三角韌帶解剖學、影像學及生物力學

1、三角韌帶解剖學、影像學及生物力學The Anatomy, Radiology and biomechanics of Deltoid Ligament張 寧 醫(yī)師Tel: +86 ；E-mail:三角韌帶解剖學、影像學及生物力學三角韌帶的解剖The Anatomy of deltoid ligament三角韌帶分為兩層三角韌帶分為兩層6 6束束，淺層淺層4 4束，深層束，深層2 2束束p 淺層:脛舟韌帶、脛跳躍韌帶、脛跟韌帶及脛距后韌帶淺層 Tibionavicular ligament, Tibiospring ligament, Tibiocalcaneal ligament, Super

2、ficial posterior tibiotalar ligament.p 深層:脛距前韌帶深層及脛距后韌帶深層 Deep anterior tibiotalar ligament, Deep posterior tibiotalar ligament.三角韌帶解剖學、影像學及生物力學三角韌帶的解剖The Anatomy of deltoid ligament三角韌帶解剖學、影像學及生物力學三角韌帶的解剖The Anatomy of deltoid ligamentABC圖圖1. A.胎兒踝部冠狀面（Mallory三色法染色），1.內踝，2.三角韌帶深層，3.三角韌帶淺層，4.脛后肌腱，5.

3、趾長屈肌腱，6.載距突，7.踇長屈肌腱，8.纖維鞘隔膜。B.三角韌帶淺層示意圖，1.脛舟韌帶，2.脛彈性韌帶，3.脛跟韌帶，4.脛距后韌帶淺層，5.跟舟上韌帶（彈性韌帶組成部分）6.脛后肌腱，7.跖側跟舟韌帶（彈性韌帶組成部分）C.三角韌帶深層，1.脛距前韌帶深層，2.脛距后韌帶深層。三角韌帶解剖學、影像學及生物力學Fig. 1. Tibionavicular ligament. 2. Deep anterior tibiotalar ligament (deep layer). 3. Tibiospring ligament. 4. Tibiocalcaneal ligament. 5. D

4、eep posterior tibiotalar ligament (deep layer). 6. Superomedial calcaneonavicular ligament (component of spring ligament). 7. Plantar calcaneonavicular ligament (component of spring ligament). 8. Navicular tuberosity. 9. Medial talar process.10. Sustentaculum tali. 11. Posterior tibial tendon (cut a

5、t the level of the insertion). 12. Flexor hallucis longus (cut proximal and distal). 13.Tibialis anterior tendon (cut at the level of insertion). 14. Long plantar ligament. 15. Plantar calcaneocuboid ligament. 16. Calcaneal tendon (cut at the level of insertion)三角韌帶的解剖The Anatomy of deltoid ligament

6、三角韌帶解剖學、影像學及生物力學三角韌帶的解剖The Anatomy of deltoid ligamentFig. 3 Medial view of the anatomical dissection of the deep layer of the deltoid ligament. The superficial layer of the deltoid ligament has been resected. Its distal insertion is maintained (arrowheads). a Plantar flexion. b Dorsiflexion. 1. Dee

7、p anterior tibiotalar ligament. 2. Deep posterior tibiotalar ligament. 3. Talar head. 4. Medial talar process. 5. Sustentaculum tali. 6. Anterior subtalar joint. 7. Posterior tibialtendon (cut at the level of insertion)三角韌帶解剖學、影像學及生物力學三角韌帶影像學（附著點）The Attachments of deltoid ligament三角韌帶解剖學、影像學及生物力學Fi

8、gure 4. Representative lateral radiographic images of a right ankle demonstrating the sites of attachment and courses of the individual bands of the (A) superficial and (B) deep deltoid: DATT, deep anterior tibiotalar ligament; DPTT, deep posterior tibiotalar ligament; SL, spring ligament; SPTT, sup

9、erficial posterior tibiotalar ligament; TC, tibiocalcaneal ligament; TN, tibionavicular ligament; TS, tibiospring ligament.三角韌帶解剖學、影像學及生物力學三角韌帶的附著點The Attachments of deltoid ligamentDATT, deep anterior tibiotalar ligament; DPTT, deep posterior tibiotalar ligament; SL, spring ligament; SPTT, superfic

10、ial posterior tibiotalar ligament; TC, tibiocalcaneal ligament; TN, tibionavicular ligament; TS, tibiospring ligament.三角韌帶解剖學、影像學及生物力學三角韌帶的MRIThe MRI of deltoid ligament三角韌帶解剖學、影像學及生物力學三角韌帶的MRIThe MRI of deltoid ligamentMR images in 56 asymptomatic subjectsFigure 2: Anterior TTL (anterior portion of

11、 the deep layer of the MCL complex) and TSL (middle portion of the superficial layer of the MCL complex) in asymptomatic 25-year-old man. 三角韌帶解剖學、影像學及生物力學三角韌帶的MRIThe MRI of deltoid ligamentMR images in 56 asymptomatic subjects三角韌帶解剖學、影像學及生物力學三角韌帶的MRIThe Attachments of deltoid ligament三角韌帶解剖學、影像學及生物力

