腕关节神经支配的解剖学研究

目的观察支配腕关节神经的来源、直径、数目及其行径;为去神经支配治疗腕关节疼痛提供解剖学资料。方法对10具20侧福马林固定的上肢标本,在手术显微镜下解剖并观察骨间后神经、前臂外侧皮神经、桡神经浅支、尺神经腕背支支配腕关节背侧的腕关节支;骨间前神经、正中神经掌皮支、尺神经深支及其主干支配腕关节掌侧的关节支。结果骨间后神经是支配腕关节背侧神经的主要来源;前臂外侧皮神经、桡神经浅支、尺神经腕背支也发支支配腕关节背侧。骨间前神经、正中神经掌皮支、尺神经深支发支参与支配腕关节的掌侧。结论用去神经支配的方法治疗腕关节顽固性疼痛主要适用于腕背侧的疼痛。     

Block of the brachial plexus branches by the humeral route. A prospective study in 503 ambulatory patients. Proposal of a nerve-blocking sequence

BACKGROUND: Brachial plexus is usually approached by the supraclavicular or axillary route. A technique for selective blockade of the branches of the plexus at the humeral canal using electrolocation has recently been proposed. The aim of the present study was to assess the feasibility of this technique in the ambulatory patient and to determine the optimal sequence of nerve-blocking. METHODS: The nerves originating from the brachial plexus were located in the humeral canal, at the junction of the proximal and the middle third of the arm, with a stimulator and blocked using either lidocaine or a mixture of lidocaine and bupivacaine, depending on the anticipated duration of surgery. The minimal stimulating intensity eliciting an adequate response, type of local anaesthetic and injected volume, and time of onset of surgical anaesthesia were collected. RESULTS: The study included 503 consecutive ambulatory patients due to undergo surgery of the elbow, wrist or hand in one year. Suitable anaesthesia was obtained with the humeral blockade in 82.1% of cases. In the remaining 17.9%, an additional block at the elbow was required, mainly for ulnar and median nerves. The onset times of sensory blocks were the longest for the median nerve, similar for the radial and ulnar nerves, shorter for the musculocutaneous nerve and the shortest for the medial brachial and antebrachial cutaneous nerves. The difference was more significant with the lidocaine-bupivacaine mixture, than with lidocaine alone (P<0.001 vs P<0.05, respectively). The onset times of motor blocks were the longest for the median nerve (P<0.05) and the shortest for the musculocutaneous nerve (P<0.001). Neither nervous nor vascular complications occurred. CONCLUSION: This study shows that the nerve block at the humeral canal is an efficient and safe technique. Considering the onset times of nerve blocks, the following sequence for blockade can be recommended: median, ulnar, radial, musculocutaneous, medial (brachial and antebrachial) cutaneous nerves. The selective blockade of the main nerves of the upper limb at the humeral canal can be recommended for surgery of the forearm and the hand in the ambulatory patient.     

Variant location of the musculocutaneous nerve during axillary nerve block

We present the case of a 56-year-old man who underwent axillary nerve block for a wrist arthroscopy procedure, with real-time ultrasound and peripheral nerve stimulator guidance. The ulnar nerve and radial nerve were located medial and posterior to the brachial artery, respectively. A large complex structure was noted in the position typically occupied by the median nerve. Contact of this structure with the stimulating needle produced strong biceps contraction, and slight adjustment of the needle resulted in forearm pronation. After injection of 10 mL of local anesthetic near this structure, it appeared to consist of two separate components on ultrasound. We believe that these components represented the median and musculocutaneous nerves lying together, lateral to the artery. Radial, median, ulnar, and musculocutaneous nerve block ensued, and wrist arthroscopy was carried out uneventfully. Knowledge of this anatomical variation may improve anesthesiologists' ability to provide effective axillary block.     

