创伤性和非创伤性踝关节损伤的核磁共振MRI中的骨髓水肿特点：2020年

发表者：陶可人已读

创伤性和非创伤性踝关节损伤的核磁共振MRI中的骨髓水肿特点：2020年

作者：Pawel Szaro, Mats Geijer, Nektarios Solidakis.

作者单位: Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden. pawel.szaro@gu.se.

译者：陶可（北京大学人民医院骨关节科）

足部骨骼结构的上面观（从上向下垂直观察）

足部骨骼结构的下面观（从下向上垂直观察）

足部骨骼结构的外侧面观（从外侧向内侧水平观察）

足部骨骼结构的内侧面观（从内侧向外侧水平观察）

踝关节周围韧带结构的后面观（从后方向前方观察）

踝关节周围韧带结构的前面观（从前方向后方观察）

踝关节周围韧带结构的起止点与重要功能

踝关节周围韧带、肌腱结构的外侧面观（从外侧向内侧观察）

踝关节周围韧带、肌腱结构的内侧面观（从内侧向外侧观察）

跖趾关节周围韧带及关节囊外面观（从外侧向内侧观察）

足踝部韧带的起止点与重要功能

足底部韧带、肌腱结构

踝关节周围肌腱结构

足踝部支持带（筋膜韧带）的重要功能

足踝部神经阻断及封闭、穿刺技术

足踝部肌腱、血管、神经的分布与支配-浅层（神经管理哪个位置的感觉与运动？血管滋养哪个位置？）

足踝部肌腱、血管、神经的分布与支配-深层（神经管理哪个位置的感觉与运动？血管滋养哪个位置？）

足底部跖腱膜分布、血管、神经的分布与支配-浅层（神经管理哪个位置的感觉与运动？血管滋养哪个位置？）-足底筋膜炎，跖膜炎、足底部疼痛解剖学基础之一

足底部肌腱分布、血管、神经的分布与支配-深层（神经管理哪个位置的感觉与运动？血管滋养哪个位置？）

足底部肌腱分布、血管、神经的分布与支配-更深层（神经管理哪个位置的感觉与运动？血管滋养哪个位置？）

足底部肌腱分布、血管、神经的分布与支配-最深层（神经管理哪个位置的感觉与运动？血管滋养哪个位置？）

足跖趾骨间结构与肌肉分布

足踝部肌腱、神经分布与支配

摘要

骨髓水肿(BME)是踝关节损伤后核磁共振成像(MRI)中最常见的发现之一，但即使没有外伤史也可能存在。本文将系统地概述与骨髓水肿BME相关的踝关节和足部最常见的疾病。骨髓水肿BME的存在是原发性病理的非特异性但敏感的标志，可以作为正确和系统解释核磁共振MR检查的指南。骨髓水肿BME的分布可确定创伤机制和正确评估软组织损伤。损伤后的骨髓水肿BME模式涉及外踝、距骨体的内侧部分和胫骨远端的内侧部分。在其他情况下，考虑骨髓水肿BME的分布可能表明损伤或撞击的机制。与肌腱直接接触的骨骼可能导致骨髓信号改变，其中骨髓水肿BME可能表明肌腱病变或动态肌腱功能障碍。改变骨骼之间的机械力应力可能会导致骨髓水肿BME。退行性改变或轻微的软骨损伤可能导致软骨下骨髓水肿BME。早期缺血性坏死、炎症或应力性骨折可能导致更广泛的骨髓水肿BME；因此，详细的病史对于正确诊断至关重要。核磁共振MRI上骨髓水肿BME的系统分析有助于确定创伤机制和原因，从而评估软组织损伤，并有助于区分非创伤性骨髓水肿BME的不同病因。

关键词：踝关节扭伤；脚踝外伤；骨髓水肿；磁共振成像；运动损伤。

结论

在特定类型的损伤中，观察到的骨髓水肿BME分布代表了踝关节核磁共振MRI中最有用的鉴别诊断线索之一。系统的骨髓水肿BME分析能正确解释、正确评估整个核磁共振MR研究。骨髓水肿BME是创伤的重要证据，有助于评估和诊断肌肉骨骼损伤，促使放射科医生评估具有可显着影响患者治疗的病变结果的骨骼结构。

