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下胫腓联合踝关节损伤(高位踝关节扭伤)

Author
Kevin deWeber, MD, FAAFP, FACSM
Section Editors
Patrice Eiff, MD
Francis G O'Connor, MD, MPH, FACSM
Deputy Editor
Jonathan Grayzel, MD, FAAEM
Translators
滕红林, 主任医师，副教授

引言

下胫腓联合踝关节扭伤是指下胫腓联合中一根或多根韧带的损伤，通常被称为“高位踝关节扭伤”。与更常见的外侧踝关节扭伤相比，高位踝关节扭伤引起的疼痛更靠近端，正好位于踝关节上方，且更常引起严重并发症。其诊断可能比较困难，临床医生在诊治有踝关节或小腿疼痛或损伤的运动员时应考虑到下胫腓联合损伤。该损伤的治疗也与典型的踝关节扭伤不同，可能需要手术，因此识别出该疾病对获得最佳康复而言有重要意义。

本文将为无相关骨折的高位踝关节扭伤总结危险因素、临床表现、诊断和治疗。常见的踝关节扭伤和其他踝关节相关损伤将单独讨论。 (参见“踝关节扭伤”和“儿童或青少年运动员足部和踝部疼痛的评估”和“成人踝关节骨折概述”和“成年人足痛常见病因的评估和诊断”和“跟腱病和跟腱断裂”和“非跟腱踝关节肌腱病”和“距骨骨折”)

流行病学及危险因素

同常见的外侧踝关节扭伤相比，高位踝关节扭伤的发生率要低得多。最大型观察性研究发现，采用临床诊断标准时(即，非影像学诊断标准)，无骨折的急性踝关节扭伤病例中约有6%为高位踝关节扭伤。美国的发生率为2.09次/100,000人年[1]。

到急诊室就诊的一般人群中，5.7%的无骨折急性踝关节扭伤是高位踝关节扭伤[2]。在美国西点军校中，6.7%的急性踝关节损伤累及下胫腓联合，下胫腓联合扭伤的发生率为4.8/1000人年[3]。西点军校一项较小型的研究报道，16%的急性踝关节扭伤累及下胫腓联合[4]。而其他亚组人群中报道的发生率差别很大。职业英式足球运动员的所有急性踝关节扭伤中有4%是高位踝关节扭伤[5]，该数据在美国大学美式橄榄球运动员中为24.6%[6]，在美国职业冰球运动员中为73%[7]。另有一些研究证实美式橄榄球运动员中的高位踝关节损伤发生率较高[8]。虽然冰球运动员中的实际发生率可能没有上述研究报道的那么高，但冰球鞋的高帮刚性护踝在近端施加了沿小腿传递的力，这可能是该人群下胫腓联合损伤发生率较高的原因之一。

在使用MRI评估损伤模式的研究中，针对急诊科中无骨折急性踝关节损伤的前瞻性研究发现：下胫腓联合损伤病例占8%-13% [9,10]。在其他亚组人群的研究中，有下胫腓联合损伤的急性踝关节损伤病例占20%-60%[11,12]。发生率范围差异很大的原因可能是针对不同研究人群的文献存在不一致。例如，有些研究只关注冬季项目运动员，而其他研究只纳入了有“严重”踝关节扭伤的患者。

                                   

