跟痛症相关的解剖学研究

An anatomical study associated with calcaneodynia

目的:探讨跟骨骨刺和小趾展神经走行的解剖学特点。方法:选取589具干燥完整的成人跟骨标本和10具以10%甲醛固定的下肢标本(范围包括小腿中段以下)。在跟骨标本上仔细观察是否存在骨刺,记录骨刺的形态、位置、数量,测量骨刺的长度和宽度,观察跖筋膜和趾短屈肌在跟骨的附着部位。从足背逐层解剖下肢标本,分离并观察小趾展神经走行及周围的结构。结果:589具跟骨标本中,左侧跟骨293具、右侧跟骨296具。119具跟骨骨刺位于跟骨结节内侧突前缘,部分跟骨骨刺还出现在跟骨结节内侧突后缘(2具)、跟骨结节外侧突(14具)、跟骨前结节和内外侧突之间(23具),有的甚至出现在跟骨前结节足底长韧带附着处周围(8具)。跟骨结节内侧突跖侧面存在一条骨嵴,将跟骨结节内侧突骨刺分为前后两部分;跟骨结节内侧突骨刺上表面光滑,下表面粗糙。119具跟骨结节内侧突存在骨刺的标本中,左侧跟骨62具、右侧跟骨57具,两侧跟骨结节内侧突骨刺的发生率比较,差异无统计学意义(χ~2=0. 331,P=0. 565);两侧跟骨结节内侧突骨刺的长度比较,差异无统计学意义(Z=-0. 396,P=0. 692);跟骨结节内侧突骨刺宽度(16. 42±5. 26) mm,其中左侧跟骨结节内侧突骨刺宽度(15. 72±5. 43) mm、右侧跟骨结节内侧突骨刺宽度(17. 19±5. 02) mm,两侧跟骨结节内侧突骨刺宽度比较,差异无统计学意义(t=-1. 533,P=0. 128)。589具跟骨标本中,230具跟腱止点处存在骨刺,其发生率高于跟骨结节内侧突骨刺的发生率(χ~2=50. 166,P=0. 000)。小趾展神经在跟骨底面的行程中伴有相关的动静脉,在跟骨底面内侧缘转折到跟骨结节外侧突之间走行的一段都被紧密的结缔组织和骨性结构包围。结论:跟骨骨刺为片状骨赘,且并非仅发生在跟骨结节内侧突;跟骨结节内侧突骨刺上下两个面接触的软组织不同,并不是都在跖筋膜里,而应该是上面与趾短屈肌接触,下面与跖筋膜接触;小趾展神经在跟骨底面内侧缘转折到跟骨结节外侧突之间走行的一段存在卡压的解剖学基础。

Objective:To explore the anatomical characteristics of calcaneal spurs and distribution of abductor digiti minimi nerve.Methods:Five hundred and eighty-nine dry intact adult cadaveric calcaneus specimens and 10 lower limb specimens(below the mid-segment of cruris)fixed with 10%formaldehyde were selected.The calcaneus specimens were observed carefully and judged whether they had bone spurs.The shape,position and number of bone spurs were recorded,and their lengths and widths were measured.The attachment positions of plantar fascia and flexor digitorum brevis to calcaneus were observed.The lower limb specimens were dissected from dorsum pedis layer by layer,and the abductor digiti minimi nerve and its surrounding structures were isolated and observed.Results:The calcaneus specimens consisted of 293 left calcaneus and 296 right calcaneus.The calcaneus spurs were found at anterior border(119 cases)and posterior border(2 cases)of medial process of calcaneal tuberosity,lateral process of calcaneal tuberosity(14 cases)and anterior tubercle of calcaneus and between medial process and lateral process(23 cases),and some were even found around the adherent positions of long plantar ligament of anterior tubercle of calcaneus(8 cases).A bony crest was found on the plantar side of medial process of calcaneal tuberosity,and it divided the bone spurs on medial process of calcaneal tuberosity into anterior part and posterior part.The upper surface of bone spurs on medial process of calcaneal tuberosity was smooth,while the lower surface was rough.The 119 calcaneus,which had bone spurs on medial process of calcaneal tuberosity,consisted of 62 left calcaneus and 57 right calcaneus,and there was no statistical difference in the incidences of bone spurs on medial process of calcaneal tuberosity between the left calcaneus and the right calcaneus(χ^2=0.331,P=0.565).There was no statistical difference in the length of bone spurs on medial process of calcaneal tuberosity between the left calcaneus and the right calcaneus(Z=-0.396,P=0.692).The width of bone spurs on medial process of calcaneal tuberosity was 16.42+/-5.26 mm,and there was no statistical difference in the width of bone spurs on medial process of calcaneal tuberosity between the left calcaneus and the right calcaneus(15.72+/-5.43 vs 17.19+/-5.02 mm,t=-1.533,P=0.128).The bone spurs were found at the ending point of tendo calcaneus in 230 out of 589 calcaneus specimens,and its incidence of bone spurs was higher than that of medial process of calcaneal tuberosity(χ^2=50.166,P=0.000).The abductor digiti minimi nerve was companied by related arteries and veins on the undersurface of calcaneus and it was surrounded by dense connective tissues and bony structures in the process of running from medial border of undersurface of calcaneus to lateral process of the calcaneus tuberosity.Conclusion:The calcaneus spur is flaky osteophytes,and it is not only found on the medial process of calcaneal tuberosity.The upper surface and lower surface of bone spur on medial process of calcaneal tuberosity touch different soft tissues,and not always metatarsal fascia.Instead,the upper surface is in contact with flexor digitorum brevis,and the lower surface is in contact with metatarsal fascia.The entrapment syndromes has the anatomical basis for abductor digiti minimi nerve in the process of running from medial border of undersurface of calcaneus to lateral process of calcaneus tuberosity.