肌骨超声诊断指南肩部.ppt

肌骨超声技术指南-肩部(欧洲肌骨放射学)n nAlthough patients positioning for shoulder US varies Although patients positioning for shoulder US varies widely across different Countries and Institutions widely across different Countries and Institutions reflecting multifaceted opinions and experiences of reflecting multifaceted opinions and experiences of different examiners,we strongly recommend to examine different examiners,we strongly recommend to examine the patient while seated on a revolving stool.This the patient while seated on a revolving stool.This position allows the examiner to reach the anterior,lateral position allows the examiner to reach the anterior,lateral and posterior aspects of the shoulder with the probe by and posterior aspects of the shoulder with the probe by simply asking the patient to rotate on the chair.simply asking the patient to rotate on the chair.n n不同的国家和机构给病人进行肩部超声检查时所采取的体不同的国家和机构给病人进行肩部超声检查时所采取的体位各不相同，体现了不同诊查者不同的观点和经验，但是，位各不相同，体现了不同诊查者不同的观点和经验，但是，我们强烈推荐让病人坐在转凳上进行检查。这个体位能够我们强烈推荐让病人坐在转凳上进行检查。这个体位能够让诊查者只要让病人转动一下凳子就能够使用探头扫查到让诊查者只要让病人转动一下凳子就能够使用探头扫查到肩的前面、侧面和后面。肩的前面、侧面和后面。n nlong head of the biceps tendonlong head of the biceps tendon二头肌腱长头二头肌腱长头Place the arm in slight internal rotation(directed Place the arm in slight internal rotation(directed towards the towards the contralateralcontralateral knee)with the elbow knee)with the elbow flexed 90,palm up.Start by finding the long flexed 90,palm up.Start by finding the long biceps tendon in between the greater and lesser biceps tendon in between the greater and lesser tuberositiestuberosities Use short and long(more limited Use short and long(more limited utility)axis planes to examine the biceps.utility)axis planes to examine the biceps.肘部屈曲肘部屈曲9090，手臂轻度内旋（指向对侧膝部），手臂轻度内旋（指向对侧膝部），掌心向上。先在大、小结节之间找到肱二头肌长掌心向上。先在大、小结节之间找到肱二头肌长头腱，采用短轴和长轴（作用有限）切面检查二头腱，采用短轴和长轴（作用有限）切面检查二头肌。头肌。Shift the probe up to examine the biceps Shift the probe up to examine the biceps in its in its intraarticularintraarticular course and down to reach the course and down to reach the myotendinousmyotendinous junction(level of the junction(level of the pectoralispectoralis major tendon).major tendon).n n向上移动探头检查二头肌关节内的走行，向下移向上移动探头检查二头肌关节内的走行，向下移动探头探测肌动探头探测肌-腱连接部（胸大肌肌腱水平）。腱连接部（胸大肌肌腱水平）。n nLegend:SubS,subscapularis tendon;SupraS,supraspinatus tendon;Arrow,long head of the biceps tendon;LT,lesser tuberosity;GT,greater tuberosity;SH,short head of the biceps;LH,long head of the biceps;H,humeral shaft;Arrowheads,pectoralis major tendonn n图例：SubS 肩胛下肌肌腱；SupraS 冈上肌肌腱；箭号，肱二头肌长头；LT 小结节；GT 大结节；SH 二头肌短头；LH 二头肌长头；H 肱骨干；箭头，胸大肌肌腱n n3 3 subscapularissubscapularis tendon tendonRotate the arm externally fixing the elbow on Rotate the arm externally fixing the elbow on the iliac crest to show the the iliac crest to show the subscapularissubscapularis tendon tendonand its insertion on the lesser and its insertion on the lesser tuberositytuberosity(slight (slight supinationsupination of the hand may be helpful of the hand may be helpfulto neutralize the tendency to lift and abduct the to neutralize the tendency to lift and abduct the elbow from the lateral chest wall).elbow from the lateral chest wall).3 3 肩胛下肌肌腱肩胛下肌肌腱将肘部固定于髂嵴处，上肢外旋可显示肩胛下肌将肘部固定于髂嵴处，上肢外旋可显示肩胛下肌肌腱及其小结节附着部。（手掌轻度后旋可有助肌腱及其小结节附着部。