三角韧带解剖学、影像学及生物力学.ppt

三角韧带解剖学、影像学及生物力学TheAnatomy,RadiologyandbiomechanicsofDeltoidLigament,张宁医师山东大学足踝外科中心山东大学第二医院手足外科Tel:+8615098950665；E-mail:zhangningno,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,Thepresettorsionbetweentibiaandcalcaneuswasprimarilysetat30ofinternalrotationonspecimeninplantarflexionandhindfootinversion.Thefirstseriesofmeasurementswereperformedonhealthyspecimensandthefollowingaftertransectingstructuresinfollowingorder:anteriortalofibularligament(ATFL)incombinationwithcalcaneofibularligament(CFL),followedbyanteriortibiotalarligamentandposteriortibiotalarligamentandfinallytibiocalcanealligament(TCL).,三角韧带的功能Thefunctionofdeltoidligament,ThecombinedlateralATFLandCFLinstabilityshowedadecreaseintheresistingtorque,whichensuresstabilityinanklespraintrauma.OnlyatransectionofTCL(superficiallayerofdeltoidligamentcomplex)withexistinglateraldual-ligamentinstabilityresultsinasignificantdecreaseintorque(p0.0001).,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,1SchuberthJM,CollmanDR,RushSM,FordLA.Deltoidligamentintegrityinlateralmalleolarfractures:acomparativeanalysisofarthroscopicandradiographicassessments.JFootAnkleSurg.2004;43:20-9.2MichelsonJD,ClarkeHJ,JinnahRH.Theeffectofloadingontibiotalaralignmentincadaverankles.FootAnkle.1990;10:280-4.3MichelsonJD,WaldmanB.Anaxiallyloadedmodeloftheankleafterpronationexternalrotationinjury.ClinOrthopRelatRes.1996:285-93.4CloseJR.Someapplicationsofthefunctionalanatomyoftheanklejoint.JBoneJointSurgAm.1956;38-A:761-81.5BodenSD,LabropoulosPA,McCowinP,LestiniWF,HurwitzSR.Mechanicalconsiderationsforthesyndesmosisscrew.Acadaverstudy.JBoneJointSurgAm.1989;71:1548-55.6RasmussenO.Stabilityoftheanklejoint.Analysisofthefunctionandtraumatologyoftheankleligaments.ActaOrthopScandSuppl.1985;211:1-75.7ZiaiP,BencaE,SkrbenskyGV,WenzelF,AuffarthA,KrpoS,etal.Theroleofthemedialligamentsinlateralstabilizationoftheanklejoint:aninvitrostudy.KneeSurgSportsTraumatolArthrosc.2015;23:1900-6.8EarllM,WayneJ,BrodrickC,VokshoorA,AdelaarR.Contributionofthedeltoidligamenttoanklejointcontactcharacteristics:acadaverstudy.