指背动脉蒂逆行岛状皮瓣的应用解剖

目的：报道指背动脉蒂逆行岛状皮瓣设计的解剖学基础。方法：对12只新鲜尸体手标本分别经动脉灌注红色乳胶及动脉铸型标本对照观察，对掌背动脉及指背动脉进行显微解剖，根据其血管分布设计成指背动脉蒂逆行岛状皮瓣。结果：掌背动脉与指掌侧固有动脉在近节指骨底有交通支相连，掌背动脉的终末支-指背动脉，位于指背腱膜的两侧，一般不超过近节指骨中部，有小分支与指掌侧固有动脉的背侧分支在指背形成丰富的血管吻合网。结论：指背动脉与指掌侧固有动脉的吻合支丰富，可以其为蒂，设计成逆行岛状皮瓣，该皮瓣设计合理、血供可靠、操作简便，是手指末端软组织缺损修复较理想皮瓣。     

以示指桡掌侧筋膜皮支为蒂逆行岛状皮瓣的应用解剖

目的：为以示指桡掌侧固有动脉近侧指间关节附近的皮支为蒂的第2掌指背侧逆行岛状皮瓣修复示指指端缺损提供解剖学基础。方法：在32个手部血管铸型标本、血管灌注标本上，解剖观察示指桡掌侧固有动脉分支与示指桡背侧指背动脉的吻合，皮瓣供区血管、神经分布。结果：示指桡掌侧固有动脉在近侧指间关节附近发出皮支与示指桡背侧动脉在桡背侧有吻合，皮瓣供区有示指背．掌背静脉和示指桡背侧神经，并形成筋膜、静脉和皮神经血管网。结论：以示指桡掌侧固有动脉在近侧指间关节附近的筋膜皮支为蒂可形成第2掌指背逆行岛状皮瓣，是示指指端软组织缺损修复的较佳皮瓣。     

虎口掌侧动脉背侧穿支蒂跨区供血皮瓣的解剖基础

目的　探讨虎口掌侧动脉背侧穿支形态学特征,为虎口掌侧动脉背侧穿支皮瓣设计提供解剖学基础。 方法　用30侧灌注红色乳胶的成尸手标本,通过巨微解剖、血管铸型等方法,重点观测：①虎口背侧营养血管的起源、走行与分布;②虎口掌侧动脉背侧穿支与虎口背侧血管的吻合特点。另1侧灌注红色乳胶的新鲜标本进行摹拟手术设计。 结果　虎口背侧血供属多源性,由虎口掌侧动脉（示指桡掌侧固有动脉、拇指尺掌侧固有动脉）背侧穿支和虎口背侧动脉（第1掌背动脉）分支供养。①第1掌背动脉恒定起自桡动脉,走行于第1掌骨间隙,分出桡侧、尺侧和中间3个终支,有桡神经浅支发出的同名指背皮神经伴行;②虎口掌侧动脉向虎口背侧发出尺侧、中间和桡侧穿支,与第1掌背动脉分支形成恒定的吻合,营养虎口背侧皮肤。 结论　以虎口掌侧动脉背侧穿支为蒂,可形成跨区域供血虎口背侧皮瓣转位修复示指近侧段、鱼际部和拇指软组织缺损。     

第4掌背动脉逆行岛状皮瓣的解剖及临床应用

目的：通过活体及标本解剖观测，为第４掌背动脉逆行皮瓣的临床应用提供解剖学依据。方法：通过对４０例活体（８０侧手）用Ｄｏｐｐｌｅｒ血流探测仪检查第４掌背动脉的出现率。８例新鲜的成人手标本灌注红色乳胶，２例在第３指掌侧总动脉起点处加压灌美蓝。结果：第４掌背动脉的出现率为９６％。以其血供来源将其分为３型。其血供的基础是第４掌背动脉远近侧轴点处２条较粗大的皮支，皮支之间在筋膜层构成了丰富的网状血管结构，在指蹼处与指掌侧总动脉或分支之间有吻合支相连，设计以此吻合支为蒂逆行岛状皮瓣。临床应用１５例，皮瓣全部成活。结论：该皮瓣适宜于修复小指、环指远指节间关节以近的不同平面的皮肤缺损，特别适宜于小指脱套伤的修复。     

