本文選題：足部韌帶 + 解剖��； 參考：《南方醫(yī)科大學(xué)》2013年博士論文

【摘要】：臨床上單純足部韌帶損傷不易引起醫(yī)生的重視,原因是醫(yī)生本身對足部韌帶的解剖和功能作用缺乏了解,若治療不當(dāng)可出現(xiàn)足部功能障礙,主要表現(xiàn)為疼痛,行走不適,嚴(yán)重者久治不愈,甚至可出現(xiàn)畸形。運動員和愛好運動的人是這一疾病好發(fā)人群。另外,外傷導(dǎo)致足部骨折脫位的患者都伴有不同程度地韌帶損傷。因此有必要認(rèn)識和了解足部韌帶的解剖及功能,減少失治、誤治,提高臨床診斷和治療水平,但目前的一些解剖書籍對足部韌帶的解剖描述不夠詳細(xì),某些圖片甚至還有錯誤�；诖�,我們對足部,主要是中后足部各韌帶的分布、走行及形態(tài)特征等進行了比較詳細(xì)解剖學(xué)觀測,并對其功能作用進行了探討,并通過MRI這一常見的檢查手段來分析其觀測足部各韌帶的情況,以期為臨床診斷和治療足部韌帶損傷提供幫助。 第一部分足部韌帶的解剖學(xué)觀測 材料和方法 選取防腐成人足部尸體標(biāo)本13例(左足7例,右足6例),標(biāo)本性別不限。在行常規(guī)解剖研究前,進行大致檢查,以排除明顯的畸形,骨折創(chuàng)傷、腫瘤和破損等。采用層次解剖法,逐層解剖,剔除皮膚、肌肉、脂肪、神經(jīng)及血管等組織后顯露足部各韌帶進行觀測。先觀測足部背側(cè)的韌帶,記錄其起止、分布走形規(guī)律,形態(tài)特征。再觀測足底韌帶,最后觀測骨間韌帶。使用分規(guī)測量韌帶的長、寬、厚3個參數(shù),然后再用精度為0.1mm的游標(biāo)卡尺測量分規(guī)兩針尖的距離。對于形態(tài)不規(guī)則的韌帶,長度都以韌帶兩頭附著的中點連線為標(biāo)準(zhǔn),而寬度取韌帶縱行的中點處為準(zhǔn),厚度取韌帶縱行中點處為準(zhǔn)。對觀測數(shù)據(jù)進行描述性統(tǒng)計學(xué)分析。對于未能觀測到起止點及解剖位置不恒定的韌帶不做測量。 結(jié)果 中后足部的韌帶按部位可分為背側(cè)、骨間和跖側(cè)3部分。 背側(cè)的大多數(shù)韌帶呈四邊形,扁而薄,各相鄰跗骨均有韌帶相連,其走形呈橫行、縱行或斜行。第1-5跖骨基底部與相應(yīng)的跗骨均有韌帶相連。其中第2跖骨基底部與3塊楔骨均有韌帶相連。除第1、2跖骨基底部沒有韌帶相連外其余相鄰跖骨基底部均有韌帶相連。足背側(cè)的主要韌帶有：①距舟韌帶,②頸韌帶,③背外側(cè)跟骰韌帶,④骰舟背側(cè)韌帶,⑤楔舟背側(cè)韌帶,⑥外側(cè)跟舟韌帶,⑦內(nèi)側(cè)跟骰韌帶,⑧跗跖背側(cè)韌帶,⑨跖骨背側(cè)韌帶。 骨間韌帶數(shù)量眾多,多數(shù)呈柱狀,長短粗細(xì)不一,呈橫行,斜行、縱行連接骨骼。并不是所有相鄰的跗骨間均有骨間韌帶,跟骨和骰骨,距骨和舟骨、舟骨和楔骨間無骨間韌帶,第2跖骨與內(nèi)側(cè)楔骨間有l(wèi)isfranc韌帶,第3、4跖骨基底部與外側(cè)楔骨有骨間韌帶相連,除第1、2跖骨間無骨間韌帶外,相鄰的跖骨基底部有骨間韌帶相連。 跖側(cè)的韌帶形態(tài)差異較大�？傮w上以舟骨結(jié)節(jié)和跟骨底面為起點向遠(yuǎn)側(cè)呈放射狀分布,止于舟骨、骰骨、楔骨和跖骨近端基底部,其中彈簧韌帶、足底長短韌帶和楔舟韌帶在足底圍成一“三角形”結(jié)構(gòu),不同個體間同一韌帶的形態(tài)有時有一定差異。足底側(cè)的主要韌帶有：①跟骰足底韌帶,②下跟舟韌帶,③內(nèi)下斜行跟舟韌帶,④上內(nèi)跟舟韌帶,⑤楔舟足底韌帶內(nèi)側(cè)束,⑥楔舟足底韌帶中間束,⑦楔舟足底韌帶外側(cè)束,⑧骰舟足底韌帶,⑨跖側(cè)lisfranc韌帶。 第二部分足部韌帶的MRI分析研究 材料和方法 選取10例志愿者,其中男7人,女3人,年齡21-54歲,平均36.7歲。檢查志愿者雙足無畸形,無足部外傷及手術(shù)史,排除類風(fēng)濕、痛風(fēng)、糖尿病等可能影響結(jié)果的疾病。選用通用1.5T超導(dǎo)型磁共振掃描儀。對志愿者雙足進行橫斷面、矢狀面和冠狀面的MRI掃描。足部呈自然體位,表面線圈中心對準(zhǔn)足長軸的中點。矢狀面和橫斷面掃描時其切面方向與足的長軸平行,冠狀面與之垂直。掃描序列選擇SE/TIWI和SE/T2WI序列。對20例(左足10例,右足10例)MR圖像中各部位韌帶結(jié)構(gòu)的可視化進行評估,并采用5級評分法對圖像顯示效果進行分析,以比較兩種MRI掃描序列對足部韌帶顯示情況的優(yōu)劣程度。評分結(jié)果采用Mann-Whitney U Test進行秩和檢驗,P0.05有統(tǒng)計學(xué)意義。 結(jié)果 T1WI及T2WI序列可以良好的顯示足部韌帶組織,呈低信號,同一韌帶在不同的層面上表現(xiàn)不同,根據(jù)掃描平面的不同表現(xiàn)為點狀、片狀、條狀低信號。對于部分薄而短小的足背韌帶和骨間韌帶,MRI顯示困難。 足背側(cè)的韌帶在矢狀面和冠狀面顯示效果較佳,橫斷面顯示困難,但由于跗跖關(guān)節(jié)的背側(cè)韌帶和跖骨背側(cè)韌帶較薄,無論哪個層面均顯示困難。骨間韌帶中,對于距跟骨間韌帶和lisfranc韌帶,三個層面均可以看到,距跟骨間韌帶以矢狀面和冠狀面顯示較佳,lisfranc韌帶以橫斷面顯示較佳。對于其他的骨間韌帶以冠狀面和橫斷面顯示較好,但由于這些韌帶數(shù)量眾多且短小,MR圖像上難以看清每條韌帶。跖側(cè)的韌帶由于其總體走行的特點,以矢狀面顯示最佳,其次是冠狀面和橫斷面,由于MRI顯示的是足部某一層面的解剖圖像,因此,并不能觀察到不同個體間韌帶形態(tài)的差異性,最佳MR掃描方位研究結(jié)果與大體解剖標(biāo)本的韌帶走行基本一致。 足背側(cè)韌帶在T1WI序列的顯示情況經(jīng)5級評分法評分,矢狀面的評分分別為0分0例,1分0例,2分1例,3分9例,4分0例；冠狀面的評分分別為0分0例,1分2例,2分8例,3分0例,4分0例；橫斷面的評分分別為0分9例,1分1例,2分0例,3分0例,4分0例。在T2WI序列矢狀面的評分分別為0分0例,1分0例,2分2例,3分8例,4分0例；冠狀面的評分分別為0分0例,1分3例,2分7例,3分0例,4分0例；橫斷面的評分分別為0分9例,1分1例,2分0例,3分0例,4分0例。將評分結(jié)果采用Mann-Whitney U Test進行秩和檢驗后發(fā)現(xiàn)差異沒有統(tǒng)計學(xué)意義(P0.05),說明對于足背側(cè)韌帶,T1WI顯示效果與T2WI沒有差別。 足底側(cè)韌帶在T1WI序列矢狀面的評分分別為0分0例,1分0例,2分1例,3分9例,4分0例；冠狀面的評分分別為0分0例,1分2例,2分8例,3分0例,4分0例；橫斷面的評分分別為0分0例,1分0例,2分7例,3分3例,4分0例。在T2WI序列矢狀面的評分分別為0分0例,1分0例,2分2例,3分8例,4分0例；冠狀面的評分分別為0分0例,1分2例,2分8例,3分0例,4分0例；橫斷面的評分分別為0分0例,1分0例,2分8例,3分2例,4分0例。將評分結(jié)果采用Mann-Whitney U Test進行秩和檢驗后發(fā)現(xiàn)差異沒有統(tǒng)計學(xué)意義(P0.05),說明對于足底側(cè)韌帶,T1WI顯示效果與T2WI沒有差別。 骨間韌帶在TlWI序列矢狀面的評分分別為0分0例,1分8例,2分2例,3分0例,4分0例；冠狀面的評分分別為0分0例,1分2例,2分8例,3分0例,4分0例；橫斷面的評分分別為0分0例,1分5例,2分5例,3分0例,4分0例。在T2WI序列矢狀面的評分分別為0分0例,1分8例,2分2例,3分0例,4分0例；冠狀面的評分分別為0分0例,1分3例,2分7例,3分0例,4分0例；橫斷面的評分分別為0分0例,1分6例,2分4例,3分0例,4分0例。將評分結(jié)果采用Mann-Whitney U Test進行秩和檢驗后發(fā)現(xiàn)差異沒有統(tǒng)計學(xué)意義(P0.05),說明對于骨間韌帶T1WI顯示效果與T2WI沒有差別。雖然TlWI序列與T2WI序列在顯示足部韌帶的情況上經(jīng)統(tǒng)計學(xué)分析沒有差別,但單純從圖像的清晰度上看,TlWI序列優(yōu)于T2WI序列。 主要結(jié)論 1、中后足部的韌帶數(shù)量眾多,分布廣泛,是維持足部功能結(jié)構(gòu)穩(wěn)定的重要組織。背側(cè)、骨間和跖側(cè)的韌帶各有其解剖特點,反映了其在維持足弓中的不同功能。 2、MRI檢查可以觀測到足部大部分的韌帶組織,但對足部細(xì)小的骨間韌帶和足背較薄的韌帶辨別困難。另外,由于MRI顯示的是某一層面的解剖圖像,因此,并不能觀察到不同個體間韌帶形態(tài)的差異性。 3、選擇合適的掃描方位及掃描序列對韌帶是否能獲得完整而清晰的觀測十分重要,一般來說MRI斷面方向最好與韌帶的走行一致,這樣才能較完整、全面地顯示韌帶的解剖特征,便于對韌帶進行精確、完整的觀察和評估。
