대한방사선의학회지 1994: 31(5) 찰하였다. 부수적인대인 meniscofemoral li gamenet의빈도와위치, 모양을관찰하였는데후방십자인대손상이의심되는 11 예를제외한 129예를대상으로하였으며시상영상에서분석하였고애매한경우관상영상에서확언하였다.

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1 대한방사선의학회지 1994: 31(5) : 후방십자연대손상의자기공명영상소견 1 조영자 박양회 이지연 지금난 이경회 목 적최근후방십자인대손상의조기진단과치료에대한임상적인의미가증가하고있다. 이에 저자들은슬관절후방십자인대손상의자기공명영상 ( 이하 MRI) 소견을분석하고그진단의정확성을 규명하고자하였다. 대상및방법 : 임상적으로슬관절의손상이의심되어 MRI 를시행한 140 예의슬관절을대상으로하 였는데이중 63 예에서는슬관절경검사및수술을시행하여서이결과와비교분석하였다. 후방십자인 대파열의 MRI 소견과동반되는슬관절주위구조물의이상을조사하였다. 또한부수적인대인전후방 meniscofemoral ligament 가관찰되는빈도를조사하였다. 결과 : MRI 소견상 11 여 에서후방십자인대손상이있을것으로판독하였는데수술소견상인대실 질내파열이 6예, 경글부착부위파열 2예, 대퇴골부착부위파열 2예, 그리고 1 예에서는인대파열없이 인대이완만이관잘되었다. 후방십자인대손상에있어서 MRI 진단의예민도, 특이도및정확도는각각 100%, 98.1 %, 98.4% 였다. 후방십자인대파열으 I MRI 소견으로인대의불연속성및국소종괴형성, 불 균질한신호강도증가, 콜파편과함께인대의박리및중복성을보였다. 또한후방십자인대손상이있 었던전예에서슬관절주위다른구조물의이상이동반되었다. 전후방 meniscofemoral ligament 는전 체관찰대상중 67.4 %( 87 / 129 ) 에서관잘되었다. 결론 : MRI 는후방십자인대손상의여부와그의정확한범위그리고중요한동반되는손상유무를 관찰하는데유용한검사방법이다. 서 로 자기공명영상술 ( 이하 MRI) 은버침습적이고슬관절주 위구조물을정확하게볼수있는장점때문에슬내장의진 단에유용한검사방법으로알려져있다 (1). 후방십자인대 손상은적기에치료하지않을경우에심각한슬관절후방 불안정성과퇴행성변화를유발할수있기때문에최근인 대손상의조기진단에대한임상적의미가증가하고있다 (2). 이에저자들은임상적으로슬관절손상이의심되어 MRI 를시행한환자들의 MRI 소견을분석하여후방십자 인대손상에대한 MRI 소견및그진단의정확도와임상적 가치를밝히고자하였다. 대상및방법 엄상적으로슬관절의손상이의심되어 MRI 를시행한 1 국립경찰병원방사선과 이논문은 1994 년 6 월 21 일접수하여 1994 년 10 월 4 일에채택되었음 14 0 예의슬관절을대상으로하여이중슬관절경검사및수 술을시행한 63 예에서그결과를비교분석하였는데, 대상 환자의연령분포는 16 세에서 56 세로평균 25 세였고남여 비는 9: 1 이었다. 0.5 Tesla( Gyroscan T5, philips, Netherland) 자기공명촬영장치를이용하여환자를앙와위로 굽힌중립자세에서, 슬관절을 1 5 도외회전한상태로슬관 절용 surface coi l 을이용하여스핀에코 (spin echo) 기법으 로 T1 강조 (TR / TE ; 450/25), 양자밀도 (TR/TE ; 1800 /2 0) 및 T2 강조 (TR/TE ; 1800/90) 관상및시상영상 (5 rnm 절편두께, 1mm 절편간격 ), 그리고삼차원용적횡단 영상 (axial 3 dimensional volume study, TR/TE ; 30/ 1 3 ) 을얻었다. Acquisition matrix 는 205 x 256 or 179 x 256, FOV 는 mm 로하였다. 후방십자인대파열은 T1 강조영상이나 T2 강조영상에서인대의불연속성및국 소종괴형성이있을때, 불균질한신호강도증가가있을때, 고신호강도의골파편과함께인대의박리및중복성 (de - tachment or redundancy) 이있을때, T1 및 T2 강조영상 에서인대모양의변화와함께약간의신호강도증가를보 일경우에손상이있다고판정하였다. 또한후방십자인대 파열과동반되는주위뼈와인대, 반월판의이상유무를관

