携带皮瓣的胸小肌移植重建拇对掌功能的应用解剖研究

目的:为临床开展携带胸外侧皮瓣的胸小肌移植重建拇对掌功能手术提供解剖学依据。方法:在10具20侧的成人胸部标本上,对以胸外侧动脉为共干血管蒂发出的胸外侧皮动脉和胸小肌支这种血管构造及其出现概率、左右两侧差异进行解剖学观测。结果:胸外侧动脉较恒定的发出皮支和肌支分别营养胸外侧皮肤和胸小肌,这种血管构造出现率为80%,左右两侧无明显差异(P>0.05)。胸外侧动脉主干外径(1.53±0.34)mm,蒂长(4.88±1.20)cm,皮支起始部外径(1.06±0.21)mm,长度(3.65±0.61)cm,肌支起始部外径(1.15±0.20)mm,长度(2.94±0.78)cm,静脉伴行于同名动脉。结论:利用携带胸外侧皮瓣的胸小肌作为移植供体重建拇对掌功能的术式是可行的。     

功能性游离肌肉移植重建部分上肢功能的临床应用

目的　探讨应用3种功能性游离肌肉移植重建部分上肢功能手术的疗效,结合相关解剖基础分享临床经验。 方法　2010年1月至2018年12月,应用功能性游离股薄肌、背阔肌、胸小肌移植重建上肢功能手术治疗患者39例,包括重建屈肘和屈指功能6例,屈指功能11例,拇对掌功能22例。根据肢体情况选择不同的动力神经和供血血管,术中调节移植肌肉于最佳肌张力水平,重建移植肌肉的神经和血运。 结果　功能性游离肌肉完全成活37例,重建的上肢功能恢复良好,优、良率达94.8%;重建功能未恢复者2例,其中1例出现移植肌肉和皮瓣部分坏死。 结论　应用功能性游离股薄肌、背阔肌和胸小肌移植重建上肢功能手术效果满意,是治疗各种原因导致的上肢肌肉缺损及严重肢体障碍的有效方法。     

胸小肌移植重建拇对掌功能的神经解剖学研究

目的为临床应用胸小肌移植重建拇对掌功能手术过程中神经吻接提供解剖学依据。方法解剖观测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,确定手术过程中神经吻接。结果胸内侧神经为胸小肌的主要支配神经,其在第3肋间隙近锁骨中线处入胸小肌,有髓神经纤维计数为(868±130)根;尺神经深支穿出内侧肌间隔后在第3、4掌骨间隙分别发出两明显肌支,其有髓神经纤维计数分别为(394±49)根、(708±78)根;P3L4(尺神经深支在第4掌骨间隙的分支,其分布于第3骨间掌侧肌和第4蚓状肌)与胸内侧神经、正中神经返支有髓神经纤维数目都比较接近。结论胸小肌移植重建拇对掌功能手术中,在切取胸小肌时以胸内侧神经作为供体神经,以第3肋间隙与锁骨中线交点为标记寻找该神经;尺神经深支中P3L4肌支与胸内侧神经吻合最匹配。     

尺侧腕伸肌-拇短伸肌腱移位重建拇对掌功能的应用解剖

目的:研究拇对掌肌、拇短展肌的解剖学特点,探讨符合人体生物力学的拇对掌功能重建的方法。方法:对20侧新鲜成人上肢标本,解剖拇对掌肌、拇短展肌,并建立尺侧腕伸肌-拇短伸肌移位重建拇对掌功能的手术模型。结果:拇短展肌肌纤维方向沿第1掌骨纵轴方向,拇对掌肌肌纤维方向与第1掌骨成一定角度。尺侧腕伸肌-拇短伸肌移位后,测量拇指远侧横纹中点到第3掌骨长轴与掌远侧横纹交点之间的最大距离可达(5.9±0.7)cm。结论(:1)尺侧腕伸肌长度、肌力足以重建拇对掌功能,拇短伸肌腱止点恒定,联合移位后其作用方向与拇短展肌方向一致,且旋前角度足够。(2)以尺侧腕伸肌-拇短伸肌移位重建拇对掌功能是一种符合拇对掌功能生物力学的简单有效的方法。     

