尤彬，安榮澤，李松軍，趙俊延

(遵義醫(yī)學(xué)院第五附屬珠海醫(yī)院骨科，廣東 珠海519100)

膝關(guān)節(jié)周圍骨挫傷診治研究進(jìn)展

尤彬，安榮澤，李松軍，趙俊延

(遵義醫(yī)學(xué)院第五附屬珠海醫(yī)院骨科，廣東 珠海519100)

骨挫傷是由一定暴力作用下導(dǎo)致皮質(zhì)下骨髓水腫、出血及骨小梁斷裂，進(jìn)而引起局部疼痛。骨挫傷可見于全身各部位，最常見于膝關(guān)節(jié)。過(guò)去臨床醫(yī)生對(duì)骨挫傷的認(rèn)識(shí)不夠，也未引起足夠重視，常以軟組織挫傷來(lái)處理。但有些患者疼痛癥狀卻長(zhǎng)期存在,對(duì)患者生活及工作帶來(lái)了極大影響。近年來(lái)由于MRI的普及，以及臨床醫(yī)生對(duì)骨挫傷的重視，關(guān)于膝關(guān)節(jié)周圍骨挫傷的研究越來(lái)越多。但膝關(guān)節(jié)周圍骨挫傷相關(guān)的治療方案、對(duì)關(guān)節(jié)的遠(yuǎn)期影響等還未形成統(tǒng)一意見。鑒于此，本文就膝關(guān)節(jié)周圍骨挫傷的損傷病因、發(fā)病機(jī)制、診斷標(biāo)準(zhǔn)、分型、治療方案等做一概述，以期為臨床創(chuàng)傷科醫(yī)師做一參考。

膝關(guān)節(jié)；核磁共振；骨挫傷；骨髓水腫

骨挫傷是由一定的暴力導(dǎo)致皮質(zhì)下骨髓水腫、出血及骨小梁斷裂，松質(zhì)骨微小壓縮性損傷，進(jìn)而引起局部疼痛[1]。骨挫傷還有很多其他名稱，比如骨小梁骨折、微骨折、隱性骨折等。由于骨挫傷在皮質(zhì)骨下有水腫、出血，MRI對(duì)含水物質(zhì)較敏感，故在T1加權(quán)像中呈低信號(hào)，在T2加權(quán)像中呈高信號(hào)[2]。在短時(shí)間反轉(zhuǎn)回復(fù)像(STRI)中呈高信號(hào)，圖像呈點(diǎn)狀或斑片狀，大片狀地圖樣或彌漫性不規(guī)則形態(tài)。骨髓水腫在脂肪抑制像中能清晰顯示。國(guó)內(nèi)有學(xué)者報(bào)道運(yùn)用雙能量CT(DECT)掃面患膝，生成虛擬去鈣(VNCa)圖像，并對(duì)VNCa圖像上每個(gè)分區(qū)單獨(dú)評(píng)級(jí)，可明確診斷骨挫傷。該方法對(duì)不能行MRI檢查者有重要意義[3]。膝關(guān)節(jié)周圍骨挫傷往往伴隨其他器官的損傷，如半月板、交叉韌帶、側(cè)副韌帶等組織的損傷，特別與前交叉韌帶(anterior cruciate ligament，ACL)損傷相關(guān)性最大[4]。

1 骨挫傷分類

Mink等[5]于1989年對(duì)大量膝關(guān)節(jié)外傷患者影像資料進(jìn)行統(tǒng)計(jì)分析后將膝關(guān)節(jié)損傷由輕至重分為4類：骨挫傷、軟骨骨折、應(yīng)力性骨折、脛骨近端股骨遠(yuǎn)端骨折。并對(duì)這4種損傷特點(diǎn)進(jìn)行總結(jié)。骨挫傷患者均有急性外傷史，常見于軟骨下骨，MRI表現(xiàn)為非線性彌散性病灶。應(yīng)力性骨折患者往往有較長(zhǎng)的病史，不常見于軟骨下骨，在T1加權(quán)像中較骨挫傷范圍更大，且信號(hào)更強(qiáng)。軟骨骨折分為兩類：(1)部分軟骨塌陷，并未波及到松質(zhì)骨髓腔；(2)軟骨塌陷，并波及到松質(zhì)骨髓腔。MRI可見膝關(guān)節(jié)周圍骨質(zhì)微小的信號(hào)改變。股骨髁或脛骨平臺(tái)骨折MRI可見明顯線性信號(hào)改變，往往波及關(guān)節(jié)軟骨表面。

