合并胸小肌止点异常的喙锁韧带损伤镜下手术技术

[目的]探讨胸小肌的解剖学变异及其在关节镜辅助下治疗喙锁韧带损伤手术中的影响。[方法]2015年1月~2016年10月,本院收治30例喙锁韧带损伤患者,其中4例在术中发现胸小肌存在镜下解剖学变异,男2例,女2例,平均年龄(40.50±8.88)岁,采用关节镜辅助下Endobutton结合锚钉双重解剖技术重建喙锁韧带。所有患者均由同一名医生施行关节镜术。[结果]4例术后随访13~20个月,平均(16.50±1.80)个月,根据ASES评分、Constant-Murley评分、UCLA评分标准评估:优3例,良1例,优良率100%。[结论]胸小肌的镜下解剖变异率13.33%。关节镜辅助下治疗合并胸小肌止点异常的喙锁韧带损伤操作安全简便、快速康复、术后较少残留肩关节功能障碍。但胸小肌变异会增加手术难度,延长手术时间及增加并发症发生率。也可能是肩关节疼痛的原因之一。     

胸小肌移植重建拇对掌功能的解剖与临床研究

目的研究选择性胸小肌移植重建拇对掌功能术式的临床解剖基础及临床治疗的效果。方法在20侧成人尸体胸部及上肢标本上，观测和比较胸小肌及拇对掌肌的解剖数据，行移植模拟试验以评估新术式的可行性；依据解剖研究结果，按新的手术方式施行临床手术治疗5例，术后随访拇对掌功能恢复情况。结果解剖研究结果显示：胸小肌位置恒定，具备独立的动、静脉和神经支配；移植肌与受区对掌肌匹配；临床手术治疗5例，术后随访6～12个月，拇对掌功能恢复，肌力均达到4级以上，大鱼际部外形满意。结论胸小肌移植重建拇对掌功能这一术式有其临床解剖基础，移植手术能达到恢复对掌功能的要求，是一种新的对掌功能重建方法。     

携带皮瓣的胸小肌移植重建拇对掌功能的解剖与临床研究

目的 研究携带皮瓣的胸小肌移植重建拇对掌功能术式的解剖基础及临床治疗效果.方法 在10具20侧成人胸部标本及8例上肢标本上,对胸外侧动脉的分支、分布等进行解剖学观测,寻找胸外侧动脉发出的皮动脉和胸小肌支;观察胸内侧神经及尺神经深支分支特点,比较相关神经有髓神经纤维数目,确定手术过程中的神经缝接.依据解剖研究结果,按新的手术方式施行临床手术治疗7例,术后随访拇对掌功能的恢复情况.结果 解剖研究结果显示:胸外侧动脉较恒定地发出皮支和肌支分别营养胸外侧皮肤和胸小肌,这种血管构造的出现率为80％,切取胸小肌时以胸内侧神经作为供体神经,以第三肋间隙与锁骨中线交点为标记寻找该神经;尺神经深支中P3、L4肌支与胸内侧神经缝合最为匹配.临床手术治疗7例,术后随访6～ 12个月,拇对掌功能恢复良好,肌力均达到M4以上,大鱼际部外形满意.结论 携带皮瓣的胸小肌移植重建拇对掌功能这一术式有其临床解剖基础,移植手术能达到恢复对掌功能的要求,扩大了胸小肌移植重建拇对掌功能的适应证.     

双侧示指伸肌变异1例的报道

正示指伸肌是一块位于前臂后面下部起伸示指作用的小肌肉。而笔者在解剖一具男尸双侧上肢过程中,发现其两侧示指伸肌起点变异,现报告如下。1解剖标本与解剖方法10%的甲醛防腐固定后的成年男性尸体标本。按要求层次解剖。2解剖结果成年男性双侧示指伸肌起点异常,且异常短小(见图     

