肩袖损伤的物理诊断和影像诊断与关节镜对照研究
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摘要
目的：分析研究肩袖损伤的症状及影像学表现，并与关节镜诊断结果相对照，评价物理检查对肩袖损伤诊断的准确性和临床应用价值以及对比分析常规MR、肩关节造影、MR肩关节造影对肩袖撕裂的价值。
材料和方法：本研究包括18例肩袖全层撕裂、11例部分撕裂和30例无肩袖撕裂病例。第一部分，重点探讨了肩袖撕裂的物理检查对肩袖撕裂的诊断价值；第二部分，重点比较了常规MR、肩关节造影、MR肩关节造影三种方法诊断肩袖撕裂的价值和优缺点。
结果：35例患者经肩关节镜检查诊断为：肩袖全层撕裂18例、肩袖部分撕裂11例、肩袖无撕裂6例。物理检查诊断准确率为83％。影像学检查对于判定有无肩袖撕裂，常规MRI的敏感性、特异性和准确性分别为78％，80％，81％；肩关节腔造影分别为94％，93％，93％；MRA为100％，95％，97％。对于判定有无肩袖全层撕裂，常规MRA的敏感性、特异性和准确性分别为83％，86％，81％；肩关节腔造影分别为91％，93％，86％；MRA为100％，100％，100％。
结论：物理检查是诊断肩袖损伤准确性相当可靠，在三种影像诊断方法中，常规MR是诊断肩袖撕裂，比较准确的方法，肩关节造影的诊断准确性要高于常规MR，MRA则是最准确的方法结论MRA是诊断肩袖撕裂准确性较高的方法
Objective: To evaluate the value of physical examination and imaging in the diagnosis of rotator cuff tears. Perspective study was also performed to compare the diagnostic value of different methods including routine MR, arthrograp, and MRA
Materials and Methods: Seventy consecutive patients with suspected rotator cuff tears were examined with physical examination, X-ray arthrography ,routine MR, arthrography, and MR arthrography before the of the examination of .shoudler arthroscope. Base on the results of the arthrography, the diagnostic sensitivity, specificity, and accuracy of the physical examination, and the diagnostic value of routine MR, arthrography, and MR arthrography were compared. The advantages and disadvantages of every method were also discussed.
Results: The 35 cases included 18 full-thickness tears, 11 Partial thickness tears and 6 non-tears. Based on the shoudler arthroscope accuracy of physical examination were83%. For the diagnosis rotator cuff tears the sensitivity, specificity, and accuracy were 78%, 80%, and 81% of the routine MR. respectively ;the figures were 94%,93%,and 93% of the X-ray arthrography. respectively ;while the date were 100%, 95%, and 97% for MRA. for the diagnosis full-thickness tears the sensitivity, specificity, and accuracy were 83%, 86%, and 81% of the routine MR ;respectively ;the figures were 91%, 93%, and 86% of the X-ray arthrography, respectively ;while the date were 100%, 100%, and 100% for MRA
Conclusion: physical examination is a good modality in the diagnosis of rotator cuff tears. The routine MR is a relatively accurate method for revealing rotator cuff tears. The accuracy of arthrography for rotator cuf tears is higher than that of routine MR. MRA is the most accurate method among these three diagnostic imaging methods.
