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上期试题：骨骺、干骺端结核的特征性X线表现为b A．破坏区边缘有硬化 B．破坏区常横跨骺线 C．破坏区较局限 D．死骨及窦道形成 E．常伴沙粒样死骨 膝关节结核多见于儿童和青壮年，30岁以上者发病率明显高于髋关节结核。后期我们再谈谈髋关节结核的影像表现。膝关节结核多为单侧关节发病，双关节发病极少见。一般症状、体征包括低热、盗汗、贫血、消瘦、易疲劳、食欲不振和血沉加速等。 The knee joint tuberculosis among children and young adults, 30 years old or above rates significantly higher than that of the hip joint tuberculosis. Later we talk about the image of the hip joint tuberculosis. Knee joint tuberculosis mostly unilateral joint disease, double joint is a rare disease. General signs and symptoms include low grade fever, night sweats, anaemic, angular, fatigue, loss of appetite and blood sedimentation speed, etc. （1）、滑膜型膝关节结核X线平片早期诊断较为困难，可表现为关节周围软组织肿胀，关节间隙增宽，局部骨质疏松，髌上囊扩大以及髌骨与股骨髁间距增宽等改变。随着病变的进展，多在半年或数年后，膝关节周围骨质疏松更加明显，关节间隙逐渐变窄，在关节边缘的非承重部位及关节中心软骨下骨性关节面出现糜烂性骨破坏，常为关节上下缘对称性受累，继而关节间隙出现非对称性狭窄；此时，关节的软组织肿胀与邻近软组织的萎缩形成肿胀改变。儿童期患者由于滑膜充血，骨骺可较健侧增大或提前骨化。 (1)、 synovial membrane type knee joint tuberculosis X-ray plain film in early diagnosis is difficult, can be characterized by articular surrounding soft tissue swelling, joint gap widened, local osteoporosis, patellar capsule on expanding and broadening of patella and femoral condyle spacing for change. With the progress of the disease, in half a year or more after a few years, around the knee joint bone loss more apparent, joint gap Narrows gradually, in the center of the non load-bearing part on the edge of the joints and joint cartilage osseous joint surface appear under erosive bone destruction, often lower edge symmetry involvement on the joints, and joint gap appears asymmetric stenosis; At this point, the joint soft tissue swelling and swelling in the adjacent soft tissue atrophy. Childhood patients with synovial hyperemia, epiphyseal than that can increase or ossification in advance. ↑右膝关节滑膜型结核 双膝关节正位X线片示：右膝关节周围软组织呈梭形肿胀及轻度骨质疏松，关节间隙变窄，骨骺较对侧增大伴轻度边缘糜烂性骨破坏 （2）、骨性膝关节结核关节周围软组织亦可发生肿胀，病变起源于骨骺或干骺端，发生骨质破坏，关节面不规则，关节间隙可出现狭窄，根据其发生位置可分为中心型和边缘型。中心型病变多见于股骨和胫骨的干骺端或骨骺，早期表现为骨质稀疏模糊，后期发生骨坏死及干酪样病灶中钙盐沉积，X线平片可呈磨玻璃样改变，死骨吸收后形成骨空洞，表现为类圆形或不规则透亮区。边缘型结核的特点是不受干骺板的限制，病变可跨越骨骺及干骺端呈偏心性骨质破坏，表现为骨质边缘区的虫蚀样或溶骨性破坏，边缘较清晰，一般无死骨形成。严重的关节破坏可导致膝关节窦道形成或出现半脱位、纤维性关节强直。 (2)、 osteoarthritis knee joint tuberculosis may also occur in the surrounding soft tissue swelling, originated in the epiphyseal lesion or stem epiphyseal end, bone destruction, joint surface is irregular, joint space can appear narrow, according to their occurrence position can be classified as center and borderline. Center type lesions in the femoral and tibial stem epiphyseal side or epiphyseal, characterized by bone sparse fuzzy, early late osteonecrosis and cheese lesion, the calcium salt deposition in X-ray plain film can change in grinding of glass samples, dead bone cavity is formed after bone absorption, show the class round or irregular bright area. The characteristics of the borderline of TB is not restricted by stem epiphyseal plate, lesions can span epiphyseal and dry epiphyseal end the skew concentric bony destruction, characterized by bone edge area or insect damage sample dissolving bony destruction, edge is clear, there is no dead bone formation. Serious joint damage can lead to knee joint fistula formation or subluxation, fibrous joint stiffness. ↑右膝关节骨性结核 关节正侧位X线片示：可见股骨外侧髁干骺端及骨骺部呈边缘性跨越骨骺板的椭圆形溶骨性骨质破坏病灶，伴有关节周围软组织肿胀 （3）、全关节结核：滑膜型与骨性膝关节结核均可演变为全关节结核。早期表现为关节软组织肿胀，软骨下骨板大部分完整。