대한방사선의학회지 1994: 31(5) 961-964 찰하였다. 부수적인대인 meniscofemoral li gamenet의빈도와위치, 모양을관찰하였는데후방십자인대손상이의심되는 11 예를제외한 129예를대상으로하였으며시상영상에서분석하였고애매한경우관상영상에서확언하였다.

2 대한방사선의학회지 1994: 31(5) 찰하였다. 부수적인대인 meniscofemoral li gamenet의빈도와위치, 모양을관찰하였는데후방십자인대손상이의심되는 11 예를제외한 129예를대상으로하였으며시상영상에서분석하였고애매한경우관상영상에서확언하였다. 결과를모르는상태에서 2명의방사선과의사가위에기술한기준으로 MRI 에서의손상여부를판독하였으며관절경검사및수술소견을기준 (gold standard) 으로후방십자인대손상에있어서 MRI 진단의예민도, 특이도및정확도를구하였다. 결과수술흑은슬관절경검사상 10예에서후방십자인대의손상이있었는데 MRI로 11예에서손상이있다고판독하였고 ( 예민도 : 100%), 정상이었던 53예중 l 예에서인대손상이있을것으로판독하였다 ( 특이도 : 98.1 %). 후방십자인대손상의예민도, 특이도, 정확도는각각 100%, 98.1%, 했으나이중 1 예에서는대퇴골부착부위에분리가있었고 나머지 6 예에서는실질중간부에파열이확언되었다. MRI 상 3 예에서인대의경골부착부위의분리가있을것으 로판독했는데이중 1 예에서는경골고평부 (tibial plateu) 의견열골절 (avu l s i on fracture) 과함께인대의박리가있 었고, 다른 1 예는수술소견상대퇴골과의견열골절을동 반한인대박리로판명되었다 (Fig. 1). 후방십자인대손상 과동반되는슬관절주위구조물의손상여부를조사하였 는데손상이있였던전예에서슬관절주위의동반되는손 상이있였다 (F i g 2). 동반되는손상으로후관절포파열 (posterior capsular tear) 이 6 예, 내외측경골과또는대 퇴골과 (ti bial condyl e or femoral co nd y l e) 의골맹이 3 예, 전방십자인대파열이 3 예, 내외측반월판손상이 3 예, 내측인대파열이 2 예였다. meniscofemoral lig ament 는 li gam ent of Humphry7} 6.2% (8/ 129), ligament of Wris berg 가 58.9%(76/129), 두분지가동시에관찰된예가 2. 3%(3 /1 29) 였다 (Fig 3). 98.4% 였다. MRI 로후방십자인대의만성파열이있을것 으로진단하였던 2예중 1 예에서는임상적그리고수솔소견상만성파열과일치하는소견을보였고, 1 예는만성파열이있을것으로판독하였으나관절경검사및수술소견에서인대파열없이인대이완만이있어서 1 예가위양성이었다. 또한 7예에서실질중간부에파열이있을것으로판독 고찰후방십자인대는경콜고평부후방에서시작하여내측대퇴골과의외측부전방에부착된다. 정상적으로아주낮은저신호강도로슬관절의신전혹은약간의굴곡시에시상면 a b Fig. 1. Ch ronic tear 01 PCL with avulsion Iracture a. The sagittal proton density weighted MR image shows redundancy 01 the PCL and bone Iragment(arrow) containing latty marrow. Avulsion Iracture 01 lemoral condyle at PCL.attchment site was conlirmed by surgery b. The sagittal T2 weighted image shows slightly increased signal intensity and irregular thickening 01 PC L( arrow), indicating librous scar tissue at lemoral attachment site / a b % Fig. 2. PCL tear and associated abnormalities a. Th e sagittal T2 weighted MR image shows discontinuity and thickened inhomogenous increased signal intensity in the PCL. Also, disruption 01 posterior capsule is noted(arrow) b. The coronal T2-weighted image in the same patient shows increased signal in. tensity in PC L( long arrow) and an associated MCL tear(short arrow). Also, bone bruise 01 lateral lemoral condyle is noted

