踝关节外侧副韧带的解剖及MRI观察及临床应用

目录1、论文：踝关节外侧副韧带的解剖和MRI观察及临床应用英汉缩略词对照表 (1)中文摘要 (2)英文摘要 (4)前言 (7)资料与方法 (8)结果 (12)讨论 (17)结论 (22)参考文献 (23)2、综述：踝关节外侧副韧带损伤的诊断研究进展 (27)3、致谢 (36)4、作者简介 (37)英文缩略词表缩略词英文全称中文全称MR Magnetic resonance 核磁共振MRI Magnetic resonance imaging 磁共振成像CT Computer tomography 计算机断层摄影ATFL Anterior talofibular ligament 距腓前韧带CFL Calcaneofibular ligament 跟腓韧带PTFL Poseterior talofibular ligament 距腓后韧带FFE Fast field echo 快速梯度回波FA Flip angle 翻转角度FOV Field of view 视野MPR Mutiplanar reconstruction 多平面重建PDW Proton density weighting 质子密度加权TE Time of echo 回波时间TR Time of repeat 重复时间T1WI T1-weighted-images T1加权像T2WI T1-weighted-images T2加权像HFUS High frequency ultrasound 高频超声踝关节外侧副韧带的解剖和MRI观察及临床应用中文摘要目的：通过解剖观察踝关节外侧副韧带及其在低场MR自然体位下扫描显示的形态特点并测量，为临床提高MRI对踝关节外侧副韧带损伤的诊断提供依据。

并回顾性分析采用保守治疗踝关节外侧副韧带损伤的临床随访资料，了解不同程度韧带损伤保守治疗的临床效疗，为治疗踝关节外侧副韧带损伤提供一定的临床参考。

方法：将10侧正常成人尸体足踝关节标本进行解剖，观察并测量外侧副韧带的解剖结构，并与自然位（约跖屈20°）置下用0.4T永磁型HITACHI APERTO MR扫描测量外侧副韧带的长度、宽度、厚度值进行配对样本均数t检验，P＜0.05时有统计学意义。

收集2010年6月至2013年10月因急性踝关节外侧副韧带损伤在遵义医学院第五附属（珠海）医院采取保守治疗的患者，共40例，其中男性27例，女性13例，年龄17岁至50岁，平均年龄33.5岁，左侧15例，右侧25例，随访时间6～15个月，平均随访10个月；受伤原因：正常行走跌倒扭伤22例，跑步等运动扭伤18例；合并骨挫伤者15例，合并腓骨长短肌肌腱牵拉伤者13例，伴关节积液者26例。

采用Liu 踝关节外侧副韧带损伤评价标准对临床疗效进行评价，结果以优、良、可和差显示，在统计分析时分别将优、良视为预后良好组（≥80分），可、差为预后不良组（≤79分）。

行行×列表资料χ2检验（bonferroni方法）进行组间临床疗效分析，以α´=0.0167为检验水准，P<0.0167表示差异有统计学意义，P＞0.0167表示差异无统计学意义。

结果：10例标本中距腓前韧带一般呈一扁状四边形纤维束，为踝关节囊在踝前局部增厚形成部分，起自腓骨外踝下1/3前缘，水平向前内侧延伸，止于距骨颈外紧靠距骨外踝关节面前方，近跗骨窦部。

本实验解剖观察有2例呈双束状分布，一束起于外踝前缘，向前内侧近似水平状行走，止于距骨颈；另一束起于外踝前缘略靠下方，向前内侧行走，止于距骨颈靠外踝关节面前下方。

跟腓韧带为关节囊外组织，起自腓骨外踝尖前方的压迹，呈一近圆形纤维索状向后内约呈30°斜行向下后行而止于跟骨外面中部的结节处，韧带跨越踝关节及跟距关节。

距腓后韧带居关节囊后外侧，位置较深，起自腓骨外踝内面的指状窝，呈三角状水平向后内侧走行，经距骨后面而止于距骨后突外侧结节，局部有纤维与足拇长屈肌腱腱鞘融合。

踝关节外侧各韧带在自然位下行常规MRI检查，观察并测量距腓前韧带、跟腓韧带及距腓后韧带的平均长度分别为（14.190±0.595）mm、（23.46±1.578）mm和（19.37±1.360）mm,平均宽度分别为（8.76±0.883）mm、（5.700±0.442）mm和（6.400±0.200)mm，平均厚度分别为（1.840±0.190)mm、（2.110±0.296)mm和（2.570±0.200)mm。

解剖测量距腓前韧带、跟腓韧带及距腓后韧带的平均长度分别为（14.128±0.610)mm、（23.452±1.506)mm和（19.220±1.164）mm,平均宽度分别为（8.782±0.916）mm、（5.704±0.453）mm和（6.400±0.174）mm，平均厚度分别为（1.882±0.224）mm、（2.106±0.313）mm和（2.588±0.206）mm。

MRI测量外侧副韧带的数据与解剖测量之间差异无统计学意义。

40例踝关节外侧副韧带不同程度损伤患者行保守治疗后，Ⅰ度损伤预后优16例、良1例、可1例、差0例；Ⅱ度损伤预后优9例、良1例、可1例、差1例；Ⅲ度损伤预后优1例、良2例、可4例、差3例。

