(讲座)踝关节MRI解剖和典型病例分析(20160314)

踝关节MRI解剖和典型病例分析浙江省人民医院放射科龚向阳[e-mail]踝关节是人体负重最大的滑车关节，站立时全身重量均落在踝关节上，行走时的负荷约为体重的5倍。踝关节损伤是最常见的运动损伤，占所有运动损伤的20-40％。虽然多数踝关节扭伤能够自愈，但有40%的患者会发生后续的踝关节慢性骨关节病。MRI是诊断的最佳方法。熟悉MRI解剖和正确的检查方法是明确诊断的必要前提。前言BoneandJoint骨和关节踝关节，也称为距小腿关节，是胫骨的下关节面和踝关节面、腓骨的踝关节面与距骨上面及其内外踝关节面构成的滑车关节。关节结构在周围韧带的支撑下，在人体直立状态下，使关节保持稳固。距骨滑车前宽后窄，关节稳定性在踝关节屈伸状态下是不同的。背伸状态下，关节稳定性较强；跖屈状态下，关节稳定性下降。BoneandJoint骨和关节BoneandJoint骨和关节踝关节撞击综合症（前撞击）胫骨关节面前缘与距骨颈部的撞击；常见于足球运动员和舞蹈演员；主要病因：经常性过度背伸；其他原因：马蹄足、外侧副韧带撕裂导致关节松弛；临床表现：足背疼痛，背伸时加剧；影像特征：胫骨前缘或/和距骨骨质增生，形成骨赘。踝关节撞击综合症（前撞击）2094123女/28岁左踝活动后疼痛3月余踝关节撞击综合症（前撞击）2789987女/28岁左踝反复肿痛半年余BoneandJoint骨和关节跗骨间关节：包括距跟关节、距跟舟关节、跟骰关节、跗横关节、楔舟关节、楔骨间关节、舟骰关节和楔骰关节。距跟关节：又称距下关节，由距骨的跟骨后关节面/跟骨的后关节面构成。距下关节是保持足部稳定的枢轴，它承受并传导人体的体重，转换下肢的旋转应力，协同和辅助踝关节的运动。anteriorgroup前组群TibialisAnterior胫骨前肌ExtensorHallucisLongus踇长伸肌ExtensorDigitorumLongus趾长伸肌PeroneusTertius第三腓骨肌lateralgroup外侧群PeroneusLongus腓骨长肌PeroneusBrevis腓骨短肌posteriorgroup后群浅层Achilles’tendon跟腱Gastrocnemius腓肠肌Soleus比目鱼肌Plantalis跖肌medialgroup后群深层TibialisPosterior胫骨后肌FlexorDigitorumLongus趾长屈肌FlexorHallucisLongus踇长屈肌Tendon肌腱anteriorgroup前组群TibialisAnterior胫骨前肌ExtensorHallucisLongus踇长伸肌ExtensorDigitorumLongus趾长伸肌PeroneusTertius第三腓骨肌tendon肌腱2319219男/29岁右足外伤后疼痛胫骨前肌腱撕裂趾长伸肌腱腱鞘炎2522502女/39岁左踝肿痛2月余lateralgroup外侧群PeroneusLongus腓骨长肌（PL）PeroneusBrevis腓骨短肌（PB）tendon肌腱在踝关节水平PB&PL位于腓骨后沟内PB位于PL的内前方两者共用一个腱鞘在腓骨结节水平腱鞘分裂成2个，上方为PB，下方为PL。tendon肌腱PBPLPBPBPLPL2321237女/53岁关节痛腓骨短肌腱撕裂tendon肌腱medialgroup后群深层TibialisPosterior胫骨后肌FlexorDigitorumLongus趾长屈肌FlexorHallucisLongus足母长屈肌tendon肌腱posteriorgroup后群浅层Gastrocnemius腓肠肌Soleus比目鱼肌Plantalis跖肌1989137男/39岁跟腱部分性撕裂DDX：Haglund’ssyndrome；Xanthomas跟腱黄色瘤（Xanthomas）Retinaculum支持带superiorextensorretinaculum伸肌上支持带（小腿横韧带）inferiorextensorretinaculum伸肌下支持带superiorperonealretinaculum腓骨肌上支持带inferiorperonealretinaculum腓骨肌下支持带flexorretinaculum屈肌支持带（分裂韧带）Anklecanal踝管flexorretinaculum屈肌支持带（分裂韧带）tibialisposteriortendon胫骨后肌腱flexorhallucislongustendon趾长屈肌腱posteriortibialartery,venaeandtibialnerve胫后动、静脉及胫神经flexorhallucislongustendon踇长屈肌腱superiorextensorretinaculum伸肌上支持带（小腿横韧带）inferiorextensorretinaculum伸肌下支持带Retinaculum支持带Retinaculum支持带Retinaculum支持带superiorperonealretinaculum腓骨肌上支持带inferiorperonealretinaculum腓骨肌下支持带Retinaculum支持带SPR撕裂，周围软组织肿胀，腓骨肌腱向前外侧脱位。