粘连性关节囊炎MR诊断

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粘连性关节囊炎，一般好发于肩关节，又叫肩周炎或冻结肩，是肩周肌肉、肌腱、滑囊及关节囊的慢性损伤性炎症。其MRI诊断要点主要包括以下几个方面：

一、MRI表现

1. 喙肱韧带增厚：在MRI中，喙肱韧带的厚度超过3mm被视为增厚，这是粘连性关节囊炎的一个典型表现。喙肱韧带位于肩袖间隙内，是一个弯曲的低信号结构，从喙突横向延伸，并穿过肩袖间隙被脂肪包围。

2. 肩袖间隙信号增高、模糊、狭窄：肩袖间隙位于肩胛下肌肌腱的上缘与冈上肌的下缘之间，是粘连性肩关节囊炎最易受累的部位。在MRI中，肩袖间隙的信号增高、模糊或狭窄，提示存在炎症或粘连。

3. 腋囊增厚：腋囊位于下孟肱韧带前、后束之间，是粘连性关节囊炎的另一个常见受累部位。在MRI中，腋囊的厚度超过4mm，且脂肪抑制序列信号增高，提示腋囊增厚和炎症。

二、诊断注意事项

1. 结合临床表现：MRI诊断应结合患者的临床表现，如肩关节周围疼痛伴活动受限，尤其是夜间痛和全方向痛性活动受限等。

2. 排除其他病变：在诊断粘连性关节囊炎时，需要排除其他可能导致肩关节粘连的病变，如孟肱关节炎、钙化性肌腱病等。这些病变在MRI上可能有不同的表现。

3. 综合分析：MRI诊断粘连性关节囊炎时，需要综合分析多个MRI征象，包括喙肱韧带增厚、肩袖间隙信号改变和腋囊增厚等。同时，还需要考虑患者的年龄、性别、病史等因素。

腋隐窝解剖示意图：

腋囊的增厚和水肿：

肩袖间隙异常软组织信号（细箭）：

腋囊增厚和水肿(细箭)：

腋囊增厚纤维化（T1/T2均为低信号）：

MRI关节囊造影提示腋囊体积缩小：

原文：https://radiopaedia.org/articles/adhesive-capsulitis-of-the-shoulder

Adhesive capsulitis of the shoulder, also known as frozen shoulder, is a condition characterised by thickening and contraction of the shoulder joint capsule and surrounding synovium. Adhesive capsulitis can rarely affect other sites such as the ankle .

粘连性肩关节囊炎 ，也称冻结肩，其特征是肩关节囊和周围滑膜的增厚和挛缩。粘连性关节囊炎很少影响其他部位，如踝关节。

Epidemiology

The incidence in the general population is thought to be 3-5%. Adhesive capsulitis typically affects women in the 5th to 6th decades of life, although patients with co-morbidities such as diabetes may develop the condition at earlier ages. The incidence in patients with diabetes is reported to be 2 to 4 times higher than in the general population.

流行病学

一般人群的发病率为3-5％。粘连性关节囊炎通常见于50-60岁的女性，患有糖尿病等并发症的患者发病年龄可能会提前。糖尿病患者的发病率高于普通人群的2〜4倍。

Clinical presentation

Adhesive capsulitis presentation can be broken into three distinct stages:

• freezing: painful stage 

• patients may not present during this stage because they think that eventually, the pain will resolve if self-treated.

• as the symptoms progress, pain worsens and both active and passive range of motion (ROM) becomes more restricted

• this can eventually result in the patient seeking medical consultation

• typically lasts between 3 and 9 months and is characterised by an acute synovitis of the glenohumeral joint

• frozen: transitional stage

• most patients will progress to the second stage

• during this stage, shoulder pain does not necessarily worsen

• because of pain at end ROM, use of the arm may be limited causing muscular disuse

• can last between 4 to 12 months

• the common capsular pattern of limitation has historically been described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation

• there eventually becomes a point in the frozen stage that pain does not occur at the end of ROM

• thawing stage

• begins when ROM begins to improve

• lasts anywhere from 12 to 42 months and is defined by a gradual return of shoulder mobility

临床症状：

粘连性关节囊炎分为三个阶段：

凝结期：疼痛期

• 患者在这个阶段可能不会出现，因为他们认为最终，如果自我治疗，疼痛就会解决。

• 随着症状的进展，疼痛恶化，主动和被动的运动范围（ROM）变得更加受限制

• 这可能最终导致病人寻求医疗咨询

• 通常持续3至9个月，其特征是盂肱关节的急性滑膜炎

冻结期：过渡期

• 大多数患者将进入此阶段

• 在这个阶段，疼痛并不一定会恶化

• 由于运动时的疼痛，手臂功能可能会受到限制，导致肌肉废用

• 可持续4至12个月

• 常见的限制模式历史上被描述为减少运动，外肩旋转是最受限的，其次是肩部屈曲和内旋

• 最终在慢性期运动受限成为一个点，在运动范围结束时不会发生疼痛

解冻期

• 开始时运动范围开始改善

• 持续12至42个月，肩关节运动逐步恢复

  
  

Pathology

Adhesive capsulitis is divided into two main types: 

• primary or idiopathic

• absence of preceding trauma

• secondary 

• major or minor repetitive trauma

• shoulder or thoracic surgery

• endocrine, e.g. diabetes, hyperthyroidism 

• rheumatological conditions

病理

粘连性关节囊炎分为两大类：

原发性或特发性

•   无外伤病史

继发性

• 重大或轻微的重复创伤

• 肩部或胸部手术

• 内分泌，例如糖尿病，甲状腺功能亢进

• 风湿病

Radiographic features

MRI/MR arthrography

• normal inferior glenohumeral ligament measures <4 mm and is best seen on coronal oblique images at the mid glenoid level; in adhesive capsulitis, the axillary recess may show thickening ≥1.3 cm

• joint capsule thickening 

• abnormal soft tissue thickening within the rotator interval with signal alteration

• abnormal soft tissue encasing the biceps anchor

• variable enhancement of the capsule and synovium within the axillary recess and rotator interval

Other MR arthrography features include

• thickening of the coracohumeral ligament (CHL) 

• subcoracoid triangle sign 

影像学表现

MRI / MRI关节造影

• 正常下盂肱韧带测量值<4毫米，在斜冠位上关节囊中间层面显示最好；在粘连性关节囊炎患者中，腋隐窝软组织增厚≥1.3厘米

• 关节囊增厚

• 肩袖间隙异常软组织增厚伴信号异常

• 异常软组织包绕肱二头肌腱

• 增强后腋隐窝和肩袖间隙的关节囊或滑囊强化

其他MR关节造影包括

• 喙肱韧带（CHL）增厚

• 喙突下三角征

• 腋囊正常容量15-18ml，本病小于10ml，多数小于5ml（文献上）

  
  

Treatment and prognosis

Adhesive capsulitis is typically a self-limiting disease that improves over 1-2 years. Treatment options include:

• physiotherapy

• corticosteroid injections

• glenohumeral hydrodilatation

• closed manipulation under anaesthesia

• arthroscopic capsular release with lysis of adhesions

• 
  

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