肌骨超聲診療指南肩部肌骨超聲診療指南肩部第1頁Althoughpatient’spositioningforshoulderUSvarieswidelyacrossdifferentCountriesandInstitutionsreflectingmultifacetedopinionsandexperiencesofdifferentexaminers,westronglyrecommendtoexaminethepatientwhileseatedonarevolvingstool.Thispositionallowstheexaminertoreachtheanterior,lateralandposterioraspectsoftheshoulderwiththeprobebysimplyaskingthepatienttorotateonthechair.

不一樣國家和機構給病人進行肩部超聲檢驗時所采取體位各不相同，表達了不一樣診查者不一樣觀點和經(jīng)驗，不過，咱們強烈推薦讓病人坐在轉凳上進行檢驗。這個體位能夠讓診查者只要讓病人轉動一下凳子就能夠使用探頭掃查到肩前面、側面和后面。肌骨超聲診療指南肩部第2頁longheadofthebicepstendon

二頭肌腱長頭

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

肘部屈曲90°，手臂輕度內旋（指向對側膝部），掌心向上。先在大、小結節(jié)之間找到肱二頭肌長頭腱，采取短軸和長軸（作用有限）切面檢驗二頭肌。Shifttheprobeuptoexaminethebicepsinitsintraarticularcourseanddowntoreachthemyotendinousjunction(levelofthepectoralismajortendon).向上移動探頭檢驗二頭肌關節(jié)內走行，向下移動探頭探測肌-腱連接部（胸大肌肌腱水平）。肌骨超聲診療指南肩部第3頁Legend:SubS,subscapularistendon;SupraS,supraspinatustendon;Arrow,longheadofthebicepstendon;LT,lessertuberosity;GT,greatertuberosity;SH,shortheadofthebiceps;LH,longheadofthebiceps;H,humeralshaft;Arrowheads,pectoralismajortendon圖例：

SubS肩胛下肌肌腱；SupraS岡上肌肌腱；箭號，肱二頭肌長頭；LT小結節(jié)；GT大結節(jié)；SH二頭肌短頭；LH二頭肌長頭；H肱骨干；箭頭，胸大肌肌腱肌骨超聲診療指南肩部第4頁肌骨超聲診療指南肩部第5頁肌骨超聲診療指南肩部第6頁3subscapularistendon

Rotatethearmexternallyfixingtheelbowontheiliaccresttoshowthesubscapularistendon

anditsinsertiononthelessertuberosity(slightsupinationofthehandmaybehelpful

toneutralizethetendencytoliftandabducttheelbowfromthelateralchestwall).

3肩胛下肌肌腱

將肘部固定于髂嵴處，上肢外旋可顯示肩胛下肌肌腱及其小結節(jié)附著部。（手掌輕度后旋可有利于抵抗肘部上抬和外展離開側胸壁力量）肌骨超聲診療指南肩部第7頁Thistendonshouldbeevaluatedalongitslong-(transverseplanes)andshort-(sagittalplanes)axisduringpassiveexternalandinternalrotationwithhangingarm.Sweepthetransducerupanddownoverthesubscapularisuntilitsfullwidthisdemonstrated.

評價該肌腱應該在手臂上舉狀態(tài)下被動外旋和內旋時沿其長軸切面（橫切面）和短軸切面（矢狀切面）進行掃查。在肩胛下肌表面上下掃查，直至整塊肌肉都能全部顯示。肌骨超聲診療指南肩部第8頁Legend:Arrow,longheadofthebicepstendon;dashedline,insertionofthesubscapularistendon;Co,coracoid;Del,deltoidmuscle;LT,lessertuberosity;SubS,subscapularistendon;voidarrowheads,tendonfasciclesofthesubscapularis;whitearrowheads,muscletissueinterposedbetweentendonfascicles

圖例：箭號，肱二頭肌長頭腱；虛線，肩胛下肌肌腱附著處；Co喙突；Del,三角肌；LT,小結節(jié)；SubS,肩胛下肌肌腱；空心箭頭，肩胛下肌肌腱束；白色箭頭，插入肌腱束之間肌肉組織；肌骨超聲診療指南肩部第9頁肌骨超聲診療指南肩部第10頁肌骨超聲診療指南肩部第11頁4anteromedialstructuresandcoracoacromialligament

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

andlessertuberositymeasuredininternalrotation).

