The Elbow Normal and Basic Pathological Sonography 肘关节正常和基础病理超声表现 Elbow anatomy 肘关节解剖 Systemic scan technique and sonographic anatomy 系统扫查技术以及超声下解剖 Ba

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1 Standardized scan elbow normal & basic pathology 肘关节标准扫描正常和基础病理超声表现 APLAR Pre-congress Course 2016 Shanghai Dr Carrel Ka-lung Yu 余嘉龙博士 Hong Kong Society of Rheumatology 香港风湿学会

2 The Elbow Normal and Basic Pathological Sonography 肘关节正常和基础病理超声表现 Elbow anatomy 肘关节解剖 Systemic scan technique and sonographic anatomy 系统扫查技术以及超声下解剖 Basic pathology findings 基础病理表现

3 Anatomy of Elbow 肘关节解剖

4 肱骨内上髁冠突窝肱骨小头外上髁桡骨头肱骨滑车环状隐窝冠突内侧桡骨尺骨外侧

5 肱骨内上髁肱桡关节肱骨小头桡骨头肱骨滑车外上髁肱尺关节环状隐窝近端桡尺关节内侧桡骨尺骨外侧

6 肱骨鹰嘴窝内上髁外上髁鹰嘴外侧尺骨桡骨内侧

7 肱骨肱骨小头鹰嘴桡骨头尺骨桡骨后方前方

8 肱骨鹰嘴窝外上髁鹰嘴滑车前方桡骨尺骨后方

9 肱肌肱肌肱桡肌

10 肱二头肌短头长头长头短头肱二头肌肌腱桡骨结节

11 肱三头肌外侧和长头表浅短头深在, 内侧长头外侧头短头肌腱近端尺骨鹰嘴

12 屈肌总腱桡侧腕屈肌掌长肌尺侧腕屈肌肱骨远端内上髁屈肌总腱指浅屈肌

13 肱骨远端伸肌总腱桡侧腕短伸肌外上髁指伸肌小指伸肌尺侧腕伸肌伸肌总腱

14 肘管尺神经肱骨肱三头肌内上髁尺骨鹰嘴与肱骨内上髁之间的空隙奥斯本筋膜尺骨鹰嘴尺侧腕屈肌

15 Systemic scan technique and sonographic anatomy 系统扫查技术以及超声下解剖

16 Technical Requirement 技术需求 A linear transducer with a frequency of at least 7.5 MHz is recommended for examining the elbow joint 检查肘关节推荐不低于 7.5MHz 的线阵探头 For superficial lying lesions a higher frequency transducer is useful,e.g MHz 检查表浅病变时, 频率更高的探头更实用, 例如 10-20MHz

17 General Principal in Scanning of the Elbow 扫查肘关节的基本原则 Static exam (Picture) 静态检查 ( 图片 ) Patient sitting in front/ next to examiner Arm supported, relaxed 患者在检查者前方或旁边坐下上臂用支撑物垫起, 放松 Linear transducer >7.5 MHz > 7.5 Mhz 的线阵探头 Minimal pressure 施予最小的压力 Dynamic exam (Video) 动态检查 ( 录像 )

18 Indication of US of the elbow 肘关节超声的指征 1. Effusion 渗出 2. Synovial proliferation 滑膜增生 3. Bursitis 滑囊炎 4. Bony lesions (erosions) 骨病变 ( 侵蚀 ) 5. Osteophytes ( 骨赘形成 ) 6. Loose joint bodies ( 关节游离体 ) 7. Differentiation between gout tophus and rheumatoid nodule 鉴别痛风石与类风湿结节 8. Tendinitis at the medial or lateral epicondyle 内上髁或外上髁肌腱炎 9. Calcinosis 钙化 10. Tendon rupture (distal biceps tendon) 肌腱撕裂 ( 远端肱二头肌 )

19 Standard views of the elbow 肘关节标准检查位置图 Anterior humero-radial long 前肱桡纵向 Posterior long 后方纵向 Anterior humero-ulnar long 前肱尺纵向 Lateral humero-radial long 外侧肱桡纵向 Posterior trans 后方横断面 Anterior transverse scan 前方横断面扫描 Medial humero-ulnar long 内侧肱尺纵向 Posterior long 后方纵向

