医学影像学：第九章 骨 第三节 软组织 .ppt

医学影像学,Medical Imaging,第一篇 影像诊断学,Verse 1.Diagnostic Imaging,第九章 骨关节与软组织,Chapter 9.The skeleton,joint and soft tissue,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织,绪论,4,第六章 消化系统与腹膜腔,8,一、医学影像学的发展简史和研究范畴,第七章 泌尿生殖系统与腹膜后间隙,4,二、医学影像学的临床应用价值,第八章 乳腺,2,三、如何学习和运用医学影像学,第九章 骨关节与软组织,4,第一篇 影像诊断学,第十章 儿科影像诊断学,第一章 影像诊断学总论,第二篇 介入放射学,4第二章 中枢神经系统,6,第十一章 介入放射学总论,第三章 头颈部,4,第十二章 血管疾病的介入治疗,第四章 呼吸系统,6,第十三章 非血管疾病的介入治疗,第五章 循环系统,4,第十四章 良、恶性肿瘤的介入治疗,医学影像学 第一篇 影像诊断学 第三章 头颈部 第一节 眼部,第九章 骨关节与软组织,第一节 骨骼,第二节 关节,第三节 软组织,一 检查技术,二 正常影像表现,三 基本病变表现,四 疾病诊断,医学影像学 第一篇 影像诊断学 第一章 影像诊断学总论,第七节 影像检查的申请和影像报告的应用,第八章 泌尿生殖系统和腹膜后间隙 第一节 泌尿系统,章节,课程内容,总学时,理论学时,实践学时,备注,第一篇,第一章,影像诊断学总论,4,4,第二章,中枢神经系统,6,6,第三章,头颈部,2,2,第四章,呼吸系统,6,6,第五章,循环系统,4,4,第六章,消化系统与腹膜腔,8,8,第七章,泌尿生殖系统与腹膜后间隙,4,4,第八章,乳腺,2,2,第九章,骨关节与软组织,4,4,第二篇,介入放射学,6,4,合 计,46,46,医学影像诊断学,第九章 关节与软组织,Chapter 9.The skeleton,joint and soft tissue,第三节 软组织,Section 3.The soft tissue,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,1检查技术,Imaging technology,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（一）,X,线检查,一般不用,血管造影：评估软组织肿块血供,介入治疗,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,平扫：对称检查，调窗检查，重建成像,强化：观察病变血供,（二）,CT,检查,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,主要检查技术,对脂肪、肌肉、肌腱及软骨等组织及病变（肿块、坏死、出血和水肿）显示优于,X,平片和,CT,。,增强：同,CT,。,（三）,MRI,检查,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,2,正常影像表现,The normal manifestation,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,3,基本病变表现,The basic lesions manifestation,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（一）软组织肿胀,Soft tissue swelling,炎症、出血、水肿或脓肿等原因引起的软组织肿大膨胀,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（二）软组织肿块,Soft tissue mass,软组织肿瘤或瘤样病变引起,骨肿瘤破坏骨皮质侵入软组织也可形成软组织肿块,软组织肿块也可见于某些炎症病变,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（三）软组织钙化和骨化,Calcification and ossification of soft tissue,软组织因出血、退变、坏死、肿瘤、结核及寄生虫感染等，而发生在肌肉、肌腱血管和淋巴管等处的钙化或骨化。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Soft Tissue Calcifications,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（四）软组织内气体,Gas in,soft tissue,外伤、手术或产气杆菌等病理情况下所致软组织内积气。,4,疾病诊断,Disease diagnosis,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,【,临床与病理,】,Clinical and pathology,不完全性撕裂，即部分纤维断裂，损伤的韧带和肌腱内有出血和水肿，邻近组织内也可出现出血和水肿。,完全性撕裂，可见韧带和肌腱的位置异常及断裂，并有邻近组织结构的出血和水肿。,急性损伤时，可合并肌腱韧带附着处的撕脱骨折；,关节内的韧带损伤常合并关节腔内出血或积液。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（一）韧带与肌腱损伤,Ligament andtendon injuries,【,临床与病理,】,Clinical and pathology,临床：局部肿胀、痛痛、压痛甚至皮下淤血，相应关节活动受限。,完全断裂时，施加外力可出现异常活动。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（一）韧带与肌腱损伤,Ligament andtendon injuries,【,影像学表现,】,Imaging manifestation,X,：一般不能显示肌腱韧带损伤的直接征象。,CT,：,损伤部位边缘模糊、肿胀，失去正常形态甚至呈碎片状，若伴有出血呈高密度影。,清晰显示撕脱骨折和关节腔积液。,MRI,：,-,最佳方法,不完全性断裂：,T2,低信号的韧带内出现高信号,完全性断裂：韧带、肌腱低信号结构完全中断，为混杂长,T1,、长,T2,信号取代，位置、走行方向发生改变。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,CT MPR of the knee demonstrate the anterior cruciate ligament(yellow arrow)and posterior cruciate ligament(blue arrow).The cruciate ligaments are better seen with MRI;however CT can be useful for those patients who cannot undergo MRI.To adequately demonstrate ligaments within the knee joint with CT,a double contrast arthrogram is performed.Radiopaque contrast material is seen within the patellofemoral joint compartment on this sagittal image.Administering single or double contrast agents into the joint capsule allows us to see it on an x-ray.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,These three CT arthrogram images demonstrate the synovial capsule of the knee.Left is the sagittal image that shows the extensive architecture of the capsule,especially the patellofemoral compartment.The middle axial image also shows the patellar femoral compartment.The right image shows the distal femur near the articular surface that is enclosed by the capsule.Although the capsule like other soft tissue structures of the knee are not fully appreciated on plain films these images are presented to help the radiographer appreciate the complexity of the knee.Many inferences can be made from plain films when properly positioned and the correct radiographic exposure made.