Anatomic study of distally based pedicle compound flaps with nutrient vessels of the cutaneous nerves and superficial veins of the forearm

The purpose of this study was to describe the anatomic basis for a distally based neurovenovascular pedicle compound flap, with nutrient vessels of the cutaneous nerves and superficial veins of the forearm. In this study, the origins, branches, and anastomoses of nutrient vessels of the cutaneous nerves and superficial veins of the forearm and their relationships with the blood supply of adjacent muscle, bone, and skin were assessed in 96 adult cadavers by perfusion of red gelatin into the superior limb arteries. The results showed that the nutrient vessels of cutaneous nerves and superficial veins of the forearm were found to have multiple origins, consisting of six longitudinal vascular plexuses and one transverse vascular plexus of the forearm, as follows: 1) the anterior-lateral vascular plexus from cutaneous branches of the radial artery; 2) the anterior-medialis vascular plexus from cutaneous branches of the ulnar artery; 3) the dorso-lateral vascular plexus from radial osteal and cutaneous branches; 4) the dorso-medialis vascular plexus from ulnar osteal and cutaneous branches; 5) the radial vascular plexus from osteal and cutaneous branches of the radial artery, cutaneous branches of the radial artery in the upper wrist, recurrent branches of the styloid process of the radius, and the radialis vascular plexus of cutaneous branches of the tabatière anatomique (anatomical snuffbox); and 6) the ulnar lateral vascular plexus from cutaneous branches of the ulnar artery in the upper wrist and osteal and cutaneous branches. The transverse vascular plexus is composed of dorsal branches of the ulnar and radial arteries. These perforating branches give fascial branches, cutaneous branches, periosteal branches, and nutrient vessels of cutaneous nerves and superficial veins. These results suggest that nutrient vessels of the cutaneous nerves and superficial veins of the forearm have the same origins as those of the nutrient vessels of adjacent muscles, bones, and skin of the forearm, which can be designated as five types of distally based pedicle flaps with nutrient vessels of cutaneous nerves and superficial veins of the forearm, whose rotation point is at the wrist joint. This flap can be applied to repair tissues of distal parts of the hand.     

健侧颈7神经根移位同时修复两条神经的初步临床疗效

目的探讨用健侧颈，神经根移位同时修复2条上肢神经的临床效果。方法设计2种移位修复的方法。(1)合干法：健侧颈，前后股→尺神经→尺神经近端分2股分别和正中神经、桡神经(或肌皮神经)缝合，共5例。(2)分干法：健侧颈前后股→尺神经、腓肠神经→正中神经、桡神经(或肌皮神经)，共3例。结果合干法4例术后随访12～19个月，1例尚在随访中。正中神经运动：2例已恢复屈腕、屈指，肌力M3。2例屈腕肌力为M1。正中神经感觉：3例为S2，1例为S0。桡神经运动：2例伸腕、伸指肌力为M2。1例伸肘肌力为M2，1例伸腕肌力为M1。桡神经感觉：1例为S2，1例为S1，2例为S0。分干法1例术后随访15个月，已恢复屈腕、屈指，肌力为M3。正中神经感觉为是。肌皮神经：屈肘肌力为M3。另2例术后时间短尚在随访中。结论健侧颈，神经根移位同时修复上肢2条主要神经的新术式，初步应用结果证实是可行的、有效的。     

Anomalous superficial ulnar artery based flap

Upper limb shows a large number of arterial variations. This case report describes the presence of additional superficial ulnar artery which was used to raise a pedicle flap to cover an arm defect thus avoided using the main vessel of the forearm - radial or ulnar artery. Vascular anomalies occurring in the arm and forearm tend to increase the likelihood of damaging the superficial anomalous arteries during surgery. Superficial ulnar or radial arteries have been described to originate from the upper third of the brachial artery; here we report the origin of the anomalous superficial ulnar artery originating from the brachial artery at the level of elbow with the concomitant presence of normal deep radial and ulnar arteries.KEY WORDS: Anomalous artery based flap, arterial variations of the forearm, superficial ulnar artery based flap     

Subclinical injury to forearm nerves during radial harvesting: electrophysiologic study