足踝部骨髓病变

创伤（骨髓水肿）

软骨及软骨下组织

与软骨无关

与骨骼有关

-微骨折

-应力性骨折

-（暴力）骨折

与软组织有关

-韧带破裂

-韧带撕裂

- 关节囊破裂

- 支持带破裂

-肌腱损伤

非创伤性

- 过度使用（劳损性）骨髓充血

软骨下（关节病）

- 骨坏死

- 不全性骨折

- 骨梗死

-炎症性关节炎

- 化脓性关节炎

- 肿瘤来源的病变

- 代谢疾病相关的病变

-艾滋病病毒相关的病变

- 神经病相关的病变（糖尿病足、夏科氏关节炎等）

Fig. 1 Common etiologies of bone marrow edema in the ankle [1–3]

图1 踝关节骨髓水肿的常见病因[1-3]

Fig. 2 A 20-year-old soccer player presented after an ankle sprain during a soccer match with suspicion of a fracture in the lateral malleolus. MRI showed bone bruise in the tibia, fibula, and talus (arrows). It revealed no fracture of the lateral malleolus.

图2 一名20岁的足球运动员在足球比赛中脚踝扭伤后就诊，疑似外踝骨折。MRI显示胫骨、腓骨和距骨有骨挫伤（箭头）。结果显示外踝没有骨折。（在急诊踝关节扭伤患者中，约95%的患者不伴有骨折）

Fig. 3 A 57-year-old male with pain in the medial malleolus without a history of trauma. a Radiograph, mortise view, b PD FS coronal image, and c T1-weighted coronal image. MRI showed an occult fracture of the medial malleolus (arrow) which in retrospect was visible on the radiographs. There is a minor irregularity of the cartilage signal in the subchondral central part of the talar trochlea, probably after previous injuries.

图3 男性，57岁，内踝疼痛，无外伤史。a X线片踝穴视图，b PD FS核磁共振冠状位图像，和c T1加权核磁共振冠状图像。核磁共振MRI显示内踝隐匿性骨折（箭头），回想起来在X线片上可见。距骨滑车软骨下中央部分的软骨信号有轻微的不规则性，可能是在先前受伤之后。

Fig. 4 A 19-year-old soccer player sustained an ankle sprain during a soccer match with suspicion of rupture of the anterior tibiofibular ligament. MRI showed avulsion (arrow) of the talar attachment of the dorsal talonavicular ligament.

图4 一名19岁的足球运动员在一场足球比赛中脚踝扭伤，怀疑胫腓前韧带断裂。（但是）核磁共振MRI显示背侧距舟韧带的距骨附着点撕脱（箭头）。

Fig. 5 A 42-year-old male with 9-month history of ankle pain and suspicion of an osteochondral lesion. MRI (a, b) revealed traction cysts at the insertion of the posterior talofibular ligament.

图5 一名42岁男性，有9个月的踝关节疼痛病史并怀疑有骨软骨损伤。核磁共振MRI（a，b）显示后距腓韧带插入处有牵张性囊肿。

Fig. 6 A 24-year-old male imaged on suspicion of an anterior tibiofibular ligament rupture 2 weeks after an ankle injury. MRI showed an avulsion of the anterior talofibular ligament. (1) BME in the lateral malleolus, (2) the anterior talofibular ligament, (3) the posterior talofibular ligament, and (4) an avulsed bone fragment from the lateral malleolus.

图6 一名24岁男性在踝关节损伤2周后因怀疑胫腓前韧带断裂而成像。核磁共振MRI显示距腓前韧带撕脱。(1)外踝骨髓水肿BME，(2)距腓前韧带，(3)距腓后韧带，和(4)外踝撕脱的骨碎片。

Fig. 7 A 39-year-old male imaged 10 days after an ankle injury on suspicion of deltoid ligament rupture. MRI showed (1) partial injury of the flexor retinaculum with (2) BME in the medial malleolus.

图7 一名39岁男性因怀疑三角韧带断裂而在脚踝受伤10天后成像。核磁共振MRI显示(1)屈肌支持带部分损伤和(2)内踝骨髓水肿BME。

Fig. 8 A 65-year-old male with chronic ankle pain after ankle trauma about 3 weeks earlier and a suspected rupture of the tibialis posterior tendon. MRI showed tendinopathy. (1) A partial rupture of the tibialis posterior tendon and (2) BME in the medial malleolus were visible.

