LERNING OBJECTIVES 学习目标 To know how to optimize the image of the rheumatic shoulder 了解如何优化风湿性疾病肩关节的影像 To discuss the applications and validity of the

ULTRASOUND DIAGNOSIS OF SHOULDER PATHOLOGY 肩部病变的超声诊断 INGRID MÖLLER ingridmoller@gmail.com Ins$tuto Poal de Reumatologia

LERNING OBJECTIVES 学习目标 To know how to optimize the image of the rheumatic shoulder 了解如何优化风湿性疾病肩关节的影像 To discuss the applications and validity of the MSUS in the shoulder: 讨论 MSUS 在肩关节中的应用和效果 ---inflammatory signs 炎症表现 ---structural damage 结构损害 To overview the main guided procedures in the rheumatic shoulder 概述风湿性疾病肩关节的引导操作步骤

THE IMPORTANCE OF SHOULDER PATHOLOGY IN RHEUMATOLOGY 风湿性疾病中肩关节病变的重要性参考文献 Close associaion between small and large joints structural damage in paients with RA Bjelle A. Clin Rheumatol 1989 Drossaers---Bakker KW. Rheumatology 2000 Rotator cuff lesions including rotator cuff tear/s are frequent in inflammatory paients consuling to the rheumatologist. Painful shoulder in RA in not always related with synoviis Vecchio Rheumatology 1995 Van de Sande, ArthriFs&care 2008 Stegbauer, Rheumatology 2008

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs 炎症表现 : Glenohumeral joint/bicipital TS 盂肱关节 / 肱二头肌腱鞘 AC joint 肩锁关节 Sternoclavicular joint 胸锁关节 Bursae 滑囊 Structural damage 结构损害 : Tendon 肌腱 Cortical bone 骨皮质 Erosion 侵蚀 Osteophytes 骨赘 Cartilage (hyaline, fibrocartilage) changes 软骨 ( 透明 纤维软骨 ) 改变

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs 炎症表现 : Glenohumeral joint/bicipital TS 盂肱关节 / 肱二头肌腱鞘

GLENOHUMERAL JOINT 盂肱关节 WHERE 位置 Posterior recess 后隐窝 Axillary recess 腋窝 Superior subscapularis (anterior) recess 肩胛下肌 ( 前方 ) 隐窝上方 Intertubercular sulcus (bicipital groove) 结节间沟 ( 肱二头肌间沟 ) PATIENT and PROBE POSITION 患者体位和探头位置 Standard position to visualize the posterior GH joint 标准体位观察后盂肱关节 Dynamic maneuvers (external rotation) 动态检查 ( 外旋 ) Decubitus and dynamic maneuvers to identify the anterior recess 卧位及动态检查确定前隐窝 ADJUST SETTING OF THE MACHINE!! 调整机器的设置!!

GLENOHUMERAL JOINT 盂肱关节 关节囊由肩胛下肌 大圆肌 冈上肌和肱三头肌长头腱的肌腱所包围

GLENOHUMERAL SYNOVITIS 盂肱关节滑膜炎 Instituto Poal de Reumatología 滑膜炎 : 积液可在关节囊内移动动态检查 : 肩外旋缺陷 : 冈下肌 ; 肥胖患者的前隐窝

GLENOHUMERAL SYNOVITIS 盂肱关节滑膜炎 参考文献 : MSUS accuracy to detect shoulder synovitis compared to MRI, surgery, aspiration. 比较 MSUS MRI 手术 穿刺探查肩关节滑膜炎的准确性 Specificity low Effusion potentially present in both inflammatory and degenerative shoulders. 特异性差 积液可同时存在于炎症和退行性变的肩关节 Correlation between GH synovitis and CRP in patients with RA. RA 患者中 GH 滑膜炎和 CRP 间的关联 Alasaarela, Koski, Bruyn, Stegbauer

GLENOHUMERAL SYNOVITIS 盂肱关节滑膜炎 Axillary recess 腋窝 Posterior and axillar recesses: sensitivity and good agreement for detecting effusion/ synovitis 后隐窝和腋窝 : 在探查积液 / 滑膜炎方面较好的敏感性和一致性 Alasaarela, Koski Axillary scanning is not possible when abduction is markedly restricted 肩关节外周明显受限时腋窝扫查不太可行