材料和方法：本研究包括18例肩袖全层撕裂、11例部分撕裂和30例无肩袖撕裂病例。第一部分，重点探讨了肩袖撕裂的物理检查对肩袖撕裂的诊断价值；第二部分，重点比较了常规MR、肩关节造影、MR肩关节造影三种方法诊断肩袖撕裂的价值和优缺点。
结果：35例患者经肩关节镜检查诊断为：肩袖全层撕裂18例、肩袖部分撕裂11例、肩袖无撕裂6例。物理检查诊断准确率为83％。影像学检查对于判定有无肩袖撕裂，常规MRI的敏感性、特异性和准确性分别为78％，80％，81％；肩关节腔造影分别为94％，93％，93％；MRA为100％，95％，97％。对于判定有无肩袖全层撕裂，常规MRA的敏感性、特异性和准确性分别为83％，86％，81％；肩关节腔造影分别为91％，93％，86％；MRA为100％，100％，100％。
结论：物理检查是诊断肩袖损伤准确性相当可靠，在三种影像诊断方法中，常规MR是诊断肩袖撕裂，比较准确的方法，肩关节造影的诊断准确性要高于常规MR，MRA则是最准确的方法结论MRA是诊断肩袖撕裂准确性较高的方法
Objective: To evaluate the value of physical examination and imaging in the diagnosis of rotator cuff tears. Perspective study was also performed to compare the diagnostic value of different methods including routine MR, arthrograp, and MRA
Materials and Methods: Seventy consecutive patients with suspected rotator cuff tears were examined with physical examination, X-ray arthrography ,routine MR, arthrography, and MR arthrography before the of the examination of .shoudler arthroscope. Base on the results of the arthrography, the diagnostic sensitivity, specificity, and accuracy of the physical examination, and the diagnostic value of routine MR, arthrography, and MR arthrography were compared. The advantages and disadvantages of every method were also discussed.
Results: The 35 cases included 18 full-thickness tears, 11 Partial thickness tears and 6 non-tears. Based on the shoudler arthroscope accuracy of physical examination were83%. For the diagnosis rotator cuff tears the sensitivity, specificity, and accuracy were 78%, 80%, and 81% of the routine MR. respectively ;the figures were 94%,93%,and 93% of the X-ray arthrography. respectively ;while the date were 100%, 95%, and 97% for MRA. for the diagnosis full-thickness tears the sensitivity, specificity, and accuracy were 83%, 86%, and 81% of the routine MR ;respectively ;the figures were 91%, 93%, and 86% of the X-ray arthrography, respectively ;while the date were 100%, 100%, and 100% for MRA
Conclusion: physical examination is a good modality in the diagnosis of rotator cuff tears. The routine MR is a relatively accurate method for revealing rotator cuff tears. The accuracy of arthrography for rotator cuf tears is higher than that of routine MR. MRA is the most accurate method among these three diagnostic imaging methods.
引文
[1] Bonafede RP, Bennet RM Soulder pain. Guidelines to diagnosis and management[J]. postgrade med, 1987, 82: 185～192
[2] 刘玉杰，卢世璧．肩袖损伤的诊断和治疗进展[J]．中华创伤杂志，1998，14：340～342
[3] 郑卓肇，谢敬霞，范家栋．肩袖全层撕裂的MRI表现[J]．临床放射学杂志，2001，20(3)：216～218
[4] 曲绵域，田得祥．运动创伤检查法．第3版．北京：北京医科大学出版社，2006．36～46
[5] 崔国庆，敖英芳，于长隆，等．肩峰下撞击综合征38例临床症状体征分析[J]．中华骨科杂志，2000，20(8)：467～469
[6] 钱明珠，林伟，黄敏华．肩关节磁共振成像扫描技术的临床[J]．海军总医院学报，2004，17：28～29
[7] 刘玉杰，王岩，王立德．实用关节镜手术学．第1版北京：人民军医出版社，2006．233～234
[8] Neer CS. Impingment lesion [J]. Clin Orthop, 1982, 173: 70～74.
