人体掌指关节活动中侧副韧带的作用（关节运动学研究）

采用４０只人体手指标本作掌指关节运动学研究。测量掌指关节伸屈时，其桡侧副韧带的长度变化、伸长率；韧带断裂时关节屈曲角度。结果表明：侧副韧带对关节屈曲幅度起决定作用，屈曲关节时侧副韧带较中立位时伸长２６．６％～３７．５％不等，伸长率从示指至小指渐减．被动活动使韧带断裂的屈曲度数由示指至小指递增。研究结果揭示恢复掌指关节屈曲幅度和关节稳定性的关键在于侧副韧带合适的紧张性。     

人体掌指关节活动中侧副韧带的作用（关于运动学研究）

采用４０只人体手指标本作掌指关节运动学研究，测量掌指关节伸屈时，其桡侧副韧带的长度变化、伸长率；韧带断裂时关节屈曲角度。结果表明：侧副韧带对关节屈曲幅度起决定作用，屈曲关节时侧副韧带较中立位时伸长２６．６％－３７．５％不等，伸长率从示指至小指渐减。被动活动使韧带断裂的屈曲率数由示指至小指递增，研究结果提示恢复掌指关节屈曲幅度和关节稳定性的关键在于侧副韧带合适的紧张性。     

腕投掷运动时腕关节韧带长度变化的活体研究

目的 探讨腕关节在投掷运动过程中腕关节韧带长度的变化.方法 对6例志愿者腕关节进行CT扫描,获取腕关节在投掷运动过程中的5个位置,即桡偏20°背伸60°,桡偏10°背伸30°,中立位,尺偏20°掌屈30°,尺偏40°掌屈60°时各腕骨、尺桡骨远段的三维重建图像,在重建图像基础上利用Mimics软件测得在腕关节投掷运动过程中掌、背侧腕关节韧带的长度.结果 腕关节由中立位至桡偏20°背伸60°时桡舟头韧带、长桡月韧带、尺头韧带、尺三角韧带长度显著伸长,分别延长(3.4±0.5)、(2.0±0.2)、(2.6±0.5)、(2.1±0.4)mm,差异均有统计学意义(P<0.05);腕关节由中立位至尺偏400掌屈60°时背侧桡腕韧带、背侧骨间韧带止于小多角骨部分长度显著伸长,分别延长(1.7 ±0.2)、(3.8 ±0.4)mm,差异有统计学意义(P<0.05).尺月韧带、背侧骨问韧带止于舟骨部分在投掷运动过程中其长度均较中立位时旱增长趋势.结论 腕关节在桡背伸至尺掌屈运动过程中,桡舟头韧带、长桡月韧带、尺头韧带、尺三角韧带缩短,提示张力减低,背侧桡腕韧带、背侧骨间韧带止于小多角骨部分伸长,张力增大,尺月韧带、背侧骨间韧带止于舟骨部分于中立位时张力最小,其变化规律有助于指导临床腕关节韧带损伤的修复.     

腕尺桡偏运动时腕韧带长度变化的活体研究

目的 研究腕关节在尺桡偏运动过程中,腕关节韧带长度的变化.方法 对6名志愿者腕关节进行CT扫描,获得腕关节在桡偏20°至尺偏40°内每隔20°的运动范围内各腕骨及尺桡骨远段三维重建图像.男3名,女3名,仅研究单侧右侧腕关节.年龄20～32岁,平均24岁.在腕关节尺桡偏运动过程中,在重建各腕骨及尺桡骨结构图像上以软件测量掌、背侧腕韧带的长度.结果 腕关节尺偏时桡舟头韧带、长桡月韧带、背侧腕间韧带止于舟骨、大多角骨和小多角骨部分的长度较中立位显著伸长,分别伸长(2.4±0.3)mm、(2.3±0.8)mm、(1.2±0.6)mm、(1.2±1.2)mm与(2.6±1.0)mm,差异均有统计学意义(P＜0.05);腕关节桡偏时尺头韧带与背侧桡腕韧带长度显著伸长(P＜0.05),分别为(0.8±0.6)mm和(1.0±0.5)mm.结论 在腕关节尺桡偏运动时,桡舟头韧带、长桡月韧带、背侧腕间韧带于桡偏位缩短,尺头韧带、背侧桡腕韧带长度于尺偏位缩短.这些位置可能使不同腕韧带张力降低,有利于损伤韧带的修复.     