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,LEFTAcute Anterior Cruciate Ligament(ACL)-tear.,ACL fibers too flat compared to condylar roof.,RIGHT:Discontinuity of fibers.,Anterior Cruciate Ligament,.,The case on the left shows a ligament thats too flat and we see disrupted fibers so there is abnormal orientation and discontinuity.Based on these images we cannot differentiate between complete tear,high grade partial tear or partial tear.MRI does not accurately differentiate between partial or complete ACL tear.But yes we can differentiate between high grade or low grade injury.A high grade injury is not able to see 50%of the fibers.So if the othopaedic surgeons operate on a high grade injury,they will either find a totally torn ACL or a high grade partial tear,that needs to be repaired.On the other hand if most of the fibers appear to be intact on MR indicating a low grade ACL tear,they will find an intact or partially torn ACL,that is stable and doesnt need any treatment.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Anterior Cruciate Ligament,.Bone bruises,擦伤,appear in a very typical location indicating the dislocation,that was the cause of the ACL-tear.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Segond fracture indicating ACL-tear,胫骨平台外缘撕脱骨折,The unhappy triad,or ODonoghues syndrome is a differentcombination of injuries.The unhappy triad injury commonly occurs in contact sports such as football when the knee is hit from the outside.This causes an injury to three knee structures:,ACL tear,MCL tear(medial collateral ligament),Medial meniscal tear,Anterior Cruciate Ligament(4),On X-rays an important indirect sign of an ACL-tear is a Segond fracture.,Difficult to see on MR,but much more easy to see on radiographs.,A Segond fracture is an avulsion fracture at the attachment of the lateral collateral band due to internal rotation and varus stress.,In 75-100%there will also be a tear of the ACL.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Torn ACL.ACL fibers are too flat(yellow arrow)compared to intercondylar roof(Blumensaats line).,ACL,撕裂。,ACL,纤维扁平（黄色箭头）与髁间屋顶（,Blumensaat,的线）,Anterior Cruciate Ligament,Case on the left shows a torn ACL.Fibers have an abnormal orientation(too flat).Yet it is difficult to see if these are attached to the femur.The acute angulation in the ligament is due to fact that the ACL and PCL have scarred together(see below).,ACL,撕裂,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,In the axial plane there is an empty notch signyellow arrows)where there should be ACL attached to the condyle.At a lower level(going right)the torn ACL is scarred to the PCL(green arrows),Sometimes it is easier to see whether these fibers are attached in the coronal plane.Against the interior part of the lateral condyle there never should be fluid.If this is the case it is called the empty notch sign indicating that the ACL is torn from its attachment to the femur.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,In the axial plane there is an empty notch sign(yellow arrows)where there should be ACL attached to the condyle.At a lower level(going right)the torn ACL is scarred to the PCL(green arrows).,轴位像：,ACL,附着于髁突处见空切迹征（黄色箭头）。在紧邻较低水平撕裂的,ACL,紧贴,PCL,（绿色箭头）,Also in the axial plane there should be ligament next to the condyle.At a lower level we see the torn ACL attached to the posterior cruciate ligament.They have scarred together.This is a very common appearance of a chronic ACL tear.This scarring leads to the acute angulation of the ligament.Even though the ACL is connected to the PCL it is not strong enough and still needs reconstruction.