肌骨超声诊疗指南肩部

肌骨超声诊疗指南肩部肌骨超声诊疗指南肩部第1页Althoughpatient’spositioningforshoulderUSvarieswidelyacrossdifferentCountriesandInstitutionsreflectingmultifacetedopinionsandexperiencesofdifferentexaminers,westronglyrecommendtoexaminethepatientwhileseatedonarevolvingstool.Thispositionallowstheexaminertoreachtheanterior,lateralandposterioraspectsoftheshoulderwiththeprobebysimplyaskingthepatienttorotateonthechair.

不一样国家和机构给病人进行肩部超声检验时所采取体位各不相同，表达了不一样诊查者不一样观点和经验，不过，咱们强烈推荐让病人坐在转凳上进行检验。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前面、侧面和后面。肌骨超声诊疗指南肩部第2页longheadofthebicepstendon

二头肌腱长头

Placethearminslightinternalrotation(directedtowardsthecontralateralknee)withtheelbowflexed90°,palmup.Startbyfindingthelongbicepstendoninbetweenthegreaterandlessertuberosities–Useshortandlong(morelimitedutility)axisplanestoexaminethebiceps.

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，采取短轴和长轴（作用有限）切面检验二头肌。Shifttheprobeuptoexaminethebicepsinitsintraarticularcourseanddowntoreachthemyotendinousjunction(levelofthepectoralismajortendon).向上移动探头检验二头肌关节内走行，向下移动探头探测肌-腱连接部（胸大肌肌腱水平）。肌骨超声诊疗指南肩部第3页Legend:SubS,subscapularistendon;SupraS,supraspinatustendon;Arrow,longheadofthebicepstendon;LT,lessertuberosity;GT,greatertuberosity;SH,shortheadofthebiceps;LH,longheadofthebiceps;H,humeralshaft;Arrowheads,pectoralismajortendon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，胸大肌肌腱肌骨超声诊疗指南肩部第4页肌骨超声诊疗指南肩部第5页肌骨超声诊疗指南肩部第6页3subscapularistendon

Rotatethearmexternallyfixingtheelbowontheiliaccresttoshowthesubscapularistendon

anditsinsertiononthelessertuberosity(slightsupinationofthehandmaybehelpful

toneutralizethetendencytoliftandabducttheelbowfromthelateralchestwall).

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。（手掌轻度后旋可有利于抵抗肘部上抬和外展离开侧胸壁力量）肌骨超声诊疗指南肩部第7页Thistendonshouldbeevaluatedalongitslong-(transverseplanes)andshort-(sagittalplanes)axisduringpassiveexternalandinternalrotationwithhangingarm.Sweepthetransducerupanddownoverthesubscapularisuntilitsfullwidthisdemonstrated.

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。肌骨超声诊疗指南肩部第8页Legend:Arrow,longheadofthebicepstendon;dashedline,insertionofthesubscapularistendon;Co,coracoid;Del,deltoidmuscle;LT,lessertuberosity;SubS,subscapularistendon;voidarrowheads,tendonfasciclesofthesubscapularis;whitearrowheads,muscletissueinterposedbetweentendonfascicles

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，插入肌腱束之间肌肉组织；肌骨超声诊疗指南肩部第9页肌骨超声诊疗指南肩部第10页肌骨超声诊疗指南肩部第11页4anteromedialstructuresandcoracoacromialligament

Movingtheprobetowardmedialontransverseplanes,lookatthecoracoidprocess,thecoracoacromialligament(themedialmarginofthetransducerisonthecoracoidprocessandthelateraledgeisshiftedupwardandlaterallytowardstheacromion),theconjoinedtendonandtheanterioraspectofthesubacromialsubdeltoidbursa.Then,checkthesubscapularisrecessandthesubcoracoidbursaforeffusion.Externalandinternalrotationmayalsousedtodemonstrateanteromedialimpingement(distancebetweencoracoidprocess

andlessertuberositymeasuredininternalrotation).

