三角韧带解剖学影像学及生物力学医学PPT课件.ppt

三角韧带解剖学 影像学及生物力学TheAnatomy RadiologyandbiomechanicsofDeltoidLigament 三角韧带的解剖TheAnatomyofdeltoidligament 三角韧带分为两层6束 浅层4束 深层2束浅层 胫舟韧带 胫跳跃韧带 胫跟韧带及胫距后韧带浅层Tibionavicularligament Tibiospringligament Tibiocalcanealligament Superficialposteriortibiotalarligament 深层 胫距前韧带深层及胫距后韧带深层Deepanteriortibiotalarligament Deepposteriortibiotalarligament 三角韧带的解剖TheAnatomyofdeltoidligament 三角韧带的解剖TheAnatomyofdeltoidligament 图1 A 胎儿踝部冠状面 Mallory三色法染色 1 内踝 2 三角韧带深层 3 三角韧带浅层 4 胫后肌腱 5 趾长屈肌腱 6 载距突 7 踇长屈肌腱 8 纤维鞘隔膜 B 三角韧带浅层示意图 1 胫舟韧带 2 胫弹性韧带 3 胫跟韧带 4 胫距后韧带浅层 5 跟舟上韧带 弹性韧带组成部分 6 胫后肌腱 7 跖侧跟舟韧带 弹性韧带组成部分 C 三角韧带深层 1 胫距前韧带深层 2 胫距后韧带深层 Fig 1 Tibionavicularligament 2 Deepanteriortibiotalarligament deeplayer 3 Tibiospringligament 4 Tibiocalcanealligament 5 Deepposteriortibiotalarligament deeplayer 6 Superomedialcalcaneonavicularligament componentofspringligament 7 Plantarcalcaneonavicularligament componentofspringligament 8 Naviculartuberosity 9 Medialtalarprocess 10 Sustentaculumtali 11 Posteriortibialtendon cutattheleveloftheinsertion 12 Flexorhallucislongus cutproximalanddistal 13 Tibialisanteriortendon cutatthelevelofinsertion 14 Longplantarligament 15 Plantarcalcaneocuboidligament 16 Calcanealtendon cutatthelevelofinsertion 三角韧带的解剖TheAnatomyofdeltoidligament 三角韧带的解剖TheAnatomyofdeltoidligament Fig 3Medialviewoftheanatomicaldissectionofthedeeplayerofthedeltoidligament Thesuperficiallayerofthedeltoidligamenthasbeenresected Itsdistalinsertionismaintained arrowheads aPlantarflexion bDorsiflexion 1 Deepanteriortibiotalarligament 2 Deepposteriortibiotalarligament 3 Talarhead 4 Medialtalarprocess 5 Sustentaculumtali 6 Anteriorsubtalarjoint 7 Posteriortibialtendon cutatthelevelofinsertion 三角韧带影像学 附着点 TheAttachmentsofdeltoidligament Figure4 Representativelateralradiographicimagesofarightankledemonstratingthesitesofattachmentandcoursesoftheindividualbandsofthe A superficialand B deepdeltoid DATT deepanteriortibiotalarligament DPTT deepposteriortibiotalarligament SL springligament SPTT superficialposteriortibiotalarligament TC tibiocalcanealligament TN tibionavicularligament TS tibiospringligament 三角韧带的附着点TheAttachmentsofdeltoidligament DATT deepanteriortibiotalarligament DPTT deepposteriortibiotalarligament SL springligament SPTT superficialposteriortibiotalarligament TC tibiocalcanealligament TN tibionavicularligament TS tibiospringligament 三角韧带的MRITheMRIofdeltoidligament 三角韧带的MRITheMRIofdeltoidligament MRimagesin56asymptomaticsubjects Figure2 AnteriorTTL anteriorportionofthedeeplayeroftheMCLcomplex andTSL middleportionofthesuperficiallayeroftheMCLcomplex inasymptomatic25 year oldman 三角韧带的MRITheMRIofdeltoidligament MRimagesin56asymptomaticsubjects 三角韧带的MRITheAttachmentsofdeltoidligament 