【作者】 刘凯；

【导师】 李义凯；

【作者基本信息】 南方医科大学 ， 中西医结合临床， 2013， 博士

【摘要】 临床上单纯足部韧带损伤不易引起医生的重视,原因是医生本身对足部韧带的解剖和功能作用缺乏了解,若治疗不当可出现足部功能障碍,主要表现为疼痛,行走不适,严重者久治不愈,甚至可出现畸形。运动员和爱好运动的人是这一疾病好发人群。另外,外伤导致足部骨折脱位的患者都伴有不同程度地韧带损伤。因此有必要认识和了解足部韧带的解剖及功能,减少失治、误治,提高临床诊断和治疗水平,但目前的一些解剖书籍对足部韧带的解剖描述不够详细,某些图片甚至还有错误。基于此,我们对足部,主要是中后足部各韧带的分布、走行及形态特征等进行了比较详细解剖学观测,并对其功能作用进行了探讨,并通过MRI这一常见的检查手段来分析其观测足部各韧带的情况,以期为临床诊断和治疗足部韧带损伤提供帮助。第一部分足部韧带的解剖学观测材料和方法选取防腐成人足部尸体标本13例(左足7例,右足6例),标本性别不限。在行常规解剖研究前,进行大致检查,以排除明显的畸形,骨折创伤、肿瘤和破损等。采用层次解剖法,逐层解剖,剔除皮肤、肌肉、脂肪、神经及血管等组织后显露足部各韧带进行观测。先观测足部背侧的韧带,记录其起止、分布走形规律,形态特征。再观测足底韧带,最后观测骨间韧带。使用分规测量韧带的长、宽、厚3个参数,然后再用精度为0.1mm的游标卡尺测量分规两针尖的距离。对于形态不规则的韧带,长度都以韧带两头附着的中点连线为标准,而宽度取韧带纵行的中点处为准,厚度取韧带纵行中点处为准。对观测数据进行描述性统计学分析。对于未能观测到起止点及解剖位置不恒定的韧带不做测量。结果中后足部的韧带按部位可分为背侧、骨间和跖侧3部分。背侧的大多数韧带呈四边形,扁而薄,各相邻跗骨均有韧带相连,其走形呈横行、纵行或斜行。第1-5跖骨基底部与相应的跗骨均有韧带相连。其中第2跖骨基底部与3块楔骨均有韧带相连。除第1、2跖骨基底部没有韧带相连外其余相邻跖骨基底部均有韧带相连。足背侧的主要韧带有：①距舟韧带,②颈韧带,③背外侧跟骰韧带,④骰舟背侧韧带,⑤楔舟背侧韧带,⑥外侧跟舟韧带,⑦内侧跟骰韧带,⑧跗跖背侧韧带,⑨跖骨背侧韧带。骨间韧带数量众多,多数呈柱状,长短粗细不一,呈横行,斜行、纵行连接骨骼。并不是所有相邻的跗骨间均有骨间韧带,跟骨和骰骨,距骨和舟骨、舟骨和楔骨间无骨间韧带,第2跖骨与内侧楔骨间有lisfranc韧带,第3、4跖骨基底部与外侧楔骨有骨间韧带相连,除第1、2跖骨间无骨间韧带外,相邻的跖骨基底部有骨间韧带相连。跖侧的韧带形态差异较大。总体上以舟骨结节和跟骨底面为起点向远侧呈放射状分布,止于舟骨、骰骨、楔骨和跖骨近端基底部,其中弹簧韧带、足底长短韧带和楔舟韧带在足底围成一“三角形”结构,不同个体间同一韧带的形态有时有一定差异。足底侧的主要韧带有：①跟骰足底韧带,②下跟舟韧带,③内下斜行跟舟韧带,④上内跟舟韧带,⑤楔舟足底韧带内侧束,⑥楔舟足底韧带中间束,⑦楔舟足底韧带外侧束,⑧骰舟足底韧带,⑨跖侧lisfranc韧带。第二部分足部韧带的MRI分析研究材料和方法选取10例志愿者,其中男7人,女3人,年龄21-54岁,平均36.7岁。检查志愿者双足无畸形,无足部外伤及手术史,排除类风湿、痛风、糖尿病等可能影响结果的疾病。选用通用1.5T超导型磁共振扫描仪。对志愿者双足进行横断面、矢状面和冠状面的MRI扫描。足部呈自然体位,表面线圈中心对准足长轴的中点。矢状面和横断面扫描时其切面方向与足的长轴平行,冠状面与之垂直。扫描序列选择SE/TIWI和SE/T2WI序列。对20例(左足10例,右足10例)MR图像中各部位韧带结构的可视化进行评估,并采用5级评分法对图像显示效果进行分析,以比较两种MRI扫描序列对足部韧带显示情况的优劣程度。评分结果采用Mann-Whitney U Test进行秩和检验,P>0.05有统计学意义。结果T1WI及T2WI序列可以良好的显示足部韧带组织,呈低信号,同一韧带在不同的层面上表现不同,根据扫描平面的不同表现为点状、片状、条状低信号。对于部分薄而短小的足背韧带和骨间韧带,MRI显示困难。足背侧的韧带在矢状面和冠状面显示效果较佳,横断面显示困难,但由于跗跖关节的背侧韧带和跖骨背侧韧带较薄,无论哪个层面均显示困难。骨间韧带中,对于距跟骨间韧带和lisfranc韧带,三个层面均可以看到,距跟骨间韧带以矢状面和冠状面显示较佳,lisfranc韧带以横断面显示较佳。对于其他的骨间韧带以冠状面和横断面显示较好,但由于这些韧带数量众多且短小,MR图像上难以看清每条韧带。跖侧的韧带由于其总体走行的特点,以矢状面显示最佳,其次是冠状面和横断面,由于MRI显示的是足部某一层面的解剖图像,因此,并不能观察到不同个体间韧带形态的差异性,最佳MR扫描方位研究结果与大体解剖标本的韧带走行基本一致。足背侧韧带在T1WI序列的显示情况经5级评分法评分,矢状面的评分分别为0分0例,1分0例,2分1例,3分9例,4分0例；冠状面的评分分别为0分0例,1分2例,2分8例,3分0例,4分0例；横断面的评分分别为0分9例,1分1例,2分0例,3分0例,4分0例。在T2WI序列矢状面的评分分别为0分0例,1分0例,2分2例,3分8例,4分0例；冠状面的评分分别为0分0例,1分3例,2分7例,3分0例,4分0例；横断面的评分分别为0分9例,1分1例,2分0例,3分0例,4分0例。将评分结果采用Mann-Whitney U Test进行秩和检验后发现差异没有统计学意义(P>0.05),说明对于足背侧韧带,T1WI显示效果与T2WI没有差别。足底侧韧带在T1WI序列矢状面的评分分别为0分0例,1分0例,2分1例,3分9例,4分0例；冠状面的评分分别为0分0例,1分2例,2分8例,3分0例,4分0例；横断面的评分分别为0分0例,1分0例,2分7例,3分3例,4分0例。在T2WI序列矢状面的评分分别为0分0例,1分0例,2分2例,3分8例,4分0例；冠状面的评分分别为0分0例,1分2例,2分8例,3分0例,4分0例；横断面的评分分别为0分0例,1分0例,2分8例,3分2例,4分0例。将评分结果采用Mann-Whitney U Test进行秩和检验后发现差异没有统计学意义(P>0.05),说明对于足底侧韧带,T1WI显示效果与T2WI没有差别。骨间韧带在TlWI序列矢状面的评分分别为0分0例,1分8例,2分2例,3分0例,4分0例；冠状面的评分分别为0分0例,1分2例,2分8例,3分0例,4分0例；横断面的评分分别为0分0例,1分5例,2分5例,3分0例,4分0例。在T2WI序列矢状面的评分分别为0分0例,1分8例,2分2例,3分0例,4分0例；冠状面的评分分别为0分0例,1分3例,2分7例,3分0例,4分0例；横断面的评分分别为0分0例,1分6例,2分4例,3分0例,4分0例。将评分结果采用Mann-Whitney U Test进行秩和检验后发现差异没有统计学意义(P>0.05),说明对于骨间韧带T1WI显示效果与T2WI没有差别。虽然TlWI序列与T2WI序列在显示足部韧带的情况上经统计学分析没有差别,但单纯从图像的清晰度上看,TlWI序列优于T2WI序列。主要结论1、中后足部的韧带数量众多,分布广泛,是维持足部功能结构稳定的重要组织。背侧、骨间和跖侧的韧带各有其解剖特点,反映了其在维持足弓中的不同功能。2、MRI检查可以观测到足部大部分的韧带组织,但对足部细小的骨间韧带和足背较薄的韧带辨别困难。另外,由于MRI显示的是某一层面的解剖图像,因此,并不能观察到不同个体间韧带形态的差异性。3、选择合适的扫描方位及扫描序列对韧带是否能获得完整而清晰的观测十分重要,一般来说MRI断面方向最好与韧带的走行一致,这样才能较完整、全面地显示韧带的解剖特征,便于对韧带进行精确、完整的观察和评估。更多还原