（手掌轻度后旋可有助于抵抗肘部上抬和外展离开侧胸壁的力量）于抵抗肘部上抬和外展离开侧胸壁的力量）n nThis tendon should be evaluated along its long-This tendon should be evaluated along its long-(transverse planes)and short-(transverse planes)and short-(sagittalsagittal planes)planes)axis during passive external and internal rotation axis during passive external and internal rotation with hanging arm.Sweep the transducer up and with hanging arm.Sweep the transducer up and down over the down over the subscapularissubscapularis until its full width is until its full width is demonstrated.demonstrated.评价该肌腱应该在手臂上举状态下被动外旋和内评价该肌腱应该在手臂上举状态下被动外旋和内旋时沿其长轴切面（横切面）和短轴切面（矢状旋时沿其长轴切面（横切面）和短轴切面（矢状切面）进行扫查。在肩胛下肌表面上下扫查，直切面）进行扫查。在肩胛下肌表面上下扫查，直至整块肌肉都能全部显示。至整块肌肉都能全部显示。n nLegend:Arrow,long head of the biceps tendon;dashed Legend:Arrow,long head of the biceps tendon;dashed line,insertion of the line,insertion of the subscapularissubscapularis tendon;Co,tendon;Co,coracoidcoracoid;Del,deltoid muscle;LT,lesser Del,deltoid muscle;LT,lesser tuberositytuberosity;SubSSubS,subscapularissubscapularis tendon;void arrowheads,tendon fascicles tendon;void arrowheads,tendon fascicles of the of the subscapularissubscapularis;white arrowheads,muscle tissue;white arrowheads,muscle tissue interposed between tendon fasciclesinterposed between tendon fasciclesn n图例：图例：箭号，肱二头肌长头腱；虚线，肩胛下肌肌腱附箭号，肱二头肌长头腱；虚线，肩胛下肌肌腱附着处；着处；CoCo喙突；喙突；Del,Del,三角肌；三角肌；LT,LT,小结节；小结节；SubSSubS,肩胛下肩胛下肌肌腱；空心箭头，肩胛下肌肌腱束；白色箭头，插入肌肌肌腱；空心箭头，肩胛下肌肌腱束；白色箭头，插入肌腱束之间的肌肉组织；腱束之间的肌肉组织；n n4 4 anteromedialanteromedial structures and structures and coracoacromialcoracoacromial ligament ligamentMoving the probe toward medial on transverse planes,Moving the probe toward medial on transverse planes,look at the look at the coracoidcoracoid process,the process,the coracoacromialcoracoacromial ligament(the medial margin of the transducer is on the ligament(the medial margin of the transducer is on the coracoidcoracoid process and the lateral edge is shifted upward process and the lateral edge is shifted upward and laterally towards the and laterally towards the acromionacromion),the conjoined),the conjoined tendon and the anterior aspect of the tendon and the anterior aspect of the subacromialsubacromial subdeltoidsubdeltoid bursa.Then,check the bursa.Then,check the subscapularissubscapularis recess recess and the and the subcoracoidsubcoracoid bursa for effusion.External and bursa for effusion.External and internal rotation may also used to demonstrate internal rotation may also used to demonstrate anteromedialanteromedial impingement(distance between impingement(distance between coracoidcoracoid processprocessand lesser and lesser tuberositytuberosity measured in internal rotation).measured in internal rotation).4.4.肩部前内侧结构和喙肩韧带在横切面上，将探头向内侧肩部前内侧结构和喙肩韧带在横切面上，将探头向内侧移动，查看肩胛骨喙突、喙肩韧带（探头的内侧固定在肩移动，查看肩胛骨喙突、喙肩韧带（探头的内侧固定在肩胛骨喙突，探头外侧缘向外上方转动指向肩峰）、联合腱胛骨喙突，探头外侧缘向外上方转动指向肩峰）、联合腱和肩峰下的三角肌下滑囊前部。然后，探测肩胛下肌隐窝和肩峰下的三角肌下滑囊前部。然后，探测肩胛下肌隐窝和喙突下囊有无积液。内旋和外旋也可用以探测前内侧的和喙突下囊有无积液。内旋和外旋也可用以探测前内侧的创伤部位（内旋可用以测量肩胛骨喙突和肱骨小结节之间创伤部位（内旋可用以测量肩胛骨喙突和肱骨小结节之间的距离）的距离）n nLegendLegend:AcrAcr,acromionacromion;Arrows,short head of;Arrows,short head of the biceps;Arrowheads,the biceps;Arrowheads,coracoacromialcoracoacromial ligament;Co,ligament;Co,coracoidcoracoid;CoBrCoBr,coraco-brachialiscoraco-brachialis;HH,humeral head;HH,humeral head;SubSSubS,subscapularissubscapularis tendon;tendon;SupraSSupraS,supraspinatussupraspinatusn n图示：图示：AcrAcr,肩峰；箭，二头肌短头；箭头，喙肩肩峰；箭，二头肌短头；箭头，喙肩韧带；韧带；Co,Co,喙突；喙突；CoBrCoBr,喙肱肌；喙肱肌；HH,HH,肱骨头；肱骨头；SubSSubS,肩胛下肌肌腱；肩胛下肌肌腱；SupraSSupraS,冈上肌冈上肌n