四肢关节结核影像诊断与鉴别-胡俊华.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master 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style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,BEA Confidential.|,四肢关节结核影像诊断与鉴别,胡俊华,BEA Confidential.|,2,临床背景,骨关节结核绝大多数是继发结核,由结核杆菌通过血行或淋巴系统播散至骨关节所致,1,脊柱结核发病率最高（以胸椎发病率高），其次为关节结核（膝关节、髋关节为多，腕关节、踝关节、肩关节及其它关节发病率较少见），骨结核最少见。,5,临床症状较为轻微，全身症状可有低热、血沉加快等。局部可有肿胀、疼痛、功能障碍，晚期肌肉萎缩，可出现畸形,4,男女发病率无明显差异，可以发生于各个年龄，,1,岁以内罕见好发于儿童、青少年及免疫力低下的人群,3,主要累及血供丰富和负重大的骨质、血运丰富的松质骨、活动较多的骨关节系统（如椎体、短管骨、长管状骨骨骺及干骺端）,2,四肢关节结核,儿童、青少年多见,以承重大的大关节多见，,好发于髋关节、膝关节；踝关节、肘关节、腕关节少见,BEA Confidential.|,4,四肢关节结核病理,早期滑膜明显充血、肿胀，表面有纤维素或者干酪样坏死物覆盖,进一步发展纤维素增生导致滑膜明显增厚，关节渗液缺少蛋白溶解酶，关节软骨破坏较晚,晚期关节软骨破坏，侵蚀关节骨质级关节内组织，关节间隙狭窄，脓肿形成，部分伴有肌肉萎缩,四肢关节结核类型,1,、,滑膜型关节结核：为结核杆菌血行感染关节滑膜，病变呈慢性过程，中晚期波及关节软骨及骨端；骨质侵蚀多为无软骨覆盖的边缘部分或非持重区,2,、,骨,型关节结核骨：为干骺和骨骺结核直接蔓延累及关节，侵犯滑膜及关节软骨,3,、全关节结核：病变晚期，关节组织和骨都累及。,关节结核影像表现（滑膜型）,1.,早期,X,线及,CT,无明显特异征象，只表现为关节囊肿肿胀，关节积液，关节间隙增宽；,2.,由于关节积液、软组织肿胀及废用性表现为骨质疏松,，导致关节面骨质模糊；,3.,中晚期，关节面骨质破坏（非常持重部位）导致关节间隙狭窄；骨质破坏区见点、片状高密度的死骨，并伴有周围软组织脓肿形成，内部可见钙化。严重者并关节半脱位。,4.MR,表现关节骨面大片状骨髓水肿，关节腔见大量积液、积脓，关节周围软组织广泛水肿，合并脓肿形成，脓肿增强呈环形明显强化，脓肿沿肌间隙蔓延（较为特异性征象）。,病例,2,、患者,4,岁，左,胫骨下端干骺端可见不规则骨质破坏区（穿过骨骺线），边界不清，内似可见点状死骨，周围轻度骨质硬化。胫骨下段可见骨膜反应，周围软组织肿胀。,结果：左胫骨下段结核,病例来源：聊城市第二人民医院葛英霖老师,BEA Confidential.|,10,病例三、男性，左膝关节疼痛数月,左膝关节骨质密度减低，关节间隙狭窄，胫骨上段及股骨下段见多发点状、小片状低密度影，边界模糊，关节面不规则（提示软骨侵蚀），未见明显骨膜反应，关节腔见积液、积脓，周围软组织肿胀并见脓肿形成，其内见多发点状钙化。,BEA Confidential.|,11,磁共振显示骨质破坏及脓肿较,CT,、,平片敏感，钙化及死骨不敏感；,MR,显示关节间隙狭窄，关节软骨不规则,缺损，非持重部位见大片状骨质破坏,T1WI,呈低信号，,T2W1,呈混杂信号，,脓肿,T2WI,明显高信号,BEA Confidential.|,12,BEA Confidential.|,13,BEA Confidential.|,14,BEA Confidential.|,15,BEA Confidential.|,16,BEA Confidential.|,17,BEA Confidential.|,18,鉴别诊断,化脓性关节炎：患者临床症状明显（高热、疼痛、功能障碍），骨质破坏为持重部位，骨膜反应较明显。,幼年性关节炎：,16,岁以下儿童发病，女性多见，不规则发热、贫血、关节肿痛，晚期关节畸形，早期双手近端指间关节肿胀，在软骨尚未破坏之前即可有骨化中心疏松、增大或变小，密度不均匀。晚期关节纤维性,/,骨性强直,类风湿关节炎：,中青年女多见，,多对称性累及双侧多个关节，手足小关节受累常见，类风湿因子阳性,色素沉着绒毛结节性滑膜炎：,MR,表现为滑膜弥漫性结节状增生，内可见含铁血黄素沉积所致的双低信号，此为,PVNS,的特征性表现，无明显死骨，骨质疏松不明显,夏科氏关节,痛风,鉴别诊断,嗜酸性肉芽肿（,LCH,）：儿童多见，多见于骨干及干骺端，很少累及骨骺，为单个或多个圆形,/,类圆形骨质破坏区，破坏区形态不规则，并见葱皮样成熟的骨膜反应，死骨少见，病变边缘及周围软组织见炎性渗出,化脓性骨髓炎：临床症状明显，病变多位于关节持重部位，骨质破坏区边界硬化，骨膜增生反应明显,骨样骨瘤：骨样骨瘤骨干级及干骺端多见，部分可在关节囊内，典型的改变是骨皮质增厚内见,“,瘤巢,”,2,、短管状骨结核,短管骨结核好发于儿童,常见于指、趾骨（近节指骨好发），病变可以多发,患儿症状较轻，,患指轻微肿胀，,大部分病变有自愈倾向,影像表现,X,线、,CT,表现为早期软组织肿胀，局部骨质密度减低，骨质疏松，呈小点状低密度孔，进一步发展数个小孔融合，呈圆形，或者类圆形的低密度骨质破坏区，病变位于骨干中央，内部死骨不明显，可见骨膜反应，,X,线典型者表现骨气鼓,”,，病变可以多发，累及指（趾）间关节少见；成人病变较局限，边界可见硬化，骨膜反应少见。