图8 一名65岁男性，约3周前踝关节外伤后出现慢性踝关节疼痛，疑似胫骨后肌腱断裂。核磁共振MRI显示肌腱病变。(1)胫后肌腱部分断裂和(2)内踝骨髓水肿BME可见。

Fig. 9 A 59-year-old female with 10-month history of lateral ankle pain and suspicion of an osteochondral lesion. MRI showed tendinopathy of the peroneus brevis tendon. (1) BME in the fibula adjacent to (2) the tendinopathy of the peroneus brevis tendon. (3) A traction cyst at the attachment of the posterior talofibular ligament.

图9 一名59岁女性，有10个月的外踝疼痛病史并怀疑有骨软骨损伤。核磁共振MRI显示腓骨短肌腱的肌腱病变。(1)腓骨附近的骨髓水肿BME，(2)腓骨短肌腱的肌腱病。(3)距腓后韧带附着处的牵张性囊肿。

Fig. 10 A 49-year-old male with chronic pain at the Achilles tendon enthesis and suspicion of a Haglund deformity. MRI showed enthesopathy of the Achilles tendon (dashed arrow) and BME in the tuber calcanei (arrow) without evidence of a Haglund deformity (curved arrow).

图10 一名49岁男性，患有跟腱附着点慢性疼痛并怀疑Haglund畸形。核磁共振MRI显示跟腱附着点病（虚线箭头）和跟骨结节（箭头）中的骨髓水肿BME，但没有Haglund畸形（弯曲箭头）的证据。

Haglund畸形：Haglund畸形指跟骨后上结节的异常突出（跟骨的骨质增生肥大），同时伴跟腱止点周围炎症，当骨质增大隆起后，后跟的皮肤反复摩擦到鞋子上时，会引起相应的肿胀、疼痛、跛行和足背伸受限，临床上习惯称之为跟腱末端病。

该病变于1928年首次由Patrick Haglund描述，故将止点性跟腱炎、跟骨后上突增生（Haglund畸形）与跟腱滑囊炎统称为Haglund综合征。

Fig. 11 A 62-year-old female with recurring symptoms after previous surgery for a Haglund deformity. MRI and radiography showed a Haglund deformity (arrow) with bone marrow edema again visible on MRI.

图11 一名62岁女性，之前因Haglund畸形手术后症状反复出现。核磁共振MRI和X线片显示Haglund畸形（箭头），在核磁共振MRI上再次可见骨髓水肿。

Fig. 12 A 43-year-old female with chronic pain in the plantar part of the heel and suspicion of a heel spur and plantar aponeurosis rupture. MRI revealed (1) enthesopathy of the plantar fascia with (2) bone marrow edema in the calcaneus.

图12 一名43岁女性，足跟跖部慢性疼痛，疑似足跟骨刺和足底腱膜破裂。核磁共振MRI显示(1)足底筋膜附着点病和(2)跟骨骨髓水肿。

Fig. 13 A 57-year-old female with hindfoot pain for 4 weeks and a suspected osteochondral lesion and osteoarthritis. MRI showed stress fractures of the tibia and calcaneus (arrows).

图13 一名57岁女性，足后部疼痛4周，疑似骨软骨病变和骨关节炎。核磁共振MRI显示胫骨和跟骨的应力性骨折（箭头）。

Fig. 14 An 18-year-old female with diffuse pain at the level of the navicular bone. MRI with (a) T2-weighted fat suppression and (b) T1-weighted coronal images revealed extensive BME (1) and a stress fracture in the navicular bone (2).

图14 一名18岁女性，在舟骨水平出现弥漫性疼痛。(a) T2加权脂肪抑制和(b) T1加权冠状位图像的核磁共振MRI显示广泛的骨髓水肿BME (1) 和舟骨中的应力性骨折(2)。

Fig. 15 A 61-year-old female with hindfoot pain. MRI showed osteonecrosis of the navicular bone (arrows; Mueller-Weiss syndrome).

