掌背动脉的解剖和临床应用观察

为了解掌背动脉的解剖资料，对４３只成人尸体手第１～４掌背动脉解剖发现：第１掌背动脉８６％由桡动脉发出，１４％由拇指主要动脉或桡动脉浅支替代，第２掌背动脉８６％起自腕背动脉，第３、４掌背动脉６７％由腕背动脉与掌深弓深支吻合而成。第１～４掌背动脉有皮支４～８支。并有远近两个吻合点。掌背血管具有多源性和吻合丰富的特点，且分布优势在掌指关节。设计皮瓣手术切取方便，特别适用于手指皮肤软组织缺损的修复。临床已应用１２例。     

掌背动脉的解剖和临床应用观察

为了解掌背动脉的解剖资料,对43只成人尸体手第1～4掌背动脉解剖发现:第1掌背动脉86％由桡动脉发出,14％由拇指主要动脉或桡动脉浅支替代,第2掌背动脉86％起自腕背动脉,第3、4掌背动脉67％由腕背动脉与掌深弓深支吻合而成。第1～4掌背动脉有皮支4～8支。并有远近两个吻合点。掌背血管具有多源性和吻合丰富的特点,且分布优势在掌指关节。设计皮瓣手术切取方便,特别适用于手指皮肤软组织缺损的修复。临床已应用12例。     

Nonunion of metacarpal extraarticular fractures in children: report of two cases and review of the literature

Extraarticular metacarpal fractures are common during childhood, and osseous healing is the rule. We have treated two patients with delayed and nonunion of three metacarpal shafts. One patient sustained closed second and third metacarpal fractures, and the other sustained an open second metacarpal fracture. Both injuries were crush-type of significant force. Although initial treatment seemed appropriate, delayed union was not appreciated. The children were referred for cosmetic deformity. One of our patients required open reduction/internal fixation with bone grafting, whereas the other was observed. All metacarpal fractures healed. Thorough clinical examination, radiographic views, reduction, and proper immobilization are factors that may help prevent this previously unreported complication in children.     

Does a Modified Technique to Achieve Arthrodesis of the Wrist After Resection of the Distal Radius and Translocating the Ipsilateral Ulna as a Vascularized Graft to Reconstruct the Defect Improve Grip Strength and Outcomes Scores?

BackgroundTen years ago, we reported the results of a procedure in which we translocated the ipsilateral ulna as a vascularized autograft to reconstruct defects of the distal radius after tumor resection, with excellent functional results. At that time, wrist arthrodesis was achieved by aligning the translocated ulna with the scapholunate area of the carpus and usually the third metacarpal. This resulted in wrist narrowing. We then wondered if aligning the translocated ulna with the scaphoid and the second metacarpal would result in ulnar deviation and thereby improve grip strength. We believed lateralization would reduce the wrist narrowing that occurs with fusion to the third metacarpal and would make the cosmesis more acceptable. We also modified the incision to dororadial to make the scar less visible and thus improve the cosmesis.Questions/purposes(1) Is there an objective improvement in grip strength and functional scores (Musculoskeletal Tumor Society [MSTS] and Mayo wrist) when the translocated ulna is lateralized and the wrist is fused with the translocated ulna and aligned with the second metacarpal versus when the translocated ulna is aligned with the third metacarpal? (2) Did lateralization caused by the wrist fusion aligned with the second metacarpal minimize wrist narrowing as measured by the circumference compared with the fusion aligned with the third metacarpal?MethodsFrom 2010 and 2018, we treated 40 patients with distal radius tumors at our institution, 30 of whom had a distal radius enbloc resection. Twenty-eight patients had an ipsilateral ulna translocation and wrist arthrodesis in which the radius and translocated ulna were aligned with either the second (n = 15) or the third (n = 13) metacarpals. Two patients in the second metacarpal group and three patients in the third metacarpal group were lost to follow-up before 24 months after surgery and were excluded. A retrospective analysis of 23 patients (20 with giant cell tumors and three with malignant bone tumors) included a review of radiographs and institutional tumor database for surgical and follow-up records to study oncologic (local disease recurrence), reconstruction (union of osteotomy junctions, implant breakage or graft fracture, and wrist circumference), and functional outcomes (MSTS and Mayo wrist scores and objective grip strength assessment compared with the contralateral side). The results were compared for each study group (second metacarpal versus third metacarpal). There was no difference in the incidence of local recurrence or the time to union between the two groups. There were no implant breakages or graft fractures noted in either group.ResultsPatients in the second metacarpal group lost less grip strength compared with the unoperated side in the third metacarpal group (median 12% [range -30% to 35%] versus median 28% [15% to 42%], difference of medians 16%; p = 0.006). There were no between-group differences in terms of MSTS (median 30 [24 to 30] versus median 26.5 [22 to 30], difference of medians 3.5; p = 0.21) or Mayo wrist scores (median 83 [65 to 100] versus median 72 [50 to 90], difference of medians 11; p = 0.10). The second metacarpal group also had less wrist narrowing as seen from the median difference in circumference between the operated and unoperated wrists (median narrowing 10 mm [3 to 35 mm] in the second metacarpal group versus median 30 mm [15 to 35 mm] in the third metacarpal group, difference of medians 20 mm; p = 0.04).ConclusionWrist arthrodesis after ulna translocation with alignment of the translocated ulna and the second metacarpal provides a functional position with ulnar deviation that offers some improvement in grip strength but no improvement in the MSTS or Mayo scores. Radialization/lateralization of the translocated ulna achieved from the alignment with the second metacarpal decreases the reduction in the wrist circumference and therefore reduces wrist narrowing.Level of EvidenceLevel III, therapeutic study.     

自体髂骨嵴移位重建掌骨头的解剖学研究

目的 :探讨髂骨嵴与掌骨头相似性,为髂骨嵴移位重建手部掌骨头提供解剖学基础。方法 :16侧上肢标本,10例骨盆标本,解剖观察第2、3、4、5掌骨头及髂骨嵴形态结构特点,测量掌骨头弧高、关节面弧长、掌背径、尺桡径和髂骨嵴弧高、弧长、内外径。将所得到的数据进行统计分析,比较各掌骨头与髂骨嵴在形态、结构特点、弧长及各径线长度相似度。结果:第2掌骨头弧长22.040(21.425,23.085)mm,掌背径(14.034±0.465)mm,弧高4.185(4.113,4.598)mm,尺桡径(12.227±0.414)mm。第3掌骨头弧长23.430(22.743,24.153)mm,掌背径(14.316±0.430)mm,弧高4.235(4.170,4.670)mm,尺桡径(12.382±0.425)mm。第4掌骨头弧长21.960(21.245,22.285)mm,掌背径(12.382±0.288)mm,弧高4.125(4.030,4.305)mm,尺桡径(11.991±0.362)mm。第5掌骨头弧长20.030(19.668,20.148)mm,掌背径(11.807±0.358)mm,弧高4.015(3.880,4.205)mm,尺桡径(11.659±0.399)mm。髂骨嵴弧长(22.930±0.701)mm,内外径14.350(13.660,14.739)mm,弧高(4.520±0.184)mm。髂骨嵴内外径与第2掌骨头掌背径差异无统计学意义(Z=-1.242,P0.05),髂骨嵴内外径与第3掌骨头掌背径差异有统计学意义(Z=-2.835,P0.05),髂骨嵴内外径与第4、5掌骨头掌背径差异有统计学意义(Z值分别为-5.094、-5.095,P0.05);髂骨嵴弧长与第2、4、5掌骨头弧长差异均有统计学意义(t值分别为1.190、-4.909、-13.791,P0.05),髂骨嵴弧长与第3掌骨头弧长差异无统计学意义(Z=-1.704,P0.05);髂骨嵴弧高与第2、3掌骨头弧高差异无统计学意义(Z值分别为-1.815、-1.386,P0.05),髂骨嵴弧高与第4、5掌骨头弧高差异有统计学意义(分别对应Z=-3.152,t=-5.639,P0.05)。结论:自体髂骨嵴与掌骨头在解剖学上有一定相似性,能够成为掌骨头移植的合适供体。     

Autograft replacements for the scapholunate ligament: a biomechanical comparison of hand-based autografts.

An ideal replacement for the scapholunate ligament (SLL) has not been found. The carpometacarpal bone-ligament-bone complex at the base of the second and third metacarpal is proposed as a replacement for the SLL in this study. A cadaveric study of matched SLL, second metacarpal-trapezoid ligament, third metacarpal-capitate ligament, and dorsal periosteal retinaculum was performed. Stiffness and strength were obtained from fresh-frozen specimens tested to failure with a hydraulic distractor. The second metacarpal-trapezoid ligament and the third metacarpal-capitate ligament most closely approximated the stiffness and strength of the SLL. The dorsal periosteal retinaculum was significantly less stiff and was significantly weaker than the SLL. This study indicates that the second or third carpometacarpal ligaments are grafts that approximate the mechanical properties of the SLL.     

The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled metacarpal bone flaps

The vascular anatomy of the dorsal aspect of the hand is variable. Nevertheless the presence of the first and the second dorsal metacarpal artery (DMA) is constant. DMA3 and 4 are more variable. The anatomical study presented demonstrates the segmental vascularization of the metacarpal bones and the possibility of harvesting metacarpal bone flaps. The reliability of such a flap decreases from the second to the fifth metacarpal bone regarding the frequency of presence of the DMAs. The authors describe six new vascularized bone flaps from the third and the fourth metacarpal bones pedicled on the second or the third dorsal metacarpal artery in an anterograde or retrograde flow mode. This study suggests that the radial and the ulnar side of the third metacarpal bone could be harvested respectively on the DMA2 and DMA3. The radial side of the fourth metacarpal bone could also be a reliable vascularized bone donor site. Flaps can be used proximally or distally based to repair bone defects either on metacarpal and carpal bones or on proximal phalanges.     

Cross transposition of short amputation stumps for reconstruction of the thumb

Cross transposition of digital rays is illustrated by a case of amputation of the thumb and the middle finger. A remnant of the stump of the middle finger was mobilised and brought on top of the first metacarpal, in order to restore a functional length to the amputated thumb. A cross transposition of the second digital ray to the third was also carried out, closing the gap left by the resection of the third metacarpal.     

Reverse second and third dorsal metacarpal artery fasciocutaneous flaps for repair of distal- and middle-segment finger soft tissue defects

The present study evaluated the clinical efficacy of reverse second and third dorsal metacarpal artery fasciocutaneous flaps for repair of distal- and middle-segment finger soft tissue defects. A total of 14 patients with distal- and middle-segment finger soft tissue defects complicated by exposure of the phalanx or tendon were repaired using second and third dorsal metacarpal artery fasciocutaneous flaps ranging between 2.0 cm × 4.5 cm and 3.0 cm × 7.0 cm. All of the skin flaps survived after surgery. Follow-up data during a 6- to 40-month period showed that the flaps exhibited a satisfactory appearance. They were not fat or clumsy, with a 2-point discrimination of 5 to 9 mm, and there was good recovery of finger function. The donor site was able to be directly sutured without dermoplasty. Pigmented linear surgical streaks appeared in the donor site. The second and third dorsal metacarpal artery fasciocutaneous flaps provide a good approach for the repair of distal- and middle-segment finger soft tissue defects and functional reconstruction because of convenient dissection, little trauma, sufficient use of the dorsal metacarpal artery, large harvested area of the flap, and a good dissection range.     

The extensor sling procedure for the unstable carpo-metacarpal joint of the thumb

Surgical Principles The sling is made by routing part of the extensor carpi radialis longus, from its insertion, through the interspace between the second and third metacarpals, encircling the base of the first metacarpal and then suturing the tendon on itself at its point of entry between the second and third metacarpal. The entire procedure is carried out from the dorsal surface of the hand and deep to the adductor pollicis. Stability of the first carpo-metacarpal joint is restored without interfering with the excursion of the first metacarpal. During pinching great lateral forces act on the first carpo-metacarpal joint and tend to dislocate it laterally. This tendency is normally kept in check by the first intermetacarpal ligament [7]. As with all joints, instability in the carpo-metacarpal joint will promote the early onset of secondary degenerative changes. Increased stability would prevent the changes, or at least delay them, until the usual age of occurrence in the general population. However, no procedure carried out at the stage where significant cartilaginous degeneration is already present, will be able to control the process of arthritis. For the first metacarpal to move laterally the intermetacarpal ligament has to stretch [1]. Re-inforcing the ligament must, therefore, control this tendency. The extensor sling procedure provides a new ligament which lies in the coronal plane of the hand between the first and second metacarpal and prevents lateral subluxation. At the same time it does not interfere with circumduction of the first metacarpal provided that the ligament is sited at the base of the metacarpal.     

Second dorsal metacarpal artery neurovascular island flap: clinical applications

This paper reports the clinical use of the second dorsal metacarpal artery island flap in a series of 12 cases and discusses the results. In two cases, a double flap based on the second dorsal metacarpal artery from the dorsal skin of the second and third fingers without using the second web was raised as a modification of the dorsal flap.     

Measurement of rotation of the first metacarpal during opposition using computed tomography

PURPOSE: Opposition is an important movement of the hand and rotation of the first metacarpal is the essential component. There is no agreement on the exact magnitude of rotation of the first metacarpal during opposition. This study used computed tomography to describe rotation measurement of the first metacarpal in the hands of a group of healthy individuals. METHODS: The rotation of the first metacarpal was measured with reference to the fixed unit of the hand. Computed tomographic images were taken of the hands of 10 healthy individuals with the thumb in retroposition, resting position, and opposition to the index, middle, ring, and small fingers. On each image a tangential line was drawn along the dorsal margin of the second and third metacarpals. A second line was drawn through the head of the first metacarpal at the level of the sesamoids. The angle between the 2 lines was measured as the angle of rotation of the first metacarpal in different thumb positions. RESULTS: The mean angle of rotation of the first metacarpal in retroposition was 54 degrees+/-10 degrees with reference to the fixed unit of the hand. In the resting position the angle of rotation of the first metacarpal changed to 74 degrees+/-10 degrees. In the position of opposition to the index, middle, ring, and small fingers the angle of rotation of the first metacarpal increased to 100 degrees+/-7 degrees , 103 degrees+/-6 degrees, 105 degrees+/-6 degrees, and 110 degrees+/-7 degrees, respectively. CONCLUSIONS: The first metacarpal rotates 56 degrees when it moves from retroposition to the position of opposition to the small finger.     

Wrist-Spanning Fixation of Radiocarpal Dislocation: A Cadaveric Assessment of Ulnar Translation

Background: Radiocarpal dislocations represent a high-energy wrist injury that can occur with or without concomitant fractures about the wrist. Poor outcomes are often due to radiocarpal instability and secondary ulnar translation. The purpose of this cadaveric study is to determine if there is any difference in the radiographic parameters in a wrist dislocation model given the different location of distal fixation. Methods: Ten paired fresh cadaver upper extremities were fluoroscopically evaluated with posterior-anterior (PA) and lateral views. We created a radiocarpal dislocation model and applied a dorsal bridge plate to either the second or third metacarpal. Repeat PA and lateral fluoroscopic views were obtained for evaluation of radial inclination, radial height, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, scapholunate angle, radial rotation index, and four indices for ulnar translation (Taleisnik, Gilula, McMurtry, and Chamay). Results: Bridge plate application to the second metacarpal resulted in a significantly greater incidence of ulnar translation compared to the third metacarpal. Application to either metacarpal resulted in extension of the carpus relative to the radius. Conclusions: A more anatomic radiocarpal relationship was restored more often when distal fixation of the dorsal wrist-spanning bridge plate was applied to the third metacarpal. Further investigation is warranted to determine clinical relevance of these findings in conjunction with clinical and radiographic outcomes.     

第二掌背动脉岛状皮瓣的临床应用

目的：通过解剖学研究，设计第２掌背动脉岛状皮瓣，临床修复手部皮肤缺损，获得成功。方法：对５０只经动脉灌注红色乳胶的成人手标本，在放大镜下观察第２掌背动脉及伴行静脉的起端，皮支、终末支的走行；测量血管各部位的直径。结果：第２掌背动脉终末支分布于第２指蹼、示中指近节皮肤；皮支和其它掌背、掌指动脉间有丰富的吻合支。临床应用８例，顺行皮瓣７例，逆行１例。修复手背、拇指皮肤缺损，皮瓣全部成活。结论：临床应用第２掌背动脉为蒂的岛状皮瓣时，可设计成顺行或逆行皮瓣，均能成活。     

Fascicular arrangement. Function and innervation of the 1st dorsal interosseous muscle of the hand

After 30 dissections done under optical magnification, the authors have shown that, the tendon of the first dorsal interosseous muscle, which was till now considered to be bifasciculare results actually from the intersection of the tendinous fibers of three muscle components: One originating from the first metacarpal bone: Heterometacarpophalangeal component. One originating from the first two metacarpal bones: Intermediate component. One originating from the second metacarpal bone: Homometacarpophalangeal component. Each of these musculotendinous components is responsible for a particular action in the different movements of the index finger: Flexion of the metacarpophalangeal joint, extension of the second and third phalanges, abduction of the index finger. Each component has its own nerve supply by branches originating from deep branch of the ulnar nerve. In total, there exists a "rule of the three". Three components--Three principal actions--Three nerve supply.     