BACKGROUND AND AIM: There are few reports about injury to forearm nerves and its potential mechanisms during radial artery (RA) harvesting. We studied electrophysiologic changes in these nerves not sought until now. METHODS: Among 152 consecutive patients who underwent coronary artery bypass surgery between February 2002 and August 2002, 20 were randomized for RA harvesting and formed the study group and 20 were randomized as control group. Neurologic examination and electrophysiologic studies were performed for sensory and motor impairment of the nerves in both groups pre- and postoperatively. RESULTS: There was no change on neurologic examinations before and after surgery. Electromyography (EMG) revealed significant reduction in sensory and motor conduction amplitudes of median, ulnar, and radial nerves and motor conduction velocities of median and ulnar nerves at the level of forearm in the study group. In the control group, ulnar nerve was mostly affected. When two groups are compared, sensory and motor amplitude drops of median and radial nerves and motor velocity impairment of median nerve in the study group are significant. Ulnar nerve impairments are identical in both groups. CONCLUSIONS: Handling of tissues, minor hematoma or edema along with chest retraction best explains these impairments. Patients were asymptomatic after surgery showing that EMG is highly sensitive and is not predictive of clinical impairment.     

Ultrasound controlled nerve stimulation in the elbow region: high currents and short distances needed to obtain motor responses

BACKGROUND: Electrical nerve stimulation is commonly used to perform peripheral nerve blocks. The purpose of this study was to investigate the relation between stimulating currents and the distance between the needle-tip and stimulated nerves. METHODS: In 18 volunteers the radial and ulnar nerves were stimulated in the elbow region from opposite directions. Needle-to-nerve distances were measured by high-frequency ultrasound when motor responses to electrical stimulation were elicited with currents of 5, 2, 1 and 0.5 mA and impulse widths of 0.1 ms. Additionally, current thresholds for nerve stimulation were identified when the needle-tip was in contact with the nerve. RESULTS: The ulnar nerves responded to electrical stimulation from a significantly greater distance than the radial nerves. Threshold levels at needle-to-nerve contact ranged from 0.4 to 4.5 mA for the radial nerve and from 0.32 to 2.0 mA for the ulnar nerve. They were significantly lower for the ulnar nerve than for the radial nerve. Currents required to obtain neuromuscular responses often exceeded the recommended current levels for nerve stimulation. CONCLUSIONS: Our results show significant differences in the ease of stimulation between the radial and ulnar nerves. High current thresholds and short nerve-to-needle distances were often needed to obtain neuromuscular responses in two nerves in the elbow region.     

Treatment of neuromas about a major amputation stump

In five patients, with intractable pain from neuromas that developed after amputations at the wrist or forearm, the neuromas were resected and the median nerve anastamosed to the ulnar nerve under the pronator teres muscle. In one patient, the anterior interosseous nerve was also anastamosed to the superficial radial nerve under the muscles of the forearm. Patients reported an 80% to 90% reduction in pain. This procedure is limited to patients in which all other treatments have failed.     

Anatomy of the ulnar artery as it relates to the transverse carpal ligament

The anatomic relationship between the ulnar artery and transverse carpal ligament (TCL) as an aid in planning for minimally invasive carpal tunnel surgery was investigated. The anatomic course of the ulnar artery and its branches toward the TCL and the location of the median nerve were determined in 24 fresh cadaver hands perfused with a silicone compound. The ulnar artery coursed from 7 mm ulnar to 2 mm radial to the hook of hamate. The average distance between the superficial palmar arch and the distal margin of the TCL was 12 mm as measured along the flexor tendon of the ring finger. The location of the median nerve extended an average of 11 mm radial to the hook of hamate. A small arterial branch (average diameter, 0.7 mm) from the ulnar artery ran transversely just over the TCL in 6 of the 24 specimens. This branch was consistently located within 15 mm proximal to the TCL distal margin. These and other microscopic observations indicated that transecting the ligament at approximately 5 mm radial to the radial margin of the hook of hamate may minimize postoperative bleeding and avoid iatrogenic vascular and neural injury. (J Hand Surg 2002;27A:101-104. Copyright © 2002 by the American Society for Surgery of the Hand.)     