图15 一名61岁女性，足后部疼痛。核磁共振MRI显示足舟骨骨坏死（箭头；Mueller-Weiss综合征）。

Fig. 16 A 45-year-old male, 2 years after kidney transplantation, presented with 6-week history of ankle pain and a suspected talar stress fracture. MRI showed bone infarcts in the distal tibia (1), fibula (4), talus (2), and calcaneus (5) and a talar fracture (3). BME in the subchondral part of the distal tibia (6).

图16 一名45岁男性，肾移植2年后，出现6周踝关节疼痛病史，疑似距骨应力性骨折。核磁共振MRI显示胫骨远端(1)、腓骨(4)、距骨(2)和跟骨(5)和距骨骨折(3)发生骨梗死。胫骨远端软骨下部分的骨髓水肿BME(6)。

Fig. 17 A 19-year-old handball player with 3-month history of ankle pain imaged for suspected anterior tibiofibular ligament rupture and stress fracture. a, b On the initial MRI, the cartilage lesion (arrow) was missed, and neither an anterior tibiofibular ligament rupture nor a stress fracture was detected. c, d Because of persistent pain preventing training, MRI was repeated after 8 months. A chondral lesion with subchondral BME was visible and could be identified retrospectively on the previous MRI (arrows).

图17 一名19岁的手球运动员，有3个月的脚踝疼痛病史，疑似胫腓前韧带断裂和应力性骨折。a，b在最初的核磁共振MRI上，软骨病变（箭头）被遗漏，既没有检测到胫腓前韧带断裂也没有检测到应力性骨折。c, d由于持续性疼痛妨碍训练，8个月后重复核磁共振MRI。可以在之前的核磁共振MRI上回顾性识别软骨下骨髓水肿BME的软骨病变（箭头）。

Fig. 18 A 29-year-old male with 4-month history of medial ankle pain and suspicion of an osteochondral lesion. (1) MRI showed a stable nondisplaced osteochondral lesion and (2) subchondral BME, consistent with early inactive osteopenia.

图18 一名29岁男性，有4个月的内侧踝关节疼痛病史并怀疑有骨软骨损伤。(1)核磁共振MRI显示稳定的非移位骨软骨病变和(2)软骨下核磁共振BME，与早期非活动性骨质减少一致。

Fig. 19 A 22-year-old soccer player presented with chronic anterior ankle pain. There was no history of specific ankle trauma leading to suspicion of anterior impingement. MRI showed anterior impingement with osteophytes (arrows) and bone marrow edema.

图19 一名22岁的足球运动员出现慢性前踝疼痛。没有导致怀疑前方撞击的特定脚踝外伤史。核磁共振MRI显示有骨赘（箭头）和前方撞击的骨髓水肿。

Fig. 20 A 55-year-old male with chronic anterior ankle pain. He had had a previous ankle injury about 8 years ago without fracture but now suspicion of developing osteoarthritis. MRI showed osteophytes at the anterior border of the distal tibia with bone marrow edema (arrows) showing anterior impingement.

图20 一名55岁男性，患有慢性前踝疼痛。大约8年前，他曾有过一次踝关节损伤，但没有骨折，但现在怀疑发展为骨关节炎。核磁共振MRI显示胫骨远端前缘有骨赘，骨髓水肿（箭头）显示前部撞击。

Fig. 21 A 16-year-old male with chronic posterior ankle pain and a suspected os trigonum with impingement. (1) MRI showed an os trigonum with BME, (2) effusion and synovitis, and (3) degenerative cysts (4) along the articulation with the posterior talar process.

图21 一名16岁男性，患有慢性后踝疼痛，疑似三角骨撞击（距骨解剖变异）。(1)核磁共振MRI显示三角骨伴骨髓水肿BME，(2)积液和滑膜炎，(3)退行性囊肿(4)沿距骨后突关节。

Fig. 22 A 32-year-old handball player presented after a match with lateral ankle pain and a suspected lateral malleolar fracture. (1) MRI revealed a split rupture of the peroneus longus tendon (2) at the level of an os peroneum with BME.

