膝关节内侧副韧带及相关内侧结构的损伤

1、InjuriestotheMedialCollateralLigamentandAssociatedMedialStructuresoftheKnee膝关节内侧副韧带及相关内侧结构的损伤CoenA.Wijdicks,PhDl,ChadJ.Griffith,MD2,SteinarJohansen,MD3,LarsEngebretsen,MD,PhD3andRobertF.LaPrade,MD,PhD4InvestigationperformedattheDepartmentofOrthopaedicSurgery,UniversityofMinnesota,Minneapolis,Minneso

2、ta,andtheOsloUniversityHospitalandFacultyofMedicine,UniversityofOslo,Oslo,NorwayThesuperficialmedialcollateralligamentandothermedialkneestabilizersi.e.,thedeepmedialcollateralligamentandtheposteriorobliqueligamentarethemostcommonlyinjuredligamentousstructuresoftheknee.Themainstructuresofthemedialasp

3、ectofthekneearetheproximalanddistaldivisionsofthesuperficialmedialcollateralligament,themeniscofemoralandmeniscotibialdivisionsofthedeepmedialcollateralligament,andtheposteriorobliqueligament.Physicalexaminationistheinitialmethodofchoiceforthediagnosisofmedialkneeinjuriesthroughtheapplicationofavalg

4、usloadbothatfullkneeextensionandbetween20and30ofkneeflexion.Becausenonoperativetreatmenthasafavorableoutcome,thereisaconsensusthatitshouldbethefirststepinthemanagementofacuteisolatedgrade-IIIinjuriesofthemedialcollateralligamentorsuchinjuriescombinedwithananteriorcruciateligamenttear.Ifoperativetrea

5、tmentisrequired,ananatomicrepairorreconstructionisrecommended.口内侧副韧带浅层及其他内侧的膝关节稳定结构一一即内侧副韧带深层和后斜韧带一一是损伤最为多见的膝关节韧带结构。口膝关节内侧的主要结构包括内侧副韧带浅层的上段和下段，内侧副韧带深层的板股韧带和板胫韧带，以及后斜韧带。口在膝关节完全伸直以及屈曲20。-30。时施加外翻应力进行体格检查是诊断膝关节内侧损伤的首要方法。口由于非手术治疗通常可获得良好的疗效，一般认为新鲜的单纯III度内侧副韧带损伤或内侧副韧带合并前交叉韧带损伤时才考虑一期进行处理。口如必需进行手术治疗则推荐进行解剖修

6、复或重建。Theunderstandingoftheanatomy,biomechanics,andtreatmentofmedialkneeinjuriescontinuestoevolve.Quantitativetechniquesforthemeasurementofanatomicstructuresandbiomechanicaltestinganddigitalradiographyhaveimprovedanatomicdefinitionoftheseverityofinjuries.Thedevelopmentofnewreconstructiontechniquesmay

7、leadtoimprovedsurgicaloutcomes.Thesuperficialmedialcollateralligamentandothermedialkneestabilizersi.e.,thedeepmedialcollateralligamentandtheposteriorobliqueligamentarethemostcommonlyinjuredligamentousstructuresofthekneel-4.Theincideneeofinjuriestothesemedialkneestructureshasbeenreportedtobe0.24per10

8、00intheUnitedStatesinanygivenyear5andtobetwiceashighinmales(0.36comparedwith0.18infemales)5.Themajorityofmedialkneeligamenttearsareisolated.Theseinjuriesoccurpredominantlyinyoungindividualsparticipatinginsportsactivities,withthemechanismofinjuryinvolvingvalguskneeloading,externalrotation,oracombined

9、forcevectoroccurringinsuchsportsasskiing,icehockey,andsoccer，whichrequirekneeflexion6-8.对膝关节内侧损伤的解剖、生物力学和治疗的探索仍在不断推进，采用定量的方法测定解剖结构以及相关的生物力学试验和数字X线摄影(DR)使得损伤的严重程度从解剖角度而言更加确切，而由此创立的新的重建方法则可能进一步改善手术结果。内侧副韧带浅层及其他内侧的膝关节稳定结构一一即内侧副韧带深层和后斜韧带一一是损伤最为多见的膝关节韧带结构1-4。据报道5,在美国每年这样的膝关节内侧结构损伤的发生率约为每1000人0.24，而男性的发生率