Lynch等[6]于1989年通過(guò)研究大量影像學(xué)資料后將骨挫傷分為3型。Ⅰ型：彌漫型，T1加權(quán)像呈彌散、網(wǎng)狀的低信號(hào)位于干骺端，T2加權(quán)像表現(xiàn)為高信號(hào)；Ⅱ型：合并軟骨與軟骨下骨之間骨皮質(zhì)的連續(xù)性中斷信號(hào)；Ⅲ型：緊貼皮質(zhì)下區(qū)的T1加權(quán)像局限性的信號(hào)減低區(qū)，而T2加權(quán)像信號(hào)無(wú)改變。Vellet等[7]于1991年對(duì)骨挫傷基于MRI影像學(xué)表現(xiàn)分為5型。Ⅰ型呈隱匿性網(wǎng)狀，T1加權(quán)像干骺端骨髓呈網(wǎng)狀圖像，低信號(hào)與關(guān)節(jié)軟骨面不相連，T2加權(quán)像可見高信號(hào)影；Ⅱ型為地圖型，表現(xiàn)為信號(hào)改變與鄰近的皮質(zhì)或軟骨下骨相連，呈地圖狀；Ⅲ型為線型，信號(hào)改變呈線性，寬度小于2 mm；Ⅳ型為軟骨壓縮型，在地圖型骨挫傷且有局部軟骨塌陷；V型為軟骨骨折，T1加權(quán)圖像上軟骨骨折邊緣有一些低信號(hào)，T2加權(quán)像上呈現(xiàn)高信號(hào)且與關(guān)節(jié)腔相通。

Bohndorf[8]于1999年根據(jù)MRI及關(guān)節(jié)鏡下直視損傷部位將膝關(guān)節(jié)損傷分為兩型。A型：關(guān)節(jié)軟骨下骨挫傷，但軟骨完整。包括兩個(gè)亞型：A1關(guān)節(jié)軟骨下骨挫傷，A2關(guān)節(jié)軟骨下壓縮性骨折。B型分為5個(gè)亞型。Terzidis等[9]根據(jù)骨挫傷部位分為2種類型：一是骨挫傷位于關(guān)節(jié)端一側(cè)的松質(zhì)骨內(nèi)；第二種類型是關(guān)節(jié)兩端對(duì)應(yīng)部位均有骨挫傷表現(xiàn)，稱為對(duì)吻性骨挫傷。前者約占骨挫傷的77.4%,后者約占22.6%。

膝關(guān)節(jié)骨挫傷的分型有多種，目前尚未形成統(tǒng)一分型。這些分型對(duì)骨挫傷的治療、研究有一定的指導(dǎo)意義。

2 骨挫傷損傷機(jī)制

Shea等[10]通過(guò)回顧性研究大量患者M(jìn)RI發(fā)現(xiàn)骨挫傷常發(fā)生于脛骨髁間嵴及股骨外側(cè)髁。骨挫傷的常見原因是關(guān)節(jié)囊及韌帶的牽拉力、垂直擠壓、直接暴力、應(yīng)力損傷、剪切暴力等[11]。主要病理學(xué)改變是骨髓水腫、病變區(qū)出血、骨小梁斷裂[12]。骨挫傷的形式各異，骨小梁出血灶呈點(diǎn)狀、斑片狀或散在分布于骨質(zhì)中。直接暴力所致骨挫傷往往造成著力處骨小梁斷裂，繼而發(fā)生廣泛滲出，可合并肌腱、關(guān)節(jié)囊、韌帶損傷。撕脫性暴力所致骨挫傷可導(dǎo)致肌腱或韌帶附著點(diǎn)骨質(zhì)水腫、出血。應(yīng)力損傷性骨挫傷特點(diǎn)為：應(yīng)力作用的方向與骨小梁斷裂的方向垂直。剪切損傷特點(diǎn)為骨挫傷的出血點(diǎn)和水腫灶呈斜行，且邊界清晰。

3 膝關(guān)節(jié)骨挫傷合并周圍器官損傷

近年來(lái)國(guó)內(nèi)外關(guān)于膝關(guān)節(jié)周圍骨挫傷合并傷研究很多。通過(guò)骨挫傷與膝關(guān)節(jié)韌帶半月板損傷的關(guān)系，可為臨床醫(yī)師判斷膝關(guān)節(jié)損傷程度及預(yù)后提供參考，并可減小漏診率。膝關(guān)節(jié)軟骨及軟骨下鈍性損傷常伴交叉韌帶及半月?lián)p傷[13]，可激活化學(xué)性炎癥反應(yīng)，刺激韌帶、軟骨、半月板、軟骨下骨細(xì)胞釋放炎性細(xì)胞因子。同時(shí)關(guān)節(jié)腔積液也可能增加，導(dǎo)致關(guān)節(jié)疼痛。有些學(xué)者認(rèn)為ACL損傷患者中70%～80%伴有骨挫傷[14]。