腕关节极度过伸位时韧带长度变化的活体研究

目的 探讨腕关节在中立位、极度过伸位及过伸桡偏位时腕关节韧带长度的变化情况.方法 对6名志愿者腕关节进行CT扫描,获取腕关节在中立位、极度过伸位及过伸桡偏位时的断层扫描图像,利用Mimics10.0软件进行三维重建,测量并比较此3种位置下的腕关节掌与背侧共9根韧带的长度. 结果 与中立位相比,腕关节极度过伸位时桡舟头、桡舟月、长桡月、尺月、尺头、尺三角及背侧骨间韧带止于舟骨部分明显伸长,差异有统计学意义(P＜0.05)；背侧桡腕、背侧骨间韧带止于小多角骨部分明显缩短,差异有统计学意义(P＜0.05)；而从极度过伸位至极度过伸桡偏位时,桡舟头、尺月、长桡月、背侧骨间韧带止于舟骨和三角骨部分明显缩短,差异有统计学意义(P＜0.05)；尺三角、尺头、桡舟月及背侧桡腕韧带明显伸长,差异有统计学意义(P＜0.05). 结论 腕过伸位时尺头韧带、尺三角韧带、桡舟月韧带、尺月韧带、桡舟头韧带、长桡月韧带、背侧骨间韧带止于舟骨部分张力较大；而背侧桡腕韧带、背侧骨间韧带止于小三角骨部分张力较小,这些变化规律有助于了解腕部韧带损伤的发生及损伤范围.     

掌指关节掌侧脱位的治疗

[目的]介绍掌指关节掌侧脱位的治疗方法及其疗效.[方法]自2000年以来,对3例掌指关节掌侧脱位的患者采用切开复位克氏针固定及关节囊修复、侧副韧带修复或重建的方法进行治疗.[结果]术后全部病例均获得24～72个月的随访,平均50个月.术后掌指关节复位良好,拇指掌指关节主动屈曲45°～60°,其他掌指关节主动屈曲80°;各掌指关节伸直均可达到0°及0°以上.[结论]采用切开复位克氏针固定及关节囊修复、侧副韧带修复或重建的方法是治疗掌指关节掌侧脱位的一种理想治疗方法.     

下尺桡关节病变和腕尺侧疼痛

下尺桡关节(DRUJ)由尺骨头、桡骨远端乙状切迹和三角纤维软骨复合体(TFCC)构成,司前臂旋前、旋后活动和腕关节由桡偏向尺偏的侧方运动,关节间还能传导载荷.TFCC是DRUJ的软组织稳定结构,由三角纤维软骨盘、尺-月和月-三角韧带、背侧和掌侧尺桡韧带、尺侧副韧带和尺侧腕伸肌腱鞘、半月板同系物等结构组成,其中尺桡韧带(背侧和掌侧)是稳定DRUJ的最重要的结构.临床上,在处理涉及DRUJ的损伤和疾病时,会遇到DRUJ病变与腕尺侧疼痛问题,需要引起重视.     