4.肩部前內側結構和喙肩韌帶在橫切面上，將探頭向內側移動，查看肩胛骨喙突、喙肩韌帶（探頭內側固定在肩胛骨喙突，探頭外側緣向外上方轉動指向肩峰）、聯(lián)合腱和肩峰下三角肌下滑囊前部。然后，探測肩胛下肌隱窩和喙突下囊有沒有積液。內旋和外旋也可用以探測前內側創(chuàng)傷部位（內旋可用以測量肩胛骨喙突和肱骨小結節(jié)之間距離）肌骨超聲診療指南肩部第12頁Legend:Acr,acromion;Arrows,shortheadofthebiceps;Arrowheads,coracoacromialligament;Co,coracoid;CoBr,coraco-brachialis;HH,humeralhead;SubS,subscapularistendon;SupraS,supraspinatus圖示：Acr,肩峰；箭，二頭肌短頭；箭頭，喙肩韌帶；Co,喙突；CoBr,喙肱肌；HH,肱骨頭；SubS,肩胛下肌肌腱；SupraS,岡上肌肌骨超聲診療指南肩部第13頁肌骨超聲診療指南肩部第14頁supraspinatustendon:positioning(1)岡上肌肌腱：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。應沿長軸和短軸觀察岡上肌肌腱。肌骨超聲診療指南肩部第15頁肌骨超聲診療指南肩部第16頁supraspinatustendon5岡上肌肌腱

Refertotheintraarticularportionofthebicepsasalandmarktoobtainpropertransducerorientationforimagingthesupraspinatus.Infact,thesetendonsrunparallelonetotheotherandtheintraarticularportionofthebicepsiseasytoberecognizedduetoamoreclearlydefinedfibrillarpattern.OneshouldrotatethetransduceruntilthebicepsisdepictedasmoreelongatedaspossibleintheUSimage.Then,theprobeisshiftedupwardandposteriorlyoverthesupraspinatuswithoutchangingitsorientation.Theresultingimageisinaxiswiththesupraspinatus.Betweenthesupraspinatusandthedeltoid,thenormalsubacromial-subdeltoidbursaappearsasathinhypoechoicband.肱二頭肌關節(jié)內個別是確定適當探頭方向以顯示岡上肌定位標志。實際上，這些肌腱是相互平行，而二頭肌關節(jié)內個別因為其邊界清楚細纖維結構而易于識別。操作者應該轉動探頭使二頭肌超聲圖像顯示得盡可能長。然后，保持探頭方向不變，在岡上肌表面向后上方移動探頭，最終圖像就是岡上肌長軸。在岡上肌和三角肌之間，正常肩峰-三角肌下滑囊呈一條薄薄低回聲帶。肌骨超聲診療指南肩部第17頁肌骨超聲診療指南肩部第18頁Tiltthetransducergentlyintheareaoverlyingthetendoninsertiontoavoidanisotropy.Remembertoscanthelateralpouchofthesubacromialsubdeltoidbursaalongthelateraledgeofthegreatertuberosity.Whenlookingforthesupraspinatusonshort-axis,thenormalcuffmusthavealmostthesamethicknessfromthebicepstendonlandmarkuntil2cmbackwards:fromthispointbackwardsthetendonseenistheinfraspinatus.

在肌腱附著端輕輕地傾斜探頭以消除各向異性假象。記住，要沿著大結節(jié)外側緣掃查肩峰下三角肌下囊側囊。在短軸上尋找岡下肌時，從二頭肌腱標識處向后2cm，正常肩袖厚度一定是不變：從該點向后看到肌腱就是岡下肌肌骨超聲診療指南肩部第19頁Legend:Acr,acromion;asterisk,myotendinousjunction;Del,deltoidmuscle;GT,greatertuberosity;voidarrow-head,articularcartilage;curvedarrow,hypoechoicartifactrelatedtoanisotropy;straightarrow,longheadofthebicepstendon;SupraS,supraspinatustendon;whitearrowhead,subacromialsubdeltoidbursa

圖例：Acr,肩峰；星號，肌-腱連接；Del,三角肌；GT,

大結節(jié)；空心箭頭，關節(jié)軟骨；彎箭頭，各向異性造成低回聲偽像；直箭頭，二頭肌肌腱；SupraS,岡上肌肌腱；白色箭頭，肩峰下三角肌下滑囊肌骨超聲診療指南肩部第20頁肌骨超聲診療指南肩部第21頁6supraspinatustendon:positioning(2)Placethedorsumofthehandovertheoppositebackpocket(forcedinternalrotation,stressmanoeuvre).Thereshouldnotbeanyspacegapbetweentheelbowandthelateralchestwall.Usingthisposition,thesupraspinatusbecomesamoreanteriorstructureandthetransducershouldbeorientedalmostverticallytobeinaxiswithit.Considerthatthetendonfibersaremorestretchedthaninthepositiondescribedatpoint-5.Thismaybepossiblecauseofoverestimationoftearsize.Duetoanexcessiveinternalr