乳腔镜淋巴结清除术应用解剖学研究

目的为乳腔镜淋巴结清扫术提供解剖学基础和依据。方法利用10％福尔马林固定的成年女性尸体10具（20侧），常规解剖方法剖出胸上神经、胸内侧神经、胸外侧神经及肋间臂神经，测量其长度及粗细，详细记录起源、分支、分布，与胸大、小肌血管的关系。临床行46例乳腔镜淋巴结清扫术，术中镜下观察胸肌神经及肋间臂神经的解剖特点及相互联系。结果（1）支配胸大肌的神经：胸上神经起于臂丛外侧束，分1～2支，长度（41．32±3．50）mm，直径（1．32±0．25）mm，与胸骨肩峰血管伴行，发出后在胸小肌的浅上方，进入并支配胸大肌上1／3的锁骨部。胸内侧神经起于臂丛外侧束，长度（46．13±4．12）mm，直径（1．92±0．21）mm，在胸小肌前方斜行经过。80％以3—4个终支进入胸大肌支配该肌的中1／3，其走行位置恒定。胸外侧神经起于臂丛内侧束，长度（51．19±6．32）mm，直径（1．19±0．31）mm，穿过胸小肌中部达胸大肌，终止于胸大肌的外上1／3。（2）肋间臂神经：起源于第2胸神经，在胸长神经前方2～3cm穿出第二肋间，长度（110．12±7．12）mm，直径（2．3±0．12）mm，横跨背阔肌前方，进入上臂后内侧。（3）乳腔镜淋巴结清除术中镜下观察：肋间臂神经是手术最先碰到的主要结构。进镜后稍加分离蜘蛛网状结构，即可“遭遇”横跨于腋窝腔、像“横梁”的1～3根较粗的肋间臂神经条索。腋静脉越过肋间臂神经，从气腔中央直指腋窝顶部推进腔镜在肋间臂神经的前下方即为腋静脉中部的解剖学位置，脂肪被抽吸特别充分时能清淅可见腋静脉。支配胸大肌的胸外侧神经进入胸大、小肌间穿过胸小肌中部达胸大肌，终止于胸大肌的外上1／3，腔镜下该神经显示良好。结论（1）了解支配胸肌神经及肋间臂神经的解剖特点，术中可更好的保留?     

颈段胸导管的临床解剖学探讨

自六十年代以来,胸导管淋巴液引流术及分流术已逐步应用于临床。颈段胸导管的解剖变异较大,为更好地推动临床工作,总结临床解剖资料实属必要。现就术者1984～1987年应用胸导管淋巴引流术260例的颈段胸导管临床解剖资料总结如下。     

胸长神经阻滞

本文介绍了胸长神经的解剖、胸长神经阻滞的方法及胸长神经阻滞用于诊断和治疗胸侧壁腋下部位难治性疼痛的经验。解剖:胸长神经发自C_5、C_6和C_7神经根的前支,少数发自C_8。通常仅支配前锯肌,不向皮肤分布。它从C_5、C_6神经根发出后进入中斜角肌,合并后再接受C_7神经根,然后从臂丛背侧下降直到胸的前侧壁,支配整个前锯肌。约5％病例C_5单独进入前锯肌上部。阻滞方法:病人去枕仰卧,令病人抬头使胸锁乳突肌更突出。操作者用示指触摸胸锁     

内镜下经腋路双平面隆乳术的应用解剖研究

目的 对女性新鲜尸体的乳房及胸大、小肌附着点,血管支配和联合腱膜等进行局部解剖学观察,为内镜下经腋路双平面隆乳术提供解剖学基础.方法 解剖并观察成年女性新鲜人体标本,精准识别乳腺,胸大、小肌的相对位置关系,重要神经、血管的走行以及与周围肌肉的腱膜连接,测量胸骨体的宽度.模拟再现手术过程,并阐明手术要点.结果 ①胸小肌外缘在胸大肌外缘后下方,其后间隙较疏松,有较密集的神经、血管分支.②胸大肌的肋部与腹直肌腱膜、腹外斜肌腱膜及前锯肌筋膜均有较致密的联合.③胸骨体中下2/3的平均宽度 （3.0±0.5）cm.结论 ①经腋路极易误入胸小肌后间隙,分离易损伤血管造成出血.②双平面腔隙内侧缘间距安全距离至少为3.0cm.③胸大肌的肋部与其他比邻肌肉腱膜的连接较致密,在直视下才能确切离断松解,使肌肉回缩形成真正的双平面假体放置腔隙,维持乳腺-胸大肌-假体三者的动力关系平衡.④内窥镜辅助在经腋路双平面隆乳术中是必要的.     