MRI評(píng)估ACL斷裂主要依據(jù)信號(hào)改變，靈敏度高達(dá)94%，特異性接近100%[15]。某些情況下膝關(guān)節(jié)關(guān)節(jié)腔水腫掩蓋了ACL斷裂，使得評(píng)估困難。有學(xué)者對(duì)30例患者研究發(fā)現(xiàn)漏診了4例ACL損傷，漏診率為13%，故除了MRI另外一些輔助癥狀可幫助診斷ACL損傷[16]，MRI鑒別診斷ACL部分?jǐn)嗔押屯耆珨嗔延行├щy。Patel等[17]通過(guò)大量病例研究后得出結(jié)論：不伴骨挫傷的膝關(guān)節(jié)損傷，ACL往往是部分?jǐn)嗔选CL完全斷裂時(shí)伴有脛骨平臺(tái)外側(cè)骨挫傷可達(dá)94%，股骨髁骨挫傷可達(dá)91%。特定解剖部位的骨挫傷往往伴ACL損傷，表明骨挫傷是膝關(guān)節(jié)韌帶損傷的輔助標(biāo)志[18]。同時(shí)他們也研究了一些20歲以下的青年特定解剖部位的骨挫傷有28%并未伴ACL損傷。故認(rèn)為青年與成年人骨挫傷的機(jī)制是一樣的，但由于青年的ACL更松弛，所以ACL不容易損傷。

有學(xué)者通過(guò)兩名經(jīng)驗(yàn)豐富的影像學(xué)醫(yī)師對(duì)39例患者的MRI進(jìn)行讀片[19]，這些患者均已行膝關(guān)節(jié)鏡檢查證實(shí)ACL損傷，發(fā)現(xiàn)脛骨平臺(tái)前側(cè)骨挫傷分別為46%和50%。因此他們得出結(jié)論：如果脛骨平臺(tái)前側(cè)發(fā)生骨挫傷，且外側(cè)半月板后角有移位，同時(shí)出現(xiàn)ACL損傷的可能性極大。他們同時(shí)也指出骨挫傷的部位與診斷ACL完全斷裂還是部分?jǐn)嗔褵o(wú)相關(guān)性。因?yàn)樵贏CL完全斷裂與部分?jǐn)嗔训膬山M患者中骨挫傷的發(fā)生機(jī)率差別不大。

4 骨挫傷的治療

國(guó)內(nèi)外對(duì)于膝關(guān)節(jié)周圍骨挫傷治療方法各異。骨挫傷的愈合時(shí)間各家報(bào)道不一，從3～12個(gè)月不等。目前骨挫傷的主要治療方法是藥物消腫止痛、石膏制動(dòng)、臥床休息、避免早期負(fù)重及應(yīng)力性骨折的發(fā)生[20]。有些學(xué)者采取保守治療后進(jìn)行MRI隨訪，發(fā)現(xiàn)MRI的骨髓水腫信號(hào)逐漸消散[21]，但沒(méi)有確切證據(jù)可證實(shí)長(zhǎng)時(shí)間石膏制動(dòng)可加速骨挫傷愈合[22]。Rangger等[23]認(rèn)為未合并韌帶損傷的單純性骨挫傷通過(guò)石膏制動(dòng)休息短期療效滿意。Vincken等[24]通過(guò)研究認(rèn)為骨挫傷后石膏制動(dòng)很可能會(huì)加速關(guān)節(jié)退變。故膝關(guān)節(jié)周圍骨挫傷是否需石膏外固定及固定時(shí)間的長(zhǎng)短還未達(dá)成共識(shí)，需大量病例資料進(jìn)行前瞻性研究。Bilik等[25]認(rèn)為關(guān)節(jié)腔積血應(yīng)盡早行關(guān)節(jié)鏡探查，若發(fā)現(xiàn)有合并損傷可一并修復(fù)。有學(xué)者認(rèn)為雙磷酸鹽藥物治療效果較好[26]，可以明顯緩解疼痛癥狀及促進(jìn)功能恢復(fù)，但具體機(jī)制仍然不清楚。Vulpiani[27]發(fā)現(xiàn)體外沖擊波(ESWT)治療骨挫傷早期階段可減少骨髓水腫和疼痛，促進(jìn)損傷愈合。其機(jī)制可能為：ESWT可誘導(dǎo)組織新生血管，促進(jìn)細(xì)胞因子表達(dá)，包括血管內(nèi)皮生長(zhǎng)因子(VEGF)、內(nèi)皮型一氧化氮合酶(eNOS)、增殖細(xì)胞核抗原(PCNA)，并且促進(jìn)細(xì)胞增殖和成骨[28]。D'Agostino等[29]認(rèn)為ESWT能夠控制炎性過(guò)程，并促進(jìn)骨細(xì)胞修復(fù)，以及活化許多成骨細(xì)胞，以及新生血管形成。國(guó)內(nèi)有人在關(guān)節(jié)鏡或C臂下以克氏針于骨挫傷部位鉆孔減壓，術(shù)后疼痛有所緩解，復(fù)查MRI骨髓水腫范圍明顯減小[30-31]。

