髕骨病變的影像學(xué)表現(xiàn)培訓(xùn)課件

髕骨病變的影像學(xué)表現(xiàn)Fig.1:Normalkneeradiographs圖1：正常膝關(guān)節(jié)2髕骨病變的影像學(xué)表現(xiàn)Sagittalprotondensity(a)andaxialfat-suppressedT2-weighted(b)MRimagesofanormalknee.Notethelowsignalpatellar(PT)andquadriceps(QT)tendonsandthethick,homogeneous-appearingpatellarcartillage(redarrows).Notethelateralandmediaretinacula,passivestabilizersofthepatella.3髕骨病變的影像學(xué)表現(xiàn)Fig.2:NormalMRimages圖2：正常膝關(guān)節(jié)MR圖像4髕骨病變的影像學(xué)表現(xiàn)In1941,Wibergclassifiedpatellarshapeintothreedifferentmorphologies:TypeI(a)demonstratesroughlysymmetricandequal-sized,concavemedial(MF)andlateral(LF)patellarfacets.TypeII(b)showsamedialfacetthatisslightlysmallerthanthelateralfacetandaconcavelateralfacet.TypeIII(c)alsoshowsasmallerandmoreverticallyorientedmedialpatellarfacet,whichisassociatedwithmaltrackingdisorders[18].5髕骨病變的影像學(xué)表現(xiàn)Fig.3:Variationsinpatellarmorphology圖3：髕骨形態(tài)變異6髕骨病變的影像學(xué)表現(xiàn)5-year-oldmalewithhereditaryosteo-onychodysplasia(nail-patellasyndrome).AP(a),later(b),andaxial(c)viewsofthekneedemonstratecompleteabsenceofthebilateralpatellarossificationcenters.7髕骨病變的影像學(xué)表現(xiàn)Fig.4:Patellaraplasia圖4：髕骨發(fā)育不良5歲男孩遺傳性指(趾)甲-髕骨綜合征（nail-patellasyndrome）8髕骨病變的影像學(xué)表現(xiàn)Anteroposteriorandaxialradiographs(a)showbilateral,well-corticatedossifiedfragmentsinthesuperolateralaspectofthepatellas(arrows).CoronalandaxialT2-weightedfat-suppressedMRimage(b)showthewell-corticatedossifiedfragment.Notethenormalbonemarrowsignalandcartilageacrossthesynchondrisis,Thewell-corticatednatureofthefragmentandlackofabnormalmarrowsignalhelptodifferentiatethisentityfromapatellarfracture.9髕骨病變的影像學(xué)表現(xiàn)Fig.5:Bipartitepatella圖5：二分髕骨10髕骨病變的影像學(xué)表現(xiàn)Anteroposterior,lateral,andaxialradiographs(s)showalucent,roundlesionwithwell-definedmarginsatthesuperolateralaspectofthepatella(arrows).SagittalprotondensityandaxialT2-weightedfat-suppressedMRimages(b)showafocalsubchondralosseousdefectwithintact-appearingoverlyingcartilage;thecartilageisthickened,andfillsthedefect.Thereisnormalbonemarrowsignalandsmooth,homogeneoussignalofthearticularcartilage.11髕骨病變的影像學(xué)表現(xiàn)Fig.6:Dorsaldefectofthepatella圖6：髕骨背側(cè)缺損（DDP）12髕骨病變的影像學(xué)表現(xiàn)Congenitalpatellaaltaisananatomicriskfactorforpatellofemoralinstability.Theinsall-Salvatiindexistheratioofthelengthofthepatella(PL)tothepatellartendon(PT).Thenormalvalueisbetween1.0and1.2,withincreasedvaluesindicatingpatellaaltaanddecreasedvalueindicatingpatellabaja.Lateralradiograph(a)atapproximately30degreesofkneeflxionshowsanoemallyplacedpatella,withInsall-Salvatiindexof1.1.Lateralradiograph(b)ofan8-year-oldmaleshowspatellaalta,withInsall-Salvatiindexmeasuring1.8.AxialT2-weightedtubrospinechoMRimage(c)formthissamepatientshowsfindingofalateralpatellardislocation.Thereisbonemarrowedemaofthemedialaspectofthepatella(arrow)anddisruptionofthemedialpatellarretinaculum(asterisk).Thispatienthadahistoryofrecurrentdislocations,likelyduetohiscongenitalpatellaalta.13髕骨病變的影像學(xué)表現(xiàn)Fig.7:Patellaalta圖7：高位髕骨a圖正常位置髕骨，髕韌帶長度（PT）/髕骨長度（PL）正常比值為1.0-1.2（國內(nèi)文獻(xiàn)一般小于0.8提示低位髕骨，大于1.2提示高位髕骨）；b圖PT/PL比值為1.8；c圖示髕骨脫位狀態(tài)，局部骨髓水腫。