[9] Bigliani LU, Morrison DS, April EW, et al. The morphology of the acrimony and its relationship to rotator cuff tear [J]. Orthop Trans, 1986, 10: 216～228
[10] Carrino JA, McCauley TR, Kats LD, et al. Rotater calf: evaluation with fast spin-echo versus conventional spin-echo[J]. MR imaging. 1997, 202: 533～539
[11] 郑燕，章士正．MRI在肩关节疼痛疾病中诊断应用．中国医学计算机成像杂志[J]．2003，9(2)：117～118
[12] Owen RS, Iannotti JP, Kneeland JB, et al. Shoulder after surgery: MR with imaging with surgical validation [J]. Radiology. 2000, 186: 443～444
[13] Kieft GJ, Bloem Jh, Rozing PM, et al. Rotator cuff imingement syndrome [J]. MR imaging. Radiology, 1998, 166: 211～213
[14] Snyder SJ. Evaluation and treatment of the rotator cuff [J]. Orthop Clin North Am 1993, 24: 173～185
[15] 倪宗瓒．卫生统计学[M]．北京：人民卫生出版社，2001，165
[16] Kursunoglu Brahme S, Resnick D. Magneic resonance imaging of the shoulder. Radiol Olin NorthAm, 1990, 28(5): 941～954
[17] Stiles RG, Otte MT. Imaging of the shoulder [J]. Radiology, 1993, 188 (3) 603～613
[18] Wonhee J, Thomas RM, etal. Meniscal Tear Configurations: Categorization with MR Imaging [J]. AJ R. 2003, 180(1): 93
[19] Buchberger DJ. Introduction of a new physical examination procedure for the differentiation ofacromioclavicular joint lesions andsubacromial impingement[J], J Manipulative Physiol Ther, 1999, 22: 316～321
[20] Brien SJ, Pagnani MJ, Fealy S, etal. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med, 1998, 26: 610～613
[21] Hertel R, Ballmer FT, Lombert SM, et al. Lag signs in the diagnosis of rotator cuff rupture[J]. J Shoulder Elbow Surg. 1996, 5: 307～313
[22] Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop. 1990, 254: 64～74
[23] Weber SC. Arthroscop icdebridement and acromiop lasty versus miniopen repair in the treatment of significant partia 12 thickness rotator cuff tears [J]. Arthroscopy. 1999, 15(2): 126～131
[24] Kannotti JP, Zlatkan MB, Esterhal JL, etal. Magnetic resonance imaging of the shoulder: sensitivity, specifity, and predictive value [J]. J Bone Joint Surg [Am]. 1999, 73-A: 17
[25] 江浩．骨与关节MRI[M]．上海：科学技术出版社，1999．267
[26] Resnick D. Shoulder arthrography. Radio Clin North Am. 1981, 19: 243～253
[27] Middleton WD. Status of rotator cuff sonography. Radiology. 1989, 173: 307-309
[28] Miniaci A, Salonen D, etal. Rotator cuff evaluation: imagine and diagnosis [J]. Orthop Clin North Am. 1997, 28: 43-58
[29] Tirman PF, Steinbach LS, Belzer JP, etal. Apractical app roach to imaging of the shoulder with emphasis on MR imaging [J]. Orthop Olin North Am. 1997, 28: 483～515
[30] Wang YM, Shin TT, Jiang CL, et al. Magnetic resonance imaging of rotator cuff lesions[J]. J Formos Med Assoc, 1994, 3: 234～239
[31] Uri DS. MR imaging of shoulder impingement and rotator cuff disease [J]. Radial Clin North Am, 1997, 1: 77～96
[32] Cordasco FA, Backer M, Craig EV, et al. The partial2thickness rotator cuff tear: is acromiop lasty without repair sufficient Am J SportsMed [J]. 2002, 30(2): 257-260
[33] 邓祖新．SAS系统和数据分析．北京：电子工业出版社，2002，216～232
[34] 金丕焕．医用SAS统计分析．上海：复旦大学出版社2002144—148