10、则是女性的两倍(0.36/0.18)。大多数膝关节内侧结构损伤均为单发，这些损伤在参加体育运动的年轻患者中尤其多见，受伤机制主要包括膝关节外翻暴力，外旋或者在需要屈膝的运动中，如滑雪、冰球、足球等，多个方向的应力联合作用导致损伤6-8。AnatomySuperficialMedialCollateralLigamentThesuperficialmedialcollateralligament,commonlycalledthetibialcollateralligament,isthelargeststructureofthemedialaspectoftheknee(Fig.1,A).Th

11、isstructureconsistsofonefemoralattachmentandtwotibialattachments9.Quantitativeassessmenthasshownthefemoralattachmenttobeovaland,ontheaverage,3.2mmproximaland4.8mmposteriortothemedialepicondyle.Asthesuperficialmedialcollateralligamentcoursesdistally,ithastwotibialattachments.Theproximaltibialattachme

12、ntisprimarilytosofttissueovertheterminationoftheanteriorarmofthesemimembranosustendonandislocatedanaverageof12.2mmdistaltothetibialjointline9.Thedistaltibialattachmentofthesuperficialmedialcollateralligamentisbroadandisdirectlytoboneatanaverageof61.2mmdistaltothetibialjointline;itislocatedjustanteri

13、ortotheposteromedialcrestofthetibia9.Thetwodistinettibialattachmentshavebeenreportedtoresultintwodistinctfunctioningdivisionsofthesuperficialmedialcollateralligament10.解剖内侧副韧带浅层内侧副韧带浅层，通常称为胫侧副韧带，是膝关节内侧最大的结构（图1-A）。该结构在股骨有一个附着点，在胫骨有两个附着点9,定量研究显示股骨附着点为卵圆形，平均距离内上髁上方3.2mm后方4.8mm。内侧副韧带浅层向远端延伸，在胫骨有两个止点，近端止

14、点主要以一层软组织覆盖半膜肌腱前头的止点，位于胫骨关节线下方平均12.2mm处9；远端止点较宽，直接附于骨上，距胫骨关节线远端平均61.2mm,恰位于胫骨后内侧嵴稍前方9。有研究表明内侧副韧带浅层胫骨上两个独立的附着点使其成为了两个不同的功能组分10。sMCL(proximal)POLsMCL(distal)snsoumqEaEE10mm,respectively,whencomparedwiththeuninjured,contralateralside3,21-24.Clinicianscanutilizethissystemtodefinetheinitialgradeofinjury,

15、toplantreatment(nonoperativeoroperative),andtodetermineevideneeofhealingwithnonoperativetreatment.分型通过体格检查来了解膝关节内侧韧带损伤的程度，主要依赖于两个方面：患者放松的程度以及医生在患膝屈曲20。至30时加载外翻负荷后检出其终点(endpoint)的能力。如果患者由于疼痛而进行保护或者医生不愿给患者造成更严重的疼痛，外翻应力试验或外翻应力位X线摄影则可能会低估膝关节内侧的松弛程度。检查过程中可以对侧为基准进行对比。膝关节内侧损伤有一个被广泛应用的等级评价方法，参照美国医学会运动损伤命名法标

16、准而制定(图2,表1)20。按照该评价系统，单纯I度：少量纤维撕裂，伴有局限性压痛无松弛；单纯II度：局限性压痛，内侧副韧带纤维及后斜纤维部分撕裂。纤维仍然存在一定的张力，伴或不伴有病理性的松弛；单纯III度：表现为外翻应力下可见完全断裂及松弛。单纯膝关节内侧损伤也可以按照施加外翻应力时松弛的程度进行分级。等级分为1+、2+和3+,相当于对内侧关节间隙进行主观评价，并与未受伤的对侧相比较，分别增宽3-5mm、6-10mm及10mm以上3,21-24。临床医生可以参照这一评价系统确定其最初的损伤等级，制定治疗计划(手术或非手术)，并可作为非手术治疗愈合与否的验证手段。PosteriorObliq

