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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,三角韌帶的解剖 The Anatomy of deltoid ligament,,三角韌帶分為兩層6束，淺層4束，深層2束 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, Tibiocalcaneal ligament, Superficial posterior tibiotalar ligament. 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.,三角韌帶的解剖 The Anatomy of deltoid ligament,三角韌帶的解剖 The Anatomy of deltoid ligament,,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，4.脛后肌腱，5.趾長屈肌腱，6.載距突，7.踇長屈肌腱，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。,Fig. 1. Tibionavicular ligament. 2. Deep anterior tibiotalar ligament (deep layer). 3. Tibiospring ligament. 4. Tibiocalcaneal ligament. 5. Deep 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 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,三角韌帶的解剖 The Anatomy of deltoid ligament,Fig. 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 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),三角韌帶影像學(xué)（附著點） The Attachments of deltoid ligament,Figure 4. Representative lateral 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 ligament; TC, tibiocalcaneal ligament; TN, tibionavicular ligament; TS, tibiospring ligament.,三角韌帶的附著點 The Attachments of deltoid ligament,DATT, deep anterior tibiotalar ligament; DPTT, deep posterior tibiotalar ligament; SL, spring ligament; SPTT, superficial posterior tibiotalar ligament; TC, tibiocalcaneal ligament; TN, tibionavicular ligament; TS, tibiospring ligament.,三角韌帶的MRI The MRI of deltoid ligament,三角韌帶的MRI The MRI of deltoid ligament,MR images in 56 asymptomatic subjects,Figure 2: Anterior TTL (anterior portion of the deep layer of the MCL complex) and TSL (middle portion of the superficial layer of the MCL complex) in asymptomatic 25-year-old man.,三角韌帶的MRI The MRI of deltoid ligament,MR images in 56 asymptomatic subjects,三角韌帶的MRI The Attachments of deltoid ligament,三角韌帶的MRI The Attachments of deltoid ligament,三角韌帶的功能 The function of deltoid ligament,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)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)[1-3]。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，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，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,下脛腓最大分離距離為1.4mm，而當(dāng)三角韌帶斷裂時,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]。,三角韌帶對踝關(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)動過程中存在韌帶束間交替工作機(jī)制。同濟(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,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,三角韌帶的功能 The function of deltoid ligament,The preset torsion between tibia and calcaneus was primarily set at 30° of internal rotation on specimen in plantar flexion and hind foot inversion. The first series of measurements were performed on healthy specimens and the following after transecting structures in following order: anterior talofibular ligament (ATFL) in combination with calcaneofibular ligament (CFL), followed by anterior tibiotalar ligament and posterior tibiotalar ligament and finally tibiocalcaneal ligament (TCL).,三角韌帶的功能 The function of deltoid ligament,The 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 deltoid ligament complex) with existing lateral dual-ligament instability results in a significant decrease in torque (p 0.0001).,Take home messages,三角韌帶2層6束，淺4深2 X線韌帶束起止點定位重要，臨床使用價值大 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,References,[1] Schuberth JM, Collman DR, Rush SM, Ford LA. Deltoid ligament integrity 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 axially 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 A, Krpo S, et al. The role of the medial ligaments in lateral stabilization of the ankle joint: an in vitro study. Knee Surg Sports Traumatol Arthrosc. 2015;23:1900-6.[8] Earll M, Wayne J, Brodrick C, Vokshoor A, Adelaar R. Contribution of the deltoid ligament to ankle joint contact characteristics: a cadaver study. Foot Ankle Int. 1996;17:317-24.[9] Yu GR, Zhang MZ, Aiyer A, Tang X, Xie M, Zeng LR, et al. Repair of the acute deltoid ligament complex rupture associated with ankle fractures: a multicenter clinical study. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 2015;54:198-202.,守 破 離,