拇短展肌对拇指指骨间关节背伸作用的解剖学研究

目的 为解决胸小肌移植重建拇对掌功能术后出现拇指指骨间关节屈曲畸形提供解剖学依据并寻找解决办法.方法 在15具尸体手标本上,使拇指处于对掌位时,测量拇指指骨间关节在拇短展肌未切断及切断两种情况下的自然屈曲角度;同时,通过外力作用使拇指指骨间关节分别屈曲处于45°及60°时,分析拇短展肌对拇指指骨间关节屈伸功能的影响.结果 拇指处于对掌位时,拇短展肌在未切断及切断两种情况下,拇指指骨间关节自然屈曲角度分别为(13.30±2.13)°及(24.03±1.25)°;同时,使拇指指骨间关节屈曲处于45°时,所用外力分别约(0.50±0.08)N及(0.22±0.07)N,而使拇指指骨间关节屈曲处于60°时,所用外力分别约(1.48±0.09)N及(1.15±0.04)N.结论 拇短展肌对拇指指骨间关节主要起背伸作用,因此胸小肌移植重建拇对掌功能时,应同时重建拇短展肌功能,才有可能纠正在拇对掌功能重建术后出现的拇指指骨间关节屈曲畸形.     

应用组合组织瓣一期修复手部毁损伤及重建部分手功能

目的:总结应用组合组织瓣移植一期修复手部毁损伤及重建部分手功能的临床疗效.方法:对24例手部毁损伤患者,应用吻合血管的皮瓣、(足母)甲瓣、组合移植一期修复创面及拇、手指再造重建部分手功能.结果:所有移植组织瓣全部成活.术后随访3～24个月,再造拇、手指功能优良率82.60%.结论:一期组合组织移植具有疗程短、手功能恢复好的优点,是治疗手部毁损伤的较好方法.     

大鱼际部血管影像学研究及其临床意义

目的：通过血管造影CT扫描的方法了解大鱼际部的动脉血管分布情况。方法：2010年2月至2011年12月我院对临床20例手部外伤的患者实施血管造影,同时用CT三维成像技术获取大鱼际部血管的影像学资料,观察其动脉血管分布情况。结果：20例患者的拇指背侧动脉在第一掌骨桡背侧恒定出现,拇指桡侧指固有动脉来源不恒定：25％（5／20）单独由掌浅支或掌浅弓发出,55％（11／20）由掌浅支与拇主要动脉在掌指关节附近汇合而成,20％（4／20）直接由拇主要动脉发出。结论：拇指背侧动脉多数位置恒定,拇指桡侧指固有动脉来源不恒定,用后者设计大鱼际部逆行皮瓣时应考虑血管分布情况。     

第一骨间背侧肌肌内神经解剖学

目的:为临床带血供的第1骨间背侧肌远端肌支神经肌蒂转移修复拇对掌功能手术提供供区肌肉神经、血管相关解剖学依据,评估切取该肌远端肌支对供区的影响.方法:手部固定标本,采用显微解剖方法,观察第1骨间背侧肌形态和神经支配情况.通过再改良Sihler's染色法对第1骨间背侧肌进行肌内神经染色.结果:第1骨间背侧肌神经来源于尺神经深支,在进入第1骨间背侧肌前分成2支.其中近端分支主要分布于肌腹的上2/3,远端分支主要分布在肌腹的下1/3.结论:切取第1骨间背侧肌远端肌支神经肌蒂转位修复拇对掌肌的功能是可行的,其对供区功能的影响较小.     

第1骨间背侧肌支神经肌蒂转移修复拇对掌肌功能应用解剖

目的探讨带血供的尺神经深支第1骨间背侧肌支神经肌蒂转移修复拇对掌肌功能术式的可行性,为临床应用提供解剖学基础。方法新鲜和固定上肢标本各10例,在手术显微镜下解剖观测尺神经第1骨间背侧肌支及其营养血管的分支、分布情况,据此设计带血管的第1骨间背侧肌支神经肌蒂转移修复拇对掌肌功能的手术方式。结果尺神经深支第1骨间背侧肌支进入肌肉前分出2个分支,分别由肌肉的上下1/3处进入肌肉;远端肌支横径(1.5±0.2)mm,可无损伤分离长度为(2.8±0.3)cm,足够到达受区,其营养血管发自第1或第2掌心动脉,起始处直径为(0.8±0.3)mm。结论带血供的尺神经第1骨间背侧肌支神经肌蒂转移修复拇指对掌肌功能的术式具有可行性,该术式实用性、有效性有待临床进一步验证。     

掌长肌内神经血管的解剖学观察及其临床意义

目的：观察掌长肌肌内神经血管解剖分布,探讨该肌肉能否被分割为若干个功能单位,以提供新的功能性骨骼肌游离移植供区.方法：解剖10具10%福尔马林固定的成人尸体共20侧掌长肌,观察其肌外神经血管的分布形式.10具新鲜成人尸体标本共20侧掌长肌,一侧的掌长肌完整剥离后用Sihler＇s染色法行肌内神经的染色,另一侧掌长肌用30%硫酸钡、乳胶混悬液血管灌注并行X线钼靶摄片.而后对照观察神经、血管在肌内分布及其关系.结果：掌长肌血供多为尺侧返动脉和尺动脉肌支,4侧出现肱动脉肌支.其神经支配来自正中神经发出的神经支.该支在进入肌肉前多为1支,有动脉伴行,构成神经血管束.尺侧返动脉肌支和正中神经分支在肌内的分布区域大致吻合.结论：根据掌长肌肌内神经血管在肌内分布的不同情况,可将其分为一个近端和两个远端的3个功能单位,供节段性游离肌肉移植.     