17、ueLigamentsuperficialMedialCollateralLigamentGradeIG日血IIFig.2Anteromedialviewoftheleftknee,showingtheinjurygradingscaleestablishedbytheAmericanMedicalAssociationStandardNomenclatureofAthleticInjuries20.Isolatedgrade-Iinjuriespresentwithlocalizedtendernessandnolaxity.Isolatedgrade-IIinjuriespresentwi

18、thabroaderareaoftendernessandpartiallytornmedialcollateralandposteriorobliquefibers.Isolatedgrade-IIIinjuriespresentwithcompletedisruption,andthereislaxitywithanappliedvalgusstress.图2左膝前内侧面观，所示为参照美国医学会运动损伤命名法标准制定的损伤等级评价标准20。单纯I度损伤表现为局限性压痛无松弛；单纯II度损伤表现为范围更大的压痛，内侧副韧带纤维及后斜纤维部分撕裂；单纯III度损伤表现为完全断裂，在外翻应力下可

19、见松弛。表1膝关节内侧损饬尊级评定标准分世运义I度當局限性压疝无不誌II度局限性压痣内鯉副韧港纤维及后斜纤维剖分撫裂III度2&完全断裂.外翻应力下存在不稳皿度量化标准上观性临床评价苹131+松弛3-5mm2+松弛6-lOiniii3+松弛lOmui以.应力位X线片单纯内侧副韧帝摄伤膝关节師励0时内啊关节间20时增宽3.2mm膝关节内删络构完仝揽伤（内侧副韧帯法层、后膝关节師曲俨时内啊关节问20斜韧带、内侧詡韧带深层、时增宽9.8nun*所例数值为项研究中的平均值，而非分空系统的评价标准DXVCHealingThesuperficialmedialcollateralligamenthasbe

20、enreportedtohaveanabundantvascularsupply.Healingofthisligamentfollowstheclassicmodelofhealinginvolvinghemorrhage,inflammation,repaii;andremodeling25.Studiesofthevariablesinvolvedinthehealingofthesuperficialmedialcollateralligamentinanimalshaveshownthatthehealingislocationdependent.Inonestudyofarabbi

21、tsuperficialmedialcollateralligamentinjurymodel,theligamenttooklongertohealwhenitwasinjuredneareitherattachmentsitethanwhenithadamidsubstaneeinjury26.Thebiologicaleffectsofimmobilizationhavealsobeenwidelystudiedinsuperficialmedialcollateralligamentinjurymodels.Inarabbitmodel,areductionofcollagenmass

22、andincreasedcollagendegradationwereobservedaftertwelveweeksofimmobilization27.Thesenegativeeffectsofimmobilizationwerenotedtobecausedbycollagenmatrixreorganizationandcatabolicbehaviorwithinthemedialcollateralligamentafterinjury28,29.Inanotherstudy,dogsthathadundergonesurgicaltransectionofthesuperfic

23、ialmedialcollateralligamentweredividedintothreetreatmentgroups:earlymotion,immobilizationforthreeweeks,andimmobilizationforsixweeks30.Theauthorsconcludedthatearlymotionprotocolsleadtoenhancedhealingandimprovedbiomechanicalpropertiesofthesuperficialmedialcollateralligament.Thisinformationwassubsequen

24、tlyusedtopromoteandreinforcesimilarnonoperativerehabilitationprotocolsfortheseinjuriesinhumans.愈合据研究报道，内侧副韧带浅层血供丰富，其愈合通常遵循经典的愈合模式：出血、炎症、修复和重建25。但也有与之不同的报道，动物实验显示内侧副韧带浅层的愈合与损伤的位置密切相关。有学者研究了兔子内侧副韧带浅层的损伤模型，发现与韧带中部损伤相比，两个附着点附近的损伤愈合时间更长26。在内侧副韧带浅层损伤的模型中制动的生物学作用也是一个被广泛研究的内容。在一个兔子模型中，制动12周以后观察到胶原的含量减少，胶原的退

25、变明显增加27。人们注意到制动带来的不良影响主要是由于内侧副韧带损伤后内部胶原基质的重组和分解代谢28,29。在另一项研究中，狗的内侧副韧带浅层经手术横行切断，然后分成3个处理组：早期活动、制动3周和制动6周30。作者的结论认为早期活动可促进内侧副韧带浅层损伤的愈合，改善其生物力学性能。这一结论后来也常常被引用，作为类似的非手术康复计划在人类相关损伤中应用的理论依据。ClinicallyRelevantBiomechanicsAcompleteunderstandingofmedialkneebiomechanicsisvaluablefortheassessmentofwhichinjure