3 초영자외 후방십자인대손상의자기공명영상 Fig. 3. a. The sagittal proton-density-weighted MR image shows a prominant meniscofemoral ligament of Humphry(long arrow) and Wrisberg(short arrow), which should not be misinterpretated as a loose body b. T1 weighted coronal image shows the normal course of meniscofemoral ligament 01 Humphry(arrow) a b 에서궁상모양으로, 관상변에서후하방을향해있는둥근난행의구조물로관찰된다. 후방십자인대의주기능은슬관절굴곡시내측대퇴골과의운동을조절함으로경골의후방전위를방지하고회전운동을막아주는역할을담당한다 (3). 후방십자인대의손상기전으로슬관절의과신전, 과굴콕, 굴곡시대퇴골에대한경골의후방전위에의해일어난다 (4). 급성손상시후방십자인대손상은처음임상적인검사에서간과할수있다. 슬관절경검사는후방십자인대가활액막외 (extr as ynovi al) 관절강내 (intra- articular) 에위치하기때문에정확한진단이어려울수있다 (2, 5). 따라서 MRI는후방십자인대손상의진단에필수적이다. 후방십자인대손상의 MRI 소견으로인대의불연속성빛국소종괴형성, 불균질한신호강도증가, 인대의중복성과경골고평부의견열골절로알려져있다 (6). Grove r( 6) 는후방십자인대손상이있는 11 명중 7명에서인대의중간실질부위의파열이있었고 3예에서는경골부착부위에서박리가있었고, 1 명에서는대퇴골근처에박리가있었음을보고하였다. 저자들의경우에서실질내파열이 6 예, 경골부착부위박리 2예, 대퇴골부착부위의박리 2예로실질내파열이가장많았다. Thomas( 7) 등은전방십자인대의경우에있어서만성파열은다양한소견을보이며정상인대와감별이용이하지않은것으로만성파열의자기공명영상소견으로국소적인각형성 ( focal angulation) 혹은반흔에의한정상인대의궁상모양이소설되는것으로보고하였다. 후방십자인대가각 (hyperbuc kling) 을형성하는경우는후방십자인대의원위부파열, 경골부착부위박리와전방십자인대의완전파열이있는경우나타난다 (8). 저자들의경우에있어서경골부착부위의박리와전방섭자인대파열뿐만아니라전후방십자인대가정상인경우에서도가끔전방각형성을하는경우도있었다. 저자들이경험한만성파열이있였던 1예에서 T1 및 T2 강조영상에서약간의신호강도증가와함께인대의불규칙한확장소견을보였는데이는섬유성반흔조직에의한변화로생각되며견열골절이동반되어있었다. 또한인대이완 1 예의 MRI 소견은인대모양 의국소적인각형성과중복성이있였고 T1 및 T2 강조영상에서약간의신호강도증가가있어서만성파열의예와 거의유사한소견을보였다. 후방십자인대는전방십자인대 보다 30% 정도그크기가크고전방십자인대나외측부인 대와비교할때 2 배의강도를갖는다 (9). 후방십자인대손상은대개슬관절외상후주위다른인 대손상을통반한다 (10). Grove r( 6) 는후방섭자인대손상 이있는 11 예중 10 예에서슬관절주위다른구조물의손상 이동반되었는데전방십자인대파열 4 예, 내측부인대파열 4 예, 하나혹은그이상의반월판손상이 5 예있었음을보고 하였다. 저자들의경우위에서언급한인대손상외에후관 절포파열과주위슬관절을구성하는뼈의골벙등이있였 다. meniscofemoral ligament 는외측반월판의후각부위 에서내측상방으로향하여내측대퇴골과의외측부에이 르는부수적인구조물로하나흑은 2 개의분지로서 liga ment of Wrisberg 는시상단면에서후방십자인대의직후 방에서분리된작은저신호강도의난형의구조물로보이고 ligament of Humphry 는후방십자인대의전방에서 ligament of Wrisberg 와유사한모양으로관찰된다 (11). 관상 변에서도저신호강도의앓은띠모양의분지가사선으로 탈리는것을볼수있다. Grove r( 6) 는 ligament of Humphry, ligament of Wrisberg, 양쪽인대가각각 24.1%, 22. 8% 와 % 로전체관찰대상중 58.5% 에서관찰되는것 으로보고하였다. 저자들의경우전체관찰대상중 67.4% 에서관찰되었고 ligament of Wrisberg가 58. 9% 에서관 찰되어높은빈도를나타내였다. 증례의수는많지않지만후방십자인대에대해 MRI 로 손상유무를판정하고슬관절경술또는수술로결과를확인 하여민감도 100%, 특이도 98.1 %, 정확도 98.4% 의결과를 얻었다. 다른임상검사및방사선학적검사의정확도와비 교해보면, 후방십자인대에대해가장많이이용되는이학 적검사인 posterior drawer test 의정확도는 31-85% 로 보고되고있고 (6), 슬관절이중조영술도후방십자인대파 열의진단에이용되지만그진단의정확도는보고된바없 다 (6). 슬관절 CT 검사의경우그진단의정확도는 % 에이르고있지만 (1 2, 13) MRI 가비침습적이고우 수한대조도와다평면영상을얻을수있는장점때문에최 신진단법으로이용되고있다. m