[Abstract]:The clinical simple foot ligament injury is not easy to cause the doctor's attention, the reason is that the doctor himself lacks the understanding of the anatomy and function of the foot ligament. If the treatment is unsuitable, the foot dysfunction can occur. The main manifestations are pain, walking discomfort, serious patients and even deformity. The athletes and the people who love sports are this disease. It is necessary to recognize and understand the anatomy and function of the foot ligaments, to reduce the loss of treatment, to reduce the treatment and to improve the level of clinical diagnosis and treatment. However, some anatomy books are not detailed in the anatomy of the foot ligaments. There are even errors. Based on this, we have made a comparative detailed anatomical observation on the distribution, walking and morphological characteristics of the feet, mainly the ligaments of the middle and posterior feet, and discussed the function of the feet, and analyzed the observation of the foot ligaments in the foot by the common means of MRI, in order to diagnose and treat the foot in clinical. The injury of the ligament is helpful.
The first part of the anatomical observation of the foot ligament
Materials and methods
13 specimens of adult cadaver specimens (7 left feet, 6 right feet) were selected and the specimen sex was not limited. Before the routine anatomical study, a general examination was carried out to exclude obvious deformities, fractures, tumors and breakages. The layers of skin, muscles, fat, nerve and blood vessels were dissected and the ligaments were exposed after the skin, muscle, fat, nerve and blood vessels. Observe the ligaments on the back of the foot first, record the beginning and stop, the distribution of the shape, the morphological characteristics. Observe the plantar ligaments and finally observe the interosseous ligaments. Use the rules to measure the length, width and thickness of the ligament with 3 parameters, and then measure the distance of the two needles with a vernier caliper with a precision of 0.1mm. The median point attached to both sides of the ligament was the standard, and the median point of the width was taken as the middle point, and the thickness was taken as the midpoint of the ligament. The statistical analysis of the observed data was carried out.
Result
The ligaments of the hind foot can be divided into 3 parts: dorsal, interosseous and metatarsal.
Most ligaments on the dorsal side are quadrangular, flat and thin, and the adjacent tarsus are connected by ligaments. The shape of the 1-5 metatarsal is connected with the corresponding tarsus. The basal part of the second metatarsal is connected with the 3 cuneies. The basal part of the metatarsal of the 1,2 metatarsal has no ligaments and the other adjacent metatarsally. The main ligaments at the bottom are ligaments. The main ligaments of the dorsum of the foot are: (1) the ligaments of the canoe, the ligaments of the neck, the lateral heel of the dice ligaments, the dorsal ligaments of the dice boat, the dorsal ligaments of the canoe, the lateral heel ligaments, the medial heel of the dice ligaments, the dorsal ligaments of the tarsus and the dorsal ligaments, and the toughened tapes of the metatarsus.