BICEPS TENDON 肱二头肌腱

肌腱长轴 : 纤维状结构

肌腱横断面 : 斑点状

肌腱的共性 ANYSOTROPHY 各向异性伪像

肌腱的长轴扫查

声波垂直 了解肌腱的走行 肌腱的长轴扫查

BICEPS TENDON and SYNOVITIS 肱二头肌肌腱和滑膜炎

BICIPITAL TENDON 肱二头肌肌腱 腱鞘炎

BICIPITAL TENDON PITFALLS 肱二头肌肌腱的检查误区

THE LIGAMENT. GENERAL L PRINCIPLES T 韧带检查的基本原则 Each ligament should be evaluated dynamically from bone to bone and starting in a full stretch position. 每条韧带都应在完全伸展位时进行动态评价, 从骨的一个附着端至另一附着端 A CAL CHL C Se

BICEPS TENDON. 肱二头肌肌腱 INTRAARTICULAR PATH. 关节腔内走行段

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs 炎症病变 : Glenohumeral joint/bicipital TS 肩锁关节 Sternoclavicular Bursae Structural damage: Tendon Cortical bone Erosion Osteophytes Cartilage changes

ACROMIOCLAVICULAR JOINT SYNOVITIS 肩锁关节滑膜炎 PATIENT and PROBE POSITION 患者和探头位置 Standard position to visualize the posterior AC joint. 患者处于标准位置, 以观察后方的肩锁关节 Be generous with the amount of gel. 别吝啬耦合剂!

ACROMIOCLAVICULAR JOINT 肩锁关节

ACROMIOCLAVICULAR JOINT CYST 肩锁关节囊肿 提示 1- intact rotator cuff (superficial and limited to the ACJ) 完整的肩袖 ( 表浅, 局限于肩锁关节 ) 提示 2 massive rotator cuff tear with cuff tear arthropathy, communication between GHJ and ACJ Aspiration : High recurrence rate of the cyst 巨大的肩袖撕裂及关节病变, 连通 GHJ 和 ACJ; 囊肿抽吸后的复发率高 Hiller, Clin Anat 2010

Sternoclavicular joint 胸锁关节

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs 炎症病变 : Glenohumeral joint/bicipital TS AC joint Sternoclavicular Bursae 滑囊 Structural damage: Tendon CorIcal bone Erosion Osteophytes Cartliage changes

SHOULDER BURSITIS 肩部滑囊炎 SUBCORACOID SPACE 喙突下区域 The subcoracoid bursa between the anterior surface of the subscapularis and the coracoid process. 喙突下滑囊 肩胛下肌的前方和喙突间 The subscapularis bursa =superior subscapularis recess. CommunicaIon with GHJ 肩胛下滑囊 = 肩胛下隐窝的上方, 与盂肱关节相通 SUBACROMIAL SPACE 肩峰下区域 The subacromialsubdeltoid bursa 肩峰下三角肌下滑囊

SUBCORACOID SPACE BURSITIS 喙突下滑囊炎

SUBCORACOID SPACE BURSITIS 喙突下滑囊炎

SUBSCAPULARIS BURSA --- SUBSCAPULARIS RECESS 肩胛下滑囊 肩胛下隐窝

SUBSCAPULARIS BURSA 肩胛下滑囊

SUBACROMIOSUBDELTOID (SASD) BURSITIS 肩峰下三角肌下 (SASD) 滑囊炎

SASD 滑囊炎

Institut o Poal de Re uma tolo gía I. Möller Bursi$s SHOULDER SASD BURSITIS 肩 SASD 滑囊炎 ---US examination revealed SASD bursitis to be the cause of most swollen shoulders 超声检查提示 SASD 滑囊炎是肩关节肿胀最常见的病因 ---Synovial hypertrophy severity is correlated with the intensity of pain. 滑膜增生的程度与疼痛程度相关 ---Widening of the bursa is associated with anterior medial shoulder pain and clinical syndrome of coracoid impingement 滑囊的增宽与肩关节前内侧疼痛和喙突撞击综合征相关

