三角韌帶解剖學(xué)、影像學(xué)及生物力學(xué)

1、編輯ppt1三角韌帶解剖學(xué)、影像學(xué)及生物力學(xué)The Anatomy, Radiology and biomechanics of Deltoid Ligament張 寧 醫(yī)師山東大學(xué)足踝外科中心山東大學(xué)第二醫(yī)院手足外科Tel: +86E-mail:編輯ppt2三角韌帶的解剖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, T

2、ibiocalcaneal ligament, Superficial 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.編輯ppt3三角韌帶的解剖The Anatomy of deltoid ligament編輯ppt4三角韌帶的解剖The Anatomy of deltoid ligamentABC圖圖1. A.胎兒踝部冠狀面（Mallory三色法染色），1.內(nèi)踝，2.三角韌帶深層，3.三角韌帶淺層，

3、4.脛后肌腱，5.趾長(zhǎng)屈肌腱，6.載距突，7.踇長(zhǎng)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(cè)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。編輯ppt5Fig. 1. Tibionavicular ligament. 2. Deep anterior tibiotalar ligament (deep layer). 3. Tibiospring ligament. 4. Tibiocalcaneal ligament. 5. De

4、ep 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 at

5、 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編

6、輯ppt6三角韌帶的解剖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. Deep anterior

7、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)編輯ppt7三角韌帶影像學(xué)（附著點(diǎn)）The Attachments of deltoid ligament編輯ppt8Figure 4. Representative lateral

8、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, superficial posterior tibiotalar l

9、igament; TC, tibiocalcaneal ligament; TN, tibionavicular ligament; TS, tibiospring ligament.編輯ppt9三角韌帶的附著點(diǎn)The Attachments of deltoid ligamentDATT, deep anterior tibiotalar ligament; DPTT, deep posterior tibiotalar ligament; SL, spring ligament; SPTT, superficial posterior tibiotalar ligament; TC, ti

10、biocalcaneal ligament; TN, tibionavicular ligament; TS, tibiospring ligament.編輯ppt10三角韌帶的MRIThe MRI of deltoid ligament編輯ppt11三角韌帶的MRIThe MRI of deltoid ligamentMR images in 56 asymptomatic subjectsFigure 2: Anterior TTL (anterior portion of the deep layer of the MCL complex) and TSL (middle portion

11、 of the superficial layer of the MCL complex) in asymptomatic 25-year-old man. 編輯ppt12三角韌帶的MRIThe MRI of deltoid ligamentMR images in 56 asymptomatic subjects編輯ppt13三角韌帶的MRIThe Attachments of deltoid ligament編輯ppt14三角韌帶的MRIThe Attachments of deltoid ligament編輯ppt15三角韌帶的功能The function of deltoid liga

12、ment 踝關(guān)節(jié)是人體中最為脆弱的負(fù)重關(guān)節(jié)，其穩(wěn)定性至關(guān)重要。研究發(fā)現(xiàn)，踝關(guān)踝關(guān)節(jié)最主要的穩(wěn)定結(jié)構(gòu)為內(nèi)側(cè)三角韌帶而非外側(cè)結(jié)構(gòu)節(jié)最主要的穩(wěn)定結(jié)構(gòu)為內(nèi)側(cè)三角韌帶而非外側(cè)結(jié)構(gòu)1-31-3。Close JR等4研究發(fā)現(xiàn)當(dāng)切斷所有踝關(guān)節(jié)外側(cè)韌帶而保留三角韌帶時(shí)，距骨移位不超過2mm；而當(dāng)踝關(guān)節(jié)外側(cè)韌帶完整而深層三角前帶斷裂時(shí)，距骨平均移位將達(dá)到3.7mm。Boden等在切斷下脛腓前、后韌帶后，由遠(yuǎn)端向近端逐漸切斷骨間膜至踝上15cm，結(jié)果發(fā)現(xiàn)在三角韌帶完整時(shí),下脛腓最大分離距離為1.4mm，而當(dāng)三角韌帶斷裂時(shí),下脛腓分離達(dá)到4.5mm，Boden等認(rèn)為三角韌帶是維持踝關(guān)節(jié)穩(wěn)定性的首要因素5。編輯ppt1

13、6 三角韌帶對(duì)踝關(guān)節(jié)的穩(wěn)定作用越來越受到國內(nèi)外學(xué)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(xué)研究發(fā)現(xiàn)在外側(cè)副韌帶損傷的情況下，三角韌帶淺層阻止了踝關(guān)節(jié)繼續(xù)外旋或外翻，而深層結(jié)構(gòu)在穩(wěn)定距下關(guān)節(jié)所起的作用較小，因此三角韌帶淺層在踝關(guān)節(jié)外側(cè)穩(wěn)定中起到了重要的作用。Earll等8報(bào)道切斷淺層三角韌帶后，脛距關(guān)節(jié)接觸面積下降43%，壓力峰值增加30%，距骨外移4mm。復(fù)旦大學(xué)上海醫(yī)學(xué)院馬昕教授及其研究生根據(jù)尸體解剖結(jié)果提出脛舟韌帶可能只是踝關(guān)節(jié)囊加強(qiáng)組織，三角韌帶在踝關(guān)節(jié)屈伸運(yùn)動(dòng)過程中存在韌帶束間交替工作機(jī)制。同

14、濟(jì)大學(xué)附屬同濟(jì)醫(yī)院俞光榮教授認(rèn)為三角韌帶對(duì)踝關(guān)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編輯ppt17三角韌帶的功能 （選擇其中一篇文獻(xiàn)復(fù)習(xí)）The function of deltoid ligament編輯ppt18三角韌帶的功能The function of deltoid ligamentThe preset torsion between tibia and calcaneus was primarily set at 30 of internal rotation on specimen in plantar flexio

15、n and hind foot inversion. The first series of measurements were performed on healthy specimens andthe following after transecting structures in following order: anterior talofibular ligament (ATFL) in combination with calcaneofibular ligament (CFL), followed by anterior tibiotalar ligament and post

16、erior tibiotalar ligament and finally tibiocalcaneal ligament (TCL).編輯ppt19三角韌帶的功能The function of deltoid ligamentThe combined lateral ATFL and CFL instability showed a decrease in the resisting torque, which ensures stability in ankle sprain trauma. Only a transection of TCL (superficial layer of d

17、eltoid ligament complex) with existing lateral dual-ligament instability results in a significant decrease in torque (p 0.0001).編輯ppt20Take home messagesp 三角韌帶2層6束，淺4深2p X線韌帶束起止點(diǎn)定位重要，臨床使用價(jià)值大p 踝關(guān)節(jié)最主要的穩(wěn)定結(jié)構(gòu)為內(nèi)側(cè)三角韌帶編輯ppt21 References 1 Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrit

18、y in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments. J Foot Ankle Surg. 2004;43:20-9. 2 Michelson JD, 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 axia

19、lly loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res. 1996:285-93. 4 Close JR. Some applications of the functional 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