【Abstract】 Doctors are unlikely to pay attention to the ligaments injury of the foot with no fracture in clinical, because doctors themselves have a lack of understanding about the anatomy and functions of the ligaments. If the injuries were not treated properly, the pain maybe appearance, severe cases maybe show continued pain or even deformity. Athletes and sports-loving people have a high risk of the disease. People who got fracture or dislocation of the foot always have ligaments injury. In order to make an accurate diagnosis and treatment, reduce mistreatment and wrong treatment, it is necessary to know the anatomy and functions of the ligaments of the foot. However, the description or introduction of the ligaments was little in anatomic books, even there was some errors in the pictures. Based on this, we did a study in cadavers for a detailed observation about the ligaments of the foot,and explored the functions of the ligaments, for the purpose of providing some anatomical information to the doctor.Part I Ligaments of the Foot:An Anatomic Observation in CadaversMaterials and MethodsThirteen embalmed human legs (six right and seven left) from eleven cadavers and two feet from one fresh cadaver donated for anatomical training were examined. The ages of the cadavers were unknown. No specimen had any apparent deformity on gross examination. The specimens were dissected by an orthopedic surgeon. Remove the skin, fat, muscle, blood vessels, nerves and other tissues to expose the dorsal and plantar ligaments, and then remove the plantar ligaments to expose the interosseous ligaments.The gross anatomy and the morphological characteristics of the ligaments were recorded.ResultsLigaments of the foot can be divided into three groups according to the position:the dorsal,interosseous and plantar ligaments.Dorsal ligamentsIn addition to the bifurcate ligament, the dorsal ligaments were flat and thin. Each of them connected the adjacent bones. The dorsal ligaments were transverse, longitudinal or oblique in the dorsal of the foot. There was no ligament between the base of the first and second metatarsal. Dorsal ligaments of the footinclude:①talonavicular ligament,②cervical ligament,③dorsolateral calcaneocuboid ligament,④dorsal cuboideonavicular ligament,⑤dorsal cuneonavicular ligament,⑥lateral calcaneonavicular ligament,⑦The medial calcaneocuboid ligament,⑧dorsal ligaments of the tarsometatarsal,⑨dorsal ligaments of the metatarsal.Plantar ligamentsThe plantar ligaments had different morphology. They were large and strong. The spring ligament, the long and short plantar ligament and the cuneonavicular ligament nearly covered the entire plantar of the foot, which formed a triangle structure in the plantar of the foot. Sometimes, the same ligament in different specimens has some differences in morphology. Plantar ligaments of the foot include:①plantar calcaneocuboid ligament,②superomedial calcaneonavicular ligament,③medioplantar oblique calcaneonavicular ligament,④inferoplantar longitudinal calcaneonavicular ligament,⑤medial bundle of Plantar cuneonavicular ligament,⑥intermediate bundle of Plantar cuneonavicular ligament,⑦lateral bundle of Plantar cuneonavicular ligament,⑧plantar cuboideonavicular ligament,⑨the plantar Lisfranc ligament.Interosseous ligamentsThe number of the interosseous ligaments was large, most of them were transverse and had the similar shape, but the length and thickness were different.There was no interosseous ligament between the calcaneus and the cuboid, the talus and the navicular, the navicular and the cuneiforms. Lisfranc ligament was an oblique ligament that arose from the lateral surface of the medial cuneiform