指固有动脉背侧支为蒂的逆行掌指背筋膜皮瓣的应用解剖

目的为指固有动脉背侧支为蒂的逆行掌指背筋膜皮瓣提供系统翔实的解剖学依据。方法14只新鲜成人尸体手标本,灌注红色乳胶,手术显微镜下解剖观测手背和2～5指指背血管的走行、分布、吻合情况及外径。结果手指近、中节每侧各有1～7支间接背侧皮支,2～8支背侧皮支。手指近节中段、近节远段、中节近段或中段每侧较为恒定的存在一支较粗大的指固有动脉背侧皮支,皮支平均外径通常≥0.30mm。掌背动脉终末段和远端掌深弓穿支的指背分支在近节指背与指固有动脉背侧皮支交通。不同节段指固有动脉背侧皮支在指背外侧缘交互吻合,在指背外侧缘形成一条营养血管链。结论以指固有动脉背侧支为蒂的逆行掌指背筋膜皮瓣解剖简单、快捷,旋转弧长,利于修复手指中远节较大面积的软组织缺损。     

大鱼际皮瓣的解剖学基础及临床应用

目的:介绍大鱼际皮瓣的血管解剖学基础,以及临床应用经验。方法:解剖20侧经动脉灌注红色乳胶的成人手标本,观察大鱼际皮肤的血供来源、走行、分支及吻合情况。临床切取3种不同设计的大鱼际皮瓣,修复拇指软组织缺损共计14例。结果:大鱼际皮肤的血供来源主要有4个方面:(1)由掌浅支或其发出的拇指桡侧指动脉发出的皮支;(2)来源于拇主要动脉的拇指桡侧指动脉发出的皮穿支;(3)拇指桡侧指背动脉向大鱼际桡背侧发出的皮支;(4)大鱼际深部血管发出的肌皮穿支。上述这些血管在大鱼际交织成网状,营养整个大鱼际皮肤。临床应用以掌浅支(弓)发出的拇指桡侧指动脉为血管蒂的大鱼际皮瓣4例,拇指桡侧指动脉穿支蒂皮瓣7例,大鱼际桡背侧筋膜血管蒂皮瓣4例,皮瓣全部成活,其中1例指动脉穿支皮瓣远端约4mm坏死,结痂后自行脱落。术后随访半年～2年,平均10个月,皮瓣血运、质地、弹性良好,外形美观。结论:三种皮瓣疗效可靠,是修复拇指软组织缺损的理想方法。临床上可依具体情况选择不同的方法来修复。     

尺动脉腕上皮支降支小鱼际皮瓣的解剖学基础

目的 为尺动脉腕上皮支降支小鱼际皮瓣修复手掌心皮肤缺损提供临床解剖学基础。 方法　自2018年5月至2019年5月,采用42侧上肢新鲜标本,其中28侧经肱动脉灌注红色乳胶并进行解剖,14侧经肱动脉灌注ABS后制作铸型标本,解剖观察尺动脉腕上皮支降支在小鱼际区的分支、走行、分布、交通和吻合形式,测量其外径。 结果 从豌豆骨到环、小指指蹼间画一连线,并将其分成3等份。结果显示每侧尺动脉腕上皮支降支发出14.5条分支,其中在远、中、近1/3段共发出皮支6.8支,交通支7.7支。各皮支在小鱼际浅筋膜内相互吻合,形成1~2级皮支链,皮支长(1.80±0.60)cm,直径(0.23±0.10)mm。交通支分别与深部的尺动脉掌深支、掌浅弓尺侧缘、尺侧指掌侧总动脉或小指尺掌侧动脉吻合,交通支长(1.60±0.50)cm,直径(0.16±0.06)mm。在近、远1/3段各有1~2支较大的交通支,是转位较理想的血管蒂。 结论 小鱼际皮瓣的尺动脉腕上皮支降支血管蒂位置恒定,皮瓣内皮支链丰富,皮肤结构与手掌心部位同源,是修复手掌心小面积皮肤缺损的较理想的供区之一。     