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。     

Medial and lateral pectoral nerves: course and branches

During modified radical mastectomy or cosmetic surgery, denervation of the lower part of the pectoralis major frequently occurs and may reduce muscle spasm, with consequent better reconstruction of the breast. The aim of this study was to determine the relationship between the pectoral nerves and the pectoral muscles. Eight unembalmed female cadavers were dissected and vascular and radiologic studies performed. The lateral pectoral nerves showed a constant course, parallel to the thoraco-acromial vessels. They coursed for 55 +/- 7 mm inferomedially on the deep surface of pectoralis major, under its fascia. The medial pectoral nerves showed two main patterns of branching, which correlated with the extent of the costal attachments of the pectoralis minor muscles. In pattern A (56%), associated with costal attachments narrower than 6.0 cm, the nerve pierced the deep aspect of the pectoralis minor as a single trunk, ramified in the muscle, and gave some branches that appeared on the superficial aspect to enter the pectoralis major. In pattern B (44%), associated with costal attachments wider than 6.6 cm, the nerve divided before entering pectoralis minor and its branches passed through the muscle or round its lower border to reach pectoralis major. The most medial branch of the medial pectoral nerve directed to the pectoralis major muscle emerged from pectoralis minor at the third intercostal space in the midclavicular line, a mean of 10.3 cm lateral to the margin of the sternum. Knowledge of the relationship between the extent of the costal attachment of pectoralis minor and the two patterns of branching of the medial pectoral nerve may be useful when performing elective denervation of the major pectoralis muscle.     

Bilateral asymmetric deficiency of the pectoralis major muscle

We observed a rare, bilateral congenital deficiency of the pectoralis major muscle in a 72-year-old female cadaver in our gross anatomy dissection laboratory. The outward appearance of the anterior thoracic wall, which included well-developed breasts, revealed no obvious abnormalities. Upon dissection, the following features were observed: 1) on the left side, the sternal portion of the sternocostal head of the pectoralis major muscle was absent, the costal portion of the sternocostal head and the clavicular head were both well developed, a normal pectoralis minor was present, and the deltoid and subclavius muscles were not hypertrophied as is often the case when the pectoralis major muscle is deficient; 2) on the right side, the entire pectoralis major muscle was absent and the pectoralis minor, deltoid, and coracobrachialis muscles were infiltrated with connective tissue and fat; and 3) on both sides, the lateral pectoral nerves were absent and the medial pectoral nerves were present. The absence of the lateral pectoral nerves suggests that the deficiencies in the pectoralis major muscles are congenital malformations resulting from a developmental failure of the embryonic muscles rather than a sequel to polio or Poland's syndrome.     

胸大肌腹部的显微外科解剖学研究

目的：为在整形外科领域中更加合理和有效地使用胸大肌提供解剖学依据。方法：对12例（24例）灌注红色乳胶的成人尸体标本的胸大肌血管、神经进行显微解剖观察和测量。结果：胸大肌腹部在形态学上具有相对的独立性，全长22.7cm，中段宽6.0cm，中段厚3.3mm，腱长3.2cm；动脉外径1.98mm，起点至肌门长度4.9cm；神经的横径1.71mm，从起点至肌门的长度5.5cm。结论：单独地使用胸大肌腹部不仅存在可能性，而且具有可操作性。     

Biometry of thenar muscle origins on the flexor retinaculum

The transverse carpal ligament (TCL), the main part of the flexor retinaculum, serves as an anchor for the thenar muscles: abductor pollicis brevis (APB), superficial head of the flexor pollicis brevis (sFPB), and opponens pollicis (OPP). Biomechanically, the thenar muscles rely on their TCL anchoring to transmit muscle contractions distally for thumb force and motion production, and reciprocally, muscle contraction interacts with the TCL at the proximal end through the origins. However, scarce knowledge exists regarding the distribution pattern of the thenar muscle origins. The purpose of this study was to understand the anatomical interface between the thenar muscles and TCL by examining the origin distributions of the individual muscles. Ten cadaveric specimens were dissected for digitization of the muscle origins and TCL volar surface. Digitized data were used for mesh reconstruction and calculation of surface areas and centroids. The origin areas for APB, sFPB, and OPP were 105.8 ± 30.3, 64.6 ± 15.2, and 245.9 ± 70.7 mm², respectively. The surface area of the TCL was 386.2 ± 86.9 mm². The origin areas of APB and OPP on the TCL were comparable, 18.4 ± 4.8% and 17.3 ± 9.6% of the TCL area, respectively. The origin locations for APB, sFPB, and OPP were in proximal-radial quadrant of the TCL, on distal aponeurosis outside the TCL, and around the ridge of trapezium, respectively. The knowledge of the anatomical interface provides a foundation for the understanding of biomechanical interactions between the muscles and ligaments and pathomechanical implications.     