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）、联合腱和肩峰下三角肌下滑囊前部。然后，探测肩胛下肌隐窝和喙突下囊有没有积液。内旋和外旋也可用以探测前内侧创伤部位（内旋可用以测量肩胛骨喙突和肱骨小结节之间距离）肌骨超声诊疗指南肩部第12页Legend:Acr,acromion;Arrows,shortheadofthebiceps;Arrowheads,coracoacromialligament;Co,coracoid;CoBr,coraco-brachialis;HH,humeralhead;SubS,subscapularistendon;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,冈上肌肌骨超声诊疗指南肩部第13页肌骨超声诊疗指南肩部第14页supraspinatustendon:positioning(1)冈上肌肌腱：定位（1）

Placethepatient’sarmposteriorly,placingthepalmarsideofthehandonthesuperioraspectoftheiliacwingwiththeelbowflexedanddirectedposteriorly.Thesupraspinatustendonshouldbeevaluatedalongitslong-andshort-axis.患者上肢后置，肘部向后屈曲，手掌面置于髂骨翼上部。应沿长轴和短轴观察冈上肌肌腱。肌骨超声诊疗指南肩部第15页肌骨超声诊疗指南肩部第16页supraspinatustendon5冈上肌肌腱

Refertotheintraarticularportionofthebicepsasalandmarktoobtainpropertransducerorientationforimagingthesupraspinatus.Infact,thesetendonsrunparallelonetotheotherandtheintraarticularportionofthebicepsiseasytoberecognizedduetoamoreclearlydefinedfibrillarpattern.OneshouldrotatethetransduceruntilthebicepsisdepictedasmoreelongatedaspossibleintheUSimage.Then,theprobeisshiftedupwardandposteriorlyoverthesupraspinatuswithoutchangingitsorientation.Theresultingimageisinaxiswiththesupraspinatus.Betweenthesupraspinatusandthedeltoid,thenormalsubacromial-subdeltoidbursaappearsasathinhypoechoicband.肱二头肌关节内个别是确定适当探头方向以显示冈上肌定位标志。实际上，这些肌腱是相互平行，而二头肌关节内个别因为其边界清楚细纤维结构而易于识别。操作者应该转动探头使二头肌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长轴。在冈上肌和三角肌之间，正常肩峰-三角肌下滑囊呈一条薄薄低回声带。肌骨超声诊疗指南肩部第17页肌骨超声诊疗指南肩部第18页Tiltthetransducergentlyintheareaoverlyingthetendoninsertiontoavoidanisotropy.Remembertoscanthelateralpouchofthesubacromialsubdeltoidbursaalongthelateraledgeofthegreatertuberosity.Whenlookingforthesupraspinatusonshort-axis,thenormalcuffmusthavealmostthesamethicknessfromthebicepstendonlandmarkuntil2cmbackwards:fromthispointbackwardsthetendonseenistheinfraspinatus.

在肌腱附着端轻轻地倾斜探头以消除各向异性假象。记住，要沿着大结节外侧缘扫查肩峰下三角肌下囊侧囊。在短轴上寻找冈下肌时，从二头肌腱标识处向后2cm，正常肩袖厚度一定是不变：从该点向后看到肌腱就是冈下肌肌骨超声诊疗指南肩部第19页Legend:Acr,acromion;asterisk,myotendinousjunction;Del,deltoidmuscle;GT,greatertuberosity;voidarrow-head,articularcartilage;curvedarrow,hypoechoicartifactrelatedtoanisotropy;straightarrow,longheadofthebicepstendon;SupraS,supraspinatustendon;whitearrowhead,subacromialsubdeltoidbursa

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，各向异性造成低回声伪像；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肌骨超声诊疗指南肩部第20页肌骨超声诊疗指南肩部第21页6supraspinatustendon:positioning(2)Placethedorsumofthehandovertheoppositebackpocket(forcedinternalrotation,stressmanoeuvre).Thereshouldnotbeanyspacegapbetweentheelbowandthelateralchestwall.Usingthisposition,thesupraspinatusbecomesamoreanteriorstructureandthetransducershouldbeorientedalmostverticallytobeinaxiswithit.Considerthatthetendonfibersaremorestretchedthaninthepositiondescribedatpoint-5.Thismaybepossiblecauseofoverestimationoftearsize.Duetoanexcessiveinternalr