20 Standard scans of the elbow 肘关节标准扫查步骤 1. Anterior humero-radial longitudinal scan 前肱桡纵向 2. Anterior humero-ulnar longitudinal scan 前肱尺纵向 3. Anterior transverse scan over the trochlea 滑车前方横断面 4. Anterior transverse scan over the radial head 桡骨头前方横断面 5. Posterior longitudinal scan (90 flexion / 180 extension) 后方纵向 (90 屈曲 / 180 伸展 ) 6. Posterior transverse scan (90 flexion / 180 extension) 后方横断面 (90 屈曲 / 180 伸展 ) 7. Posterior longitudinal scan (distal from the olecranon) 后方纵向 ( 鹰嘴远端 ) 8. Lateral humero-radial longitudinal scan (along lateral epicondyle) 肱桡外侧纵向 ( 沿外上髁 ) 9. Medial humero-ulnar longitudinal scan (along medial epicondyle) 肱尺内侧纵向 ( 沿内上髁 ) 10. Longitudinal scan along sulcus ulnaris 沿尺神经沟纵向 11. Transverse scan along sulcus ulnaris 沿尺神经沟横断面

21 Longitudinal scan of the anterior humeroradial recess 前肱桡隐窝纵向扫描 Brachioradialis m. 肱桡肌 Radial fossa 桡窝 Humeral capitellum 肱骨小头 Radial head 桡骨头 Proximal 近端 Distal 远端

22 Longitudinal scan of anterior humuroulnar recess 前肱尺隐窝纵向扫描 Brachialis 肱肌 Pronator teres 旋前圆肌 Humeral trochlea 肱骨滑车 Proximal 近端 Ulnar coronoid process 尺骨冠突 Distal 远端

23 Transverse scan of anterior synovial recess 前滑膜隐窝横断面扫描 Brachialis 肱肌 Humeral Capitellum 肱骨小头 Humeral Trochlea 肱骨滑车

24 Anterior transverse scan over radial head 桡骨头前方横断面扫描 Radial head 桡骨头

25 Medial Humero-ulnar Longitudinal Scan Common Flexor Tendon 内侧肱尺纵向扫描屈肌总腱 Medial Epicondyle 内上髁 Common flexor 屈肌总腱 Ulnar 尺骨 Proximal 近端 Distal 远端

26 Lateral Humero-radial Longitudinal Scan Common Extensor Tendon 外侧肱桡纵向扫描伸肌总腱 Lateral Epicondyle 外上髁 Common extensor 伸肌总腱 Radial head 桡骨头 Proximal 近端 Distal 远端

27 Posterior Joint Recess 后关节隐窝 Triceps tendon 肱三头肌腱 Triceps muscle 肱三头肌 Olecranon 鹰嘴 Olecranon fossa 鹰嘴窝 Proximal 近端 Distal 远端

28 Triceps Tendon 肱三头肌腱 Triceps tendon 肱三头肌腱 Olecranon 鹰嘴 Proximal 近端 Distal 远端

29 Posterior transverse scan 后方横断面扫描 Medial Epicondyle of humerus 肱骨内上髁 Lateral Epicondyle of humerus 肱骨外上髁 Medial 内侧 Lateral 外侧

30 Posterior longitudinal scan 后方纵向扫描 Olecranon 鹰嘴 Ulnar 尺骨 Proximal 近端 Distal 远端

31 Transverse & longitudinal Scan of the Ulnar Nerve 尺神经横断面和纵向扫描 Ulnar nerve 尺神经 Medial Epicondyle 内上髁 Medial 内侧 Olecranon 鹰嘴 Lateral 外侧 Proximal 近端 Distal 远端 Ulnar nerve 尺神经 Distal 远端

32 Basic Pathology of Elbow 肘关节基础病理

33 Elbow swelling 肘关节肿胀 smaller effusions may not be palpable 少量积液可能不能被手法检查出来 synovitis or effusion, or to another cause 滑膜炎渗出或其他原因