关节间隙正常或稍变窄；晚期可见明显骨质破坏，软骨下骨破坏消失，关节间隙狭窄或消失，严重者可出现骨性强直、关节畸形及病理性脱位。儿童患者可见股骨和胫骨的发育障碍。长期的混合感染可见明显骨质增生硬化改变，长时间的冷脓肿可发生钙化。 (3)、the joint tuberculosis: synovial membrane type and osteoarthritis knee joint tuberculosis can be turned into joint tuberculosis. Early performance for joint soft tissue swelling, most complete the subchondral bone plate. The joint normal or slightly narrowed; Can be obviously bone destruction, the late disappear the subchondral bone destruction, joint space narrowing or disappearance, serious can appear osseous stiffness, joint deformity and pathological dislocation. Children with the developmental disorders of the femur and tibia. Long term can be obviously bone hyperplasia hardening mixed infection of change, the long cold abscess can happen calcification. ↑左膝关节结核伴骨性强直 左膝关节正侧位X线片示： 显示左膝关节骨质疏松，膝关节面破坏，关节间隙狭窄或消失，骨小梁部分通过关节腔，形成骨质强直，膝关节脱位 CT对膝关节结核的早期诊断明显优于X线检查，不仅可以早期发现关节周围软组织肿胀、关节腔积液、细微的骨质破坏、死骨形成以及周围骨质疏松等情况，而且可以更加明确的判断骨质破坏的具体部位、破坏程度以及继发性改变，还有助于早期发现钙化，了解脓肿的累及范围，有利于脓肿的穿刺检查、指导治疗以及治疗后的病情随访等。 CT is obviously better than the early diagnosis of the knee joint tuberculosis X-ray examination, not only can the early detection of articular surrounding soft tissue swelling, articular cavity effusion, slight bone destruction, and death and the surrounding bone formation and osteoporosis, etc., and can be more clear judgment bone destruction of the site, extent of damage and secondary change, also is helpful to the early detection of calcification, abscess involving the scope, is advantageous to the abscess puncture check and guide the treatment and follow-up after treatment condition, etc. ↑左膝关节结核 膝关节CT扫描： 左：骨窗显示股骨髁内骨质疏松，局部关节面破坏 右：软组织窗显示关节周围软组织肿胀 MRI检查亦有助于早期膝关节结核病变的发现和诊断，对关节积液、积脓、关节软骨下脓肿和前后交叉韧带、半月软骨板破坏的显示很有价值。膝关节结核的滑膜增生常表现为弥漫性，在T1WI上呈均等的中、低信号表现，在T2WI上呈中、高信号为主的混杂信号，但其中可见不规则低信号的条状、结节状或团块影；关节积液呈明显的高信号，但信号可以不均匀。矢状面和横断面可见增生的滑膜充填于髌上囊，致使髌上囊容积较正常缩小。MRI增强扫描后，肉芽组织增生的滑膜增生及病灶中的活动性病变可出现较明显的强化。在全膝关节结核病变中，滑膜的混杂信号更加明显，并可见明显的不规则结节或团块状低信号影，脂肪抑制T2WI序列显示病变更加敏感和清晰。 MRI also helps to knee joint tuberculosis early detection and diagnosis, under the joint effusion, empyema, articular cartilage abscess and cruciate ligament, cartilage plate and a half months before and after the destruction of display is very valuable. Synovial hyperplasia of knee joint tuberculosis often characterized by diffuse, in equal in middle and low signal on T1WI, mainly in medium and high signal on T2WI mixed signals, but the irregular low signal of strip, nodular or mass shadow; Joint effusion was significantly high signal, but the signal can be uneven. Sagittal and transverse section visible hyperplasia of the synovial filling on patellar capsule, the capsule on patellar volume than normal. After MRI enhancement scanning, granulation tissue hyperplasia of the synovial hyperplasia and lesions of active lesions can appear obviously improved. In total knee tuberculous synovitis of the mixed signal more apparent, clearly visible and irregular nodules or crumb low signal, fat suppression T2WI sequences showed lesions are more sensitive and clear. ↑右膝关节结核 矢状面与冠状面MRI检查示： 膝关节面软骨明显变薄；关节面下两端骨质破坏，T1WI呈低信号，脂肪抑制T2WI呈高信号；关节腔内少量积液；T1WI增强扫描检查可见滑膜增厚及较明显强化 MRI检查还有助于膝关节软骨异常的显示，表现为软骨表面毛糙不平，软骨局部缺损、变薄，重症或晚期的膝关节结核患者可见软骨全层缺失及大面积剥脱。在脂肪抑制T2WI序列中，骨髓水肿表现为片状信号，膝关节结核的骨质破坏表现为虫蚀样改变，在T1WI上呈大小不等的低信号影，T2WI上呈高、中、低混杂信号影；骨髓水肿在T1WI上呈稍低信号影，T2WI上呈局限性或弥漫性片状稍高信号。骨质破坏与骨髓水肿等改变在脂肪抑制序列上显示更清晰，关节积液与滑膜可进入破坏的骨质内。除上述表现外，还可以伴有半月软骨板和韧带的损伤与破坏。 