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1、骨与关节影像诊断学 （二）,北京大学第一医院医学影像科 王继琛,骨关节结核,继发性结核病，血行感染 儿童、青少年多见 脊柱及髋、膝关节好发 临床经过缓慢,骨关节结核,长骨干骺端结核 短管状骨骨干结核 关节结核（滑膜型） 脊柱结核,骺和干骺端结核,骨质疏松 类圆形限局性骨质破坏 中间可有碎屑死骨 周围骨增生硬化不明显,短管状骨骨干结核,四肢短管状骨 儿童多见，病变多发 骨质破坏在骨内呈囊性改变 骨膜增生使骨干增粗 骨气鼓征,Spina ventosa in a 22-year-old woman. Anteroposterior (a) and magnified (b) radiographs
2、 show extensive soft-tissue swelling with ballooning of the third metacarpal of the left hand. Findings of tuberculous arthritis are also seen in the adjacent joint (arrowheads),滑膜型关节结核,青年人髋、膝大关节常见 早期关节周围软组织肿胀，骨质疏松 关节面非持重边缘部先有先有骨质破坏 关节间隙狭窄,Tuberculous arthritis in a 28-year-old man with pain. A-P (a
3、) and magnified (b) radiographs show marginal osseous erosions of the femoral head (arrows) with relative preservation of the left hip joint space. There is also evidence of periarticular osteopenia. Tuberculous disease was confirmed with bone biopsy,脊柱结核,椎体破坏 椎间隙狭窄 椎旁脓肿 脊柱畸形,Tuberculous spondylitis
4、 in a 17-year-old girl with low back pain. (a, b) A-P (a) and lateral (b) plain radiographs show loss of vertebral body height (arrowhead in a), sclerosis of the end plates, and anterior scalloping (arrowheads in b). (c) Sagittal T1 image shows focal decreased signal intensity (arrow).,Sagittal T2-w
5、eighted (d) and Gd- T1-weighted (e) MR images show increased signal intensity (arrow). Tuberculous disease was confirmed with bone biopsy,Tuberculous spondylitis with psoas abscess in a 21-year-old woman. (a) Midsagittal T1-MR images show loss of vertebral body height and decreased signal intensity
6、at T4 (arrows). (b) Coronal T2-weighted MR image of the upper dorsal spine shows bilateral paraspinal abscesses (arrows) with involvement of T4.,(c, d) Axial T2-weighted (c) and parasagittal T2-weighted (d) MR images show a large, lobulated paraspinal mass with high signal intensity that extends to
7、the posterior paravertebral region (arrows). The diagnosis was confirmed with biopsy of the abscess,骨肿瘤,良性 骨软骨瘤 骨巨细胞瘤 恶性 原发：骨肉瘤 继发：骨转移瘤,骨软骨瘤,起于长骨干骺端，邻近骺线 向外突出的骨性肿块，皮质与正常骨相连 有细长的蒂和宽基底 软骨帽，可发生钙化 骨骺闭合即停止生长,Benign osteochondroma of the tibia in a 15-yrs boy with lesion growth. (a) Initial radiograph sho
8、ws pathognomonic features of osteochondroma. The cortical (solid arrows) and medullary (*) continuity with the tibia was seen on radiographs. The cartilage cap is not mineralized and cannot be seen. (b-d) Axial MR images T1 obtained before (b) and after (c) Gd administration also reveal the cortical
9、 (arrowheads) and marrow (*) continuity with the underlying bone and yellow marrow in the lesion. The hyaline cartilage cap is 3 cm thick (curved arrows), shows mild peripheral and septal contrast material enhancement (straight arrows), and becomes very high signal intensity on the sagittal STIR MR
10、image (d).,Lateral radiograph obtained 2 years later shows lesion growth and mineralization that simulate malignant transformation but represent only growth in the immature patient. (f) Bone scan demonstrates marked increased uptake of radionuclide. (g) Photograph of the sagittally sectioned specime
11、n correlates with the imaging appearance, revealing yellow marrow (*) and the thick hyaline cartilage cap (arrows). Foci of mineralization (x) are also seen, as noted previously in the MR images (b-d).,骨巨细胞瘤,青壮年（2040岁）多见，好发于股骨远端、胫骨近端、桡骨远端 病变在骨端，偏心性，皂泡状溶骨破坏 肿瘤呈膨胀性增大，骨皮质变薄 无骨膜反应 一般不破坏关节面,Benign metast
12、asizing GCT of the proximal tibia in a 30-year-old woman. (a) Anteroposterior radiograph shows an eccentric lytic metaepiphyseal lesion extending to subchondral bone with a narrow zone of transition (arrow). (b) Bone scintigram reveals increased radionuclide uptake peripherally and photopenia centra
13、lly (“donut sign“). (c) CT scan demonstrates mild expansion and sclerosis about the GCT (arrows) but no soft-tissue mass.,On a coronal T2WI, the GCT demonstrates predominantly intermediate signal intensity with several high-signal-intensity foci (arrowheads) corresponding to secondary ABC regions. (
14、e) Chest CT scan shows multiple pulmonary nodules in both lungs (arrowheads). (f) Photograph of the coronally sectioned whole mounted specimen (H-E stain) reveals a GCT extending to subchondral bone with ABC regions (white *) and solid areas (black *),成骨肉瘤,青年男性（20岁以下）多见，好发于膝关节周围，长骨干骺端 溶骨型：大片骨质破坏，骨膜反
15、应呈“袖口征”，软组织肿块明显 成骨型：大量瘤骨及骨膜新生骨 多为混合型,H,骨转移瘤,血行转移，多见于乳癌、肺癌、甲状腺癌、前列腺癌、肾癌等 好发于脊柱、骨盆、颅骨等，且病变常为多发 多为溶骨性破坏，可发生病理性骨折 成骨转移多为前列腺癌等，在骨盆和腰椎松质骨内见到境界不清的斑片状致密影,metastasis,良、恶性骨肿瘤的鉴别,生长情况 局部骨变化 骨膜增生 周围软组织变化,慢性骨关节病,退行性骨关节病 类风湿性关节炎 强直性脊柱炎,退行性骨关节病,40岁以上男性多见，脊柱和髋、膝关节好发 关节间隙狭窄 关节面不规则 骨质增生硬化，骨赘形成,Case 1,Case 2, T1 & T2,
16、类风湿性关节炎,多见于中年女性，累及近侧指间关节，多发 软组织肿胀 关节间隙变窄 关节面边缘骨质虫蚀样破坏 关节半脱位 邻近骨骼骨质疏松,RA in a 42-year-old woman. (a) Posteroanterior radiograph of the hands shows no evidence of erosion or joint space narrowing,Coronal fat-suppressed Gd T1WI show marked periarticular enhancement (arrows) in multiple PIP and MCP joints,强直性脊柱炎,见于成年男性 病变从骶髂关节开始，早期表现为关节面凹凸不平，边缘模糊，以后关节间隙逐渐狭窄，以致完全消失，形成骨性强直 病变向上发展，侵犯脊柱小关节 椎旁韧带钙化，呈“竹节样”改变,全身性骨病,佝偻病,长骨干骺端（尤其尺桡关节远端）表现典型 干骺端加宽，呈杯口样凹陷 先期钙化带模糊，出现毛刷样改变 骨骺小，与干骺端距离加大 普遍骨质密度减低,其他骨关节疾病,骨髓梗