[35] 吴逸明．职业性肺癌高危人群筛检的聚类与判别分析．河南医科大学学报，2000，35(3)：203～205．
[36] Chesley LC, Sibai BM. Clinical significance of elevated mean arterial pressure in the second trimester [J]. Am J Obstet Gyneco 1, 1988, 159: ～751
[37] RodriguezMH, Masaki DI, Mestman J, etal. Calcium creatinine ratio and microalbum inuria in the prediction of p reeclamp sia. Am J Obstet Gyneco 1. 1988, 159(6): 1452～1485
[38] 方积乾．生存量测定方法及应用[M]．北京：北京医科大学出版社，2000．118～124
[39] 苏金明，等，统计软件SPSS for Windows使用指南[M]．北京：电予工业出版社．2000，478～492
[1] 刘玉杰，卢世璧．肩袖损伤的诊断和治疗进展．中华创伤杂志，1998，14：340～342
[2] Neer CS. Impingment lesion [J]. Clin Orthop, 1982, 173: 70～74
[3] Bigliani LU, Morrison DS, April EW, et al. The morphology of the acrimony and its relationship to rotator cuff tear [J]. Orthop Trans, 1986, 10: 216～228
[4] Middleton WD. Status of rotator cuff sonography [J]. Radiology, 1989, 173: 307～309
[5] Miniaci A, Salonen D, et al. Rotator cuff evaluation: imagine and diagnosis[J]. Orthop Clin North Am. 1997,. 28: 43～58
[6] Teffey SA, Hasan SA, Middleton WD, et al. Ultrasonography of t he rotator cuff: a comparison of ultrasonographic and art hroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am, 2000, 822A: 498～504
[7] Paavolainen WE, Ahovuo J, et al Ultrasonography and arthrography in the diagnosis of tears of the rotator cuff [J]. JBone Joint Surg(Am), 1994, 76: 335～340
[8] Sofka CM, Adler RS, et al. Sonographic evaluation of shoulder arthroplasty [J]. Am J Roentgenol, 2003, 180: 1117～1120
[9] 郭艾，藤田健司，水野耕作．肩袖损伤诊断中肩关节造影和MRI的敏感性特异性比较[J]．中华外科杂志，2000，38：263～265
[10] Palmer WE, Caslowitz PL, Chew FS, et al. MR arthrography of the shoulder: normal intraarticular structures and common abnormalities [J]. AJR, 1995, 164(1): 141～146
[11] Iannotti J P, Zlatain MB, Esterhai JL, et al. Magnetic resonense imaging of the shoulder. Sensitivity. Specificity and predictive value [J]. J Bone Joint Surg (Am), 1991, 73: 17～29
[12] 唐三元，徐永年，郑玉明．肩袖损伤(一)中国矫形外科志，1999，6(2)：140～141
[13] Tirman PF, Steinbach LS, Belzer J P, et al. Apractical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin Nort h Am. 1997, 28: 483～515
[14] Palmer WJ, Browon J H, Rosenthal DI, et al. Rotator cuff: Evaluat ion wit h fat suppessed MR arthrography. Radiology .1993, 188: 683～687
[15] Yagci B, Manisali M, Yilmaz E, et al. Indirect MR arthrography of the shoulder in detection of rotator cuff ruptures. EurRadiol. 2001, 11: 258-262
[16] 崔国庆，郑卓肇，于长隆．MRI和MR关节造影在肩部损伤中的诊断价值[J]．中国运动医学杂志．2000，19(3)：233～236
[17] Tirman PF, Steinbach LS, Belzer JP, etal. Apractical app roach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 1997; 28: 483～515
[18] 郑卓肇，谢敬霞，范家栋肩袖全层撕裂的MRI表现[J]．临床放射学杂志，2001，20(3)：216～218．
[2] 刘玉杰，卢世璧．肩袖损伤的诊断和治疗进展[J]．中华创伤杂志，1998，14：340～342
[3] 郑卓肇，谢敬霞，范家栋．肩袖全层撕裂的MRI表现[J]．临床放射学杂志，2001，20(3)：216～218
[4] 曲绵域，田得祥．运动创伤检查法．第3版．北京：北京医科大学出版社，2006．36～46
[5] 崔国庆，敖英芳，于长隆，等．肩峰下撞击综合征38例临床症状体征分析[J]．中华骨科杂志，2000，20(8)：467～469
[6] 钱明珠，林伟，黄敏华．肩关节磁共振成像扫描技术的临床[J]．海军总医院学报，2004，17：28～29
[7] 刘玉杰，王岩，王立德．实用关节镜手术学．第1版北京：人民军医出版社，2006．233～234
[8] Neer CS. Impingment lesion [J]. Clin Orthop, 1982, 173: 70～74.