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Literature review current through: 2017-06 . | This topic last updated: 2016-12-07.
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References
Top
  1. Vosseller JT, Karl JW, Greisberg JK. Incidence of syndesmotic injury. Orthopedics 2014; 37:e226.
  2. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 1998; 37:280.
  3. Waterman BR, Belmont PJ Jr, Cameron KL, et al. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med 2011; 39:992.
  4. Gerber JP, Williams GN, Scoville CR, et al. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int 1998; 19:653.
  5. Woods C, Hawkins R, Hulse M, Hodson A. The Football Association Medical Research Programme: an audit of injuries in professional football: an analysis of ankle sprains. Br J Sports Med 2003; 37:233.
  6. Hunt KJ, George E, Harris AH, Dragoo JL. Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clin J Sport Med 2013; 23:278.
  7. Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med 2004; 32:1941.
  8. Nussbaum ED, Hosea TM, Sieler SD, et al. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med 2001; 29:31.
  9. Langner I, Frank M, Kuehn JP, et al. Acute inversion injury of the ankle without radiological abnormalities: assessment with high-field MR imaging and correlation of findings with clinical outcome. Skeletal Radiol 2011; 40:423.
  10. Schoennagel BP, Karul M, Avanesov M, et al. Isolated syndesmotic injury in acute ankle trauma: comparison of plain film radiography with 3T MRI. Eur J Radiol 2014; 83:1856.
  11. Crim JR. Winter sports injuries. The 2002 Winter Olympics experience and a review of the literature. Magn Reson Imaging Clin N Am 2003; 11:311.
  12. Brown KW, Morrison WB, Schweitzer ME, et al. MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol 2004; 182:131.
  13. Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat 2010; 217:633.
  14. Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 1994; 10:558.
  15. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med 1991; 19:294.
  16. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the ankle. Foot Ankle 1990; 10:325.
  17. Beumer A, Valstar ER, Garling EH, et al. Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment. Acta Orthop 2006; 77:531.
  18. Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med 2015; 49:323.
  19. Sman AD, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med 2013; 47:620.
  20. Ogilvie-Harris DJ, Reed SC. Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy 1994; 10:561.
  21. Teitz CC, Harrington RM. A biochemical analysis of the squeeze test for sprains of the syndesmotic ligaments of the ankle. Foot Ankle Int 1998; 19:489.
  22. Kellett JJ. The clinical features of ankle syndesmosis injuries: a general review. Clin J Sport Med 2011; 21:524.
  23. Stricker PR, Spindler KP, Gautier KB. Prospective evaluation of history and physical examination: variables to determine radiography in acute ankle injuries. Clin J Sport Med 1998; 8:209.
  24. Molloy A, Selvan D. Ligamentous injuries of the foot and ankle. In: DeLee & Drez’s Orthopaedic Sports Medicine Principles and Practice, 4th ed, MD, Thompson SR (Eds), Elsevier Saunders, Philadelphia 2015. p.1392.
  25. Ebraheim NA, Lu J, Yang H, et al. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int 1997; 18:693.
  26. Shah AS, Kadakia AR, Tan GJ, et al. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int 2012; 33:870.
  27. Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle 1989; 10:156.
  28. Jenkinson RJ, Sanders DW, Macleod MD, et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma 2005; 19:604.
  29. Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 2004; :227.
  30. Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int 2002; 23:107.
  31. Ostrum RF, De Meo P, Subramanian R. A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot Ankle Int 1995; 16:128.
  32. Pakarinen H, Flinkkilä T, Ohtonen P, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am 2011; 93:2057.
  33. Vogl TJ, Hochmuth K, Diebold T, et al. Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis. Invest Radiol 1997; 32:401.
  34. Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 2003; 227:155.
  35. Han SH, Lee JW, Kim S, et al. Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int 2007; 28:336.
  36. Kim S, Huh YM, Song HT, et al. Chronic tibiofibular syndesmosis injury of ankle: evaluation with contrast-enhanced fat-suppressed 3D fast spoiled gradient-recalled acquisition in the steady state MR imaging. Radiology 2007; 242:225.
  37. Sikka RS, Fetzer GB, Sugarman E, et al. Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot Ankle Int 2012; 33:371.
  38. Malhotra G, Cameron J, Toolan BC. Diagnosing chronic diastasis of the syndesmosis: a novel measurement using computed tomography. Foot Ankle Int 2014; 35:483.
  39. Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma 2012; 26:433.
  40. Mei-Dan O, Kots E, Barchilon V, et al. A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: a preliminary study. Am J Sports Med 2009; 37:1009.
  41. Rammelt S, Zwipp H, Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin 2008; 13:611.
  42. Miller TL, Skalak T. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Med 2014; 44:179.
  43. Porter DA, Jaggers RR, Barnes AF, Rund AM. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med 2014; 5:173.
  44. Bassett FH 3rd, Gates HS 3rd, Billys JB, et al. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am 1990; 72:55.
  45. Taylor DC, Englehardt DL, Bassett FH 3rd. Syndesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports Med 1992; 20:146.
  46. Sman AD, Hiller CE, Rae K, et al. Prognosis of ankle syndesmosis injury. Med Sci Sports Exerc 2014; 46:671.
  47. Osbahr DC, Drakos MC, O'Loughlin PF, et al. Syndesmosis and lateral ankle sprains in the National Football League. Orthopedics 2013; 36:e1378.