bone, attached to the lower half of the medial aspect of the second metatarsal. In addition, we found several ligaments arose from the lateral surface of the lateral cuneiform bone attached to the lateral surface of the third metatarsal and to the medial surface of the fourth metatarsal. There was interosseous ligaments between the bases of the metatarsal bones except the first metatarsal bone.Part Ⅱ Ligaments of the Foot:An Observation and analysis in MR imageMaterials and MethodsWe selected10cases of volunteers,7were male,3were female, age from21to54years old, the feet of the volunteers had no deformity, without trauma and operation history, eliminate the disease like rheumatoid arthritis, gout, diabetes, which may affect the outcome. Choose GM1.5T superconducting magnetic resonance scanner. Axial, sagittal and coronal planes MRI scans of volunteers was be made. Sagittal and axial plane was parallel to the long axis of the foot when scanning, while coronal plane was vertical to the long axis of the foot when scanning. Select T1WI and T2WI scanning sequence. The visualization of the ligaments in MR image of20feet were assessed, and the effect of image display was analyzed with a5Scores, in order to compare the two kinds of MRI sequences on display the degree of the foot ligaments. Use Mann-Whitney U Test, there was statistical significance when P>0.05.ResultsT1WI sequence and T2WI sequence can display foot ligaments very well, with a low signal in MR image. The same ligament has different appearance in different plane. Some dorsal ligaments and interosseous ligaments were thin and short, they were difficult to be seen in MR image。Dorsal ligaments has a good display in the sagittal and coronal plane, they were hard to see in axial plane. Because of the dorsal tarsometatarsal ligaments and the dorsal metatarsal ligaments were thin, MRI was difficult to display. In the interosseous ligaments, the interosseous talocalcaneal ligament and Lisfranc ligament can be seen on the three plane, the interosseous talocalcaneal ligament can be better seen in sagittal and coronal plane, Lisfranc ligament was display better in axial plane. The rest of the interosseous ligaments can be showed on coronal and axial planes, but because these ligaments are numerous and short, it is difficult to identify each ligament in MR images. Plantar ligaments has a good display in the sagittal plane because of their anatomical features, followed by the coronal plane and the axial plane. MRI is a anatomical image of one aspect of the foot, so, it could not be observed the differences morphological of the ligament between different individuals. The best MR scanning range is consistent with the gross anatomy ligament walking.The score of dorsal ligaments in sagittal plane of the T1WI were0case with0score,0case with1score,1cases with2score,9cases with3score,0case with4score respectly. The score in coronal plane were0case with0score,2cases with1score,8cases with2score,0case with3score,0case with4score respectly. The score in axial plane were9cases with0score,1cases with1score,0case with2score,0case with3score,0case with4score respectly. The score of dorsal ligaments in sagittal plane of the T2WI were0case with0score,0case with1score, 2cases with2score,8cases with3score,0case with4score respectly. The score in coronal plane were0case with0score,3cases with1score,7cases with2score,0case with3score,0case with4score respectly. The score in axial plane were9cases with0score,1cases