BURSA COMMUNICATION 滑囊的交通

POLYMYALGIA RHEUMATICA 风湿性多肌痛 Ultrasound further increases the specificity of the classification criteria of PMR. 超声提高了 PMR 分类标准的特异性 MSUS is useful in identifying uni or bilateral 可用于鉴别单侧或双侧 GLENOHUMERAL ARTHRITIS 盂肱关节炎 ++ SASD BURSITIS SASD 滑囊炎 ++ BICEPS TENOSYNOVITIS 肱二头肌腱鞘炎 +++ Hip involvement 髋关节受累 + MSUS is applicable to identify PMR relapses 可用于判断复发 GS---bursitis, arthritis 灰阶 滑囊炎, 关节炎 Doppler---active inflammation 多普勒 活动性炎症 MSUS showed sensitivity to change in monitoring PMR patient s response to corticosteroid 超声对监测患者对激素的反应非常敏感 Weigand, Machioni, Lange, Jimenez

SHOULDER IMPINGEMENT SYNDROME 肩部撞击综合征

SHOULDER IMPINGEMENT SYNDROME 肩部撞击综合征 Less organization of the fibrillar pattern 纤维状结构的紊乱

SHOULDER IMPINGEMENT SYNDROME 肩部撞击综合征 The syndrome is attributed to the compression of soft tissue by bones and ligaments while moving the joint 该综合征是由关节运动时骨骼和韧带压迫软组织所致

SHOULDER: LATERAL IMPINGEMENT SYNDROME 肩 : 侧方撞击综合征

SHOULDER: LATERAL IMPINGEMENT SYNDROME 肩 : 侧方撞击综合征

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs: Glenohumeral joint/bicipital TS AC joint Bursae Structural damage 结构损害 : Tendon 肌腱 CorIcal bone Erosion Osteophytes Cartilage changes

ROTATOR CUFF TENDONS 肩袖的肌腱

SUPRASPINATUS 冈上肌 Superior facet

TENDINOPATHY 肌腱病变 Tendinosis 肌腱炎 : ill---defined swollen hypoechoic area with a normal underlying bone cortex 肌腱肿胀, 回声减低, 下方骨皮质正常 Partial thickness tear 部分撕裂 : interruption of tendon fibres with or without hypoechoic material filling the defect 肌腱纤维中断, 缺损处伴或不伴低回声物质充填 Full---thickness tear 全层撕裂 : absence of the tendon fibers with or without hypoechoic material filling the defect 肌腱纤维的缺失, 缺损处伴或不伴低回声物质充填 Calcifications 钙化

TENDINOPATHY TEARS 肌腱病变 撕裂 ( 左图 )Tendinosis 肌腱炎 内撕裂 ( 右图 )Delaminating tear with horizontal component and fibrilar retraction 水平撕裂, 纤维回缩

Partial Full Thickness Tears 部分 全层撕裂 Rotator Most of them are articular side tears 大部分为关节面撕裂 delaminaing tear Instituto Poal de Reumatología

ROTATOR CUFF TEARS 肩袖撕裂

Classification 分类 TENDON TEAR 肌腱撕裂 PARTIAL 部分 FULL THICKNESS 全层 : complete (full width) 完全 incomplete (partial width) 不完全 SIZE 大小 Small full thickness <1 cm (Wiener, Seitz 1993) 小的全层撕裂 <2 cm (Van Holsbeeck 1996) Large full thickness 1---3 cm width (Wiener, Seitz 1993) 大的全层撕裂 2---4 cm (Van Holsbeeck 1996) Massive full thickness >3 cm width (Wiener, Seitz 1993) 巨大全层撕裂 >4 cm (Van Holsbeeck 1996)

ROTATOR CUFF TEARS 肩袖撕裂 Defects are hypoechoic in acute/recent tears,echogenic in subacute or chronic tears. 急性 / 近期撕裂中的缺损为低回声, 亚急性或慢性撕裂为等回声 Full thickness tear: there is an absence of tendon at its anatomic location 全层撕裂 : 原解剖部位的肌腱回声缺失 Campbell 2001, MarInolli 2002, De Maesener 2009, Robinson 2009

I. Möller FULL TICKNESS TEARS (FTT) 全层撕裂 US and MR imaging have comparable accuracy for FTT detection with MR having advantages in evaluating the extent, location and classification of associated pathologies US 和 MRI 在诊断 FTT 的准确性相当,MRI 在判断程度 位置和相关病变的分类上更有优势 Teefey