12、學三角韌帶的MRIThe Attachments of deltoid ligament三角韌帶解剖學、影像學及生物力學三角韌帶的功能The function of deltoid ligament 踝關節(jié)是人體中最為脆弱的負重關節(jié)，其穩(wěn)定性至關重要。研究發(fā)現(xiàn)，踝關踝關節(jié)最主要的穩(wěn)定結構為內側三角韌帶而非外側結構節(jié)最主要的穩(wěn)定結構為內側三角韌帶而非外側結構1-31-3。Close JR等4研究發(fā)現(xiàn)當切斷所有踝關節(jié)外側韌帶而保留三角韌帶時，距骨移位不超過2mm；而當踝關節(jié)外側韌帶完整而深層三角前帶斷裂時，距骨平均移位將達到3.7mm。Boden等在切斷下脛腓前、后韌帶后，由遠端向近端逐漸切斷骨間

13、膜至踝上15cm，結果發(fā)現(xiàn)在三角韌帶完整時,下脛腓最大分離距離為1.4mm，而當三角韌帶斷裂時,下脛腓分離達到4.5mm，Boden等認為三角韌帶是維持踝關節(jié)穩(wěn)定性的首要因素5。三角韌帶解剖學、影像學及生物力學 三角韌帶對踝關節(jié)的穩(wěn)定作用越來越受到國內外學者的重視。Rasmussen等6發(fā)現(xiàn)三角韌帶淺層主要限制距骨外移及外翻，三角韌帶深層主要限制距骨的外旋。Ziai P等7通過體外生物力學研究發(fā)現(xiàn)在外側副韌帶損傷的情況下，三角韌帶淺層阻止了踝關節(jié)繼續(xù)外旋或外翻，而深層結構在穩(wěn)定距下關節(jié)所起的作用較小，因此三角韌帶淺層在踝關節(jié)外側穩(wěn)定中起到了重要的作用。Earll等8報道切斷淺層三角韌帶后，脛距

14、關節(jié)接觸面積下降43%，壓力峰值增加30%，距骨外移4mm。復旦大學上海醫(yī)學院馬昕教授及其研究生根據尸體解剖結果提出脛舟韌帶可能只是踝關節(jié)囊加強組織，三角韌帶在踝關節(jié)屈伸運動過程中存在韌帶束間交替工作機制。同濟大學附屬同濟醫(yī)院俞光榮教授認為三角韌帶對踝關節(jié)的穩(wěn)定作用非常重要9。三角韌帶的功能The function of deltoid ligament三角韌帶解剖學、影像學及生物力學三角韌帶的功能 （選擇其中一篇文獻復習）The function of deltoid ligament三角韌帶解剖學、影像學及生物力學三角韌帶的功能The function of deltoid ligamen

15、tThe preset torsion between tibia and calcaneus was primarily set at 30 of internal rotation on specimen in plantar flexion and hind foot inversion. The first series of measurements were performed on healthy specimens andthe following after transecting structures in following order: anterior talofib

16、ular ligament (ATFL) in combination with calcaneofibular ligament (CFL), followed by anterior tibiotalar ligament and posterior tibiotalar ligament and finally tibiocalcaneal ligament (TCL).三角韌帶解剖學、影像學及生物力學三角韌帶的功能The function of deltoid ligamentThe combined lateral ATFL and CFL instability showed a

17、decrease in the resisting torque, which ensures stability in ankle sprain trauma. Only a transection of TCL (superficial layer of deltoid ligament complex) with existing lateral dual-ligament instability results in a significant decrease in torque (p 0.0001).三角韌帶解剖學、影像學及生物力學Take home messagesp 三角韌帶2

18、層6束，淺4深2p X線韌帶束起止點定位重要，臨床使用價值大p 踝關節(jié)最主要的穩(wěn)定結構為內側三角韌帶三角韌帶解剖學、影像學及生物力學 References 1 Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg. 2004;43:20-9. 2 Michelson JD,

19、 Clarke HJ, Jinnah RH. The effect of loading on tibiotalar alignment in cadaver ankles. Foot Ankle. 1990;10:280-4. 3 Michelson JD, Waldman B. An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res. 1996:285-93. 4 Close JR. Some applications of the functi

20、onal anatomy of the ankle joint. J Bone Joint Surg Am. 1956;38-A:761-81. 5 Boden SD, Labropoulos PA, McCowin P, Lestini WF, Hurwitz SR. Mechanical considerations for the syndesmosis screw. A cadaver study. J Bone Joint Surg Am. 1989;71:1548-55. 6 Rasmussen O. Stability of the ankle joint. Analysis of the function and traumatology of the ankle ligaments. Acta Orthop Scand Suppl. 1985;211:1-75. 7 Ziai P, Benca E, Skrbensky GV, Wenzel F, Auffarth A, Krpo S, et al. The role of the medial ligaments in lateral stabili