图22 一名32岁的手球运动员在赛后，出现踝关节外侧疼痛并疑似外踝骨折。(1)核磁共振MRI显示腓骨长肌腱断裂(2)在腓骨水平的骨髓水肿BME。

Fig. 23 A 43-year-old female with chronic ankle pain and suspicion of an osteochondral lesion and osteoarthritis. MRI showed a talocalcaneal coalition (arrow) with BME in the talus (dashed arrow).

图23 一名43岁女性，患有慢性踝关节疼痛，怀疑有骨软骨病变和骨关节炎。核磁共振MRI显示距骨联合（距下关节）（箭头）与距骨下方的骨髓水肿BME（虚线箭头）。

Fig. 24 A 51-year-old female with diffuse pain in the ankle and Chopart joints with suspected osteoarthritis. MRI showed a calcaneonavicular coalition (arrows) with adjacent BME (dashed arrow).

图24 一名51岁女性，踝关节和Chopart关节弥漫性疼痛，疑似骨关节炎。核磁共振MRI显示跟舟联合（箭头）与相邻的骨髓水肿BME（虚线箭头）。

Fig. 25 A 32-year-old runner with 1-month history of right medial ankle pain and suspected stress fracture of the medial malleolus. a Drawing of blood vessels in the bone marrow. b MRI showed hyperemia of bone marrow in the medial malleolus on the symptomatic side (arrows). c On the contralateral side, no vessels were visualized (arrow).

图25 32岁跑步者，右内踝疼痛1个月，疑似内踝应力性骨折。a骨髓中的血管示意图。b核磁共振MRI显示症状侧的内踝骨髓充血（箭头）。c在对侧，未观察到血管（箭头）。

Fig. 26 A 13-year-old female with intermittent moderate ankle pain for 3 weeks. a Radiographs showed a well-defined radiolucent lesion centrally in the distal tibial metaphysis (arrow). b, c MRI showed a Brodie abscess (arrow) with BME (dashed arrows) and contrast enhancement in distal tibia (arrow).

图26 一名13岁女性，间歇性中度踝关节疼痛3周。a X线片显示胫骨远端干骺端中央有明确的射线可透性病变（箭头）。b、c核磁共振MRI显示布罗迪脓肿（箭头）伴骨髓水肿BME（虚线箭头）和胫骨远端对比增强（箭头）。

Fig. 27 A 66-year-old male with diabetes. a Osteomyelitis in calcaneus was suspected clinically and on radiographs. b, c MRI confirmed the diagnosis (arrows), BME (dashed arrow).

图27 一名66岁男性糖尿病患者。a临床和X线片怀疑跟骨骨髓炎。b、c核磁共振MRI证实了诊断（箭头），骨髓水肿BME（虚线箭头）。

Fig. 28 A 70-year-old female with diabetes and Charcot foot. MRI showed extensive bone marrow edema (dashed arrows) in all bones of the foot suggesting active Charcot changes, most prominent at the level of the Lisfranc joint, where dorsal dislocation of os cuneiforme intermedium is visible (arrow).

图28 一名70岁女性，患有糖尿病和夏科氏足。核磁共振MRI显示足部所有骨骼中广泛的骨髓水肿（虚线箭头）表明活跃的Charcot变化，在Lisfranc关节水平最突出，其中可见中体楔骨背侧脱位（箭头）。

Fig. 29 A 28-year-old male presented with ankle pain for 3 months without a history of trauma and suspicion of tumor. There was extensive bone marrow edema in all bones of the foot, most pronounced in the talus (dashed arrow on a) and calcaneus (arrow on b). CRMO was diagnosed after a couple of months.

图29 男性，28岁，踝关节疼痛3个月，无外伤史，疑似肿瘤。足部所有骨骼均有广泛的骨髓水肿，最明显的是距骨（a上的虚线箭头）和跟骨（b上的箭头）。几个月后诊断出慢性复发性多灶性骨髓炎chronic recurrent multifocal osteomyelitis, CRMO。

Fig. 30 A 28-year-old male presented with 3-month history of ankle pain and a suspected osteochondral lesion. MRI showed a solid lesion in the talar head and neck (arrow) with BME as a perilesional reaction (dashed arrow). Histological diagnosis was giant cell tumor.