MEASUREMENT OF THE TEAR 撕裂的测量 Instituto Poal de Reumatología An estimation of the tear width can be obtained by measuring the distance between the torn ends on short axis 撕裂的宽度可在短轴上测量两个断端间的距离

THE ROTATOR CABLE 肩袖索 注释 : C: 喙突 D: 胸锁乳突肌 CHL: 喙肱韧带 BT: 肱二头肌肌腱 RC: 肩袖索 H: 肱骨头

ROTATOR CUFF PITFALLS 肩袖检查的误区

肩袖检查的误区 假阳性 假阴性 技术解剖疾病 各向异性伪像, 探头位置 肩袖间隔, 肩袖撕裂的诊断标准 冈上肌 / 冈下肌的界面, 三角肌隔膜造成的声窗 肌肉肌腱连接处 肌腱的不均一性, 设置 : 频率 焦点 纤维软骨插入点 慢性肌腱撕裂 标记的变化 步骤 创伤后 患者因素 探头把握 手术后 瘢痕组织钙化肩袖变薄肌腱炎, 钙化, 滑膜增 生, 肉芽或瘢痕组织滑囊增厚, 巨大肩袖撕裂 Maahieu Radiraphics 2006

Instituto Poal de Reumatología

An

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Biceps tendon rupture in 35 % of the shoulders in RA. 35% 的 RA 肩关节中发生肱二头肌肌腱断裂 1/3 of rotator cuff surgical cases have some type of biceps tendon lesions. 1/3 的外科肩袖手术患者中存在某种形式的肱二头肌腱损伤 Instituto Poal de Reumatología Lesion can occur at the myotendinous junction, intertubercular groove, the rotator interval or biceps anchor. 损伤可发生在肌肉肌腱连接处, 结节间沟, 肩袖间隔或肱二头肌锚

BICIPITAL TENDON PITFALLS 肱二头肌腱的检查误区

TENDON CALCIFICATIONS 肌腱钙化

TENDON CALCIFICATIONS 肌腱钙化

I. Möller 肩袖中的钙化组织, 前面观 Instituto Poal de Reumatología

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs: Glenohumeral joint/bicipital TS AC joint Bursae Structural damage: Tendon Cortical bone 骨皮质 Erosion 侵蚀 Osteophytes 骨赘

EROSION BY US 超声发现的侵蚀 An intraarticular discontinuity of the bone surface that is visible in 2 perpendicular planes 2 个垂直平面内可见的关节内骨皮质的不连续 Wakefield 2005

CORTICAL EROSIONS 皮质侵蚀

I. Möller Cortical erosion: MRI>US>XR 骨皮质侵蚀 :MRI>US>XR

CORTICAL EROSIONS 骨皮质侵蚀 Inflammatory shoulder 肩关节炎 Post traumatic osteolysis (only at the clavicular end) 创伤后骨破坏 ( 仅在锁骨端 )

SHOULDER PATHOLOGY BY MSUS MSUS 中的肩部病变 Inflammatory signs: Glenohumeral joint/bicipital TS AC joint Bursae Structural damage: Tendon CorIcal bone Erosion Osteophytes Cartilage (hyaline, fibrocartilage) changes 软骨 ( 透明 纤维软骨 ) 病变

CRISTAL DEPOSITION 晶体沉积 纤维软骨连接了肱骨的结节间沟

CRYSTAL DEPOSITION 晶体沉积 The prevalence of AC joint CC increases with age and is associated with knee 肩锁关节的晶体沉积发生率随年龄增长, 并与膝关节相关 Parpekis, Clin Rheumatol 2013

GUIDED INJECTIONS 引导穿刺

GUIDED INJECTIONS 引导穿刺

GUIDED INJECTIONS 引导穿刺

SHOULDER PATHOLOGY BY US. CONCLUSION 超声下的肩关节病变总结 IN INFLAMMATORY, DEGENERATIVE AND TRAUMATIC DISORDERS OF THE SHOULDER US IS A VALUABLE AND VALIDATED APPROACH FOR: 超声可用于炎症性 退行性和创伤性肩部病变的如下方面 : Instituto Poal de Reumatología 1--- DIAGNOSIS 诊断 2---MONITORING DISEASE PROGRESS 监测疾病进展 3---GUIDED PROCEDURES 引导操作 4--- MONITORING TREATMENT RESPONSE 监测治疗反应

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