Abnormal MRI can also help the knee joint cartilage, characterized by cartilage surface coarse, partial cartilage defect, thinning, severe or late of the knee joint tuberculosis patients visible cartilage full-thickness defects and large area of stripping. In fat suppression T2WI sequences, bone marrow edema of flake signal, the knee joint bone destruction of TB is insect damage appearance change, in sizes in low signal on T1WI, T2WI in high, medium and low mixed signals on shadow; Bone marrow edema in is slightly low signal on T1WI, show limitations or diffuse lamellar slightly high signal on T2WI. Bone damage and bone marrow edema changes in fat suppression sequence shows more clearly, and synovial joint effusion can enter within the bone. In addition to the above performance, but also can be accompanied by half plate cartilage and ligament damage and destruction. ↑左膝关节结核 矢状面MRI检查示： 股骨远端髓内水肿，T1WI呈低信号，FS-T2WI呈高信号；T1WI增强及脂肪抑制FSPGR增强可见关节周围滑囊、脓肿壁呈明显环形强化，部分进入骨质内 医学博士专栏 第二十四期：来自宾放博士的建议之飞蚊和眼前闪光 问：最近我经常看到眼前有许多小黑点飞来飞去，这是怎么回事呢？ Q: recently, I often see flew at present there are many small black dot, how did this happen? 答：这些斑点被称为玻璃体飞蚊。飞蚊是 填充眼球的玻璃球凝胶中微小的结块。一般来说，它们是自然老化的凝胶的一部分。你所看到的飞蚊就是这些粒子投射在视网膜上的阴影。所以如果有些阴影在你的眼中存在长达数月，一般不需要太担心。但是，玻璃体凝胶中任何固体物质都能在视网膜上造成相同的阴影。最近出现了一些非常特别的飞蚊，它们可能是由于眼内出血或视网膜轻度破裂所引起的。如果你眼中的飞蚊是最近爆发的，或者和之前出现的飞蚊相比有显著的变化，应该去找眼科医生检查。 A: these spots are called vitreous floaters. Floaters are filled eye ball gel in small lumps. In general, they are part of the natural aging of gel. You can see floaters is the particles in the retina of shadows. So if some shadows exist in your eyes for months, generally do not need to worry too much. However, any solid material in the vitreous gel can be in the retina caused by the shadow of the same. Recently there have been some very special floaters, they may be caused by intraocular hemorrhage or mild retinal burst. If you in the eyes of floaters is the recent outbreak of, or occurring before and floaters than a significant change, should go to an eye doctor check. 问：我偶尔会在眼中感觉像星星一样的闪光，这会很危险吗？ Q: I sometimes feel like stars in my eyes flashing, it would be dangerous? 答：如果感觉闪光确实位于视野中的某一个点，应该让眼科医生来检查一下。这些闪光可能是由于视网膜有孔隙或是视网膜出现造成的。如果闪光覆盖了你视野的绝大部分，则会存在以下两种可能：首先是偏头痛发作。偏头痛发作经常令双眼产生看到亮光或微光这样的幻觉；其次是眼部暂时性的循环不良。就像你蹲久了之后站起来时的感觉一样。其实这种感觉可能也是眼睛血液循环不良的征兆之一。 A: if feel flash is located at a certain point in the field of vision, should let an eye doctor to check it. The flash may have been caused by the retina has a pore or retinal appear. If the flash cover most of your field of vision, will exist the following two possibilities: first is migraine attacks. Migraine attacks often make his eyes see light or light such illusion. The second is the eye temporary bad circulation. As you stand after sitting for a long time feeling. Actually this kind of feeling may also be a sign of poor circulation eyes. 另一种类型的眼前闪光呈弧形或半弧形，产生于某只眼睛侧面视角的远端，而且经常由于眼睛活动而出现。眼中闪光通常是由于玻璃体凝胶对视网膜周边进行拉伸造成的。这种拉伸可能暗示视网膜出现空洞或视网膜轻度脱落。 Another type of eyes flash with arc or half arc, produced in one eye view of the distal side, and often appear due to eye activities. Eyes flashing is usually caused by vitreous gel on the retina around drawing. This drawing may indicate retinal hole or retinal light off. 本期试题：确诊膝关节滑膜结核时，以下哪项最可靠？ A．低烧、盗汗、食欲差 B．膝关节肿胀、疼痛、功能受限 C．血沉增快 D．X线检查膝关节骨质疏松 E．滑膜病理检查
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来自： zskyteacher > 《西航港之临床影像学习平台》
