膝关节和肩关节的MRI解剖

James Y. Song MSIV Gillian Lieberman, MD MRI Anatomy of the Knee and Shoulder James Y. Song, UC San Francisco MSIV Gillian Lieberman MD November 2002 2 James Y. Song MSIV Gillian Lieberman, MD Agenda • Knee Sagittal, Coronal FSE PD Ligamentous (ACL, PCL, MCL, LCL) and meniscal injury • Shoulder Sagittal, Coronal T2WI Shoulder impingement classification 3 James Y. Song MSIV Gillian Lieberman, MD Anatomy: Knee Sagittal patellar articular cartilage lateral meniscus (post.horn) lateral meniscus (ant.horn) tibia, articular cartilage infrapatellar fat pad gastroc (m) tibialis posterior P S G (l) plantaris BIDMC 2002 4 James Y. Song MSIV Gillian Lieberman, MD Anatomy: Knee Coronal PCLACL vastus lateralis biceps femoris popliteal a + v. gastroc. (medial) iliotibial tract MCL tendon of sartorious peroneus longus BIDMC 2002 gastroc. (lateral) 5 James Y. Song MSIV Gillian Lieberman, MD Anterior Cruciate Ligament • Functional Anatomy Intra-articular, extra-synovial, extends from anterior tibia to to inner portion of lateral femoral condyle Limits anterior translation of tibia, hyperextension, internal rotation • Mechanism of Injury External rotation and abduction w/ hyperextension, direct forward displacement of tibia, internal rotation w/ fully extended knee Can occur in conjunction w/ meniscal tears (41-68%), injury of other collateral ligaments, osteochondral or compression fractures 6 James Y. Song MSIV Gillian Lieberman, MD MRI Criteria for ACL rupture Complete Rupture DIRECT SIGNS: -complete fiber disruption -abnormal course of cruciate ligament -intracapsular pseudomass in position of ACL INDIRECT SIGNS: -acute angulation of PCL -drawer phenomenon -”kissing contusions” 7 James Y. Song MSIV Gillian Lieberman, MD MRI Criteria for ACL Rupture Incomplete Rupture -thinning of ACL < 10mm -periligamentous pseudomass in presence of intact fibers -increased intraligamentous signal with remnants of intact fibers 8 James Y. Song MSIV Gillian Lieberman, MD ACL Tear Sagittal PD Sagittal T2WI Graf et al. Am. J. Sports. Med. 1993; 21(2): 220-3. James Y. Song MSIV Gillian Lieberman, MD • Functional Anatomy Extends from posterior tibia to inner aspect of medial femoral condyle Post Cruciate Ligament Limits anterior translation of femur, stabilizes knee in extension • Mechanism of Injury Isolated tear secondary to fall on flexed knee, assoc. w/ osseous avulsion fracture at tibial insertion site 9 10 James Y. Song MSIV Gillian Lieberman, MD MRI Criteria for PCL Rupture - confined areas of increased signal intensity along course of the ligament (= partial rupture) - continuity disruption (= complete rupture) 11 James Y. Song MSIV Gillian Lieberman, MD Medial Cruciate Ligament and Lateral Cruciate Ligament • Functional Anatomy MCL: 8-10 cm, from medial epicondylar region to 4-5cm inferior to tibial plateau LCL: 5-7 cm, extracapsular, from lateral femoral epicondyle to conjoined insertion w/ biceps femoris tendon on fibular head • Mechanisms of Injury MCL: valgus stress without rotation, and direct trauma with valgus stress PCL: varus stress with out without rotation 12 James Y. Song MSIV Gillian Lieberman, MD MRI Criteria for MCL/LCL rupture Bohndorf et al. Musculoskeletal Imaging: A concise multimodality approach. Thieme 2001: 112. 13 James Y. Song MSIV Gillian Lieberman, MD Meniscus Anatomy Anterior horn Three Units Intermediate zone (pars intermedia) Posterior horn Anterior meniscus body Posterior meniscus body Posterior horn Anterior hornPeripheral meniscus body 25-50-25 Rule • each meniscus can be divided into 3 zones • lateral meniscus is more C-shaped, with a shorter radius 14 James Y. Song MSIV Gillian Lieberman, MD MRI Evaluation of Meniscal Damage • Size • Configuration of meniscus and signal pattern • Depth and width of altered signal • Location within meniscus 15 James Y. Song MSIV Gillian Lieberman, MD Gradation of Signal Alteration in Menisci (Stoller) 0 1 2 3A 3B 16 James Y. Song MSIV Gillian Lieberman, MD Meniscal Tear Morphology • Vertical (traumatic or degenerative) • Horizontal (usually traumatic, posterior horn) • Bucket-Handle Tear (subtype of vertical) • Peripheral (within 5mm of periphery) • Amputating (truncated free border or tip) • Radial (traumatic or degenerative, medial) 17 James Y. Song MSIV Gillian Lieberman, MD Bucket-Handle Tear Weiss KL et al. AJR. 1991: 156(1): 117-119. 