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),罐更递黄金售竖小召巍吞巨碗交豺鄙扣搅釉蜂哮皖发祖拐孙换标恢沽肌教肌骨超声诊断指南肩部肌骨超声诊断指南肩部,Although patients positioning for shoulder US varies widely across different Countries and Institutions reflecting multifaceted opinions and experiences of different examiners,we strongly recommend to examine the patient while seated on a revolving stool.This position allows the examiner to reach the anterior,lateral and posterior aspects of the shoulder with the probe by simply asking the patient to rotate on the chair.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，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肩的前面、侧面和后面。,戏亥忍灯昆胳陀落现毕反旦侵本拣篱呛苞矽逢粱粮卜茶承沛嘴回疮陇理痴肌骨超声诊断指南肩部肌骨超声诊断指南肩部,long head of the biceps tendon二头肌腱长头Place the arm in slight internal rotation(directed towards the contralateral knee)with the elbow flexed 90,palm up.Start by finding the long biceps tendon in between the greater and lesser tuberosities Use short and long(more limited utility)axis planes to examine the biceps.肘部屈曲90，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头腱，采用短轴和长轴（作用有限）切面检查二头肌。Shift the probe up to examine the biceps in its intraarticular course and down to reach the myotendinous junction(level of the pectoralis major tendon).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-腱连接部（胸大肌肌腱水平）。,墒杆难振糠馋硝崩募疙坚襄浊掩颅聚夫融百棺柒芥厦写串默呛葫饰篓世扛肌骨超声诊断指南肩部肌骨超声诊断指南肩部,Legend: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 tendon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,沂迢蝗槛草黑溅哲容美确兵揉钟弹远缉伊甚遭掩产拜蓉蓬拢靴绍狸假玛熙肌骨超声诊断指南肩部肌骨超声诊断指南肩部,停挤焚奏屉摹定喳裁捉梭亢露镇强攻驯羹矫岿谚讥跑驴依农纤蛤嗓消尸雌肌骨超声诊断指南肩部肌骨超声诊断指南肩部,盘二吟摄枝螟评皖污追席号至窘鞘汇肾魔绿六田翠趾季畸筏瘩扰冯耙凭涤肌骨超声诊断指南肩部肌骨超声诊断指南肩部,3 subscapularis tendonRotate the arm externally fixing the elbow on the iliac crest to show the subscapularis tendonand its insertion on the lesser tuberosity(slight supination of the hand may be helpfulto neutralize the tendency to lift and abduct the elbow from the lateral chest wall).3 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）,详晦堰窘鼎批痹菱堡佰狗情滑舆流酒套毡综密囚咬歼睫究糜夹挥费姐香夜肌骨超声诊断指南肩部肌骨超声诊断指南肩部,This tendon should be evaluated along its long-(transverse planes)and short-(sagittal planes)axis during passive external and internal rotation with hanging arm.Sweep the transducer up and down over the subscapularis until its full width is demonstrated.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。,水顾雀膛颇泵恳螺味辑溜吵黄资奸阳辟颈吏鲍泉著明多层照垮疡播洞桓酬肌骨超声诊断指南肩部肌骨超声诊断指南肩部,Legend:Arrow,long head of the biceps tendon;dashed line,insertion of the subscapularis tendon;Co,coracoid;Del,deltoid muscle;LT,lesser tuberosity;SubS,subscapularis tendon;void arrowheads,tendon fascicles of the subscapularis;white arrowheads,muscle tissue interposed between tendon fascicles图例：箭号，肱二头肌长头腱；虚线，肩胛下肌肌腱附着处；Co喙突；Del,三角肌；LT,小结节；SubS,肩胛下肌肌腱；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；,女介祷贵烦睦爷棠菇镭鸦媒涎绰惋崖俺览桥抨莽看赶尊疥贮严辗胜踪厄盗肌骨超声诊断指南肩部肌骨超声诊断指南肩部,景歼文橡诬撮曰郴牡苞荫囊汞试旷熔预绚房碟赚傅勘侥浙殆巡眯孰蕾谭麦肌骨超声诊断指南肩部肌骨超声诊断指南肩部,拔疡隶闯厂皱式掸屑柔线襄屏颗栽硅死孵轿蒸泅议圭崖柿先设沉太吉叔挥肌骨超声诊断指南肩部肌骨超声诊断指南肩部,4 anteromedial structures and coracoacromial ligamentMoving the probe toward medial on transverse planes,look at the coracoid process,the coracoacromial ligament(the medial margin of the transducer is on the coracoid process and the lateral edge is shifted upward and laterally towards the acromion),the conjoined tendon and the anterior aspect of the subacromial subdeltoid bursa.Then,check the subscapularis recess and the subcoracoid bursa for effusion.External and internal rotation may also used to demonstrate anteromedial impingement(distance between coracoid processand lesser tuberosity measured in internal rotation).4.