Infraclavicular plexus block: multiple injection versus single injection

BACKGROUND AND OBJECTIVES: This prospective, randomized, and multicentered study was undertaken to evaluate the success rate of coracoid infraclavicular nerve block performed with a nerve stimulator when either 1 or 3 motor responses were sought. METHODS: Eighty patients who presented for elbow, forearm, or wrist surgery were randomly allocated to one of the following groups: in group 1 (single stimulation), 30 mL local anesthetic (LA) was injected after locating only 1 of the median, ulnar, or radial motor responses. In group 2 (multistimulation), 3 responses were located: musculocutaneous, median or ulnar, and radial response, corresponding, respectively, to the lateral, medial, and posterior cords. A total of 10 mL LA was injected on each response. Bupivacaine 0.5% and lidocaine 2% with epinephrine 1:200000 (1:1 vol) were used as the LA mixture. Sensory and motor blocks were tested by a blinded observer. RESULTS: Block duration was slightly increased in the multistimulation group (P =.004). The onset time of sensory and motor block was faster in each nerve distribution, particularly in the radial, musculocutaneous, and antebrachial nerves. The success of anesthesia increased in the multistimulation group. The success rate of the block, without any additional block, sedation, or general anesthesia, increased from 40% in the single stimulation group to 72.5% in the multistimulation group (P <.0001). If the brachial and antebrachial cutaneous nerves were not included in the evaluation, success rate reached 87.5%. CONCLUSIONS: We conclude that by performing an infraclavicular block with stimulation of all 3 cords of the brachial plexus, the success rate is higher than when only a single stimulation is used.     

Superficial upper limb vasculature and its surgical implications

Any kind of anatomical variation whether encountered during cadaveric dissections or routine clinical or surgical procedures needs to be reported and taken into account. This can be quite helpful in planning surgeries accordingly and avoid disastrous complications. During routine cadaveric dissection, authors found a superficial course of arteries of the arm as well as the forearm, unilaterally in one cadaver. In this case, there were two brachial arteries – superficial and deep. Superficial brachial artery terminated into superficial radial and superficial ulnar artery. Deep brachial artery was trifurcated into common interosseous, medial and lateral artery branches. Authors have also discussed the developmental anomaly, which could have led to the observed morphological variation. Superficial vessels can provide large size pedicles for raising flaps for local reconstructive surgeries in the region of axilla, elbow, wrist or hand, or other regions.KEY WORDS: Artery, brachial, radial, superficial, ulnar     

健侧颈7神经根移位修复多条神经模型的建立及功能恢复动态观察

目的比较七种不同术式的健侧颈，神经根移位术后受体神经的功能以探讨颈，神经重建多组神经的可行性。方法SD大鼠105只，随机分为7组，每组15只。建立传统的健侧颈，移位经尺神经近端（单根）接正中神经或肌皮神经或桡神经（A、D、G组），健侧颈，经尺神经近端（2股，合干法）接正中、肌皮神经或正中、桡神经（B、E组），健侧颈，经尺神经及腓肠神经（分干法）接正中、肌皮神经或正中、桡神经（C、F组）。术后观察患肢功能，抓握力及梳洗动作出现时间。结果术后2个月，修复正中和肌皮神经的B、C组，均出现主动屈趾、屈肘功能。抓握力比较：合干法（B、E组）、分干法（C、F组）及传统法（A、D、G组）的差异均有统计学意义（P〈0．05）。术后3、6个月合干、分干法与传统法比较差异无统计学意义（P〉0．05）。梳洗试验出现时间：合干、分干法及传统法比较差异无统计学意义（P〉0．05）。结论颈，神经根能提供足够的神经再生纤维，可同时恢复2条神经功能。     

尺骨干骺端续连症不同手术方法的疗效观察

目的:探讨尺骨骨软骨瘤切除、尺骨微创截骨、外固定尺骨延长术治疗尺骨干骺端续连症前臂畸形治疗效果和安全性.方法:自2005年8月至2013年12月,20例尺骨干骺端续连症患者,男15例,女5例;年龄7～13(10.00±2.34)岁;病程6～11(8.10±1.52)个月;临床表现为患侧前臂短缩并向尺侧弯曲畸形.采用尺骨...     