26、dstructuresshouldberepairedorreconstructed.Anunderstandingofthedegreeofabnormaljointmotionthatoccurswhenastructureisinjuredgreatlyassistswiththeinterpretationoftheresultsoftheclinicalexaminationandhelpstodeterminethepresenceofconcurrentligamentinjury.Withthetrendtowardmoreanatomicreconstruction,itis

27、importanttounderstandthefunctionof,andthedifferencesbetween,theindividualcomponentsofthesemainmedialknee-stabilizingstructures.Biomechanicalstudieshaveshownthatthesuperficialmedialcollateralligamentistheprimaryrestrainttovalguslaxityoftheknee1,31-34.Onestudy,inwhichbuckletransducerswereused,quantita

28、tivelydemonstrateddifferencesbetweenthetwodivisionsofthesuperficialmedialcollateralligamentintermsoftheirresponsestoappliedloads10.Theimplicationsoftheseobservationsarethat,althoughthesuperficialmedialcollateralligamenthaspreviouslybeenbiomechanicallytestedandoperativelyreconstructedundertheassumpti

29、onthatitisonecontinuousstructure1,33,35-40,thetwodivisionsoftheligamentactuallyfunctionasconjoinedbutdistinctstructures.Thus,thebiomechanicalstudy10suggeststhattheaimofanoperativerepairorreconstructionofthesuperficialmedialcollateralligamentshouldbetorestorethedistinctfunctionsofbothdivisionsbyreatt

30、achingthetwotibialattachmentsinanattempttoreproducetheoverallfunctionofthesuperficialmedialcollateralligamentconstruct.临床生物力学深入了解膝关节内侧结构的生物力学性能对于明确哪些结构损伤必须进行修复或重建意义重大。认识清楚某一结构损伤后导致关节异常活动的程度，对于解释临床查体的结果以及确定是否存在合并的韧带损伤都是很有帮助的。随着越来越提倡解剖重建，理解膝关节内侧稳定结构各个组分的功能及其相互之间的差异则显得尤为重要。生物力学研究显示内侧副韧带浅层主要起到限制膝关节过度外翻的

31、作用1,31-34。其中有一项研究，应用环扣传感器进行了定量分析，结果显示了内侧副韧带浅层在加载负荷后两个部分之间的反应不同10。这一研究提示，尽管以前的生物力学试验和手术重建都将内侧副韧带浅层当作一个连续的结构来处理1,33,35-40,而事实上该韧带的两个组分虽然协同作用但却是两个相互独立的结构。因此，有生物力学研究10主张在对内侧副韧带浅层进行手术修复或重建时，应以恢复其两个组分不同的功能为目的，分别重建两个胫骨附着点以求还原内侧副韧带浅层的所有功能。Theposteriorobliqueligamentreinforcestheposteromedialaspectofthecapsu

32、le,whichcoursesoffthedistalaspectofthesemimembranosustendon2,9,14.Fromabiomechanicalperspective,theposteriorobliqueligamentfunctionsasaninternalrotatorandvalgusstabilizeratbetween0and30ofkneeflexion1,2,10,35,37,38,41,42.Ithasalsobeenreportedthat,withappliedinternalrotationtorquesat0ofkneeflexion,the

33、loadsontheposteriorobliqueligamentaresignificantlyhigherthanthoseoneitherdivisionofthesuperficialmedialcollateralligament10.Inaddition,ithasbeenreportedthatthereisareciprocalloadresponsetointernalrotationtorquebetweentheposteriorobliqueligamentandthesuperficialmedialcollateralligamentasthedegreeofkn

34、eeflexionincreases,withahigherloadresponseinthesuperficialmedialcollateralligamentat90ofkneeflexion.Thisobservationdemonstratesthatthereisacomplementaryrelationshipbetweentheposteriorobliqueligamentandthesuperficialmedialcollateralligamentwithregardtotheresistanceofinternalrotationtorquesthatdepends