三角纤维软骨复合体解剖及生物力学研究

目的从解剖完整的腕关节入手,阐明三角纤维软骨复合体各组成部分的解剖特点,评估三角纤维软骨复合体(TFCC)对于维持远侧桡尺关节稳定的重要性。方法对8个新鲜解冻的腕关节和6个经甲醛浸泡的腕关节进行显微解剖。同时对影响远侧桡尺关节稳定性的因素作了初步的评估。前臂中旋位,垂直于尺骨予20N拉力下测量尺骨相对于桡骨的位移,然后先后切断掌背侧桡尺韧带,测量尺骨相对于桡骨的位移变化。结果发现掌背桡尺韧带由三角纤维软骨盘外周增厚而成,止于尺骨茎突基底部,是维持远侧桡尺关节稳定性的主要因素之一,切断掌背侧桡尺韧带会导致远侧桡尺关节明显不稳。结论TFCC由三角纤维软骨盘、掌背侧桡尺韧带、尺骨月骨韧带、尺骨三角骨韧带、尺侧腕伸肌下腱鞘、半月板同源物、尺侧囊组成。掌背桡尺韧带是维持远侧桡尺关节稳定性的主要因素之一,掌背侧桡尺韧带损伤会导致远侧桡尺关节明显不稳。     

陈旧性拇指掌指关节尺侧副韧带损伤的手术治疗

拇指掌指关节尺侧副韧带损伤的发生率远多于桡侧，损伤的早期如处理不当，晚期将出现掌指关节的不稳和疼痛。陈旧损伤病例多因韧带挛缩而无法直接缝合修补。我们于1999—2003年利用掌长肌腱移植的方法，对拇指掌指关节的韧带进行了重建，取得了良好的临床疗效。     

掌指关节背侧脱位手术治疗二例

病例1女,59岁.2012年4月,摔伤致左手肿胀、疼痛、活动受限2h来我院治疗.X线片显示:左示指掌指关节背侧脱位及第二掌骨撕脱性骨折,急诊行牵引复位未成功而收住入院.临床检查:左第二掌指关节掌侧处皮肤发红并凹陷,掌骨头明显前凸,抵压手掌皮肤,皮肤张力高,左第二掌指关节呈过伸位,主、被动屈曲活动均受限.在局部麻醉下,取示指掌指关节(掌侧)远侧掌横纹处"L"形切口,切开掌浅横韧带,即可见掌骨头向前方突出,指深、浅屈肌腱滑向并卡压于掌骨头尺侧,第一蚓状肌断裂,术野内未见掌板,考虑掌板断裂并进入关节内,卡压于掌骨头背侧与近节指骨近端之间,牵引掌指关节并用血管钳将掌板从掌骨头背侧从后向前撬拨出后成功复位,掌骨头即被掌板覆盖,见掌板近侧横行断裂,予修复掌板及第一蚓状肌,间断缝合伤口.术后掌指关节屈曲70°位石膏固定.术后X线片显示掌指关节已复位,3周后拆除石膏开始功能锻炼,术后示指关节功能恢复正常.     

Ligamentous structures of the metacarpophalangeal joint: A quantitative anatomic study

The ligamentous structure of the metacarpophalangeal (MCP) joint of the index finger in human cadavers was studied by gross examination and quantitative measurement. Anatomically, the collateral ligament is separable into two layers, with the precise origin arising from the metacarpal head and inserting on the proximal phalanx. Quantitatively, the change in length of the collateral ligament was studied with biplanar radiographic techniques. The distance between the origin and insertion of the collateral ligament changed in different portions of the ligament when the joint was moved from a position of hyperextension to that of flexion. When the MCP joint was flexed from 0° to 80°, the dorsal portions of both the radial and ulnar collateral ligaments were lengthened (3–4 mm). The middle portions of both ligaments were slightly elongated (0.4–1.0 mm), and the volar portions of the ligaments were shortened (1–2 mm). When the MCP joint extended into hyperextension, the dorsal portions of the ligaments shortened 2–3 mm, the middle thirds of the ligaments shortened slightly, and the volar thirds of the ligaments lengthened. The results of this study suggest that the dorsal and volar portions of the collateral ligament provide MCP joint constraint at the flexed and extended positions, respectively.     