A comparison of stimulation patterns in axillary block: part 2

BACKGROUND AND OBJECTIVES: Radial plus musculocutaneous nerve stimulation may have a predominant role in the success of an axillary block, producing more extensive anesthesia of the upper limb than median plus musculocutaneous nerve stimulation. However, no comparison has been made with ulnar plus musculocutaneous nerve stimulation. We compared the extent of both sensory and motor block after ulnar plus musculocutaneous nerve stimulation or radial plus musculocutaneous nerve stimulation. METHODS: Sixty patients were randomly assigned to receive an axillary block using either radial plus musculocutaneous or ulnar plus musculocutaneous nerve stimulation with 40 mL plain 1.5% mepivacaine. Patients were assessed for sensory block by the pinprick method at 5 and 20 minutes. RESULTS: No statistically significant differences were found in the rates of anesthesia at 20 minutes in the cutaneous nerve distributions of the upper limb between radial plus musculocutaneous and ulnar plus musculocutaneous nerve stimulation except for the following nerves: radial (90% and 63.3%, respectively), medial cutaneous of the forearm (83.3% and 100%, respectively), and medial cutaneous of the arm (73.3% and 93.3%, respectively). Global sensory score (minimum: 0; maximum: 12 points) at 20 minutes was significantly higher after radial plus musculocutaneous than after ulnar plus musculocutaneous nerve stimulation: 12 (11-13) and 11 (10-12), respectively. The rates of median nerve blockade were 50% and 53%, respectively. CONCLUSIONS: Radial plus musculocutaneous nerve stimulation produced more extensive anesthesia of the upper limb than did ulnar plus musculocutaneous nerve stimulation. However, there is not an optimal combination of 2 responses in axillary brachial plexus block.     

Radial nerve excursion and strain at the elbow and wrist associated with upper-extremity motion

PURPOSE: This study evaluated the excursion necessary to accommodate common motions of daily living and associated strain on the radial nerve. The radial nerve was evaluated at the wrist and proximal to the elbow before it bifurcated. METHODS: Five fresh-frozen transthoracic cadaver specimens (10 arms) were dissected; the radial nerve was exposed at the elbow and wrist only enough to be marked with a microsuture. Excursion was measured using a laser mounted on a caliper fixed to the bone and aligned in the direction of nerve motion. Strain was measured with a device applied to the nerve at the elbow. Nerve excursion associated with motion of the shoulder, elbow, wrist, and fingers (measured by a goniometer) was assessed at the wrist and elbow. RESULTS: An average of 4.3 mm of radial nerve excursion was required at the wrist to accommodate wrist motion from 15 degrees of radial deviation to 30 degrees of ulnar deviation and 8.8 mm was needed for elbow motion from 10 degrees to 90 degrees . The radial nerve at the elbow experienced a 28% strain associated with the same motion of flexion and extension at the elbow. When all the motions of the wrist, fingers, elbow, and shoulder were combined 9.4 mm of radial nerve excursion was required at the wrist and 14.2 mm at the elbow. CONCLUSIONS: Any factor that limits excursion at these sites could result in repetitive traction of the nerve and possibly could play a role in the pathophysiology of a mechanical neuropathy, which in the case of the radial nerve most often manifests as pain.     

Neurilemmomas of the forearm and hand.

Neurilemmoma is the most common tumor arising from peripheral nerves. Although infrequently encountered, it must be included in the differential diagnosis of soft tissue tumors. Because of its cystic consistency, a neurilemmoma in the hand or wrist may be mistaken for a ganglion. In this series of 17 neurilemmomas, 6 were present in the forearm, and 11 were in the hand and wrist. There were 5 tumors in fingers, 1 in the thumb, 3 in the palm, and 2 in the wrist. In the forearm, 3 tumors involved the median nerve, 2 involved the ulnar nerve, and 1 arose from a small sensory branch of the radial nerve. Neurilemmomas arise from a benign proliferation of the Schwann cells and rarely disturb the function of the involved nerve. The tumors are well encapsulated and may be easily enucleated from the parent nerve. Resection of the involved nerve is seldom necessary except when small nerves are extensively involved.     

Nerve entrapment around elbow

Entrapment neuropathy around elbow is a common cause of disability across all age groups. The major nerves that traverse the elbow are ulnar, median and radial nerves and their branches. Cubital tunnel syndrome leading to ulnar nerve compression can often present with significant pain, paresthesia or weakness. Median and Radial nerve compression around the elbow, albeit less frequent, can also lead to significant morbidity and must be kept in the differential diagnosis when dealing with patients complaining of persistent pain around the elbow and weakness of forearm/hand muscles. Electrodiagnostic studies can be a useful adjunct to clinical examination, to help localize the site and quantify the grade of compression. Management should involve a trial of conservative treatment and failing that, surgical treatment should be considered. We hereby provide an overview of nerve entrapments around the elbow including their applied anatomy, etiology, clinical assessment and overview of the current concepts in surgical treatment.     

Ultrasound-guided infraclavicular brachial plexus block: an alternative technique to anatomical landmark-guided approaches

BACKGROUND AND OBJECTIVES: Infraclavicular brachial plexus block has been used less than other approaches because of its less uniform landmarks and the necessity of a longer needle, which increases the patient's discomfort. To overcome these drawbacks, we applied ultrasound guidance to infraclavicular approach and prospectively evaluated its feasibility and usefulness in 60 patients undergoing upper extremity surgery. METHODS: A 7.0-MHz ultrasound probe was placed near the lower edge of the clavicle, and a transverse view of the subclavian artery and vein was visualized. Using a needle guide, a 23-gauge needle was advanced under real-time ultrasound guidance, and 1.5% lidocaine with 1:200,000 epinephrine was injected near the subclavian artery, 15 mm medially and 15 mm laterally to the artery. The extent of sensory and motor block was evaluated at 30 minutes after the injection. RESULTS: An adequate ultrasound image was obtained for all the patients. In 57 patients (95%), surgery was performed without supplementation of any other anesthetics or analgesics. The complete sensory block was obtained in 100% of patients for the musculocutaneous and medial antebrachial cutaneous nerves, 96.7% for the median nerve, and 95% for the ulnar and radial nerves. The complete motor block was achieved in 100% of patients for the musculocutaneous nerve, 96.7% for the median nerve, 90% for the ulnar nerve, and 93.3% for the radial nerve. No evidence of any complications was identified. CONCLUSIONS: Real-time ultrasound guidance facilitates accurate infraclavicular approach to the brachial plexus. It could be used as an alternative to the landmark-guided techniques.     

The cutaneous innervation of the dorsal hand: detailed anatomy with clinical implications

PURPOSE: Detailed knowledge of the anatomy of the cutaneous innervation to the dorsal surface of the hand is valuable information. Because surgical access to the wrist often is obtained via the dorsal skin it would be helpful particularly to delineate an area where surgical incisions would not injure underlying nerves. METHODS: Thirty cadaver forearms were dissected carefully to examine in detail the anatomy of the lateral antebrachial cutaneous nerve, the superficial branch of the radial nerve, and the dorsal branch of the ulnar nerve. Each hand then was evaluated for an area free of any major nerve branches over the dorsal wrist. RESULTS: Although the innervation to the dorsal hand varies certain patterns exist. The innervation pattern between the superficial branch of the radial nerve and the dorsal branch of the ulnar nerve is distributed evenly, dual innervation is frequent between the 2 nerves, and the lateral antebrachial cutaneous nerve is a common contributor to the innervation of the thumb. The superficial branch of the radial nerve and the dorsal branch of the ulnar nerve have identifiable branching patterns and have been classified according to a system developed for this study. CONCLUSIONS: Two classification systems based on detailed dorsal hand cutaneous innervation patterns can be used to specify the placement of a safe dorsal skin incision away from major nerve branches.