三角韧带的MRITheAttachmentsofdeltoidligament 三角韧带的功能Thefunctionofdeltoidligament 踝关节是人体中最为脆弱的负重关节 其稳定性至关重要 研究发现 踝关节最主要的稳定结构为内侧三角韧带而非外侧结构 1 3 CloseJR等 4 研究发现当切断所有踝关节外侧韧带而保留三角韧带时 距骨移位不超过2mm 而当踝关节外侧韧带完整而深层三角前带断裂时 距骨平均移位将达到3 7mm Boden等在切断下胫腓前 后韧带后 由远端向近端逐渐切断骨间膜至踝上15cm 结果发现在三角韧带完整时 下胫腓最大分离距离为1 4mm 而当三角韧带断裂时 下胫腓分离达到4 5mm Boden等认为三角韧带是维持踝关节稳定性的首要因素 5 三角韧带对踝关节的稳定作用越来越受到国内外学者的重视 Rasmussen等 6 发现三角韧带浅层主要限制距骨外移及外翻 三角韧带深层主要限制距骨的外旋 ZiaiP等 7 通过体外生物力学研究发现在外侧副韧带损伤的情况下 三角韧带浅层阻止了踝关节继续外旋或外翻 而深层结构在稳定距下关节所起的作用较小 因此三角韧带浅层在踝关节外侧稳定中起到了重要的作用 Earll等 8 报道切断浅层三角韧带后 胫距关节接触面积下降43 压力峰值增加30 距骨外移4mm 复旦大学上海医学院马昕教授及其研究生根据尸体解剖结果提出胫舟韧带可能只是踝关节囊加强组织 三角韧带在踝关节屈伸运动过程中存在韧带束间交替工作机制 同济大学附属同济医院俞光荣教授认为三角韧带对踝关节的稳定作用非常重要 9 三角韧带的功能Thefunctionofdeltoidligament 三角韧带的功能 选择其中一篇文献复习 Thefunctionofdeltoidligament 三角韧带的功能Thefunctionofdeltoidligament Thepresettorsionbetweentibiaandcalcaneuswasprimarilysetat30 ofinternalrotationonspecimeninplantarflexionandhindfootinversion Thefirstseriesofmeasurementswereperformedonhealthyspecimensandthefollowingaftertransectingstructuresinfollowingorder anteriortalofibularligament ATFL incombinationwithcalcaneofibularligament CFL followedbyanteriortibiotalarligamentandposteriortibiotalarligamentandfinallytibiocalcanealligament TCL 三角韧带的功能Thefunctionofdeltoidligament ThecombinedlateralATFLandCFLinstabilityshowedadecreaseintheresistingtorque whichensuresstabilityinanklespraintrauma OnlyatransectionofTCL superficiallayerofdeltoidligamentcomplex withexistinglateraldual ligamentinstabilityresultsinasignificantdecreaseintorque p 0 0001 Takehomemessages 三角韧带2层6束 浅4深2X线韧带束起止点定位重要 临床使用价值大踝关节最主要的稳定结构为内侧三角韧带 References 1 SchuberthJM CollmanDR RushSM FordLA Deltoidligamentintegrityinlateralmalleolarfractures acomparativeanalysisofarthroscopicandradiographicassessments JFootAnkleSurg 2004 43 20 9 2 MichelsonJD ClarkeHJ JinnahRH Theeffectofloadingontibiotalaralignmentincadaverankles FootAnkle 1990 10 280 4 3 MichelsonJD WaldmanB Anaxiallyloadedmodeloftheankleafterpronationexternalrotationinjury ClinOrthopRelatRes 1996 285 93 4 CloseJR Someapplicationsofthefunctionalanatomyoftheanklejoint JBoneJointSurgAm 1956 38 A 761 81 5 BodenSD LabropoulosPA McCowinP LestiniWF HurwitzSR Mechanicalconsiderationsforthesyndesmosisscrew Acadaverstudy JBoneJointSurgAm 1989 71 1548 55 6 RasmussenO Stabilityoftheanklejoint Analysisofthefunctionandtraumatologyoftheankleligaments ActaOrthopScandSuppl 1985 211 1 75 7 ZiaiP BencaE SkrbenskyGV WenzelF AuffarthA KrpoS etal Theroleofthemedialligamentsinlateralstabilizationoftheanklejoint aninvitrostudy KneeSurgSportsTraumatolArthrosc 2015 23 1900 6 8 EarllM WayneJ BrodrickC VokshoorA AdelaarR Contributionofthedeltoidligamenttoanklejointcontactcharacteristics acadaverstudy Foo