with1score,0case with2score,0case with3score,0case with4score respectly. After Mann-Whitney U Test,there was not statistically significant (P>0.05), it may be considered that T1WI and T2WI had no difference on display dorsal ligament of the foot.The score of plantar ligaments in sagittal plane of the T1WI were0case with0score,0case with1score,1cases with2score,9cases with3score,0case with4score respectly. The score in coronal plane were0case with0score,2cases with1score,8cases with2score,0case with3score,0case with4score respectly. The score in axial plane were0case with0score,0cases with1score,7cases with2score,3cases with3score,0case with4score respectly. The score of plantar ligaments in sagittal plane of the T2WI were0case with0score,0case with1score,2cases with2score,8cases with3score,0case with4score respectly. The score in coronal plane were0case with0score,2cases with1score,8cases with2score,0case with3score,0case with4score respectly. The score in axial plane were0case with0score,0cases with1score,8cases with2score,2cases with3score,0case with4score respectly. After Mann-Whitney U Test,there was not statistically significant (P>0.05), it may be considered that T1WI and T2WI had no difference on display plantar ligament of the foot.The score of interosseous ligaments in sagittal plane of the T1WI were0case with0score,8cases with1score,2cases with2score,0case with3score,0case with4score respectly. The score in coronal plane were0case with0score,2cases with1score,8cases with2score,0case with3score,0case with4score respectly. The score in axial plane were0case with0score,5cases with1score,5cases with2score,0case with3score,0case with4score respectly. The score of interosseous ligaments in sagittal plane of the T2WI were0case with0score,8cases with1score,2cases with2score,0case with3score,0case with4score respectly. The score in coronal plane were0case with0score,3cases with1score,7cases with2score,0case with3score,0case with4score respectly. The score in axial plane were0case with0score,6cases with1score,4cases with2score,0case with3score,0case with4score respectly. After Mann-Whitney U Test,there was not statistically significant (P>0.05), it may be considered that T1WI and T2WI had no difference on display interosseous ligaments of the foot. Although the T1WI and T2WI display the ligaments of the foot have no difference on statistically, but the clarity of T1WI was superior to T2WI.Conclusion1, The number of the ligaments of the foot is large and the distribution is broad. They are one of the most important stabilizers to the arch of the foot. Dorsal, interosseous and plantar ligaments have their own anatomical characteristics, which reflect their different functions in maintaining the arch of the foot.2, Most of the foot ligaments can be observed in MR image. But some dorsal ligaments and interosseous ligaments were thin and short, they were difficult to be seen in MR image. Because MRI is an anatomical image of a certain section, it could not be observed the differences of the ligaments in morphology between different individuals.3, It is very important to choose a suitable scanning range and sequence for the ligaments in order to obtain a complete and clear observation. In general, when MRI section consisted with the ligament walking,a completely, fully displayed the anatomic characteristics of ligament can be seen on MR image, which is better for getting an accurate, complete observation and evaluation of the ligament.更多还原