正常成人足部韧带的解剖观测及MRI分析研究

发布时间：2018-06-02 15:45

本文选题：足部韧带 + 解剖　；参考：《南方医科大学》2013年博士论文

【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,P0.05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(P0.05),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(P0.05),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(P0.05),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。
[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.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R686

【参考文献】