4 대한방사선의학회지 1994; 31(5) : 결론적으로 MRI 는후방십자인대파열의여부와그의 정확한범위, 그리고중요한통반되는손상유무를관찰하 고수술계획을세우는데유용한검사방법이다. 차며고C 그 ~ - 헌 6. Grover JS, Seeger LL, Finerman GAM, et al. Posterior cruciate ligament : MR imaging. Radiology 1990 ;174 : Thomas N, Vahey D, Dale R. Acute and chronic tear 01 ACL Differential leatures at MR imaging. Radiology 1991 ; Jerrold H, Mink JH, Deutsch AL. Magnetic resonance imaging 01 the knee. Clin Orthop 1989; 244: Kennedy JC, Hawkins RJ, Willis ED, Danyl Chuk KD. Tension 1. Lee JK, Yao L, Phelps CT, Wirth CR, Czajka J, Lozman J. An- studies 01 human knee ligament :yield point, ultimate 1리 lure, terior cruicate ligament tears: MR imaging compared with and disruption 01 the cruciate and tibial collateral ligamen t. J arthroscopy and cl inical tests. Radiology 1988; Bone Joint Surg(Am) 1976 ;58: Van Dommelen BA, Fowler PJ. Anatomy 01 posterior cruciate 10. Loos WC, Fox JM, Blazina ME, Del pizzow, Friedman MJ. ligament ; a review. Am J Sports Med 1989 ; 17: Acute PCL injuries. Am J Sports Med 1981 ; 9 : Kennedy JC, Weinberg HW, Wilson AS. The anatomy and 11. Watanabe AT, Carter BC, Teitelbaum GP, Seeger LL, Bradley lunction 01 the anterior cruciate ligament. J Bone Joint Surg WG. Normal variations in MR imaging 01 the knee; appear- 1974; 56 : ance and Irequency. AJR 1989 ; 153 : Fowler PJ. The classilicaiton and early diagnosis 01 knee 12 장병원권중혁, 박성학등슬관절의전산화단층촬영 대한방사섣 joint instability. Clin Orthop 1980; 147: 15-2 의혁t 회지 1986 ; 22 : Polly DW, Callaghan JJ, Sikes RA, Mccabe JM, McMahon K, 13. Passariello R, Trecco F, De Paulis F et al. Computed Tom- Savory CG. The acuracy 01 selective magnetic resonance ography 01 the Knee Joint: Clinical Results. J Comput Assist imaging compared with the lindings 01 arthroscopy 01 the Tomogr 1983 ; 7(6): knee. J Bone Joint Surg(Am) 1988 ; 70: 192 Journal of the Korean Radiological Society, 1994; 31(5) : MR Imaging of Posterior Cruciate Ligament Injury1 Young Ja Cho, M.D., Yang Hee Park, M.D., Jee Yean Lee, M.D., Keum Nahn Jee, M.D., Kyung Hee Lee, M.D. 10epartment o( Radiology, National Police Hospital Purpose: There is increasing awareness of the clinical importance of early detection and treatment of posterior cruciate ligament(pcu injury. We evaluate the usefulness of Magnetic resonance(mr) imaging in the diagnosis of PCL injury. Materials and Methods: We retrospectively analysed the MR images of 140 cases with clinically suspected knee injury. Arthroscopic or surgical correlation was available in 63 cases. We observed the finding and extent of PCL injury and other associated abnormalities. The frequency of anterior and pα, terior meniscofemoral ligament was evaluated Results: Eleven PCL injuries were observed, six midsubstance tears, two tibial attachment tears, two fem ral attachment tear, one laxity. The sensitivity, specificity and accuracy of MR imaging diagnosis are 100%, 98.1 %, 98.4 %. MR findings of PCL injury are discontin 비 ty and focal mass formation, irregular increased signal intensity, detachment or redundancy of the ligament with avulsed bony fragment. In all cases of injured PCL, other associated abnormalities of adjacent structures were observed. Accessory anterior and posterior meniscofemoralligaments were observed in 67.4%(87/129) Conclusion: MR imaging is useful in evaluation of presence or absence of PCL i 미 ury, accurate extent of PCLi 미 ury and other important associated abnormalities of adjacent structures. Index Words: Knee. MR Knee, injuries Knee, ligaments, menisci, and cartilage Address reprint reques t s t o : Yang Hee Park, M.D., Department of Radiology, Nati onal police Hospi t al. # 58, K ara k B on 강 on g, Songpa-gu, Seoul, Korea. T el