35、onthekneeflexionangle.Asubsequentstudyofloaddistributionwithbuckletransducersshowedthatsectioningofthecomponentsofboththedeepmedialcollateralligamentandthesuperficialmedialcollateralligamentresultedinsignificantincreases,comparedwiththeintactstate,intheforcesexperieneedbytheposteriorobliqueligamentu

36、ndervalgusloadsat0,20,and30ofkneeflexion42.Thisobservationcorrelatesbothwithpreviousreportsthattheposteriorobliqueligamentinintactkneesexperiencestensileloadwithvalgusforces,especiallyclosetokneeextension10,42,andthattheposteriorobliqueligamenthasasecondaryroleinprovidingvalgusstabilityoftheknee35,4

37、3,44.后斜韧带远离半膜肌腱远端走行，加强后内侧关节囊2,9,14。从生物力学角度而言，在膝关节屈曲0至30。时后斜韧带主要起到内旋和外翻稳定作用1,2,10,35,37,38,41,42。也有报道在膝关节屈曲0并加载内旋扭矩时，后斜韧带承受的负荷要明显高于内侧副韧带浅层的任一部分10。此外，还有研究指出，加载内旋扭矩时，随着膝关节屈曲的度数增加，后斜韧带与内侧副韧带浅层的负荷变化趋势相反，屈膝90时内侧副韧带浅层的负荷反应较高。这一观测显示根据膝关节屈曲的角度不同，后斜韧带与内侧副韧带浅层对内旋扭矩的抵抗存在互补关系。随后的研究应用环扣传感器对负荷的分配进行了探讨，结果显示膝关节屈曲0、2

38、0及30。时，切断内侧副韧带深层和浅层都可观测到后斜韧带承载的负荷明显增加42。这一观测结果与上文提到的两方面的研究都是密切相关的，在完整的膝关节中加载外翻应力时后斜韧带承载张力负荷，膝关节接近于伸直时尤其明显10,42；后斜韧带对膝关节的外翻稳定有辅助作用35,43,44。Comparedwiththenumberofstudiesonthefunctionofthesuperficialmedialcollateralligament,therearefewerreportsontheisolatedfunctionofthedeepmedialcollateralligament.The

39、authorsofprevioussequentialsectioningstudiesdonetoevaluatethefunctionofthedeepmedialcollateralligamentdescribeditasasecondaryrestrainttovalgusloads41-43.Morespecifically,theyfoundthatvalgusstabilizationwasprovidedbythemeniscofemoralportionofthedeepmedialcollateralligamentatalltestedflexionanglesandb

40、ythemeniscotibialportionofthedeepmedialcollateralligamentat60ofkneeflexion.Thedeepmedialcollateralligamentwasalsoreportedtoproviderestraintagainstexternalrotationtorqueinkneesflexedbetween30and9041,43.有关内侧副韧带浅层功能的研究很多，与之相比，单纯研究内侧副韧带深层相关功能的报道则相对较少。上文提到的顺序切断的研究对内侧副韧带深层的功能进行了评估，作者将其描述为一个对抗外翻负荷的辅助结构41-4

41、3。更确切地说，他们发现外翻稳定性的维持在膝关节的各个屈曲角度，内侧副韧带深层的板股韧带更为重要，而屈膝60时内侧副韧带深层的板胫韧带则发挥主要作用。另外也有研究表明膝关节屈曲30至90时内侧副韧带深层也可对抗外旋扭矩41,43。Theseresultsdemonstratethatinjuriestotheindividualcomponentsofthemedialaspectofthekneealtertheintricateload-sharingrelationshipsthatexistamongallofthemedialkneestructuresand,ifleftuntre

42、ated,couldpotentiallyincreasetheriskoffurtherinjury42,45.Therefore,onthebasisofthesynthesisofinformationfromtheliteratureandourpersonalperspective,webelievethat,incasesinwhichanoperativerepairorreconstructionisindicated,considerationshouldbegiventorepairingorreconstructingallinjuredmedialkneestructu

43、restorestorethenormalload-sharingrelationshipsamongthosestructuresatthetimeofoperativetreatment.Ananatomicmedialkneereconstructiontechnique(Fig.3)46,basedonpreviousquantitativeanatomic9andbiomechanicalstudies10,42,wasdevelopedinanattempttorestorenormalstabilitytoakneefollowingcompletesectioningofthe