Ligamentous structures of the metacarpophalangeal joint: a quantitative anatomic study

The ligamentous structure of the metacarpophalangeal (MCP) joint of the index finger in human cadavers was studied by gross examination and quantitative measurement. Anatomically, the collateral ligament is separable into two layers, with the precise origin arising from the metacarpal head and inserting on the proximal phalanx. Quantitatively, the change in length of the collateral ligament was studied with biplanar radiographic techniques. The distance between the origin and insertion of the collateral ligament changed in different portions of the ligament when the joint was moved from a position of hyperextension to that of flexion. When the MCP joint was flexed from 0 degree to 80 degrees, the dorsal portions of both the radial and ulnar collateral ligaments were lengthened (3-4 mm). The middle portions of both ligaments were slightly elongated (0.4-1.0 mm), and the volar portions of the ligaments were shortened (1-2 mm). When the MCP joint extended into hyperextension, the dorsal portions of the ligaments shortened 2-3 mm, the middle thirds of the ligaments shortened slightly, and the volar thirds of the ligaments lengthened. The results of this study suggest that the dorsal and volar portions of the collateral ligament provide MCP joint constraint at the flexed and extended positions, respectively.     

手部近指间关节闭合性损伤的基础与临床研究

目的 探讨近指间关节(proximal interphalangeal joint,PIP)闭合性损伤的解剖特点及不同结构损伤的治疗及预后.方法 通过对20个成年人新鲜尸体手指标本的解剖学研究,了解近指间关节损伤及关节囊挛缩发生的机制.临床上对21例近指间关节损伤的患者进行手术.结果 解剖学研究发现,副韧带及掌板近侧损伤对近指间关节活动度无明显影响.侧副韧带损伤主要破坏关节侧方的稳定性,掌板损伤主要破坏关节前后方的稳定性.21例术后随访3～13个月,平均7个月.各指近指间关节主动屈、伸活动范围:屈曲60°～95°,平均78°;背伸0°～15°,平均8°.被动屈、伸活动范围:屈曲71°～98°,平均82°;背伸0°～18°,平均11°.结论 对于掌板及侧副韧带损伤,应尽早进行手术修复及止点重建,可防止关节囊挛缩.     

侧方入路关节松解术治疗外伤性掌指关节僵硬

目的 介绍手外伤后掌指关节伸直位僵硬的临床分型,以及侧方入路关节松解术的临床疗效.方法 根据术前、术中检查,对非骨性原因引起的掌指关节僵硬进行分型:Ⅰ型,单纯侧副韧带挛缩;Ⅱ型,侧副韧带挛缩合并伸肌腱、关节囊粘连;Ⅲ型,Ⅱ型基础上合并掌板粘连;Ⅳ型,Ⅲ型基础上合并背侧皮肤较大面积致密瘢痕粘连.对15例(54指)保守治疗无效的Ⅱ～Ⅳ型掌指关节僵硬者,采用侧方入路关节松解术,术后3d内以掌指关节屈曲80°～90°位石膏固定,之后改为最大屈指位支具固定,并逐步开始功能训练.结果 术后13例(46指)获得8～30个月的随访(平均21个月),2例(8指)失访.掌指关节主动活动度恢复至70～90°者5例,50°～69°者8例,除1例轻微疼痛及1例小指轻度尺偏外,未发现伸肌腱滑脱及关节不稳定和退行性改变.结论 对于外伤后具备手术指证的非骨性因素掌指关节伸直位僵硬,准确判断僵硬的分型及选择相应的术式,是充分恢复掌指关节活动度的关键所在,而术后系列康复训练是手术成功的必要条件.     

Anatomic relation between the medial collateral ligament of the elbow and the humero-ulnar joint axis

The anatomic relation between the proximal attachment of the medial collateral ligament of the elbow joint and the humero-ulnar joint axis has not been clearly shown in a published study. We examined cadaveric specimens to find the exact relation between them. The medial collateral ligament was microscopically dissected to isolate specific fiber bundles. The length of each bundle was measured with a charge-coupled device camera system that faced the medial side of the elbow joint. The measurements indicated that the projected length of the deep middle bundle of the anterior oblique ligament, which is the strong cord-like part of the medial collateral ligament, is isometric during elbow flexion. The proximal end of the deep middle bundle was thus considered to be located almost on the humero-ulnar joint axis.     