高位髕骨通常無癥狀，盡管它是膝關(guān)節(jié)不穩(wěn)定的重要解剖危險(xiǎn)因素之一。14髕骨病變的影像學(xué)表現(xiàn)Anteroposterior(a)andlateral(b)radiographsofa15-year-oldfemalepatientwithcingenitalright-sidedpatellabaja.Lateralradiographsofapatientoneyearfollowingtotalkneearthroplastydemonstratespatellabaja.Thepatellartendonisscarredtotheuppertibia(arrow).Patellabajamayalsobeseeninassociationwithneuromusculardiseases.Fromtal(c)andlateral(d)radiographsinthispatientwithahistoryofpolioshowmarkedpatellabaja.Alsonitethatthebineareosteopenicandgracileandthatthereisapaucityofsofttissues,inkeepingwiththepatient`shistoryofpolio.15髕骨病變的影像學(xué)表現(xiàn)Fig.8:Patellabaja圖8：低位髕骨a,b圖，15歲女孩右膝先天性低位髕骨。c,d圖，低位髕骨也見于神經(jīng)肌肉疾??；患者既往有脊髓灰質(zhì)炎病史。e圖，人工膝關(guān)節(jié)置換后患者一年復(fù)查，側(cè)位片提示低位髕骨；箭頭是髕韌帶疤痕形成。16髕骨病變的影像學(xué)表現(xiàn)TrochleardysplasiaisamongthemostsignificantanstomicfactorscontributingtopatellarmaltrackingLateralradiograph(a)depictsonesign,thecrossingsign,inwhichthelineofthedeepestaspectofthetrochleargroovecrossesovertheantenoraspectofthefemoralcondyles(arrow).Sagittalprotondensityimage(b)depictsanotherhndingoftrochleardysplasia.Theventraltrochlearprominence(vtp)hasbeendetinedasthedistancebetweenthelineparallelingtheventralcorticalsurfaceofthedistalfemurandthemostanteriorpointofthefemoraltrochlearfloor.Inthisimageisseenastep-likedeformityattheintertaceoftheanteriorfemoralcortexandtrochieawithavtemeasuring9mm,consistentwithtrochleardysplasia.AxialT2-weightedfat-suppressedimage(c)showsacongenitalydysplastictrochleawithamarkedlyshallowtrochieardepth(arrow),consistentwithtrochleardysolbsiaAddisanallynotedismarkedasymmetryofthemedial(MF)andlateral(LF)trochlearfacets.Alateraltomedalfemoralfacet.ranootgreaterthan1.75isgenerallyconsidereddiagrosncfortrochleardysplasia.Inthiscasetheratiomeasures23.representinganothertindingoftrochleardoplasia17髕骨病變的影像學(xué)表現(xiàn)Fig.9:Trochleardysplasia圖9：（股骨）滑車發(fā)育不良股骨滑車發(fā)育不良是指滑車溝前部的幾何外形和深度存在的解剖學(xué)異常?？梢痼x骨軌跡不良或慢性膝關(guān)節(jié)不穩(wěn)。18髕骨病變的影像學(xué)表現(xiàn)TrochleardepthassessedonaxialT2-weightedfat-suppressedimages.Alineisfirstdrawnparalleltotheposteriortemoralcondies(A).Linesdrawnperpendiculartothisindicatetheanteroposteriordimensionsofthelateral(B)andmedial(C)trochlearfacetsandofthedeepestportionofthelemoraltrochlea(D)Calculatetrochleardepthwiththeequaion(B·C/2)-D.Trochleardepthof3mmorlessindicatestrochleardysplasia.image(a)showsanormaltrochleardepth,image(b)showsadysplasnctrochleawithmarkedflattening19髕骨病變的影像學(xué)表現(xiàn)Fig.10:Trochleardysplasia–measurementoftrochleardepth圖10：滑車發(fā)育不良--滑車深度的測量計(jì)算公式：（B+C/2）-D；小于3mm提示滑車發(fā)育不良。