44、superficialmedialcollateralligamentandposteriorobliqueligament.Itwasreportedthatthisreconstructionrestorednearlynormalstabilitytothekneeandthat,followinganappliedload,thereconstructedligamentsdidnothaveagreaterforceresponsethanintactligamentsatanypointduringtesting46.Thissuggeststhatoverconstraintof

45、thekneeandoverloadingofthereconstructiongrafts,whichcouldleadtograftfailure,waspreventedbytheuseofthistechnique.这些研究结果提示，膝关节内侧单一结构的损伤，可改变膝关节内侧所有相关结构之间存在的负荷分担关系，如果不进行妥善处理的话，可能会增加进一步损伤的风险42,45。因此，综合文献中的信息及我们个人的观点，我们认为，对于具备手术修复或重建指征的病例，进行手术治疗时应考虑修复或重建所有受损的膝关节内侧结构，以恢复这些结构相互间正常的负荷分担关系。以上述定量解剖和生物力学研究为基础创立

46、的膝关节内侧解剖重建方法（图3）46,通过完全切开暴露内侧副韧带浅层和后斜韧带，以期恢复膝关节正常的稳定性。有研究认为该重建方法可恢复几近于正常的膝关节稳定性，此外，在试验过程中加载负荷后，重建的韧带任一点上的应力反应都不大于正常完整的韧带46o这表明通过应用这一方法可防止出现膝关节过紧，并可避免重建的移植物承受过大的负荷，而这些都是导致移植物失效的常见原因。Fig.3Illustrationofamedialkneereconstructonprocedure(medialviewofaleftknee).Thesuperficialmedialcollateralligament(sMCL

47、)andposteriorobliqueligament(POL)arereconstructedwithuseoftwoseparategraftsandfourreconstructiontunnels.Notethattheproximaltibialattachmentofthesuperficialmedialcollateralligament,whichisprimarilytosofttissuesandislocatedjustdistaltothejointline,wasrecreatedbysuturingthesuperficialmedialcollateralli

48、gamentgrafttotheanteriorarmofthesemimembranosusmuscle.(Reproduced,withpermission,from:CoobsBR,WijdicksCA,ArmitageBM,SpiridonovSI,WesterhausBD,JohansenS,EngebretsenL,LaPradeRF.Aninvitroanalysisofananatomicalmedialkneereconstruction.AmJSportsMed.2010;38:339-47.)图3图示为膝关节内侧重建方法(左膝内侧面观)。内侧副韧带浅层(sMCL)和后斜韧

49、带(POL)分别应用两条移植腱经4个骨隧道进行重建。注意内侧副韧带浅层的近侧胫骨附着点主要通过软组织附于关节线稍下方，术中可将内侧副韧带浅层的移植物缝合到半膜肌的前头进行重建。(经惠允引自：CoobsBR,WijdicksCA,ArmitageBM,SpiridonovSI,WesterhausBD,JohansenS,EngebretsenL,LaPradeRF.Aninvitroanalysisofananatomicalmedialkneereconstruction.AmJSportsMed.2010;38:339-47.)DiagnosisHistoryPatientsoftende

50、scribeamechanismofinjuryinvolvingacontactornoncontactvalgusforcetotheknee.Theyalsoreportpainandswellingalongthemedialaspectoftheknee.Whenaskedtoexplainthetypeofinstabilitythattheyfeelwithactivities,individualswithmedialkneeinjuriesinvolvingthesuperficialmedialcollateralligament,posteriorobliqueligam

51、ent,anddeepmedialcollateralligamentoftendescribedaside-to-sidefeelingofinstability,especiallywhentheywereathleteswhoperformedcuttingandpivotingmaneuvers.诊断病史患者自述的受伤机制通常包括膝关节接触性或非接触性的外翻暴力，主诉通常为膝关节内侧面的疼痛和肿胀。而为了判断不稳的类型而进一步询问其活动时的感受时，膝关节内侧结构损伤的患者，包括内侧副韧带浅层、后斜韧带、内侧副韧带深层，一般都会诉边对边动作(sidetoside)时有不稳的感觉，尤其患者