图30 一名28岁男性，因3个月的踝关节疼痛病史和疑似骨软骨损伤就诊。核磁共振MRI显示距骨头颈部有实性病变（箭头），骨髓水肿BME为病灶周围反应（虚线箭头）。组织学诊断为巨细胞瘤。

Fig. 31 A 19-year-old male presented with nightly ankle pain. MRI confirmed a suspected osteoid osteoma, showing an intra-articular osteoid osteoma (arrow) with minimal sclerosis and extensive BME (dashed arrows) as a perilesional reaction.

图31 一名19岁男性出现夜间脚踝疼痛。核磁共振MRI证实疑似骨样骨瘤，显示关节内骨样骨瘤（箭头）伴有轻微硬化和病灶周围广泛反应性骨髓水肿BME（虚线箭头）。

Fig. 32 A 21-year-old male with inactive osteopenia after immobilization for some weeks. Patchy lesions are visible in all bones (dashed arrows).

图32 一名21岁男性，在固定数周后出现非活动性骨质减少（骨量减低）。在所有骨骼中都可见斑片状病变（虚线箭头）。

Fig. 33 A 7-year-old girl with chronic pain in both feet. MRI shows a developmental variation in the bone marrow signal in the calcaneus (arrows).

图33 一名7岁女孩，双足部慢性疼痛。核磁共振MRI显示跟骨中骨髓信号的发育变化（箭头）。

Fig. 34 A 30-year old patient after ankle joint sprain. Radiographs revealed a Lisfranc fracture-dislocation. (1) MRI showed a vascular remnant, a pitfall, in the calcaneus. (2) BME was seen at the level of the Lisfranc joint.

图34 一名30岁的踝关节扭伤患者。X线片显示Lisfranc骨折脱位。(1)核磁共振MRI显示跟骨中的血管残余物。(2) Lisfranc关节水平可见骨髓水肿BME。

Fig. 35 An 18-year-old runner with Achilles tendon pain. MRI showed a typical artifact in the lateral malleolus on an FS sequence (arrows). There were no changes in the Achilles tendon.

图35 一名患有跟腱疼痛的18岁跑步者。核磁共振MRI在FS序列（箭头）上显示外踝中的典型伪影。跟腱没有变化。

Traumatic and non-traumatic bone marrow edema in ankle MRI: a pictorial essay.

Abstract

Bone marrow edema (BME) is one of the most common findings on magnetic resonance imaging (MRI) after an ankle injury but can be present even without a history of trauma. This article will provide a systematic overview of the most common disorders in the ankle and foot associated with BME.The presence of BME is an unspecific but sensitive sign of primary pathology and may act as a guide to correct and systematic interpretation of the MR examination. The distribution of BME allows for a determination of the trauma mechanism and a correct assessment of soft tissue injury. The BME pattern following an inversion injury involves the lateral malleolus, the medial part of the talar body, and the medial part of the distal tibia. In other cases, a consideration of the distribution of BME may indicate the mechanism of injury or impingement. Bone in direct contact with a tendon may lead to alterations in the bone marrow signal where BME may indicate tendinopathy or dynamic tendon dysfunction. Changed mechanical forces between bones in coalition may lead to BME. Degenerative changes or minor cartilage damage may lead to subchondral BME. Early avascular necrosis, inflammation, or stress fracture may lead to more diffuse BME; therefore, a detailed medical history is crucial for correct diagnosis.A systematic analysis of BME on MRI can help to determine the trauma mechanism and thus assess soft tissue injuries and help to differentiate between different etiologies of nontraumatic BME.

Keywords: Ankle sprain; Ankle trauma; Bone marrow edema; Magnetic resonance imaging; Sports injury.

Conclusion

The distribution of BME seen in specific types of injury represents one of the most useful differential diagnostic clues in ankle MRI. A systematic BME analysis allows for correct interpretation, which enables a correct assessment of the entire MR study. Configurations of BME act as footprints in trauma and help in an assessment and diagnosis of musculoskeletal injuries, prompting the radiologist to assess structures with pathologic findings which can significantly influence patient treatment.

文献出处：Pawel Szaro, Mats Geijer, Nektarios Solidakis. Traumatic and non-traumatic bone marrow edema in ankle MRI: a pictorial essay. Review, Insights Imaging. 2020 Aug 17;11(1):97. doi: 10.1186/s13244-020-00900-8.