There is a large number of interosseous ligaments, most of them are columnar, and the length and length are different. The interosseous, oblique line, connective bone. Not all adjacent tarsal bones have interosseous ligaments, calcaneus and cuboid bones, talus and scaphoid, scaphoid and cuneiform bone without interosseous ligaments, the second metatarsal and medial cuneium have Lisfranc ligaments, the basal part of the 3,4 metatarsal and the lateral cuneium. The interosseous ligaments are connected by interosseous ligaments at the base of the metatarsus except for the interosseous ligament between the 1,2 metatarsophalangeal bones.
The morphological differences of the ligaments on the plantar side are large. On the whole, the scaphoid nodule and the calcaneus base are radially distributed from the beginning to the far side. It stops at the scaphoid, the dice, the cuneiform and the proximal metatarsal base, in which the spring ligaments, the long and short ligaments of the plantar and the canoe ligaments are formed in a "triangle" structure, and the form of the same ligaments between the different individuals sometimes has a shape. The main ligaments of the foot side were: (1) the ligaments of the foot of the foot: (1) the ligaments of the dice foot, the inferior heel ligament, the inferior oblique line of the canoe ligament, the upper inner heel ligaments, the medial fasciculus of the wedged plantar ligaments, the central bundle of the wedged plantar ligaments, the distal ligaments of the crapooe canoe, the Lisfranc ligaments of the plantar side of the canoe.
MRI analysis of the second part of the foot ligament
Materials and methods
10 volunteers were selected, including 7 men, 3 women, 21-54 years old and 36.7 years old. The volunteers had no deformity, no foot trauma and operation history, and the rheumatoid, gout, diabetes and other diseases that could affect the results were excluded. The general 1.5T superconducting magnetic resonance scanner was selected. The cross section, sagittal and coronal surface of the volunteers were MRI Scanning. The foot is in a natural position with the center of the surface coil aligned with the midpoint of the foot long axis. The direction of the sagittal plane and the transverse section is parallel to the long axis of the foot, and the coronal plane is vertical. The scanning sequence selects the SE/TIWI and SE/T2WI sequences. The visualization of the ligament structures of the various parts of the MR images of 20 cases (10 left feet in the left foot, 10 right feet) is evaluated. The 5 grade scoring method was used to analyze the effect of the image display to compare the good and bad degree of the two MRI scan sequences on the display of the foot ligaments. The results were tested by Mann-Whitney U Test, and P0.05 had statistical significance.
Result
The T1WI and T2WI sequences can show the ligament tissue of the foot well, show low signal and the same ligament at different levels. According to the different manifestations of the scanning plane, it is punctiform, flaky, and low signal. For some thin and short dorsal ligaments and interosseous ligaments, MRI shows difficulties.