掌短肌皮瓣的应用解剖学

目的：为吻合血管的掌短肌皮瓣移植提供解剖学基础。方法：３０侧灌注红色乳胶成人上肢标本,观测掌短肌的形态,肌皮瓣的血供、神经分布。结果：掌短肌呈斜方形,其桡侧长２．２±０．８ｃｍ,尺侧长２．８±０．９ｃｍ,中部宽２．８±０．６ｃｍ,中部厚２．８±０．９ｍｍ。掌短肌为尺神经浅支支配,其浅面的皮肤为尺神经浅支和尺神经的尺动脉支支配。掌短肌皮瓣的动脉血供来源有４：即尺动脉本干、掌浅支的肌皮支和皮支、掌深支和小指尺侧固有动脉的肌皮支。其静脉回流为上述动脉的伴行静脉,汇入到尺静脉,以及与手掌尺侧皮肤相连的前臂尺侧静脉。结论：以尺动、静脉为血管蒂的掌短肌皮瓣的血供来源较多,可以利用尺神经浅支和尺神经的尺动脉支形成带感觉神经的皮瓣。是修复拇指指腹大面积缺损较好的供区之一。     

第2指蹼动脉吻合类型及其在手背逆行岛状皮瓣中的意义

目的：研究第２指蹼动脉的吻合类型,为临床以第１指掌侧血管为蒂的手背逆行岛状皮瓣转位提供解剖学基础。方法：使用２２只经血管灌注乳胶的手标本和３４只手动脉铸型标本,对第２指蹼动脉分支分布及与手掌侧和背侧动脉的连接形式等进行解剖观测。结果：第２指蹼动脉恒定存在,外径０．８±０．２ｍｍ,有１～２条伴行静脉。依其与指掌侧总动脉和掌背动脉的连接部位可分为：Ⅰ．中央型（６６．１％）;Ⅱ．掌侧偏型（２５％）;Ⅲ．背侧偏型（７．１％）;Ⅳ．双侧偏型（１．８％）。结论：①第２指蹼动脉吻合恒定存在,这是形成以手掌侧血管为蒂的手背逆行岛状皮瓣的解剖基础;②Ⅰ、Ⅱ型指蹼动脉可为皮瓣提供良好的血供,Ⅲ、Ⅳ型则欠佳     

改良指固有动脉背侧支皮瓣游离移植修复指端缺损

目的　报道应用带指固有动脉的指固有动脉背侧支皮瓣游离移植修复指端皮肤缺损的临床效果。 方法　2014年1月至2018年10月,23例23指指端皮肤软组织缺损,均伴有指骨外露,应用带指固有动脉的指固有动脉背侧支皮瓣游离移植修复。术中不用特意寻找指固有动脉背侧皮支,保留指固有动脉近节中远1/3处1cm往背侧的筋膜组织,连同指固有动脉一并切取,切除的指固有动脉予以指背静脉桥接修复,切取皮瓣面积为1.5cm×1.0cm～2.5cm×2.0cm,供区取前臂全厚皮片植皮修复。 结果　23例皮瓣全部成活,术后随访3～18个月,平均10个月,皮瓣质地佳,手指外形及感觉恢复良好,两点辨别觉为 8～14mm。皮瓣供区植皮愈合良好。 结论　运用改良指固有动脉背侧支皮瓣,可降低了切取难度,减少背侧支损伤可能,增加供血动脉吻合口径,降低吻合难度,是修复指端缺损一种较好的方法。     

Arterial anatomical basis of the dorsal digito-metacarpal flap for long fingers

Several flaps have been described to treat severe soft tissue defects of the finger dorsal side. Many authors studied vascular organization of the hand on its dorsal side; most of them insisted on deep vascularization into the intermetacarpal spaces, which is formed by the dorsal metacarpal arteries. Those dorsal metacarpal arteries are the anatomical support of many flaps, which do not preserve the dorsal interosseous muscles fascias. Only few authors described dorsal vascular organization at the level of the proximal phalanx; however, using a rotation point of a flap distally to the metacarpal head with a donor site on the dorsal aspect of the hand could cover all distal soft tissue defect of long finger. In order to determine the technical limitations of dorsal digito-metacarpal flap procedures, we studied number and location of arterial anastomoses between the reticular subcutaneous dorsal network and the rest of the vascularization at this level, which was formed by the deeper dorsal metacarpal arteries, common palmar digital arteries and proper palmar digital arteries, and between the dorsal digital arteries. Twenty-four long fingers from embalmed cadavers were studied after a reverse flow injection of colored latex and dissected layer-by-layer preserving the digital-metacarpal arterial network. At the level of the hand, the dorsal metacarpal arteries of the third and fourth intermetacarpal spaces were inconstant. When present, two or three arteries anastomosed in star shape with the reticular network. No such arterial anastomosis was observed proximally to the level of the intertendinous connections (junctura tendinorum) that bridge the extensor digitorum communis tendons. When no dorsal metacarpal artery was present, some communicant arteries arose from the common palmar digital arteries. Moreover, all the nutrient branches were more numerous distally to the intertendinous connections (junctura tendinorum). At the level of the metacarpophalangeal joints, the hand cutaneous network was always anastomosed with the dorsal cutaneous network. At the level of fingers, the dorsal cutaneous network was always supplied by four branches arising from the proper digital artery. Our study supported the reliability of dorsal digitometacarpal flaps, supplied by numerous palmodorsal digital anastomoses and by a rich plexiforme network joining the hand skin supply and that of the dorsal finger skin. During the procedure, we recommend limiting the surgical dissection of the flap at the level of the middle phalanx.     

