肩袖不完

37、整，撕裂累及岡上肌腱和岡下肌腱，肩峰下滑囊內(nèi)(箭)可見(jiàn)高信號(hào)對(duì)比劑Patients with secondary to anterior dislocation of shoulder joint, typically more than 40 years繼發(fā)于肩關(guān)節(jié)前脫位，患者一般大于40歲Secondary to the rear of the shoulder joint dislocation, visible at any age繼發(fā)于肩關(guān)節(jié)后脫位，可見(jiàn)于任何年齡Tendon signal uneven; Tendon in see water signal; Different d

38、egree of tendon retraction.肌腱信號(hào)不均勻；肌腱中見(jiàn)水樣信號(hào)；不同程度肌腱回縮。Plain radiographs, shows the humerus small tubercle fracture平片可見(jiàn)肱骨小結(jié)節(jié)骨折斜失 T1WI軸位MR arthrogramT1WI：Edge is clear, uniform low signal邊緣清楚，均勻低信號(hào)0級(jí)：19Y，F(xiàn)，Arthroscopy has confirmed the normal hills muscle tendon關(guān)節(jié)鏡證實(shí)的正常崗上肌肌腱MR arthrogram：Complete tendon (arrow), no leakage of contrast media, head of biceps tendon is located in the central完整的肌腱（箭頭），無(wú)造影劑滲漏，肱二頭肌腱居中斜失 T1WI軸位MR arthrogramT1WI：Below the shoulde