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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,正常肩峰轴位形态,
2、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
3、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 Plane),-评价肩胛下肌的最好平面Pri
4、mary 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，完全撕裂Musculotendinous Retraction肌肉肌
5、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-SignalT1W延续性中等信号表现,T2: Fluid Signal T2：出现液性信号 Partial Thickness 部分撕裂U
6、ndersurface 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液性信号存在于肌腱内-Does Not Touch the Surface不影响到
7、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 Undersurface P.T. Tear小的创伤后撕裂,全层撕裂 Full Thickness Tear,-Fl
8、uid 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 Thickness Tear,-Gad Arthrogram: Demonstrates Full Thicknes
9、s 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 Musculotendinous retraction,-Greater than 3 cm retraction- poor prognosis
10、 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 Fatty Atrophy,钙化性肌腱炎 Calcific Tendonitis,-Dark Globular Area on al
11、l 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
12、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 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
13、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 Through 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
14、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 Superior 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
15、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,-Humeral epiphysis: Only Epiphysis that Normally contains Hematopoietic Marrow肱骨红骨髓变：正常情况下仅骨骺
16、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 Trauma,-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
17、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 StandardT1加权：肌肉作为对照-T1 Signal 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 wit
18、h 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
19、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
20、 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
21、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 the Knee 类似于膝关节半月板囊肿T2 Images- Multi-lobulated Fluid Collections T2加权像-多房液性信号Location: Posterior, Superior, Inferior 部位：盂唇后，上，下部Can Caus
22、e 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,-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 Suprascapul
23、ar 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 (High 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 Den
24、ervation 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 PositionABER位局部严重肩痛-Atrophy
25、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 ImagesT1加权高信号表现,四边孔综合征Quadrilateral Space Syndrome,Systema
26、tic Approach to the Shoulder肩关节读片要领,Osseous Outlet and AcromionAcromial Type, Anterior/Lateral Down Sloping, Spur, Os Acromiale; AC Joint; 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
27、裂，全层撕裂，完全撕裂，脂肪性萎缩，韧带回缩,Capsule and LabrumLabral 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 SurfacesTrauma; Arthritis; Infection; Tumor骨性结构和关节面创伤；关节炎；感染；肿瘤Biceps TendonTendonopathy; 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,
