三角韧带解剖学、影像学及生物力学

1、编辑ppt1三角韧带解剖学、影像学及生物力学The Anatomy, Radiology and biomechanics of Deltoid Ligament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: +86E-mail:编辑ppt2三角韧带的解剖The Anatomy of deltoid ligament三角韧带分为两层三角韧带分为两层6 6束束，浅层浅层4 4束，深层束，深层2 2束束p 浅层:胫舟韧带、胫跳跃韧带、胫跟韧带及胫距后韧带浅层 Tibionavicular ligament, Tibiospring ligament, T

2、ibiocalcaneal ligament, Superficial posterior tibiotalar ligament.p 深层:胫距前韧带深层及胫距后韧带深层 Deep anterior tibiotalar ligament, Deep posterior tibiotalar ligament.编辑ppt3三角韧带的解剖The Anatomy of deltoid ligament编辑ppt4三角韧带的解剖The Anatomy of deltoid ligamentABC图图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，

3、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。编辑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)三角韧带的解剖The Anatomy of deltoid ligament编

6、辑ppt6三角韧带的解剖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)编辑ppt7三角韧带影像学（附着点）The Attachments of deltoid ligament编辑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.编辑ppt9三角韧带的附着点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.编辑ppt10三角韧带的MRIThe MRI of deltoid ligament编辑ppt11三角韧带的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. 编辑ppt12三角韧带的MRIThe MRI of deltoid ligamentMR images in 56 asymptomatic subjects编辑ppt13三角韧带的MRIThe Attachments of deltoid ligament编辑ppt14三角韧带的MRIThe Attachments of deltoid ligament编辑ppt15三角韧带的功能The function of deltoid liga

12、ment 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，踝关踝关节最主要的稳定结构为内侧三角韧带而非外侧结构节最主要的稳定结构为内侧三角韧带而非外侧结构1-31-3。Close JR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。编辑ppt1

13、6 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。Ziai P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

14、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The function of deltoid ligament编辑ppt17三角韧带的功能 （选择其中一篇文献复习）The function of deltoid ligament编辑ppt18三角韧带的功能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).编辑ppt19三角韧带的功能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).编辑ppt20Take home messagesp 三角韧带2层6束，浅4深2p X线韧带束起止点定位重要，临床使用价值大p 踝关节最主要的稳定结构为内侧三角韧带编辑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