nsupraspinatussupraspinatus tendon:positioning(1)tendon:positioning(1)n n冈上肌肌腱：定位（冈上肌肌腱：定位（1 1）n nPlace the patients arm Place the patients arm posteriorlyposteriorly,placing the,placing the palmarpalmar side of the hand on the superior aspect side of the hand on the superior aspect of the iliac wing with the elbow flexed and of the iliac wing with the elbow flexed and directed directed posteriorlyposteriorly.The.The supraspinatussupraspinatus tendon tendon should be evaluated along its long-and short-should be evaluated along its long-and short-axis.axis.n n患者上肢后置，肘部向后屈曲，手掌面置于髂骨患者上肢后置，肘部向后屈曲，手掌面置于髂骨翼上部。应沿长轴和短轴观测冈上肌肌腱。翼上部。应沿长轴和短轴观测冈上肌肌腱。n nsupraspinatussupraspinatus tendon tendonn n5 5 冈上肌肌腱冈上肌肌腱n nRefer to the Refer to the intraarticularintraarticular portion of the biceps as a landmark to portion of the biceps as a landmark to obtain proper transducer orientation for imaging the obtain proper transducer orientation for imaging the supraspinatussupraspinatus.In fact,these tendons run parallel one to the other and the In fact,these tendons run parallel one to the other and the intraarticularintraarticular portion of the biceps is easy to be recognized due to a portion of the biceps is easy to be recognized due to a more clearly defined more clearly defined fibrillarfibrillar pattern.One should rotate the pattern.One should rotate the transducer until the biceps is depicted as more elongated as transducer until the biceps is depicted as more elongated as possible in the US image.Then,the probe is shifted upward and possible in the US image.Then,the probe is shifted upward and posteriorlyposteriorly over the over the supraspinatussupraspinatus without changing its orientation.without changing its orientation.The resulting image is in axis with the The resulting image is in axis with the supraspinatussupraspinatus.Between the.Between the supraspinatussupraspinatus and the deltoid,the normal and the deltoid,the normal subacromial-subdeltoidsubacromial-subdeltoid bursa appears as a thin bursa appears as a thin hypoechoichypoechoic band.band.n n肱二头肌的关节内部分是确定合适的探头方向以显示冈上肌的定位标肱二头肌的关节内部分是确定合适的探头方向以显示冈上肌的定位标志。事实上，这些肌腱是相互平行的，而二头肌关节内的部分由于其志。事实上，这些肌腱是相互平行的，而二头肌关节内的部分由于其边界清晰的细纤维结构而易于辨认。操作者应该转动探头使二头肌的边界清晰的细纤维结构而易于辨认。操作者应该转动探头使二头肌的超声图像显示得尽可能长。然后，保持探头方向不变，在冈上肌表面超声图像显示得尽可能长。然后，保持探头方向不变，在冈上肌表面向后上方移动探头，最终图像就是冈上肌的长轴。在冈上肌和三角肌向后上方移动探头，最终图像就是冈上肌的长轴。在冈上肌和三角肌之间，正常的肩峰之间，正常的肩峰-三角肌下滑囊呈一条薄薄的低回声带。三角肌下滑囊呈一条薄薄的低回声带。n nTilt the transducer gently in the area overlying Tilt the transducer gently in the area overlying the tendon insertion to avoid anisotropy.the tendon insertion to avoid anisotropy.Remember to scan the lateral pouch of the Remember to scan the lateral pouch of the subacromialsubacromial subdeltoidsubdeltoid bursa along the lateral bursa along the lateral edge of the greater edge of the greater tuberositytuberosity.When looking for.When looking for the the supraspinatussupraspinatus on short-axis,the normal cuff on short-axis,the normal cuff must have almost the same thickness from the must have almost the same thickness from the biceps tendon landmark until 2cm backwards:biceps tendon landmark until 2cm backwards:from this point backwards the tendon seen is the from this point backwards the tendon seen is the infraspinatusinfraspinatus.在肌腱附着端轻轻地倾斜探头以消除各向异性假在肌腱附着端轻轻地倾斜探头以消除各向异性假象。象。记住，要沿着大结节的外侧缘扫查肩峰下三记住，要沿着大结节的外侧缘扫查肩峰下三角肌下囊的侧囊。在短轴上寻找冈下肌时，从二角肌下囊的侧囊。