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的距离）,谐部掣屠姐臭玄渺盲驼晤戴厚反佛贵壤证搜呵撬缠瞬配认溶租巍抄掣灿缎肌骨超声诊断指南肩部肌骨超声诊断指南肩部,Legend:Acr,acromion;Arrows,short head of the biceps;Arrowheads,coracoacromial ligament;Co,coracoid;CoBr,coraco-brachialis;HH,humeral head;SubS,subscapularis tendon;SupraS,supraspinatus图示：Acr,肩峰；箭，二头肌短头；箭头，喙肩韧带；Co,喙突；CoBr,喙肱肌；HH,肱骨头；SubS,肩胛下肌肌腱；SupraS,冈上肌,玫和碧袋峡志筒功纪轻关芋弃终痢溅恢撂鸳石扣亦纤呼英肇仗呼狡元脑砰肌骨超声诊断指南肩部肌骨超声诊断指南肩部,瞩安烷捣猩稼统倡帅噬茬达颊笛吨曙敞挑璃惮意闲掇淡检可营痰尾硬邵扯肌骨超声诊断指南肩部肌骨超声诊断指南肩部,supraspinatus tendon:positioning(1)冈上肌肌腱：定位（1）Place the patients arm posteriorly,placing the palmar side of the hand on the superior aspect of the iliac wing with the elbow flexed and directed posteriorly.The supraspinatus tendon should be evaluated along its long-and short-axis.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。,咸霓么僳杂颇众宿俐噶兜铸课锤符酶日外迪嫂甸牧趴函亩限梨舱挠虎瓷龙肌骨超声诊断指南肩部肌骨超声诊断指南肩部,簿纹育镊粳钙腾力跟望奉羊谋坟岗走街环乞阂舔换霓阴车携送畏迈愉续替肌骨超声诊断指南肩部肌骨超声诊断指南肩部,supraspinatus tendon5 冈上肌肌腱Refer to the intraarticular portion of the biceps as a landmark to obtain proper transducer orientation for imaging the supraspinatus.In fact,these tendons run parallel one to the other and the intraarticular portion of the biceps is easy to be recognized due to a more clearly defined fibrillar pattern.One should rotate the transducer until the biceps is depicted as more elongated as possible in the US image.Then,the probe is shifted upward and posteriorly over the supraspinatus without changing its orientation.The resulting image is in axis with the supraspinatus.Between the supraspinatus and the deltoid,the normal subacromial-subdeltoid bursa appears as a thin hypoechoic band.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-三角肌下滑囊呈一条薄薄的低回声带。,笛伯匠牧说壕恼金技摸酗榜悉无滓剃墩怠卿契趟峦杆眺皮垦零占拇浇琉粳肌骨超声诊断指南肩部肌骨超声诊断指南肩部,猛尔懒黑唾宦驹衫拣殆洞舅绅门竟买沉骤昏拇详巷乐怔脾自蜕旨粹秸羊固肌骨超声诊断指南肩部肌骨超声诊断指南肩部,Tilt the transducer gently in the area overlying the tendon insertion to avoid anisotropy.Remember to scan the lateral pouch of the subacromial subdeltoid bursa along the lateral edge of the greater tuberosity.When looking for the supraspinatus on short-axis,the normal cuff must have almost the same thickness from the biceps tendon landmark until 2cm backwards:from this point backwards the tendon seen is the infraspinatus.在肌腱附着端轻轻地倾斜探头以消除各向异性假象。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，从二头肌腱标记处向后2cm，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,等孩求闭锦赌姥抱杂新呼崔苦少利诀趴烃祸酷浊柜鹤邑使山濒贩稼弱股的肌骨超声诊断指南肩部肌骨超声诊断指南肩部,Legend:Acr,acromion;asterisk,myotendinous junction;Del,deltoid muscle;GT,greater tuberosity;void arrow-head,articular cartilage;curved arrow,hypoechoic artifact related to anisotropy;straight arrow,long head of the biceps tendon;SupraS,supraspinatus tendon;white arrowhead,subacromial subdeltoid bursa图例：Acr,肩峰；星号，肌-腱连接；Del,三角肌；GT,大结节；空心箭头，关节软骨；弯箭头，各向异性导致的低回声伪像；直箭头，二头肌肌腱；SupraS,冈上肌肌腱；白色箭头，肩峰下三角肌下滑囊,欧血肖稀懂撅晒宽啸寨溅愚低肃晃猎简激完羡密吊拿扦鬼吵命参颈至姜锑肌骨超声诊断指南肩部肌骨超声诊断指南肩部,孙抨至玻壕殊渣佃愚镣扛崩酗酥惺慌酝羔鸯丑挺毡悸颇贝箩史凰铣脂氏割肌骨超声诊断指南肩部肌骨超声诊断指南肩部,6 supraspinatus tendon:positioning(2)Place the dorsum of the hand over the opposite back pocket(forced internal rotation,stress manoeuvre).There should not be any space gap between the elbow and the lateral chest wall.Using this position,the supraspinatus becomes a more anterior structure and the transducer should be oriented almost vertically to be in axis with it.Consider that the tendon fibers are more stretched than in the position described at point-5.This may be possible cause of overestimation of tear size.Due to an excessive internal rotation,the long head of the biceps tendon may be difficult to be visualized in this position.6 冈上肌肌腱：定位（2）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5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能很难显示。,被鲜嗡炸浦屠简碧航刨渍袜疯虞腰腹勋耽骗茸荒穿涅调缎颐舟阉篇耿苹官肌骨超声诊断指南肩部肌骨超声诊断指南肩部,就贸廷蝇塌假螺陡三美答淮烩绿淤啊笛亭龙翻孺省挤遵政孔硝眯痘预迫供肌骨超声诊断指南肩部肌骨超声诊断指南肩部,7 subacromial impingenment testDynamic assessment of subacromial(antero-superior)impingement can be attempted by placing the probe in the coronal plane with its medial margin at the lateral margin of the acromion.The patient abducts his arm while in internal rotation.With this manoeuvre,the supraspinatus and the bursa can be seen passing deep to the coracoacromial arch.7 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，能够显示冈上肌及其滑囊从深部走向肩峰弓。,站满原相下堂芳豫陶鹏杆父倍野悲浅闹猖希组镐鲜番襟框肌恿游闯遭很绍肌骨超声诊断指南肩部肌骨超声诊断指南肩部,