소장검사의판독연습 : 정답 l Fig.16. Fig.17. Case 1. Tuberculosis of the jejunum Some of thickened folds (Fig. 16) are paral ~I each other (arrows) but mostly are nodular (curved arrow) in appearance.

5 소장검사의판독연습 : 정답 l Fig.16. Fig.17. Case 1. Tuberculosis of the jejunum Some of thickened folds (Fig. 16) are paral ~I each other (arrows) but mostly are nodular (curved arrow) in appearance. Note another segment with nodular mucosal change (arrowheads). Chest X-ray showed active pulmonary tuberculosis. The patient was given antituberculous treatment and the symptoms improved. Case 2. Eosinophilic gastroenteritis Small bowel series shows subtle abnormality, that is, minimal dilatation of jejunal loops with parallel arrangement of intestinal folds (Ioss of criss-cross patternl. The folds are equivocally thick measuring mm in thickness. The patient underwent peritoneal, hepatic, and duodenal biopsy, and pathologic examination disclosed eosinophilic inflammation. Case 3. Henoch-Schonlein purpura The small bowel series shows parallel thickening of jejunal folds. The thickness is about 2-4mm. Countour of the involved segment is spiky. The involved segment is relatively long from the 3rd portion of the duodenum to the proximal ileum. The patient presented with purpurae at legs. Abdominal symptoms developed after purpural lesions Case 4. Lymphoma of the duodenum, jejunum and mesentery The mucosal folds (Fig. 17) are nodular in the duodenal C loop, and thickened in the jejunum with parallel arrangement (arrow) as well as irregular arrangement (curved arrow). Note more severe mucosal change along the mesenteric border of jejunal loops (open arrow). The patient underwent exploratory laparotomy (July 1978) and Iymphoma involving duodenum, jejunum and mesentery was confirmed. Case 5. Systemic lupus erythematosus Mucosal folds are thick in regular spiky pattern, like picket-fence". The whole intestinal loops are involved. The pathology of small bowel in system-

6 Fig.18. Fig. 19. mic lupus erythematosus is edema, cell infiltration and hemorrhage, due to diffuse vasculitis Case 6. Stromal tumor with unknown malignant patential at duodenojenunal junction Spot film of the small bowel series focusing on the duodenojejunal junction (Fig. 18) disciosed irregular thickening of the intestinal folds with several nodules (arrows). The lesion is limited to a short segment. There is no definite ulcer. CT scan showed a large mass in the upper left abdomen with irregular margin. At surgery, an exophytic mass measuring 6.0 X 4.5cm arising from the duodenojejunal junction was resected. Case 7. Ischemic jejunitis A spot film focusing on the proximal jejunum (Fig 19) shows regular spiky thickening of the folds Note a scalloped margin (arrowhead), one of characteristic findings of intramural bowel hemorrhage

( ) Jkra076.hwp

( ) Jkra076.hwp Vol. 11, No. 4, December, 2004 Objective: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic