尺神经及其血供在肘管综合征手术中应用解剖研穷

目的观察肘部尺神经及其血供,为尺神经前移术治疗肘管综合征提供解剖学基础。方法50侧成人上肢标本观察测量肘部尺神经及其血供情况。结果肘部尺神经血供有3个来源:尺侧上副动脉(IUCA)、尺侧下副动脉(IUCA)和尺侧返动脉后支(PURA),分别与尺神经伴行长度为(15.1±2.0)cm、(5.0±1.1)cm和(6.4±1.2)cm;尺神经在肘部发出1～2支关节支,2～3支肌支。结论行尺神经前移术治疗肘管综合征时保护尺神经及其血供是完全可能的。     

带尺侧上副动脉尺神经转位的解剖及临床意义

目的为临床上带血管蒂的尺神经移植在健侧颈7移位治疗臂丛根性撕脱伤中的应用提供解剖学依据。方法取新鲜经动脉灌注红色乳胶的成人上肢标本22侧进行显微解剖,观察尺神经外部营养动脉的来源。另取患骨肿瘤而截肢新鲜成人上肢6侧作仅保留尺侧上副动脉的尺神经游离,采用动脉灌注墨汁和尺神经组织切片的方法,观察尺侧上副动脉对尺神经内部血供营养的范围。结果尺神经在腋部由胸外侧或腋动脉的分支供应,在内侧肌间隔后方由尺侧上副动脉供应,在尺神经沟由尺侧上副动脉与尺侧返动脉后支的吻合支供应,在前臂由尺侧返动脉和尺动脉的分支供应。尺侧上副动脉灌注墨汁后,尺神经腕部、手背支及腋部的神经束内微血管被墨汁充填。结论以尺侧上副动脉的起始处为血管蒂部旋转点,尺神经可提供平均为(46.5±2.6)cm的有血供的移植长度,可经胸前皮下隧道逆向转位与对侧颈7神经根吻合。以尺侧上副动脉为血供的尺神经移植的设计是合理的。     

尺神经血液供应神经前置的解剖分析

目的对肘部供应神经、尺神经分支、尺侧上副动脉灌注尺神经的长度、肘部前内侧深筋膜血供等情况进行解剖学分析。方法对10具正常成人新鲜尸体进行解剖,观察肘部神经分支、血液供应。通过对新鲜尸体进行模拟尺神经的手术操作过程,主要是采用尺神经松解前置的方法,将尺神经进行充分的手术,游离尸体肘部后侧神经,同时观察肘部神经供养血管,最后再进行前置,这样就能够合理地测量出尺神经能够达到的最大前置距离。深筋膜动脉采用肘动脉灌注墨汁,同时将尺神经组织切片的方法观察足侧上副动脉对尺神经内部血供营养的长度。结果尺神经的营养血供、腋部内侧肌间隔后方、尺神经沟、前臂部。通过手术测试发现动脉和神经的伴行距离分别是15.0 cm、5.0cm和5.5 cm,神经的起点距离肱骨内上髁的距离,通过测试分别是15.5 cm、6.0 cm和5.5 cm。通过对新鲜的尸体进行手术后,游离的神经可以和尺神经一起跨过内侧的上上髁向桡侧方向,前置的距离最少也可以达到7 cm。结论行尺神经深筋膜瓣下手术,至少应该保留尺侧上或是尺侧下的副动脉,从而达到手术的目的。应依据任意皮瓣原则进行深筋膜瓣的制作。     

带血管蒂尺神经前移治疗肘管综合征的基础与临床应用研究

目的:报道带血管蒂尺神经前移术治疗肘管综合征的解剖基础和临床应用效果。方法:20侧福尔马林固定的成人尸体上肢标本观测尺神经在肘部的血供。35例肘管综合征患者采用带血管尺神经前移术治疗,检测术中尺神经的血氧饱和度(SpO2)及其手术前后肘部运动神经传导速度(MCV)变化。术后随访2.5年。结果:肘部尺神经的营养血管主要来自尺侧上副动脉(SUCA)、尺侧下副动脉(IUCA)和尺侧返动脉(PURA)后支。3条动脉的起点距肱骨内上髁的距离分别为:(15.0±1.5)、(4.6±1.3)和(6.0±0.8)cm;与尺神经伴行长度分别为:(16.5±2.5)、(5.2±1.1)和(6.6±1.4)cm。有30%(6侧)IUCA缺如。35例患者均得到随访。术中SpO2检测显示,SUCA、IUCA和PURA均保持通畅组尺神经SpO2为(90±2.5)%。与之相比,阻断2支后尺神经SpO2明显降低(P<0.05)),均阻断后进一步降低(P<0.05)),保留2支则无显著变化(P>0.05))。电生理检测显示术后MCV较术前均显著提高(P<0.05))。临床结果按中华医学会手外科学会上肢功能评定试用标准进行评价,优良率为94%。结论:带血管蒂尺神经前移术是治疗肘管综合征的可行、有效的方法。     

尺神经手背支营养血管皮瓣的应用解剖

目的 :为带尺神经手背支营养血管的皮瓣提供形态学基础。方法 :在 3 0侧成人上肢标本上 ,观测尺神经手背支营养血管及其与周围皮肤的供血情况。结果 :尺神经手背支的血供近侧端来自尺动脉腕上皮支降支 ,起始处外径为 ( 0 .9± 0 .3 )mm ;远端为第 4或第 3掌背动脉。起始处外径分别为 ( 0 .6± 0 .2 )mm和 ( 0 .7± 0 .2 )mm。其神经支在神经束间和神经旁相互吻合成纵行血管网 ,并借分支与筋膜皮支构成丰富的皮下筋膜血管网。结论 :以尺神经手背支及其营养血管为蒂可形成手背尺侧筋膜皮瓣 ,可顺行或逆行转位修复邻近部位的组织缺损。     

肘内侧入路的临床应用解剖及其意义

目的:为肘内侧入路手术避免损伤重要结构提供解剖学基础。方法:选教学用的固定尸体标本24具(男18女6)48侧,按手术入路层次,对肘内侧入路的相关血管神经进行解剖学观测。结果:(1)臂内侧皮神经于臂中部的内侧面浅出,直径为(1.05±0.35)mm;前臂内侧皮神经于臂内侧中下1/3肱二头肌内侧沟伴贵要静脉浅出,直径为(1.50±0.55)mm。(2)尺神经干在肘部发出1~3肘关节支、1~4尺侧腕屈肌支和1~4指深屈肌支。(3)尺侧上副动脉、尺侧下副动脉和尺侧返动脉后支从肱动脉的起点处至尺神经垂直距离分别为(1.65±0.35)cm、(2.43±0.54)cm、(1.86±0.41)cm;与尺神经伴行至内上髁的距离分别为(14.38±1.82)cm、(4.51±1.16)cm、(5.91±0.67)cm。肘部附近尺侧下副动脉和尺侧返动脉后支与尺侧上副动脉在尺神经外膜相吻合。结论:(1)肘内侧入路浅层必须寻找和保护臂内侧皮神经和前臂内侧皮神经;(2)肘内侧入路保护尺神经血供及其肌支是临床手术成败的关键。     

上肢皮神经及其营养血管皮瓣的应用解剖

目的：为上肢皮神经及其营养血管为蒂的岛状皮瓣提供解剖学依据。方法：在34侧经动脉灌注红色乳胶的成人上肢标本上,解剖观察了上肢皮神经及其营养血管的来源、走行、分布、吻合及外径;2侧成人新鲜上肢标本墨汁灌注,观测营养血管的墨染范围。结果：上肢所有皮神经都有来源于知名血管的营养血管伴行,在神经旁形成纵向血管链,除营养神经外,发出众多皮支深筋膜血管网、皮下血管网广泛吻合营养皮肤。结论：以上肢皮神经及其营养血管为蒂可设计顺利或逆行岛状皮瓣。     

吻合臂内侧皮神经及其血管筋膜皮瓣的解剖与临床

目的:为带臂内侧皮神经及其营养血管筋膜皮瓣提供形态学基础。方法:在32侧成人上肢标本上,观测臂内侧皮神经营养血管及其周围皮肤的供血情况。结果:臂内侧皮神经的血供为尺侧上副动脉肌间隔皮支、肱动脉肌间隔皮支和尺侧下副动脉肌间隔皮支,起始处外径分别为1.0mm、0.6mm和0.7mm,穿出深筋膜前长为1.5cm、1.1cm和1.2cm。其神经支在神经束间或神经旁相互吻合构成丰富的血管网,并借分支与筋膜皮支所形成的皮下筋膜血管网沟通。结论:可设计成带臂内侧皮神经及其营养血管的筋膜皮瓣,顺行或逆行转位修复邻近部位的软组织缺损。     

双轴点动脉蒂桡神经浅支移位术的解剖学研究

目的 :为以桡侧副动脉和桡侧返动脉为动脉蒂的双轴点桡神经浅支折叠移位治疗上肢长段神经缺损提供解剖学基础。方法 :通过解剖 2 0侧灌注红色乳胶的新鲜成人上肢标本 ,观测桡神经浅支的血供 ,分别对桡神经浅支、正中神经、尺神经作不同横断面切片 ,观测神经纤维数 ;测量腕部桡神经浅支与尺神经手背支和正中神经间的距离。结果 :①桡侧副动脉终支与桡侧返动脉升支恒定地存在网状血管吻合。桡侧副动脉走行中发 (2 .7± 1.2 )支 ,桡侧返动脉呈扇形发 (3 .7± 1.9)支的滋养动脉分布于桡神经浅支外膜。②桡神经浅支自然分束可达肱骨内、外髁连线 (又称Huelter′s线 )上 (5 .3± 1.2 )cm ,强行分离长度为(2 .5± 1.1)cm ,可切取长度超过 2 4cm。③桡神经浅支平均神经束数与上臀正中神经之比为 1∶3 .14 ;与上臂尺神经之比为 1∶2 .42。④桡神经浅支在腕部至尺神经手背支的距离为 (3 .4± 1.2 )cm ,至正中神经的距离为 (5 .6± 1.3 )cm。结论 :桡神经浅支具有双重血供来源。本术式既可治疗上肢长段神经缺损 ,亦可恢复供区神经支配区的感觉功能。     

以皮神经及营养血管为蒂臂内侧皮瓣的应用解剖

目的：为带臂内侧以神经及其营养血管筋膜皮瓣提供形态学基础。方法：在３２侧成人上肢标本上,观测臂内侧皮神经营养血管及其周围皮肤的供血情况。结果：臂内侧皮神经的血供来自尺侧上副动脉肌间隔皮支、肱动脉肌间隔皮支和尺侧下副动脉肌间隔皮支,起始处外径分别为１．０ｍｍ、０．６ｍｍ和０．７ｍｍ,穿出深筋膜前长为１．５ｃｍ、１．１ｃｍ和１．２ｃｍ。其神经支在神经束间或神经旁相互吻合构成丰富的血管网,并借分支与筋膜     

神经生长因子对周围神经损伤后再生和修复的实验研究

手术切除５ｍｍ兔的尺神经，在两断端间连接肌桥并套装硅胶管，形成一个封闭腔，向腔内注入神经生长因子。间隔不同时间取尺神经桥接区、桥接区近段、远段、尺神经的脊髓投射节段和相应脊神经节，用光镜和电镜观察神经溃变和再生情况并作图像分析；用酶标示踪和电生理方法检测神经通路的重建状况。结果显示，周围神经离断后，肌束桥接并用硅胶管套装后注入外源性神经生长因子，可明显地促进离断神经的再生和修复。     

Intramuscular Martin-Gruber anastomosis

The incidence and morphology of the intramuscular Martin-Gruber anastomosis are presented based on the study of 118 human cadavers (55 male, 63 female). The Martin-Gruber anastomosis was found in 25 (21.2%) of the 118 cadavers. It occurred in 11 (20%) of the 55 male cadavers (4 bilateral, 7 unilateral; 5 left and 2 right) and in 14 (22.2%) of the 63 female cadavers (2 bilateral, 12 unilateral; 8 left and 4 right). Therefore, the Martin-Gruber anastomosis was found in 31 (13.1%) of the 236 upper limbs. According to a recent classification (Rodríguez-Niedenführ et al., 2000), pattern I was found in 29 cases (93.5%), corresponding to Type A in 13 (41.9%), Type B in 3 (9.7%) and Type C in 13 (41.9%), whereas pattern II was found in 2 cases (6.5%), both being a duplication of Type IC. Intramuscular Martin-Gruber anastomosis was a single anastomosis that originated in all cases from the anterior interosseous nerve (pattern IC) and then passed through a muscle bundle of the flexor digitorum profundus and behind the ulnar artery to join the ulnar nerve as a single connecting branch. It did not send branches to the flexor digitorum profundus. This intramuscular course was observed in 3 of the 13 cases of Type C anastomosis (23.1%) or 3 cases out of 31 Martin-Gruber anastomoses (10%).     

Martin-Gruber anastomosis revisited

Based on a study of 70 human cadavers (31 male, 39 female) and on cases described previously, we propose a new classification of the Martin-Gruber anastomosis, a neural connection between the median and ulnar nerves in the forearm. The anastomosis was found in 16 (22.9%) cadavers, being bilateral in three (18.7%) and unilateral in 13 (81.3%), five right and eight left. It occurred in eight (25.8%) of the 31 male cadavers and in eight (20.5%) of the 39 females. Therefore, the anastomosis was found in 19 (13.6%) of the 140 forearms. In Pattern I (89.5%) the anastomosis was made by only one branch, whereas in Pattern II (10.5%) it was made by two. The individual branches were classified as Types a, b, and c based on the nature of their origin from the median nerve. Type a (47.3%) arose from the branch to the superficial forearm flexor muscles, Type b (10.6%) from the common trunk, and Type c (31.6%) from the anterior interosseous nerve. Pattern II was a duplication of Type c (10.5%). The anastomotic branch took an oblique or arched course before joining the ulnar nerve, undivided in 15 cases, but divided into two branches in four cases. The anastomosis passed in front of the ulnar artery in four cases, behind it in six, and in nine cases it was related to the anterior ulnar recurrent artery.     

尺神经深支的形态特点及其临床意义

目的：为临床尺管综合征和尺神经深支损伤的诊治提供解剖学基础。方法：在３０只成人手标本上解剖观测了尺神经深支的走行、毗邻关系、终末分支和分布。结果：依据尺神经深支的走行可分为：豆钩管段、小鱼际肌段、掌中段和终末段。小鱼际肌段行于小指对掌肌与第５掌骨之间的占５６．７％；在小指对掌肌间隙的走行占３０％；在小指短屈肌与小指对掌肌之间占１３．３％。终末段分支为４支型的占８６．７％，３支型占１３．３％。结论：尺神经深支的豆钩管段与豌豆骨、钩状骨钩关系密切；小鱼际肌段与第５掌骨基底紧邻。豌豆骨、钩骨钩和第５掌骨基底部骨折，极易损伤此神经。     

尺神经深支,骨间前神经旋前方肌支的应用解剖

尺神经深支向近侧无损伤分离后,可超越旋前方肌上缘以上26.58mm,此时宽1.80mm、厚1.00mm,可与宽1.35mm、厚0.89mm的旋前方肌支缝合。     

Anatomical basis for a technique of ulnar nerve transposition

Summary There are five major anatomical locations where the ulnar nerve may be compressed near the elbow. Multiple sites of compression are often noted clinically; in other cases, the site of compression is difficult to identify. Clinical experience and results of a series of 20 anatomical dissections suggest that local decompression or subcutaneous transfer may be performed without necessarily exposing all five locations, posing a risk of incomplete decompression. Submuscular transfer of the ulnar nerve decompresses all five locations simultaneously and thus theoretically may be more reliable. The potentially superior results predicted by this anatomical investigation have been confirmed in a clinical case review. Submuscular transposition of the ulnar nerve is reliable and safe, not only in the primary treatment of ulnar neuropathy at the elbow but also in revision of previous operations. Presented at the Second Annual Meeting of the American Association of Clinical Anatomists, Omaha, June 7 to 8, 1985     

Alternative approaches for regional ulnar nerve blockade: a cadaveric study

Wrist blockade is a safe and effective alternative to general anesthesia in surgery of hand injuries. With regard to the ulnar nerve, the volar approach is used, where the needle passes through or medial to the flexor carpi ulnaris tendon; however, the ulnar artery is at risk because the needle may accidentally penetrate it, causing profuse bleeding. Alternatively, the wrist may be approached medially, the ulnar approach, and the needle tip placed posterior to the flexor carpi ulnaris tendon. To determine which of these methods may be preferable for avoiding ulnar artery injury, needles were inserted into the wrist area of cadaver hands (n = 57) using the volar and ulnar approaches; detailed dissection of the region around the inserted needles was subsequently carried out. The position of the ulnar nerve relative to the ulnar artery and injury to the artery was documented. Damage to the ulnar artery using the volar approach was 36.8% (21/57 cases) compared to no (0%) injury observed using the ulnar approach. At the level of the wrist crease just proximal to the pisiform bone, the ulnar nerve was medial to the artery in 92.9% (53/57) of cases, medial and posterior in 5.3% (3/57), and anterior to the artery in 1.8% (1/57) of cases. This study suggests that in cases where ulnar artery pulsation is not reliable, the ulnar approach may be preferable for ulnar nerve blockade due to an increased incidence of ulnar artery penetration with the volar approach.     

尺神经中第七颈神经成份的行径及临床意义

用神经束追踪分离法解剖观察100侧成人第七颈神经分布至尺神经内的纤维行径。结合临床观察认为,尺神经内部有来自颈七的纤维,主要经4个交通部位加入到尺神经分布区内。证明脊神经相应节段与骨骼肌或肌群的支配关系是恒定的,只是由于在胚胎发生上臂丛组合的不同,使脊神经的分支到所支配的骨骼肌间的行径出现差异。上述研究结果,对臂丛中、下干损伤准确定位诊断有重要意义。     

Stratification of the flexor retinaculum and the course and distribution of the ulnar, median, and palmar digital nerves: an anatomical study

A gross anatomic study of 169 hands from 94 human adult cadavers was carried out to define the morphology of the flexor retinaculum and the relationship of the flexor retinaculum to the course of the median and ulnar nerves and branching of the palmar digital nerves. The following results were obtained. Three parts of the flexor retinaculum were arranged like overlapping tiles on a roof, and in all cases, the median nerve passed deep to the flexor retinaculum, whereas the ulnar nerve passed through various parts of the flexor retinaculum in 19% of cases irrespective of its proximal form and branching of the palmar digital nerves.