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,MCL from medial epicondyle(yellow arrow)to below the inferomedial geniculate vessels(red arrow)about 7 cm below the joint space.,Medial collateral ligament-,anatomy,The superficial medial collateral ligament(MCL)extends from the medial epicondyle to insert not just near the joint but 7 cm below the joint space.At that point there are three landmarks:the inferomedial geniculate artery and paired veins(figure).The deep part of the MCL,even when it is normal,you may not be able to see.It is closely applied to the medial meniscus and the superficial MCL.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,The case on the left shows a Grade I sprain of the medial collateral ligament.,内侧副韧带扭伤,I,级,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Grade II MCL Sprain,扭伤,内侧副韧带扭伤,II,级,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Superficial MCL-tear(yellow arrow)and deep MCL tear(orange arrow).,The case on the left shows a superficial MCL that is torn from its attachment on the tibia.Remember it should be attached 7 cm below the joint line.,MCL,撕裂,【,临床与病理,】,Clinical and pathology,可原发于软组织或继发于骨的感染。,临床：局部红、肿、热、痛。全身发热，白细胞计数升高。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（二）软组织炎症,Soft tissue inflammation,【,影像学表现,】,Imaging manifestation,X,：软组织肿胀。,CT,：,平扫：软组织肿胀，片状低密度影，肌间隙和脂肪层模糊囊肿表现为液性低密度区，内有气体提示产气菌感染。,增强：脓肿壁环形强化。,MRI,：,-,最佳方法,平扫：受累肌肉肿胀，肌间隙模糊，呈弥漫性长,T1,长,T2,信号，脓液呈,T1,长,T2,信号，有包膜，脓肿边缘光整，,强化：脓肿壁环形强化，脓腔不强化。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,Case 2.,Pyomyositis of bilateral paraspinal and both thighs at its invasive or early stage(no abscess formation).Contrast-enhanced CT.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,The patient was a 9 1/2 year old boy with pain in his left proximal medial thigh.,LEFT THIGH MASS,BIOPSY:MYOSITIS OSSIFICANS.,左大腿肿块，活检：骨化性肌炎。,Axial post-contrast T1 weighted image,demonstrates a densely enhancing mass arising within the left adductor magnus muscle.The margins of the mass are somewhat indistinct due to adjacent intramuscular edema and inflammation.,Coronal T2 weighted image,demonstrates the full extent of the intramuscular abnormality.,Nuclear medicine whole body image,demostrates a mass in the left medial thigh.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,嗜酸性筋膜炎,Eosinophilic fasciitis,Typical depressed veins aspect(“groove sign”)of the left forearm of a patient with an eosinophilic fasciitis(EF).,Thigh muscle magnetic resonance imaging(MRI)of a patient with EF:the axial fat-suppressed,T2-weighted fast spin-echo MR image shows a markedly increased signal intensity within superficial and deep fascial layers and a mildly increased T2 signal intensity within superficial muscle fibres adjacent to the fascia(arrows).,Skin-fascio-muscular biopsy of a patient with EF:the haematoxylin-eosin staining shows intense,diffuse and perivascular inflammatory infiltrates within the fascia,composed mainly of lymphocytes,but also eosinophils(arrows).,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,慢性肉芽肿性曲霉滑膜炎,Chronic Granulomatous Aspergillus Synovitis,Knee MRI showing synovia inflammation.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,四肢炎症性肌纤维母细胞瘤,Inflammatory Myofibroblastic Tumor of Extremities,53-year old woman with inflammatory myofibroblastic tumor on right thigh.(A,B)Initial MRI shows 14611 cm sized poorly marginated high SI on T2WI soft tissue mass abutted to deep femoral vessel and proximal femoral shaft.(C)Spindle cells with abundant plasma cells and lymphocytes infiltrating between collagen fibers were observed(H&E,400).(D)Recurrence was found 19 months after marginal excision.MRI shows 855.3 cm sized infiltrating soft tissue mass which abutted to deep femoral vessels.