52、是运动员，做斜切及扭转动作时则更为明显。ClinicalEvaluationPhysicalexaminationofthekneeremainsthemostsuitabletoolforobtainingadiagnosisofinjurytoitsmedialstructures.Beginningwithvisualinspection,cliniciansmayobservelocalizedswellingorecchymosisoverthefemoralortibialattachmentofthesuperficialmedialcollateralligament9.The

53、seareascanbepalpatedtohelptoidentifytendernessofthesuperficialmedialcollateralligament.Itisimportanttounderstandtheanatomyofthemedialsideofthekneetoappropriatelypalpateandassessthestructuresinvolved9.Avalgusloadappliedat20to30ofkneeflexionisusedtodetectmedialjointopening(Fig.4,A).Applyingthevalgusst

54、ressatboth0and30ofkneeflexioncanfurtherassistinthediagnosisoftheinjurypatternbecausewhenakneehasincreasedmedialjointspaceopeningat30offlexionbutnotat0theposteriorobliqueligamentismostlikelystillintact.Anadditionalassessmentperformedatthistimeofvalgusmomentapplicationisevaluationoftheintegrityoftheso

55、-calledendpoint.Ifthemedialkneestructuresarecompletelyruptured,therewillbenodefinitiveendpointandtheanteriorcruciateligamentmaybeprovidingasecondaryrestrainttothevalgusstress41.ItisthereforeimportanttoverifythisobservationwiththeLachman47,anteriordrawei,andpivotshifttestsandassesstheintegrityofthean

56、teriorcruciateligamentinassociationwithmedialkneeinjury.临床评估膝关节的体格检查仍然是诊断相关内侧结构损伤最为合适的手段。首先进行视诊，医生可以观察局部肿胀，以及内侧副韧带浅层股骨或胫骨附着点周围的皮下瘀斑等情况9。对这些区域进行触诊，明确内侧副韧带浅层是否存在压痛。深入了解膝关节内侧的解剖对于准确地触诊和评估受累的结构都是非常重要的9。膝关节屈曲20。至30，加载外翻负荷以检查膝关节内侧间隙的宽度（图4-A）。在膝关节屈曲0。和30。时施加外翻应力可作为进一步诊断损伤类型的辅助手段，因为膝关节屈曲30。时内侧关节间隙增宽而屈曲0。时无明

57、显增宽则意味着后斜韧带很有可能仍保持完整。此时，加载外翻力矩后还须要评估其是否具有明显的终点。如果膝关节内侧结构完全断裂，则可能没有明确的终点，此时前交叉韧带可能对外翻应力提供一定的对抗作用41。因此，通过Lachman试验、前抽屉试验、轴移试验等对这一检查进行验证，并检查膝关节内侧损伤是否合并有前交叉韧带损伤也是十分重要的。Fig.4A:Avalgusloadisappliedat20to30ofkneeflexiontodetectmedialjointopening.Thepatientsthighisallowedtorestontheexaminationtableinorderto

58、relaxthethighmuscles.Whilethevalgusforceisbeingappliedthroughthefootandankle,theexaminerpalpatesthemedialjointareatodeterminetheamountofmedialjointlinegapping.B:Completeinjurytothemedialstructuresincreasesexternalrotationatboth30and90ofkneeflexion,resultinginapositivedialtest41,48.Asdemonstrated,the

59、patientslowerlimbisplacedin9O5ofkneeflexionandtheamountofexternalrotationiscomparedwiththatofthenormal,contralateralknee.图4A：屈膝20。至30施加外翻应力检查膝关节内侧间隙的宽度。患者的大腿置于检查床上以放松大腿的肌肉。通过足踝部对膝关节施加外翻应力，然后进行触诊检查膝关节内侧间隙的宽度，以确定关节间隙是否存在增宽。B：内侧结构完全损伤在膝关节屈曲30。和90时都可使外旋异常增加，导致胫骨外旋试验(dialtest)阳性41,48。如图所示，患者的下肢置于90屈膝位，并与

60、对侧正常的膝关节比对其外旋的程度。Palpationofthefemur-basedandtibia-basedportionsofthemedialkneestructurescanoftendelineatethelocationoftheligamentinjury.Theanteromedialdrawertest,performedbyflexingthekneeapproximately90whileexternallyrotatingthefoot10to15andapplyingananteromedialrotationalforcetotheknee,shouldalsob