18 James Y. Song MSIV Gillian Lieberman, MD Shoulder Anatomy • Bones (shoulder girdle, humerus) • Joints (glenohumeral, scapulothoracic, acromioclavicular; all synovial) • Muscles (attachments at ant/post scapula, ant/post humerus, ant/inf clavicle) • Nerves and arteries James Y. Song MSIV Gillian Lieberman, MD Shoulder Anatomy: Coronal 1 clavicle coracoid process supraspinatus (+tendon) subscapularis serratus anterior brachial plexus coracobrachialis tendon of biceps brachii (short head) BIDMC 2002 20 James Y. Song MSIV Gillian Lieberman, MD Shoulder Anatomy: Coronal 2 glenohumeral ligament biceps brachii m. (short and long head) suprascapular a. + n. tendon of biceps brachii m. (long head) BIDMC 2002 21 James Y. Song MSIV Gillian Lieberman, MD Shoulder Anatomy: Coronal 3 superior glenoid labrum inferior glenoid labrumscapula glenoid cavity trapezius spine of scapula clavicle acromion BIDMC 2002 22 James Y. Song MSIV Gillian Lieberman, MD Glenohumeral Joint 1. Anterior labrum 2. Subscapularis 3. Infraspinatus 4. Posterior labrum 5. Humerus 6. Glenoid cavity CyberAnatomy Tutorials, University of Newcastle upon Tyne. 23 James Y. Song MSIV Gillian Lieberman, MD Shoulder Anatomy: Sagittal 1 acromion supraspinatus glenohumeral and coracohumeral lig. deltoid teres minor anterior circumflex humeral a. + v. coracromial lig. biceps t. triceps brachii infraspinatus BIDMC 2002 24 James Y. Song MSIV Gillian Lieberman, MD Shoulder Anatomy: Sagittal 2 clavicle scapulasupraspinatus tendon of biceps brachii m. (long) latissimus dorsi coracoid tendon of biceps brachii m. (short) teres major infraspinatus teres minor BIDMC 2002 25 James Y. Song MSIV Gillian Lieberman, MD Shoulder impingement syndrome • Stage I: <25 yrs., w/ edema and hemorrhage • Stage II: 25-40 yrs., w/ tendinitis and fibrosis of rotator cuff, thickening of subacromial bursa • Stage III: > 40 yrs., = tear James Y. Song MSIV Gillian Lieberman, MD References Bohndorf K., Imhof H., Pope TL. Musculoskeletal Imaging: A concise multimodality approach. Thieme 2001: 112. Slide 12. Graf et al. Bone bruises on MRI evaluation of ACL injuries. Am. J. Sports. Med. 1993; 21(2): 220-3. Weiss KL, Morehouse HT, Levy IM. Sagittal MR images of the knee: a low-signal band parallel to the posterior cruciate ligament caused by a displaced bucket-handle tear. AJR Am J Roentgenol. 1991; 56(1): 117- 9. Slide 17. Shanahan D. Cyberanatomy Tutorials: http://numedsun.ncl.ac.uk/~nds4/tutorials/. Anatomy and Clinical Skills Centre, University of Newcastle Upon Tyne. 2002. Slide 22. 26 27 James Y. Song MSIV Gillian Lieberman, MD Acknowledgements • Steve Reddy, MD • Larry Barbaras and Cara Lyn D’amour • Gillian Lieberman, MD • Pamela Lepkowski MRI Anatomy of the Knee and Shoulder Agenda Anatomy: Knee Sagittal Anatomy: Knee Coronal Slide Number 5 MRI Criteria for ACL rupture MRI Criteria for ACL Rupture ACL Tear Slide Number 9 MRI Criteria for PCL Rupture Medial Cruciate Ligament and Lateral Cruciate Ligament MRI Criteria for MCL/LCL rupture Meniscus Anatomy MRI Evaluation of Meniscal Damage Gradation of Signal Alteration in Menisci (Stoller) Meniscal Tear Morphology Bucket-Handle Tear Shoulder Anatomy Shoulder �Anatomy: Coronal 1 Shoulder �Anatomy: Coronal 2 Shoulder �Anatomy: Coronal 3 Glenohumeral Joint Shoulder �Anatomy: Sagittal 1 Shoulder �Anatomy: Sagittal 2 Shoulder impingement syndrome References Acknowledgements