中指主要血管神经的断面观测

用２７例成人中指作组织切片后，取近侧，中间和锭侧指横纹及相邻指横纹中点处的横断面切片，对指掌侧固有动脉，神经及静脉的位置，管径进行了观测。指掌桡侧固有动脉，神经在－Ⅰ，Ⅱ，Ⅲ，Ⅴ断面中的４，５区和ＩＶ断中３，４区内的出现率都高于９０％，它们纵径的平均值分别大于０．８０ｍｍ和１．３０ｍｍ。     

The arterial supply to the digits of the forelimb in the Bactrian camel (Camelus bactrianus)

The arterial supply of the digits of the forelimb of the Bactrian camel is described. The arteries supplying the digits were the palmar metacarpal and common palmar digital arteries III. The palmar metacarpal artery III was the continuation of the deep medial proximal metacarpal branch which was derived from the medial branch of the radial artery. It gave rise to a nutrient branch, medial branch, lateral branch and distal perforating palmar branch at the proximal end of the distal sixth of the cannon bone (fused third and fourth metacarpal bones). The common palmar digital artery III was the continuation of the median artery, which divided into medial and lateral branches. The medial branch of common palmar digital artery III which occasionally arose from the axial palmar proper digital artery III, after giving rise to the axial proximal proximal phalangeal branch, divided into the axial and abaxial palmar proper digital arteries III. The axial palmar proper digital artery III gave off the dorsoaxial distal proximal phalangeal, dorsoaxial proximal middle phalangeal, dorsoaxial distal middle phalangeal, palmoaxial middle phalangeal, palmoaxial distal phalangeal, dorsoaxial distal phalangeal branches, coronal artery and some digital tori branches. The abaxial palmar proper digital artery III gave rise to the abaxial proximal proximal phalangeal, dorsoabaxial distal proximal phalangeal, dorsoabaxial middle phalangeal, palmoabaxial middle phalangeal, palmoabaxial distal phalangeal, dorsoabaxial distal phalangeal branches, coronal artery and some digital tori branches. The lateral branch of the common palmar digital artery III in its origin, course, branching pattern and supply in the fourth digit was similar to the medial branch of common palmar digital artery III in the third digit.     

吻合指神经的指动脉逆行岛状皮瓣修复指腹缺损

目的：报道吻合指神经的指动脉逆行岛状皮瓣修复指腹缺损的解剖学基础及其临床应用。方法：对20具成人尸体40例手的指掌侧固有神经直径和分支进行了测量；并对39例患者的39指指腹缺损行吻合指掌侧固有神经的指动脉逆行岛皮瓣修复术。结果：（1）指掌侧固有神经平近节指横纹处理1．4－2．0mm，厚0．8－1．0mm；平末节指横纹处宽1．0－1．4mm，厚0．6－0．8mm。（2）近节掌侧支为4．4－5．3支，背侧支为3．8－4．0支；中节掌侧支为3．5－4．6支，背侧支为3．4－4．1支；末节终支为3．8－4．6支。（3）39例患指中38例一期成活，指腹饱满，外观理想，耐磨性好，两点辨别觉达5mm内，指腹感觉达S3以上。结论：吻合指神经的指动脉逆行岛状皮瓣修复指腹缺损，优于未吻合神经的术式。     