PLPBSPRflexorretinaculum屈肌支持带（分裂韧带）Retinaculum支持带腱鞘囊肿致跗管综合症tibiofibular胫腓tibiofibularcombinedlig.胫腓韧带联合transversetibiofibularlig.胫腓横韧带anteriortibiofibularlig.前胫腓韧带posteriortibiofibularlig.后胫腓韧带lateral外侧anteriortalofibularlig.前距腓韧带posteriortalofibularlig.后距腓韧带calcaneofibularlig.跟腓韧带medial内侧DeltoidLig.（三角韧带）anteriortibiotalarlig.前胫距韧带posteriortibiotalarlig.后胫距韧带tibiocalcaneouslig.胫跟韧带tibionavicularlig.胫舟韧带others其他longplantarligment足底长韧带plantarcalcaneocuboidlig.跟舟足底韧带（跳跃韧带）ligament韧带tibiofibular胫腓tibiofibularcombinedlig.胫腓韧带联合transversetibiofibularlig.胫腓横韧带anteriortibiofibularlig.前胫腓韧带posteriortibiofibularlig.后胫腓韧带tibiofibular胫腓tibiofibularcombinedlig.胫腓韧带联合transversetibiofibularlig.胫腓横韧带anteriortibiofibularlig.前胫腓韧带posteriortibiofibularlig.后胫腓韧带lateral外侧anteriortalofibularlig.前距腓韧带posteriortalofibularlig.后距腓韧带calcaneofibularlig.跟腓韧带lateral外侧anteriortalofibularlig.前距腓韧带posteriortalofibularlig.后距腓韧带calcaneofibularlig.跟腓韧带lateral外侧anteriortalofibularlig.前距腓韧带posteriortalofibularlig.后距腓韧带calcaneofibularlig.跟腓韧带左踝前距腓韧带撕裂2426151男/13岁踝关节外伤1天踝外侧副韧带较内侧薄弱，而足部内翻肌群较外翻肌群力量强，造成踝内翻损伤多见，外侧副韧带损伤好发。右侧前距腓韧带、跟腓韧带撕裂2745340女/22岁右踝扭伤2小时左跟腓韧带陈旧撕裂2357061女/41岁左踝扭伤后肿痛不适4月余anteriortibiotalarlig.前胫距韧带posteriortibiotalarlig.后胫距韧带tibiocalcaneouslig.胫跟韧带tibionavicularlig.胫舟韧带medial内侧DeltoidLig.（三角韧带）ligament韧带medial内侧DeltoidLig.（三角韧带）anteriortibiotalarlig.胫距前韧带（1）posteriortibiotalarlig.胫距后韧带（2）tibiocalcaneouslig.胫跟韧带（3）tibionavicularlig.胫舟韧带（4）1234223213medial内侧DeltoidLig.（三角韧带）anteriortibiotalarlig.胫距前韧带（1）posteriortibiotalarlig.胫距后韧带（2）tibiocalcaneouslig.胫跟韧带（3）tibionavicularlig.胫舟韧带（4）左后胫距韧带撕裂149573男/13岁左踝扭伤后肿痛1月余others其他longplantarligment足底长韧带（1）plantarcalcaneocuboidlig.跟舟足底韧带（跳跃韧带）（2）112others其他longplantarligment足底长韧带（1）plantarcalcaneocuboidlig.跟舟足底韧带（跳跃韧带）（2）222fat脂肪nerve神经vessels血管Talocalcanealinterosseouslig.距跟骨间韧带cervicallig.颈韧带inferiorextensorretinaculum(up)伸肌下支持带内侧束inferiorextensorretinaculum(medial)伸肌下支持带中间束inferiorextensorretinaculum(low)伸肌下支持带外侧束Tarsalsinus跗骨窦Tarsalsinus跗骨窦cervicallig.颈韧带（1）Talocalcanealinterosseouslig.跟距骨间韧带（2）Themedial(3),intermediate(4),andlateral(5)rootsoftheinferiorextensorretinaculum.212842607/F/61岁右踝肿痛不适数年，逐渐加重，疼痛评分1分右跟距骨间韧带撕裂THANKYOUFORYOURATTENTION