a圖是正常的滑車深度，b圖是滑車發(fā)育不良，呈扁平狀。20髕骨病變的影像學(xué)表現(xiàn)ThedistancefromthetibialtubercletothetrochileargrooveismeasuredonaxialMRimages.Adistanceof<15mmisnormal,a15-20mmdistanceisborderline,andadistanceof>20mmindicatesconsiderablelateralizationandisalmostalwaysassociatedwithpatellarinstability.AxialMRimagesinthetoprow(a)showanormaltibial-tuberclegroovedistance(bluedouble-headedarrow).Imagesinthesecondrow(b)showmarkedlylateralpositionofthetibialtubercleinrelationtothetrochleargroove(bluedouble-headedarrow).21髕骨病變的影像學(xué)表現(xiàn)Fig.11:Lateralizationofthetibialtubercle圖11：脛骨結(jié)節(jié)的偏側(cè)性脛骨結(jié)節(jié)的偏側(cè)性通過測量脛骨結(jié)節(jié)-股骨滑車間距離來定性，測量方法：分別選擇通過脛骨結(jié)節(jié)的橫斷面圖像，及通過股骨髁間窩呈“羅馬拱門”形態(tài)的層面；勾畫出脛骨結(jié)節(jié)的層面，通過軟件和股骨髁間窩層面圖像融合，在此新的圖像上標(biāo)記股骨后髁的切線作為參考線，然后分別過股骨滑車最低點(diǎn)和脛骨結(jié)節(jié)中點(diǎn)作股骨后髁切線的垂線，2條垂線的距離即為脛骨結(jié)節(jié)-股骨滑車間距離。意義：反映施加于膝關(guān)節(jié)的屈伸裝置的外翻矢量。小于15mm正常；15-20毫米臨界；大于20mm診斷髕骨不穩(wěn)。a圖是正常，b圖提示髕骨不穩(wěn)。22髕骨病變的影像學(xué)表現(xiàn)30-vearoldfemaleformerlongdistancerunnerpresentswithprogressivelyincreasingkneepainfor3years,nowsugnihcantlylimitingheractintyLateralradiograph(a)showssubchondralsclerosis(bluearrow)ofthepatela.Sagittalprotondensity(b),sagittalT2-weightedfat-suppressed(cl,andanialT2-weightedfat-suppressed(d)imagesshowmuitifocalareasoffull-thicknesscartilagefissuringalongthepatelitlafwhitearrows).withsubjacentareasofmarrowedema(redarrows)andsubcorticalcysticchange.Notethenormalcarhlageelsewhere.23髕骨病變的影像學(xué)表現(xiàn)Fig.12:Chondromalaciapatellae圖12：髕骨軟化癥女，30歲，長跑運(yùn)動(dòng)員，進(jìn)行性膝關(guān)節(jié)疼痛3年；運(yùn)動(dòng)受限就診。a圖藍(lán)箭示髕骨軟骨下骨質(zhì)硬化；b，c，d圖示多發(fā)局灶性全層軟骨裂隙伴相軟骨下骨髓水腫和皮質(zhì)下囊變。24髕骨病變的影像學(xué)表現(xiàn)15-year-oldmalepatientwithkneepain.Lateral(a)andaxial(b)radiographsshowirregularityandadefectalongthepatellarapex(arrows).Sagittalprotondensity(c)andaxialT2-weightedfat-suppressed(d)imagesshowanosteochondrallesioninthemidpatellaattheapexwithbonemarrowedema(asterisk).Sagittalprotondensityimage(e)fromMRIperformed6yearslatershowsintervalresolutionofthelesion.25髕骨病變的影像學(xué)表現(xiàn)Fig.13:Osteochondritisdissecans圖13：剝脫性骨軟骨炎15歲男孩，膝關(guān)節(jié)痛。a，b圖示髕骨下級(jí)不規(guī)則缺損；c，d圖示局部骨軟骨游離伴軟骨下骨髓水腫；e圖示6年后復(fù)查，病灶修復(fù)。26髕骨病變的影像學(xué)表現(xiàn)13-year-oldfemalepresentingwithkneepain.Sagittalprotondensity(a),sagittalfatsuppressedprotondensity(b),andaxialfat-saturatedprotondensity(c)MRimagesshowanosteochondritisdissecanslesion.Thereissurroundinghighsignal(blackarrows)withsmallcysticchangeandfocalcartilagedefect.Sagittalprotondensityimage(d)fromfourmonthslater,followingarthroscopiclesionrepair,showsawell:incorporatedbonegraft.27髕骨病變的影像學(xué)表現(xiàn)Fig.14:Unstableosteochondritisdissecanslesion圖14：不穩(wěn)定的剝脫性骨軟骨炎13歲女孩膝關(guān)節(jié)疼痛；a，b，c圖示髕骨局部骨軟骨病灶周圍見液體信號(hào)影；d圖關(guān)節(jié)鏡修復(fù)后4個(gè)月復(fù)查，顯示移植骨愈合良好。