Microsurgical second dorsal metacarpal artery cutaneous and tenocutaneous flap for distal finger reconstruction: anatomic study and clinical application

In this paper, we report on the anatomical study of 34 cadaveric forearms with red latex injection and the clinical application of this study to 11 cases of microsurgical second dorsal metacarpal artery (SDMA) flaps. There were 8 cutaneous cases and 3 tenocutaneous cases using SDMA flaps for distal finger reconstruction. The SDMA was classified into 2 types and 4 subtypes according to its anatomical origin and course. Type I (76.5%) originated from the dorsal branch of the radial artery at the snuffbox. Type II (23.5%) originated from the perforating branch of the deep palmar arch at the bases of second and third metacarpal bones. Diameter of the SDMA was 1.2 +/- 0.2 mm at its snuffbox origin, and 1.0 +/- 0.1 mm at the base of the second and third metacarpal bones. Clinically, microsurgical SDMA free flaps were raised and transferred for repair of finger injuries. Ten flaps survived completely. One flap failed due to thrombosis of vascular anastomosis. In conclusion, the second dorsal metacarpal artery is a constant and reliable vessel for microvascular anastomosis in microsurgical SDMA flap transfer. This flap can be used as an alternative for hand and finger reconstruction, and especially repair of a distal phalanx, when either an orthograde or retrograde island SDMA flap is unable to reach the defect.     

Isolated pain of the hand revealing a metastatic tumor of the hand. Report of a case

INTRODUCTION: Metastatic malignant tumors of the hand are unusual. We describe a patient with gastric cancer. OBSERVATION: A 64-year-old man in remission of a gastric adenocarcinoma treated surgically one year previously was admitted to hospital for a pain of the right hand associated with an edema. The radiography of the hand established an osteolysis of the third metacarpal. The surgical operation revealed an important inflammatory zone associated with a wide osseous destruction. It consisted of an osteosynthesis of the second and third metacarpal with destruction of lytic fabric. The anatomopathologic examination revealed an osseous metastasis of a gastric adenocarcinoma. The patient died five months after the diagnosis of acrometastasis. DISCUSSION: The acrometastases are difficult to diagnose, a biopsy is often necessary. Evolution during acrometastasis of gastric cancer is the same one as in the other acrometastases. Their treatment is primarily palliative because of their very bad forecast.     

Diagnosis and treatment of injury to the second and third carpometacarpal joints

We describe the diagnosis, treatment, and follow-up of a group of 13 patients with hand pain traced to pathologic conditions of the second or third carpometacarpal joints. Missed diagnosis was universal. With suspicion raised by history of injury or repeated stress and point tenderness on examination, diagnosis was confirmed by complete pain relief after injection of 1% lidocaine locally. In management of patients with occult pain in the hand, attention should be directed to the second or third carpometacarpal joints. Arthrodesis with use of an inverted triangular graft from the base of the metacarpal provides predictable and lasting relief.     

The locked metacarpophalangeal joint: report of four cases and review of the literature

Four cases of locked finger metacarpophalangeal joints are reported. Two of these cases were caused by entrapment of the sesamoid behind an exostosis off the second metacarpal head. The third was from subluxation of the dorsal interosseous tendon over a dorsal osteophyte on the metacarpal. The fourth was from an exostosis tethering the accessory collateral ligament. Surgical exploration using a palmar approach was the treatment of choice. All patients regained full range of motion within two months. A review of the various causes and treatment options for this unusual condition is presented.     

Prospective assessment of bone texture parameters at the hand in rheumatoid arthritis

ObjectiveFractal bone analysis (Hmean) is a texture parameter reflecting bone microarchitecture. The BMA device (D3A? Medical Systems, Orléans, France) is a high-resolution X-ray device that allows assessment of bone texture analysis. We aimed to measure Hmean in rheumatoid arthritis patients at the second and third metacarpal bones, at baseline and after 1 year of follow-up, and to assess the relationship of Hmean and rheumatoid arthritis disease parameters.MethodsPatients with rheumatoid arthritis according to ACR criteria were included. They were assessed over 1 year, in the context of a prospective study conducted in Maastricht. For this substudy, activity of the disease was assessed by erythrocyte sedimentation rate, C-reactive protein and Disease Activity Score 28 performed at each visit. Radiographic bone damage was assessed using hand and feet radiographs at baseline and on a 1-year basis. The bone texture parameters were evaluated on the second and third metacarpal heads of the left hand using BMA device.ResultsOne hundred and sixty-five rheumatoid arthritis patients were included in this study. At baseline, Hmean was negatively correlated with age [r = ?0.22 (P = 0.013)] and erythrocyte sedimentation rate [r = ?0.16 (P = 0.039)]. No significant correlation was found between Hmean and Disease Activity Score, disease activity Visual Analog Scale, daily corticosteroid dose and C-reactive protein. There was a significant increase in Hmean of second and third metacarpal bones over 1 year (1.6% and 1.3%, P < 0.01) except in patients with local second and third metacarpal bones erosion.ConclusionThe bone texture parameter Hmean is influenced by age, inflammation and local erosions in rheumatoid arthritis.