[9] Bigliani LU, Morrison DS, April EW, et al. The morphology of the acrimony and its relationship to rotator cuff tear [J]. Orthop Trans, 1986, 10: 216～228
[10] Carrino JA, McCauley TR, Kats LD, et al. Rotater calf: evaluation with fast spin-echo versus conventional spin-echo[J]. MR imaging. 1997, 202: 533～539
[11] 郑燕，章士正．MRI在肩关节疼痛疾病中诊断应用．中国医学计算机成像杂志[J]．2003，9(2)：117～118
[12] Owen RS, Iannotti JP, Kneeland JB, et al. Shoulder after surgery: MR with imaging with surgical validation [J]. Radiology. 2000, 186: 443～444
[13] Kieft GJ, Bloem Jh, Rozing PM, et al. Rotator cuff imingement syndrome [J]. MR imaging. Radiology, 1998, 166: 211～213
[14] Snyder SJ. Evaluation and treatment of the rotator cuff [J]. Orthop Clin North Am 1993, 24: 173～185
[15] 倪宗瓒．卫生统计学[M]．北京：人民卫生出版社，2001，165
[16] Kursunoglu Brahme S, Resnick D. Magneic resonance imaging of the shoulder. Radiol Olin NorthAm, 1990, 28(5): 941～954
[17] Stiles RG, Otte MT. Imaging of the shoulder [J]. Radiology, 1993, 188 (3) 603～613
[18] Wonhee J, Thomas RM, etal. Meniscal Tear Configurations: Categorization with MR Imaging [J]. AJ R. 2003, 180(1): 93
[19] Buchberger DJ. Introduction of a new physical examination procedure for the differentiation ofacromioclavicular joint lesions andsubacromial impingement[J], J Manipulative Physiol Ther, 1999, 22: 316～321
[20] Brien SJ, Pagnani MJ, Fealy S, etal. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med, 1998, 26: 610～613
[21] Hertel R, Ballmer FT, Lombert SM, et al. Lag signs in the diagnosis of rotator cuff rupture[J]. J Shoulder Elbow Surg. 1996, 5: 307～313
[22] Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop. 1990, 254: 64～74
[23] Weber SC. Arthroscop icdebridement and acromiop lasty versus miniopen repair in the treatment of significant partia 12 thickness rotator cuff tears [J]. Arthroscopy. 1999, 15(2): 126～131
[24] Kannotti JP, Zlatkan MB, Esterhal JL, etal. Magnetic resonance imaging of the shoulder: sensitivity, specifity, and predictive value [J]. J Bone Joint Surg [Am]. 1999, 73-A: 17
[25] 江浩．骨与关节MRI[M]．上海：科学技术出版社，1999．267
[26] Resnick D. Shoulder arthrography. Radio Clin North Am. 1981, 19: 243～253
[27] Middleton WD. Status of rotator cuff sonography. Radiology. 1989, 173: 307-309
[28] Miniaci A, Salonen D, etal. Rotator cuff evaluation: imagine and diagnosis [J]. Orthop Clin North Am. 1997, 28: 43-58
[29] Tirman PF, Steinbach LS, Belzer JP, etal. Apractical app roach to imaging of the shoulder with emphasis on MR imaging [J]. Orthop Olin North Am. 1997, 28: 483～515
[30] Wang YM, Shin TT, Jiang CL, et al. Magnetic resonance imaging of rotator cuff lesions[J]. J Formos Med Assoc, 1994, 3: 234～239
[31] Uri DS. MR imaging of shoulder impingement and rotator cuff disease [J]. Radial Clin North Am, 1997, 1: 77～96