34 Effusion 渗出 anechoic or hypo-echoic, compressible and displaceable, not exhibiting color signals 等回声或低回声区, 可被压缩, 不能移动, 无血流信号 smaller effusions typically localize in the radial groove or the coronoid fossa, because or the lowest pressure of the joint capsule in this region 少量积液常常出现在桡窝或冠突窝, 因为关节囊中该部位压力最低 large effusions can fill the olecranon fossa, small effusions can only be visualized by flexing and extending the elbow. 大量积液可以填充鹰嘴窝, 少量积液只在屈伸肘关节时可以观察到

35 Synovitis 滑膜炎 hypo-echoic, poorly compressible, not displaceable, perhaps exhibiting color signals 低回声区, 不易被压缩, 不能移动, 可能呈现出血流信号

36 Enthesiopathy 肌腱端病 occurs most commonly at the lateral aspects of the humeral epicondyle, followed by the medial humeral epicondyle and the triceps tendon 最常出现在肱骨外上髁, 其次是肱骨内上髁和肱三头肌腱 The tendons become hypo-echoic, inhomogeneus and thickened in case of enthesiopathy 肌腱端病中肌腱呈现低回声, 不均匀及增厚的特点 Acute enthesitis Doppler signals 急性肌腱端炎 - 多普勒信号 Chronic enthesiopathy calcifications 慢性肌腱端病 - 钙化

37 Bursitis 滑囊炎 Fluid is anechoic and easily compressible 液体为无回声, 容易被压缩 Septic bursitis often contains fluctuating particles 化脓性滑囊炎囊内常常漂浮游移的颗粒 Gouty tophi occur as hyper-echoic, cloudy structures with partial or complete posterior shadowing 痛风石表现为高回声, 云雾状结构, 后带部分或完全声影 Rheumatoid nodules are hypo-echoic, usually with rather clear borders and no or only few color signals 类风湿结节常常表现为低回声, 边界清晰, 不伴有或仅伴有少量血流信号

38 Nerve pathology 神经病变 hypoechoic swelling of the nerve 神经呈现出低回声肿胀的特点 nerve entrapment due to synovitis, effusion, tumors or bony spurs 神经由于滑膜炎渗出肿瘤或骨赘而卡压

39 Elbow Synovial Proliferation 肘关节滑膜增生 Brachioradialis 肱桡肌 Brachialis 肱肌 Synovial proliferation 滑膜增生 Synovial proliferation 滑膜增生 Capitellum 肱骨小头 Radial head 桡骨头 Capitellum 肱骨小头 Trochlea 滑车

40 Elbow Synovitis 肘关节滑膜炎 Capitellum 肱骨小头 Radial head 桡骨头 Capitellum 肱骨小头 Radial head 桡骨头

41 Elbow Effusion 肘关节渗出 Triceps Brachii 肱三头肌 Olecranon 鹰嘴 Synovial thickening 滑膜增厚 Effusion 渗出 Olecranon fossa 鹰嘴窝

42 Elbow Synovial Proliferation with Effusion 肘关节滑膜增生伴渗出 Trochlear 滑车 Synovial proliferation 滑膜增生 Ulna 尺骨

43 Elbow Erosion 肘关节骨侵蚀 Capitellum 肱骨小头 erosion 骨侵蚀 Radial head 桡骨头 Radial head 桡骨头 erosion 骨侵蚀 Longitudinal Scan 纵向扫描 Transverse Scan 横断面扫描

44 Elbow Lateral Epicondylitis 肘外上髁炎 Lateral Epicondyle 外上髁 Common extensor 伸肌总腱 Radial head 桡骨头

45 Other pathology of elbow 肘关节其他病变 Rupture bicep tendon 肱二头肌腱撕裂 Olecrenon bursitis 鹰嘴窝滑囊炎 Effusion and synovial thickening 渗出和滑膜增厚 Osteoarthritis with loose body 骨关节炎游离体 Coronoid fossa 冠突窝

46 Live Demo of Elbow Ultrasound 肘关节扫查现场演示

Radiocarpal- and midcarpal joints 桡腕关节及中腕关节 Midcarpal Radio-carpal

手 / 腕关节标准扫查 & 基本病变 Hilde Berner Hammer Senior consultant, PhD Dept. of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway Radiocarpal- and midcarpal joints 桡腕关节及中腕关节 Midcarpal Radio-carpal Ultralyd MR