Contracture of the proximal interphalangeal joint in Dupuytren's disease.

The correction of fixed flexion deformity at the P.I.P. joint in Dupuytren's disease is often difficult. This paper reports an anatomical study of this joint in fingers amputated because of this condition. all the joints would extend fully after release of the accessory collateral ligaments and volar plate. Lateral and dorsal structures showed severe secondary damage and it is suggested that these changes may explain the poor results of corrective surgery to this joint in Dupuytren's disease.     

In vitro kinematics of the proximal interphalangeal joint in the finger after progressive disruption of the main supporting structures

Background

Fractures and dislocations of the proximal interphalangeal (PIP) joint of the fingers are among the most common causes of injury in the hand. Objective assessment of the kinematic alterations occurring when the supporting structures are disrupted is critical to obtain a more accurate indication of joint stability.

Methods

An in vitro cadaver model of the hand was used to evaluate the kinematics of the PIP joint in the finger during active unrestrained flexion and extension. The kinematics of the PIP joint following progressive disruption of the main supporting structures was measured using an optical tracking system and compared with those in the intact joint.

Results

Flexion of the intact PIP joint was associated with joint compression, volar displacement, and rotational movements. Release of the main soft-tissue stabilizers and 30 % of volar lip disruption resulted in substantial alteration of several kinematic variables. The normalized maximum dorsal/volar translation was 0.1 ± 1.3 % in the intact group and 14.4 ± 11.3 % in the injured joint.

Conclusions

In the intact PIP joint, rotations and translation are strongly coupled to the amount of joint flexion. Gross instability of the PIP joint occurs when disruption of the collateral ligaments and volar plate is accompanied by resection of at least 30 % of volar lip of the middle phalanx. Collateral ligament injuries, volar plate injuries alone, and fractures at the volar base of the middle phalanx that involve less than 30 % of the articular surface are unlikely to result in gross instability and may be managed effectively with non-operative treatments.     

Material properties of the trapezial and trapeziometacarpal ligaments

Destabilization of the trapezium from its normal orientation with respect to the trapezoid, second metacarpal, and thumb metacarpal leads to incongruity at the trapeziometacarpal (TMC) joint. Abnormal shear forces may eventually result in TMC joint arthritis. By determining the relative stiffness and strength of the ligaments that stabilize this joint, one may infer their role in providing stability to the TMC joint. This study addresses the material properties of the ligaments stabilizing the trapezium and TMC joint to better understand the mechanics and kinematics of this joint. Fresh-frozen cadaveric hands (10 males and 10 females) were used to obtain bone-ligament-bone complexes from the dorsal and volar trapeziotrapezoid ligaments, dorsal and volar trapezio-second metacarpal ligaments, anterior oblique ligament, dorsoradial ligament, and trapezio-third metacarpal (T-III MC) ligament. The following material properties were derived from our data: ultimate load, ultimate stress (normalized failure load), ultimate strain (percent elongation), stiffness, toughness (energy to failure), and hysteresis. The dorsoradial ligament demonstrated the greatest ultimate load and toughness (energy to failure). The T-III MC ligament demonstrated the greatest ultimate stress (normalized failure load) and stiffness. The anterior oblique ligament demonstrated the least stiffness and the greatest hysteresis. The material properties of capsuloligamentous structures may be a good indicator of their importance to joint stability. Using these criteria we conclude that the T-III MC and dorsoradial ligaments are important stabilizers of the trapezium and TMC joint, respectively. These two ligaments were found to be the strongest, stiffest, and toughest ligaments, while the anterior oblique ligament was relatively weak and compliant. The dorsal trapezio-second metacarpal, volar trapezio-second metacarpal, and T-III MC ligaments were all relatively strong and are anatomically aligned to function as tension bands to restrain the trapezium against cantilever bending forces applied to it by the thumb during key or tip pinch.