Ⅰ度损伤与Ⅱ度损伤疗效差异无统计学意义；Ⅰ度损伤、Ⅱ度损伤分别与Ⅲ度损伤疗效进行统计学分析，差异均有统计学意义。

结论：自然位置下行常规MR检查是踝关节外侧副韧带损伤的较理想体位；低场强MR扫描和解剖所测值间差异均无统计学；低场MR能较好的观察外侧副韧带的形态结构；临床踝关节外侧副韧带Ⅰ度、Ⅱ度损伤后可暂予行保守治疗观察，Ⅲ损伤后建议患者尽可能行手术治疗。

关键词：踝关节外侧副韧带 MRI（磁共振成像）解剖学保守治疗诊断Anatomy and MRI observation of ankle’s lateral collateral ligamentand its clinical applicationAbstractObjective: To measure the anatomic morphology of the lateral collateral ankle ligament in cadavers, and compare it with the data measured by magnetic resonance imaging(MRI),in order to provide the basis for improving the clinical diagnosis of the ligament injury. Retrospective to analyze of the clinical data of the lateral ligament about ankle joint injury. The purpose of this stuy was to analysis the clinical efficacy in conservative treatment for providing some valuable clinical references.Methods: 10 lateral ankle joints of normal adult cadavers specimens were observed anatomically. The length, width and thickness of the ligaments were observed and measured both by the MRI of 0.4T HITACHI APERTO and anatomy in natural position(about in plantar flexion 20 °), and the data was used the paired t test to statistically analyzed. The study retrospectively analyzed the 40 cases of the lateral ligament about ankle joint injury that was treated by conservative treatment with U-shaped plaster in the period from June 2010 to October 2013 in the fifth Affiliated Hospital (Zhuhai) of Zunyi Medical College. This research that involved 27 males and 13 females, the age was from 17 to 50, with the average age 33.5. And 15 cases on the left side, right side 25 cases. Cause of injury : 22 cases of fall sprain in the normal walking, and 18 cases of sprain in running.In the 40 cases,of which 15 cases of bone contusion, 13 cases with the peroneal tendon injury, 26 cases with joint hydrops. The curative effect outcomes which was expressed by treatment ankle function were scored by the Liu standard, and the results were showed such as excellent,good,fair and poor. When we used the statistical analysis, the results were divided into two groups,one group included excellent and good(≥80 points), the other included fair and poor(≤79 points), were used as chi square test(bonferroni methods). There were the statistically significant which were showed byp<0.0167.Results: The collateral ligament of the ankle joint was constituted by the three ligaments and also called fibular collateral ligament, Its mainly composition has three independent structure:the front is talofibular ligaments, middle is talofibular ligament and poseterior talofibular ligament is located in the posterolateral of ankle joint. Two cases of the ATFL were different from that described in the literatures.Variable anterior talofibular ligament was of double strip distribution. One strip began from front edges of the external malleolus, went anterior medially, and ended at the neck of talus, another one was located below it. The CFL was outside organization who on the joint capsule,started from the front of the lateral malleolus tip and ended at outside of the calcaneus.The PTFL was starting at articular capsule of posterolateral and ended at the tal us’lateral tubercle. The MR can better display the ligaments of the anatomical morphology on natural position. The ATFL,CFL and PTFL were measured by MR, the average length respective were (14.190±0.595) mm, (23.46±1.578)mm and (19.37±1.360) mm,while the average width were (8.76±0.883) mm, (5.700±0.442)mm and(6.400±0.200)mm.The thickness were(1.840±0.190)mm,(2.110±0.2 96)mm and (2.570±0. 200)mm respectively.And the anatomic length were(14.128±0.610) mm,(23.452± 1.506)mm and (19.220±1.164)mm.The width were(8.782±0.916)mm,(5.704 ±0.453)mm and(6.400±0.174)mm,and the average thickness were(1.882±0.224)mm,(2.106 ±0.313)mm and (2.588±0.206) mm respectively.The data had no significant differences(P ＞0.05)between the results of MR and anatomic.In 40 patients’ curative effect outcomesⅠdegrees injury were 17 excellent and good，fair and poor were 1;Ⅱ degrees were 10 excell -ent and good，fair and poor were 2; and then the former were 3, but the latter were achieve -d to 7 in the Ⅲ degrees injury. There was not statistical difference between theⅠdegrees andⅡdegrees(P＞0.0167);The Ⅲ degrees had statistical difference between theⅠdegrees andⅡ degrees (P＜0.0167) .Conclusion: All of measurements showed that have no statistical discrepancy between MR and anatomical.The supine natural position was the better MR examinational posturefor the lateral ligament of ankle joint. The low field strengths MR can accurate observe the morphological structure of the lateral collateral ligament. With regard to the patients whose ligament were injuredⅠdegrees andⅡdegrees maybe restore to health by conservative treatment, but others people who was recommended to accept the surgery treatment inⅢdegrees injury.Key Words：ankle joint lateral collateral ligament MRI conservative treatment diagnosis anatomy前言踝关节是由内外侧副韧带、胫腓骨下端及距骨组成的人体小腿和足部重要的运动枢纽，是人体弹跳离地的启动器，同时在人足落地时起着缓冲作用。