28髕骨病變的影像學(xué)表現(xiàn)16-year-oldmalewithahistoryofacutelymphoblasticleukemia(nowinremissionl,diabetesmelitus,andobesity.Anteroposterior(a),lateral(b),andaxial(c)radiographsshowalucentareainthecentralposteriorregionoftherightpatella,withahaloofsclerosis.Sagitalprotondensity(d),andcoronal(e)andacial(f)T2weightedfat-suppressedimagesdemonstratealesionofintermediateandlowsignalintensity,suroundedbyaperipheralmarginoflowsignalintensityDarkareasrepresentboneinfarcts.29髕骨病變的影像學(xué)表現(xiàn)Fig.15:Patellarosteonecrosis圖15：髕骨骨壞死16歲男孩；急性淋巴結(jié)細(xì)胞性白血?。ìF(xiàn)緩解期）、糖尿病、肥胖病史。30髕骨病變的影像學(xué)表現(xiàn)Fig.16:Lateralpatellardislocation圖16：髕骨外側(cè)脫位慢性不穩(wěn)定/復(fù)發(fā)性脫位患者，如果不積極治療可能導(dǎo)致進(jìn)行性軟骨損傷和嚴(yán)重骨性關(guān)節(jié)炎。32髕骨病變的影像學(xué)表現(xiàn)Anteroposterior(a)andlateral(b)radiographsinapatierntpresentingwithadirectfallontothepatellashowacomminutedfractureofthepatella,with8mmofdistractionatthemidbone.33髕骨病變的影像學(xué)表現(xiàn)Fig.17:Acutefractureofthepatella圖17：髕骨骨折34髕骨病變的影像學(xué)表現(xiàn)Threeimagesofa12-year-oldmalefollowingafallwhopresentedwithanteriorkneepain,swelling,anddecreasedambulation.Lateralradiograph(a)showsaminimallydisplacedfractureoftheinteriorpatelia(arrow)withthickeningofthepatellartendonandasmallkneejointeffusion.Sagirtalprotondensityimage(b)showsatractureattheinferiorpoleofthepatella(arrow)withedemaofthepatellartendon.AxtialT2-weightedfat-suppressedimage(c)showsedemaattheinferiorpole.35髕骨病變的影像學(xué)表現(xiàn)Fig.18:Patellarsleeveavulsionfracture圖18：髕骨袖套狀撕脫骨折是兒童特有的一種髕骨骨折。因?yàn)轶x骨軟骨骨轉(zhuǎn)化過程中的髕骨骺生長板，位于其骨化核周緣，骺板的增殖、肥大細(xì)胞帶和初級(jí)鈣化帶薄弱，常不能耐受剪式應(yīng)力而分離損傷。當(dāng)膝關(guān)節(jié)處于半屈曲位股四頭肌強(qiáng)烈收縮時(shí)，牽引髕骨向上，而髕韌帶固定髕骨形成作用力和反作用力，髕骨下部的軟骨受股四頭肌強(qiáng)烈收縮而發(fā)生的撕脫性骨折，帶有少量骨組織或無骨組織被拔除，呈套狀。36髕骨病變的影像學(xué)表現(xiàn)34-vear-oldmalepresentingwithpersistentanteriorrightkneepain,associatedwithkneeswelling.locking,andbuckling.Sagittalprotondensity(a)andsagittal(b)andaxial(c)T2-weightedfat-suppressedimageswereobtainedshowingseverethickeningoftheproximalpatellartendonandincreasedsignal(arrows),consistentwithseveretendinopathyoftheproximalpatellartendon.44-year-oldmaleformerprofessionalbasketballplayerwithchronickneepain.Lateralradiograph(d)showsdiffusethickeningandheterogeneityofthepatellartendon(arrow),withasmallmaturecalcificationwithintheproximalaspect,findingsrepresentingchronictendinopathy.37髕骨病變的影像學(xué)表現(xiàn)Fig.19:Patellartendinopathy圖19：髕腱末端病（髕腱腱?。?8髕骨病變的影像學(xué)表現(xiàn)38year-oldmalefollowinginjurytohisleftkneewhileplayingsoftball;reportsfeelingatearingsensation.Lateralradiograph(a)showssoftissueprominencealongtheinftrapatellartencon(astersk)andasubtletransverselucenmintheinferiorpateltla(whitearrow).ThereispatellaaltaSagiftalprotondensity(b)andsagirtalT2-weightedfat-suppressed(c)MRimagesshowacompletetearofthepatellartendonattheinferio