胸心血管外科学(十七)

汉　文　名英　文　名汉　文　名英　文　名胸大肌缺如absenceofpectoralismajor胸小肌缺如absenceofpectoralisminor胸小肌发育不良dysplasiaofpectoralisminor肋软骨炎costalchondriti胸心血管外科学(十七)     

带胸大肌蒂锁骨膜瓣转位治疗锁骨骨折不愈合的解剖学研究

目的为带胸大肌蒂锁骨膜瓣转位治疗锁骨骨折不愈合提供解剖学基础。方法观测10例成人上肢标本胸大肌锁骨部解剖学形态,设计带胸大肌蒂锁骨膜瓣转位治疗锁骨骨折不愈合的新术式。结果胸大肌锁骨部血供主要来自胸肩峰动脉三角肌支,进入三角肌前发出1～3支进入锁骨部,并参与锁骨骨膜血管的形成。结论胸大肌蒂锁骨的鳃剖学研究为该部位的相关手术操作提供了必要的解剖学数据。根据胸大肌锁骨部的解剖特点设计带胸大肌蒂锁骨膜瓣治疗锁骨骨折不愈合的新术式。     

Measurement of pectoralis minor muscle length: validation and clinical application

STUDY DESIGN: Clinical measurement validity study. OBJECTIVES: To validate the measurement of the pectoralis minor muscle length using palpable landmarks and to explore the accuracy of the measurement using a clinical instrument. BACKGROUND: The pectoralis minor is believed to adaptively shorten. Individuals with a relatively short pectoralis minor demonstrate scapular kinematic alterations that have been associated with shoulder impingement. METHODS AND MEASURES: A 3-dimensional electromagnetic motion capture system was used to calculate the length of the pectoralis minor in 11 cadavers, using 2 measurement techniques. In addition, a measurement with the electromagnetic system using palpable landmarks was compared to a measurement with both a caliper and tape measure in vivo. RESULTS: In cadavers, a measurement using palpable landmarks was determined to be a valid measure of the actual muscle length visualized and measured following dissection. There was a high intraclass correlation coefficient and a small root-mean-square error between these 2 measures. High intraclass correlation coefficients were also calculated in vivo when measurements with the clinical instruments were compared with the electromagnetic device measures. CONCLUSION: A measurement using palpable landmarks for pectoralis minor length validly represents the muscle length in cadavers. A caliper or tape measure may be used clinically with high accuracy and may help clinicians determine the need for and the effectiveness of interventions for lengthening this muscle.     

Anatomic evaluation of the subcoracoid pectoralis major transfer in human cadavers

Subcoracoid transfer of the pectoralis major has recently been described as a reconstruction for subscapularis insufficiency. The purpose of this study was to examine the surgically relevant anatomy of this transfer. The importance of understanding this anatomy was recently highlighted to us following our encounter with musculocutaneous neuropraxia in 2 patients after transfer of the entire pectoralis major, one deep to the musculocutaneous nerve. Dissections were performed on 20 fresh, whole human cadavers in which the entire pectoralis major muscle, medial and lateral pectoral nerves, and musculocutaneous nerve were explored and quantified. The relationship between the pectoralis major and the conjoined tendon was studied in situ and after simulated transfers. The medial and lateral pectoral nerves were located far medial to the pectoralis major tendon insertion and appeared to be safe from injury as long as surgical dissection remained lateral to the pectoris minor and less than 8.5 cm from the humeral insertion. Transfer of the pectoralis major superficial to the musculocutaneous nerve created less tension than transfer deep to the musculocutaneous nerve. Because proximal innervation of the coracobrachialis and short head of the biceps is not an uncommon occurrence, a split pectoralis major transfer, release of the proximal musculocutaneous branches, or debulking of the pectoralis major muscle belly may be required in some instances to prevent tension on the nerve. Because of the variability and location of the musculocutaneous nerve, it should always be visualized operatively. Transfer of the pectoralis major tendon lateral to the biceps tendon appeared to best restore the muscle length-tension relationship.     