[32] Cordasco FA, Backer M, Craig EV, et al. The partial2thickness rotator cuff tear: is acromiop lasty without repair sufficient Am J SportsMed [J]. 2002, 30(2): 257-260
[33] 邓祖新．SAS系统和数据分析．北京：电子工业出版社，2002，216～232
[34] 金丕焕．医用SAS统计分析．上海：复旦大学出版社2002144—148
[35] 吴逸明．职业性肺癌高危人群筛检的聚类与判别分析．河南医科大学学报，2000，35(3)：203～205．
[36] Chesley LC, Sibai BM. Clinical significance of elevated mean arterial pressure in the second trimester [J]. Am J Obstet Gyneco 1, 1988, 159: ～751
[37] RodriguezMH, Masaki DI, Mestman J, etal. Calcium creatinine ratio and microalbum inuria in the prediction of p reeclamp sia. Am J Obstet Gyneco 1. 1988, 159(6): 1452～1485
[38] 方积乾．生存量测定方法及应用[M]．北京：北京医科大学出版社，2000．118～124
[39] 苏金明，等，统计软件SPSS for Windows使用指南[M]．北京：电予工业出版社．2000，478～492
[1] 刘玉杰，卢世璧．肩袖损伤的诊断和治疗进展．中华创伤杂志，1998，14：340～342
[2] Neer CS. Impingment lesion [J]. Clin Orthop, 1982, 173: 70～74
[3] Bigliani LU, Morrison DS, April EW, et al. The morphology of the acrimony and its relationship to rotator cuff tear [J]. Orthop Trans, 1986, 10: 216～228
[4] Middleton WD. Status of rotator cuff sonography [J]. Radiology, 1989, 173: 307～309
[5] Miniaci A, Salonen D, et al. Rotator cuff evaluation: imagine and diagnosis[J]. Orthop Clin North Am. 1997,. 28: 43～58
[6] Teffey SA, Hasan SA, Middleton WD, et al. Ultrasonography of t he rotator cuff: a comparison of ultrasonographic and art hroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am, 2000, 822A: 498～504
[7] Paavolainen WE, Ahovuo J, et al Ultrasonography and arthrography in the diagnosis of tears of the rotator cuff [J]. JBone Joint Surg(Am), 1994, 76: 335～340
[8] Sofka CM, Adler RS, et al. Sonographic evaluation of shoulder arthroplasty [J]. Am J Roentgenol, 2003, 180: 1117～1120
[9] 郭艾，藤田健司，水野耕作．肩袖损伤诊断中肩关节造影和MRI的敏感性特异性比较[J]．中华外科杂志，2000，38：263～265
[10] Palmer WE, Caslowitz PL, Chew FS, et al. MR arthrography of the shoulder: normal intraarticular structures and common abnormalities [J]. AJR, 1995, 164(1): 141～146
[11] Iannotti J P, Zlatain MB, Esterhai JL, et al. Magnetic resonense imaging of the shoulder. Sensitivity. Specificity and predictive value [J]. J Bone Joint Surg (Am), 1991, 73: 17～29
[12] 唐三元，徐永年，郑玉明．肩袖损伤(一)中国矫形外科志，1999，6(2)：140～141
[13] Tirman PF, Steinbach LS, Belzer J P, et al. Apractical approach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin Nort h Am. 1997, 28: 483～515
[14] Palmer WJ, Browon J H, Rosenthal DI, et al. Rotator cuff: Evaluat ion wit h fat suppessed MR arthrography. Radiology .1993, 188: 683～687
[15] Yagci B, Manisali M, Yilmaz E, et al. Indirect MR arthrography of the shoulder in detection of rotator cuff ruptures. EurRadiol. 2001, 11: 258-262
[16] 崔国庆，郑卓肇，于长隆．MRI和MR关节造影在肩部损伤中的诊断价值[J]．中国运动医学杂志．2000，19(3)：233～236
[17] Tirman PF, Steinbach LS, Belzer JP, etal. Apractical app roach to imaging of the shoulder with emphasis on MR imaging. Orthop Clin North Am 1997; 28: 483～515
[18] 郑卓肇，谢敬霞，范家栋肩袖全层撕裂的MRI表现[J]．临床放射学杂志，2001，20(3)：216～218．