,鉴别诊断,1.,短管状骨结合主要与内生软骨瘤鉴别，内生软骨瘤可以多发，呈膨胀性改变，内见点状钙化，周围无明显软组织肿胀,2.,小骨巨细胞病变：小骨巨细胞病变呈膨胀性改变，内无明显死骨，,MR,表现,T1WI,稍低信号，,T2WI,呈高,/,混杂信号，增强扫描明显强化,二、,关节结核,三、,脊柱结核,临床背景,脊椎结核是最常见的骨关节结核,好发于儿童和青年。以胸腰段最为多见。儿童好发于胸椎，成人好发于腰椎，,约,90%,的脊柱结核发生于椎体，附件结核罕见,常累及两个相邻椎体，也可以累及多个椎体,BEA Confidential.|,28,影像表现（,X,线）,边缘型,此型成年人多见，胸腰段。腰椎为好发部位,早期表现为椎体边缘骨质破坏，边缘不规则，范围局限，内见死骨形成,中晚期椎间隙狭窄，相邻椎体骨质破坏，并可见椎旁软组织肿胀（冷脓肿形成）,BEA Confidential.|,29,影像表现（,X,线）,中心型,好发于胸椎，儿童多见,早期表现为椎体中心松质骨中出现骨质破坏区，边缘模糊，内可见死骨，周围硬化不明显，椎间隙无明显狭窄,中晚期，椎体骨质破坏区明显，累及椎间盘，导致椎间隙狭窄，椎旁脓肿,X,线表现为软组织肿胀,影像表现,X,线、,CT,征象：,早期表现为骨质疏松，骨质吸收，继而发展骨骺、干骺端圆形、类圆形骨质破坏区，边缘见少许硬化，内点状死骨，周围软组织肿胀,部分软组织内见多发点状高密度影，,病变常穿过骨骺线、骺板（比较有特异性的征象）。,MRI,征象：干骺端大片状骨髓水肿区，,中央骨质破坏脓肿区,T1WI,呈稍低信号，,T2WI,呈混杂信号，周围软组织肿胀，增强扫描病变呈环形强化，中央区及软组织脓肿不强化。,BEA Confidential.|,31,影像表现（,X,线）,韧带下型,临床少见，多见于胸椎,韧带感染结核菌引起韧带下积脓，然后侵蚀椎体,表现为一个或多个椎体前部凹陷性骨质破坏，此型可以无椎间隙狭窄,BEA Confidential.|,32,影像表现（,CT,、,MR,）,CT,：,表现为椎体骨质破坏，椎体边缘缺损，并见死骨形成，周围软组织脓肿形成，沿腰大肌向下发展，呈流注改变，向下达髂腰肌囊，增强扫描脓肿呈环形强化。（,CT,发现死骨及脓肿敏感性优于,X,线），晚期表现为椎间隙狭窄，椎体变扁，脊柱畸形。,MR,：,MR,表现为椎体广泛骨髓水肿，,T1WI,呈低信号，,T2WI,呈混杂信号，中央干酪样坏死呈等低信号，增强扫描环形强化，,MR,显示脓肿较,X,线、,CT,敏感，,T1WI,呈稍低,/,稍高信号，,T2WI,呈稍高信号，脓肿壁,T1WI,呈稍高信号，增强扫描环形强化，病变晚期椎间隙狭窄，,MR,对于死骨、细微钙化不敏感。,BEA Confidential.|,33,鉴别诊断,脊柱化脓性感染,：,化脓性脊柱炎椎间隙狭窄不明显，腰椎节段多见，骨质破坏较轻，椎体压缩性改变少见，出现死骨几率较结核小；椎旁脓肿相对较少，椎旁无明显流注改变，钙化少见；病变修复增生明显，临床症状较结核明显，,WBC,升高，可以伴有全身感染症状。,布氏杆菌脊柱炎：,明确牛羊接触史，骨质破坏多为边缘性破坏，破坏范围小，骨质增生硬化较为明显，可在新生骨中又出现破坏，死骨少见；脓肿多较小，局限于椎体周边，腰大肌脓肿罕见,BEA Confidential.|,34,Example of a Diagram,Service,Infrastructure,Services Management,Service Bus,Common Services,Information Access Services,Presentation Services,Shared Business Services,Composite Applications,BEA Confidential.|,35,BEA Confidential.|,36,Slide Animation Guidelines,The purpose of slide animation and builds is to enhance the message,not detract from it,Because of this,it is important to use slide animation sparingly and only when necessary,To adjust the slide animations,select“Custom Animation”under the Task Pane,Use“Appear”option for the animation,BEA Confidential.|,37,Saving This Template as Your Default Design Template,Color Palette and Sample Charts,BEA Confidential.|,39,Color 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