Functional pectoralis minor muscle flap transplantation for reconstruction of thumb opposition: an anatomic study and clinical applications

In this report, we present the results of an anatomic study on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers, in attempt to evaluate the feasibility of microsurgical transplantation of a part of the muscle for thumb opposition reconstruction. A series of five patients consequently underwent thenar reconstruction with the pectoralis minor muscle flap from December 2004 to October 2006. The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Follow-up assessment showed that the patients recovered functional opposition of carpometacarpal joint with 24 degrees of pronation, and a muscle power with M4 to M5. All patients were satisfied with the appearance of reconstructed thenar eminence. We recommend this new technique for thenar and opposition reconstruction in patients who have severe loss of thenar muscles, injury to the median nerve, and wish to improve the appearance of thenar eminence.     

Total mastectomy with complete axillary dissection.

A technique for total mastectomy with complete axillary dissection, which uses division of the insertion of the sternal portion of the pectoralis major muscle, preservation of its innervation, reconstruction after completion of the dissection and resection of the pectoralis minor muscle has been evaluated for 115 consecutive procedures. This modification facilitates a thorough axillary dissection, while preserving the cosmetic and functional benefits of the Patey operation.     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II, and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.     

The anatomy of the pectoral nerves and its significance to the general and plastic surgeon.

It has previously been shown that in 62% of patients the medial pectoral nerve courses through the pectoralis minor muscle to innervate the lower half or two thirds of the pectoralis major muscle. In the other 38% of patients, the medial pectoral nerve exits around the lateral aspect of the pectoralis minor muscle. The lateral pectoral nerve courses on the undersurface of the pectoralis major muscle, innervating the proximal one third or more of the muscle. Consequently, when the pectoralis minor muscle is removed in a modified radical mastectomy, or dissection between the two muscles is performed, there is partial deinnervation of the pectoralis major muscle with partial atrophy and a decrease in size. Further, if the lateral pectoral nerve also is injured or removed, it can result in total deinnervation of the pectoralis major muscle with more severe atrophy and fibrosis of the muscle. In cosmetic augmentations, when the breast implant is placed behind the pectoralis major muscle, that muscle is partially deinnervated. In this clinical situation, this is believed to be advantageous because it allows the breast to project better. This paper details the anatomy of the pectoral nerves and discusses the clinical implications of surgery in this region as it relates to the size and function of the pectoral muscles.     

Comparison of three stretches for the pectoralis minor muscle

Pectoralis minor adaptive shortening in healthy individuals is associated with altered scapular kinematics similar to the alterations demonstrated in individuals with subacromial impingement. This associative relationship suggests that stretching of the pectoralis minor may improve scapular kinematics and assist in the management of shoulder impingement. Several stretches for the pectoralis minor are used clinically, although it is not known which stretch optimally lengthens the muscle. The purpose of this analysis was to compare the mean length change for 3 pectoralis minor stretches. Fifty subjects without shoulder pathology were examined for the change in length of the pectoralis minor during 3 separate stretches by use of an electromagnetic motion-capture system. The stretches analyzed were a unilateral self-stretch, a supine manual stretch, and a sitting manual stretch. Each stretch was significantly different from the other two (df, 2/98; F ratio, 39.09; P < .00001), with the unilateral self-stretch demonstrating the greatest length change (2.24 cm), followed by the supine manual stretch (1.69 cm) and the sitting manual stretch (0.77 cm). Knowledge of the most effective method of elongating the pectoralis minor muscle may improve clinical decision making when targeting this anterior scapulothoracic muscle as part of intervention for or prevention of shoulder impingement.