The ligament of the dorsum of the foot showed a better effect on the sagittal and coronal surface, but it was difficult in the cross section. But the dorsal ligament of the tarsus and the dorsal metatarsal ligament were thinner and difficult. In the interosseous ligaments, the interosseous ligaments and the Lisfranc ligaments were seen at three levels, and the interosseous ligaments were sagittal. The Lisfranc ligaments were better displayed in the cross section. For the other interosseous ligaments, the ligaments were shown on the coronal and cross sections. But because of the large number and short size of these ligaments, each ligament was difficult to see on the MR image. The plantar ligaments showed the best in the sagittal plane, followed by the coronal surface and the coronal surface. Cross section, because MRI shows an anatomical image at a certain level of the foot, it is not possible to observe the difference in the morphology of the ligaments between different individuals. The best MR scanning orientation is basically the same as the ligaments of the general anatomical specimens.
The display of the dorsum of the foot in the T1WI sequence was scored by the 5 grade scoring method. The sagittal plane score was 0 points, 0 cases, 0 cases, 2 points, 9 cases, 4 0 cases, 4 scores of 4 points and 4 scores respectively. The scores of sagittal plane were 0, 0, 1, 0, 2, 2, 3, 8, 4, 0, and 0, 4, 0, 1, 0, 1. Statistical significance (P0.05) showed that T1WI showed no difference with T2WI in dorsal ligaments of foot.
The score of the lateral ligaments of the plantar side in the sagittal plane of the T1WI sequence were 0, 0, 2, 1, 3, 9, 4, 0. The coronary surface scores were 0, 0, 1, respectively. There were 0 cases, 2 points, 2 cases, 3 points and 8 cases, 4 points 0 cases, and the coronal surface scores were 0, 1, 2, 2, 2, and divided respectively. The score results were used Mann-Whitney U Test for the rank sum test and found no statistical significance (P0.05), indicating that the difference was not statistically significant (P0.05), indicating that the difference was not statistically significant T1WI showed no difference from T2WI in plantar collateral ligament.
The score of the interosseous ligaments in the sagittal plane of TlWI sequence were 0, 0, 8, 2, 2, 3, 0, 4, 0, and 0, 4, 0, 1 in 0, respectively. There were 2 points, 2 cases, 3 points and 0 cases, 4 points and 0 cases, and the coronary surface scores were 0, 0, 3, 2, 7, 3, respectively. T1WI showed no difference from T2WI. Although there was no difference between the TlWI sequence and the T2WI sequence in displaying the foot ligaments, the TlWI sequence was superior to the T2WI sequence simply from the definition of the image.
Main conclusions
1, the ligaments of the medial and posterior feet are numerous and widely distributed. It is an important organization to maintain the stability of the functional structure of the foot. The dorsal, interosseous and metatarsal ligaments each have their anatomical characteristics, reflecting their different functions in the maintenance of the arch.
2, MRI examination can detect most of the ligaments in the foot, but it is difficult to identify the thin interosseous ligaments of the foot and the thinner ligaments of the foot. In addition, because MRI shows an anatomical image at a certain level, there is no difference in the form of the ligaments among the different individuals.
3, it is very important to choose the suitable scanning orientation and scanning sequence for the complete and clear observation of the ligament. Generally, the direction of the MRI section is the best in accordance with the ligaments, so that the anatomical features of the ligaments can be fully displayed, and the accurate and complete observation and evaluation of the ligaments can be made.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R686