5 骨挫傷和骨關(guān)節(jié)炎

膝關(guān)節(jié)周圍骨挫傷后可能會(huì)導(dǎo)致關(guān)節(jié)軟骨退變和骨質(zhì)硬化[32]，進(jìn)而發(fā)生骨關(guān)節(jié)炎。骨挫傷及關(guān)節(jié)軟骨損傷會(huì)導(dǎo)致細(xì)胞外基質(zhì)發(fā)生變化[33]。有學(xué)者認(rèn)為，骨挫傷修復(fù)后，原先富有彈性的軟骨下骨被新生骨取代，順應(yīng)性降低，導(dǎo)致關(guān)節(jié)軟骨負(fù)荷增大，容易引發(fā)關(guān)節(jié)軟骨的退變。Ⅱ型膠原羧基端肽(CTX-Ⅱ)是Ⅱ型膠原纖維的降解產(chǎn)物，廣泛存在于關(guān)節(jié)液中，是骨關(guān)節(jié)炎的標(biāo)志物之一。孫國(guó)靜等[34]通過(guò)提取關(guān)節(jié)液分析化學(xué)成分發(fā)現(xiàn)骨挫傷后膝關(guān)節(jié)液中Ⅱ型膠原羧基端肽(CTX-Ⅱ)含量較正常關(guān)節(jié)液升高?？赏茰y(cè)膝關(guān)節(jié)周圍骨挫傷與骨關(guān)節(jié)炎關(guān)系密切，但還需進(jìn)一步研究證實(shí)。

6 展望

膝關(guān)節(jié)周圍骨挫傷是近年才被人們重視，大量文獻(xiàn)證明膝關(guān)節(jié)遭受暴力打擊時(shí)可造成骨髓水腫、出血、骨小梁斷裂。雖然近年國(guó)內(nèi)外對(duì)膝關(guān)節(jié)周圍骨挫傷的研究取得了很大的進(jìn)步。國(guó)內(nèi)外公認(rèn)MRI可明確診斷膝關(guān)節(jié)周圍骨挫傷。但對(duì)骨挫傷的損傷機(jī)制、病理轉(zhuǎn)歸、治療及預(yù)后等諸多問(wèn)題還不十分清楚，還需進(jìn)一步研究。

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Progress of study on diagnosis and treatment of bone contusion around knee joint.

YOU Bin,AN Rong-ze,LI Song-jun,ZHAO Jun-yan.Department of Orthopaedics,Zhuhai Hospital,the Fifth Affiliated Hospital of Zunyi Medical University,Zhuhai 519100,Guangdong,CHINA

Bone contusion is caused by direct or indirect violence,bone marrow edema,bleeding and trabecular bone fracture,which can lead to local pain.Bone contusion can be found in all parts of the body,mostly in the knee joint. In the past,as the doctors didn't know enough about the bone contusion and did not pay enough attention to it,the bone contusion was often treated as soft tissue contusion in clinical treatment.This leads to that some patients still had painsymptoms in a long time after treatment,exerting a great impact on the patient's life and work.In recent years,due to the popularity of MRI and the doctor's attention to bone contusion,more and more researches on bone contusion were conducted.But the opinions on treatment options related to bone contusion around knee joint and the long-term impact on the joint are not yet uniform.This article focuses on the cause of bone contusion around knee joint,pathogenesis,diagnostic criteria,classification,treatment,in order to provide a reference for doctors.

Knee joint;Magnetic resonance imaging(MRI);Bone contusion;Bone marrow edema

R684

A

1003—6350(2017）02—0277—04

10.3969/j.issn.1003-6350.2017.02.035

2016-08-06)

貴州省科學(xué)技術(shù)基金（編號(hào)：LKZ【2013】43）；廣東省珠海市科技計(jì)劃醫(yī)療衛(wèi)生項(xiàng)目（編號(hào)：2015A1028）

安榮澤。E-mail：anrongze1955@163.com