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,四肢炎症性肌纤维母细胞瘤,Inflammatory Myofibroblastic Tumor of Extremities,37-year old woman with inflammatory myofibroblastic tumor on left elbow.Incisional biopsy was done at another hospital and patient was referred to our clinic.(A,B)Initial MRI shows 84.64.6 cm sized poorly marginated,infiltrative soft tissue mass in left elbow surrounding meta-diaphysis of radius and abutted to proximal ulnar.Tumor encases ulnar and inter-osseous artery with suspicious invasion of ulnar nerve,and abutted to radial neurovascular bundle.(C)Marginal excision including radial head and ulnar artery,alcohol ablation of resected radial head,internal fixation and arteriorrhapy with vein graft were done.(D)Pathologic examination shows scar-like,hypocellular pattern which resembles fibromatosis.Spindle cells are dispersed in background of loose collagen and inflammatory cells(H&E,400).(E)Local recurrence was developed 9 months after marginal excision.Tumor abutted to ulnar neurovascular bundle.,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,四肢炎症性肌纤维母细胞瘤,Inflammatory Myofibroblastic Tumor of Extremities,33-year old woman with inflammatory myofibroblastic tumor on right buttock.(A,B)Initial MRI shows 665.6 cm sized tumor in right sciatic foramen involving sciatic nerve.After intralesional excision,adjuvant chemotherapy and radiation therapy was done.(C)Initial diagnosis was inflammatory myofibroblastic tumor.Loosely arranged spindle or plump cells are noted in a vascular and abundant collagenous background with a few chronic inflammatory cells(H&E,400).(D)8 months later,local recurrence was developed and patient was referred to our clinic.(E)Neoadjuvant chemotherapy was done.MRI shows unchanged size with partial necrosis.Intralesional excision and following adjuvant chemotherapy were done.(F)10 months later,local recurrence was found and excision was done.(G)Diagnosis was grade 3 spindle cell sarcoma.Tumor shows necrosis and compact fascicles,which consists of spindle cells with pleomorphism and marked hyperchromasia(H&E,400).,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,钙化性肌坏死,Calcific Myonecrosis,Figure 1 shows a large fusiform-shaped area of calcification overlying the anterior compartment of the left leg extending from just below the proximal tibiofibular articulation to the level of the distal shaft of the fibula.Magnetic resonance imaging(MRI)showed extensive replacement of the lateral compartment muscles by a central high and peripheral low T1 signal and diffuse low T2 signal tissue(Figures 2,3).Computed tomography(CT)performed for better characterization of the calcification pattern and distribution demonstrated predominantly peripheral distribution of the calcifications in the muscles of the lateral compartment(Figures 4,5).,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,（三）软组织肿瘤,Tumor of soft tissue,脂肪瘤,Lipoma,血管瘤,hemangioma,脂肪肉瘤,Liposarcoma,【,临床与病理,】,Clinical and pathology,脂肪瘤由分化良好的脂肪组织构成。女性多于男性。,多见于背部、臀部及四肢，为良性肿瘤。,常为单发，生长缓慢、质地柔软，常无临床症状。多发性脂肪瘤的瘤体较小，直径约,1cm,，一般不需处理，单发较大脂肪瘤宜行手术切除。,病理：包膜完整，肿瘤巨大时可坏死、液化、囊变和钙化。医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,脂肪瘤,Lipoma,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,【,影像学表现,】,Imaging manifestation,X,：圆形或类圆形脂肪样低密度区，边界清晰。,CT,：,平扫：圆形或类圆形脂肪样低密度区，边界清晰，,CT,值,-100-40Hu,，内部可有分隔，偶见钙化。,增强：无强化。,MRI,：,-,最佳方法,平扫：圆形或类圆形，边界清晰，呈短,T1,中长,T2,信号，脂肪抑制：病变低信号。分隔呈低信号。,强化：不强化，分隔可轻度强化。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,LIPOMA IN THE RIGHT ARM,【,诊断和鉴别诊断,】,Diagnosis and differential diagnosis,典型的脂肪组织密度和信号，诊断不难。,与含有脂肪组织的其它病变鉴别,分化良好的脂肪肉瘤：瘤内含有软组织密度和信号,畸胎瘤：三个胚层组织构成，除脂肪外，还含有其它成分，如钙化、骨骼、牙齿和液体成分。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节 软组织,【,临床与病理,】,Clinical and pathology,分为毛细血管型、海绵型、静脉型和混合型。,毛细血管瘤,Capillary hemangioma,：紫红色隆起包块，边界清楚，无包膜，主要发生于,1,岁内；好发于头面部皮肤和皮下组织,海绵状血管瘤,Cavernous hemangioma,：质地柔软，有假包膜，切面呈腔隙状，由囊性扩张管腔、薄壁的大血管构成，内有大量瘀滞的血流。,医学影像学 第一篇 影像诊断学 第九章 骨关节与软组织 第三节