在短轴上寻找冈下肌时，从二头肌腱标记处向后头肌腱标记处向后2cm2cm，正常肩袖的厚度一定是，正常肩袖的厚度一定是不变的：从该点向后看到的肌腱就是冈下肌不变的：从该点向后看到的肌腱就是冈下肌n nLegend:Legend:AcrAcr,acromionacromion;asterisk,;asterisk,myotendinousmyotendinous junction;junction;Del,deltoid muscle;GT,greater Del,deltoid muscle;GT,greater tuberositytuberosity;void arrow-;void arrow-head,head,articulararticular cartilage;curved arrow,cartilage;curved arrow,hypoechoichypoechoic artifact related to anisotropy;straight arrow,long head artifact related to anisotropy;straight arrow,long head of the biceps tendon;of the biceps tendon;SupraSSupraS,supraspinatussupraspinatus tendon;tendon;white arrowhead,white arrowhead,subacromialsubacromial subdeltoidsubdeltoid bursa bursan n图例：图例：AcrAcr,肩峰；星号，肌肩峰；星号，肌-腱连接；腱连接；Del,Del,三角肌；三角肌；GT,GT,大结节；空心箭头，关节软骨；大结节；空心箭头，关节软骨；弯箭头，各向异性导致弯箭头，各向异性导致的低回声伪像；直箭头，二头肌肌腱；的低回声伪像；直箭头，二头肌肌腱；SupraSSupraS,冈上肌肌冈上肌肌腱；白色箭头，肩峰下三角肌下滑囊腱；白色箭头，肩峰下三角肌下滑囊n n6 6 supraspinatussupraspinatus tendon:positioning(2)tendon:positioning(2)n nPlace the dorsum of the hand over the opposite back Place the dorsum of the hand over the opposite back pocket(forced internal rotation,stress pocket(forced internal rotation,stress manoeuvremanoeuvre).).There should not be any space gap between the elbow There should not be any space gap between the elbow and the lateral chest wall.Using this position,the and the lateral chest wall.Using this position,the supraspinatussupraspinatus becomes a more anterior structure and becomes a more anterior structure and the transducer should be oriented almost vertically to be the transducer should be oriented almost vertically to be in axis with it.Consider that the tendon fibers are more in axis with it.Consider that the tendon fibers are more stretched than in the position described at point-5.This stretched than in the position described at point-5.This may be possible cause of overestimation of tear size.may be possible cause of overestimation of tear size.Due to an excessive internal rotation,the long head of Due to an excessive internal rotation,the long head of the biceps tendon may be difficult to be visualized in this the biceps tendon may be difficult to be visualized in this position.position.n n6 6 冈上肌肌腱：定位（冈上肌肌腱：定位（2 2）n n将手背放在后兜位置（被动内旋，加压手法），肘部应该将手背放在后兜位置（被动内旋，加压手法），肘部应该紧贴和侧胸壁。采用这个体位，冈上肌就会前移，探头要紧贴和侧胸壁。采用这个体位，冈上肌就会前移，探头要垂直放置以与其处于同一轴线上。我们认为该肌腱纤维比垂直放置以与其处于同一轴线上。我们认为该肌腱纤维比第第5 5点中描述的那个位置更加伸展。这样就有可能夸大撕点中描述的那个位置更加伸展。这样就有可能夸大撕裂的范围。由于过度内旋，这个体位时二头肌长头肌腱可裂的范围。由于过度内旋，这个体位时二头肌长头肌腱可能很难显示。能很难显示。n n7 7 subacromialsubacromial impingenmentimpingenment test testDynamic assessment of Dynamic assessment of subacromialsubacromial(anteroantero-superior)impingement can be attempted by superior)impingement can be attempted by placing the probe in the coronal plane with its placing the probe in the coronal plane with its medial margin at the lateral margin of the medial margin at the lateral margin of the acromionacromion.The patient abducts his arm while in.The patient abducts his arm while in internal rotation.With this internal rotation.With this manoeuvremanoeuvre,the,the supraspinatussupraspinatus and the bursa can be seen and the bursa can be seen passing deep to the passing deep to the coracoacromialcoracoacromial arch.arch.7 7 肩峰下冲击试验肩峰下冲击试验将探头的内侧缘置于肩峰的外侧缘取冠状切面能将探头的内侧缘置于肩峰的外侧缘取冠状切面能够动态观察肩峰下的（前上）冲击，病人手臂内够动态观察肩峰下的（前上）冲击，病人手臂内旋的同时外展，通过此种手法，能够显示冈上肌旋的同时外展，通过此种手法，能够显示冈上肌及其滑囊从深部走向肩峰弓。及其滑囊从深部走向肩峰弓。