Anatomical study on 2 cases of the congenital partial defect of pectoralis major and minor muscles

2 cases of the defect of pectoralis major muscle observed in male cadavers allocated for routine dissection were investigated anatomically, especially on the nerve supply for the defected muscles. In both cases, one on the left and the other on the right side, pectoralis major muscle was defected, the clavicular portion and a small part of sternocostal portion only persisting. Meanwhile, the ipsilateral pectoralis minor muscle was defected in the first case to be a string-like muscle band and was missing in the second case substituted by a membrane which seemed not to be the degenerated same muscle. Both the lateral and medial pectoral nerves supplied the pectoral muscles in the first case. One of rami of the medial pectoral nerve was distributed unusually to the most lateral part of the persisted sternocostal portion. Only the lateral pectoral nerve existed in the second case. In both cases nerves derived from 2 caudal segments, C8 and Th1, were lacking or poor. However, it was suggested that the defect of the muscles was not due to the nonparticipation of these nerves but due to the failure of caudal growth of the pectoral premuscle mass in a five-week embryo (Lewis 1901).     

The thenar muscles

Examination of the thenar muscles in 30 anatomical preparations of the hand have shown that the abductor pollicis brevis, the opponens pollicis, and the adductor pollicis muscles are made up of several muscle bellies. The number and insertions of these bellies are varied. Both heads of flexor pollicis brevis do not originate from any particular muscle belly. The superficial head of this muscle always inserted into the head of the thumb metacarpal, either completely, or, some of the fibres of the dorsal aponeurosis of the thumb were attached to the base of the proximal phalanx. Furthermore the anatomy of the abductor pollicis brevis muscle was related to the presence of a tendinous slip from abductor pollicis longus. These variations could have an influence on proprioception in the thumb ray.     

A study on the communication between the pectoral nerve and the extramural nerve branches of the intercostal nerves]

Kumaki et al. (1979) defined the extramural nerve as the rudimentary sensory nerve which appeared on the upper thoracic wall; it branched off the root of the lateral cutaneous nerve of the second, third or fourth intercostal nerve, ran inferomedially adhering to the fascia of the intercostalis externus muscle and ended supplying the membrane covering the adjacent rib. They also stated that the extramural nerve (Rxm) occasionally became a cutaneous nerve which pierced the pectoralis muscles and supplied the skin covering the thoracic wall similar to the lateral cutaneous nerve (Rcl) or the anterior cutaneous nerve (Rca). Further, they proposed that the muscular nerves to the obliquus externus abdominis muscle which are usually situated below the fifth rib might be considered a part of this Rxm series. Although the definition of Rxm is still not widely accepted, Rxm is thought to be a key morphological factor influencing the variations of peripheral nerve arrangement on the thoracic wall. In the student course of gross anatomy dissection at Iwate Medical University School of Medicine during the years 1987-1991, three cases of Rxm communicating with the pectoral nerve and supplying the pectoralis major muscle were observed. Some cases have been reported in which Rcl innervates part of the pectoral muscles. However, the communication between the pectoral nerve and Rxm has not yet been discussed. Therefore, to clarify the morphological significance of the communication between Rxm and the pectoral nerve, the branching pattern and the distribution of the pectoral nerves were extensively investigated and the intramuscular nerve supply of some pectoral nerves, especially the pectoral nerves which communicated with Rxm, was examined in detail under a stereomicroscope. The results are summarized as follows: 1. In the first case, Rxm of the second intercostal nerve originated from Rcl, ran inferomedially adhering to the fascia of the intercostalis externus muscle and pierced the origin of the pectoralis minor muscle at the third intercostal space. Then Rxm turned superolaterally to communicate with a pectoral nerve which originated from the loop composed of the lateral and medial pectoral nerves and passed inferior to the pectoralis minor muscle. After communication, the pectoral nerve with Rxm supplied the caudalmost part of the sternocostal portion of the pectoralis major muscle. In the second case, a similar branch of Rxm of the second intercostal nerve passed inferior to the pectoralis minor muscle.(ABSTRACT TRUNCATED AT 400 WORDS)