【參考文獻(xiàn)】

相關(guān)期刊論文 前9條

1 沙勇,張紹祥,劉正津,譚立文;踝關(guān)節(jié)外側(cè)副韌帶和距下關(guān)節(jié)韌帶的斷層解剖學(xué)研究[J];第三軍醫(yī)大學(xué)學(xué)報;2001年01期

2 譚琦tD;王青云;朱剛明;陳科;李楊彬;;正常足部軟組織的MRI解剖研究[J];局解手術(shù)學(xué)雜志;2008年02期

3 任彥玲;侯建明;葉添生;;正常踝距腓前韌帶和跟腓韌帶的解剖學(xué)觀察及其MRI掃描方法學(xué)的研究[J];臨床放射學(xué)雜志;2008年09期

4 張凱,俞光榮,施向挺,倪之挺,陳實;距跟骨間韌帶的應(yīng)用解剖[J];同濟大學(xué)學(xué)報(醫(yī)學(xué)版);2005年02期

5 毛賓堯,劉明廷,李保文,楊星光,高文彬;距下關(guān)節(jié)的解剖學(xué)測量和運動學(xué)分析[J];中華骨科雜志;1996年01期

6 沙勇,張紹祥,劉正津,譚立文;踝、距下關(guān)節(jié)外側(cè)韌帶斷層與MRI圖像的對照研究及臨床意義[J];中國臨床解剖學(xué)雜志;2000年04期

7 丁晶,徐達(dá)傳;踝關(guān)節(jié)外側(cè)韌帶和距下關(guān)節(jié)韌帶修復(fù)重建的應(yīng)用解剖[J];中國臨床解剖學(xué)雜志;2002年05期

8 張凱;距下關(guān)節(jié)韌帶的解剖學(xué)和生物力學(xué)特性研究進展[J];中國臨床解剖學(xué)雜志;2004年01期

9 朱躍良;徐永清;丁晶;楊軍;何曉清;陳海東;唐輝;;足韌帶的解剖學(xué)研究及其臨床意義[J];中國臨床解剖學(xué)雜志;2008年06期

，

本文編號：1969318