手指神经血管束的巨微解剖

在30例成人尸体的手上,对手指神经血管束进行了应用解剖学研究。手指掌侧的神经血管束位置恒定,神经横径和血管外径在掌指关节平面和第一指间关节平面间均相差约0.3mm。食指、中指和环指指背第一指节远侧半至指尖大部由指固有神经背侧支分布。认为,手指神经和血管的主干横径变化不大,有利于修复。在手指部作手术切口时,应注意保护指固有神经背侧支。     

示指血管神经的断面观测

用２７个成人示指作组织切片后，选取近侧、中间和远侧指横纹及相邻横纹１／２处的横断面切片，对指掌侧固有动脉、静脉和神经的位置、形态进行了观测。     

Anatomic basis of ulnar index metacarpal reverse flow vascularized bone graft for index distal bone loss

Well-known advantages of vascularized bone grafts led us to determine the anatomical basis of a metacarpal vascularized bone graft to find a solution for distal index bone loss. Seventeen adult human hands from fresh cadavers were dissected and analyzed. For each hand, we studied the second dorsal metacarpal artery, the ulnar dorsal proper digital artery of index, and the ulnar palmar proper digital artery of the index. Location, diameters, origins, and anastomoses were observed, and at the end, the vascularised bone graft was raised. The second dorsal metacarpal artery was present in all hands, always arising from the dorsal carpal arch with a 1-mm mean diameter. The ulnar dorsal proper digital artery of index was isolated on all dissections, with a subcutaneous location on the ulno-dorsal side of the proximal phalanx. The mean diameter of ulnar dorsal proper digital artery at the level of index proximal phalanx was 0.4 mm. We found anastomotic branches between the ulnar dorsal and palmar proper digital artery of index at the level of the proximal phalanx which permitted us to elevate a vascularised bone graft. We succeeded in removing the graft in all specimens. Its pivot point was always more distal than the middle of the proximal phalanx. The arc of rotation allowed the graft to reach the distal phalanx in 80% of the cases. This anatomical study has demonstrated the theoretical possibility of a reversed pedicled bone graft taken from the ulnar neck of the second metacarpal. This graft brings the following benefits: (a) the use of a minor vascular axis, (b) a surgical technique with a dorsal approach allowing the elevation and the use of the graft at the same time. It can be used on the index for failures of DIP joint arthrodesis, huge chondroma, or traumatology.     

手部血管的应用解剖学研究

对66侧(左31,右35)成人手的血管进行了系统的观察。平第三掌骨处掌浅弓外径1.79±0.5(1.0—2.7)mm;掌深弓1.4±0.29(0.9—1.9)mm。掌浅弓分支的变异观以小指尺侧动脉起端多见。掌深弓除传统介绍外尚见到由桡动脉和小指尺侧动脉分支所形成。并就指掌侧总动脉、指掌侧固有动脉局部位置及其有关变异结合实际应用进行了讨论。     

Anatomical basis for functional treatment of dorsolateral dislocation of the proximal interphalangeal joint

Dorsolateral dislocation of the proximal interphalangeal (PIP) joint is a common injury to the hand. Closed reduction of the dislocation anatomically realigns the avulsed ligaments; thus patients may be managed non-operatively. Standard treatment involves placement of a dorsal splint to prevent hyperextension and lateral stresses. This allows early active motion of the PIP joint while preventing a flexion contracture. In this fresh cadaver study, the PIP joint in 24 fingers was dorsolaterally dislocated. Four digits had to be excluded from the investigation due to a fracture dislocation with a bony fragment of >40% of the articular surface of the middle phalanx. After closed reduction, seven digits were further studied using the cryosection technique described by Kathrein et al. (1996, Clin. Anat. 9:227-231) to demonstrate the position of the avulsed palmar plate. In another 13 joints, the torn ligaments were examined by gross dissection. In 10 degrees of finger flexion, the avulsed palmar plate lay at its previous attachment to the base of the middle phalanx. The collateral ligament, ruptured at its attachment to the side of the head of the proximal phalanx, returned to its original position and was not interposed in the joint. The split between the collateral ligament and the accessory collateral ligament was also closed. Our data suggest that the ligamentous structures of the PIP joint, namely the palmar plate and collateral ligaments, typically return to their anatomic positions upon simple closed reduction of dorsolateral dislocations in fresh cadavers.