前臂近中段Thompson入路中桡神经深支医源性损伤的解剖学因素及对策

目的　探讨前臂近中段Thompson入路中容易发生桡神经深支损伤的解剖学因素并提出对策。 方法　教学用成人尸体标本48具,按照Thompson入路显露,观察前臂伸肌与桡神经深支及其肌支的位置关系;测量桡神经深支穿出旋后肌的位置距离桡侧腕短伸肌的横向距离;观察指伸肌和桡侧腕短伸肌在前臂近段的愈着情况,测量二者在肱桡关节线以远的愈着长度。 结果　指伸肌和桡侧腕短伸肌在前臂近段相愈着,愈着长度在肱桡关节以远(7.1±2.1)cm;桡神经深支在旋后肌下缘的穿出点与桡侧腕短伸肌尺侧缘的水平距离为(1.3±0.3) cm,与肱桡关节线距离为(6.1±1.8) cm。 结论　前臂近中段Thompson入路中容易发生桡神经深支损伤存在着解剖学因素,了解桡神经深支的解剖特点及其与前臂伸肌的位置关系可以避免桡神经深支损伤。     

前臂桡侧头静脉-皮神经的营养血管的解剖学

目的：为前臂桡侧头静脉-皮神经营养血管远端蒂复合瓣设计提供解剖学基础。方法：动脉灌注红色乳胶成人上肢标本,解剖观测头静脉-前臂外侧皮神经下1/3段营养血管的来源、分支及其与桡骨膜血管的关系。结果：头静脉-前臂外侧皮神经下1/3段的营养血管来自：桡动脉皮支,掌浅支皮支,桡骨茎突返支皮支和桡动脉肌间隙骨皮支。上述诸支血管发皮支、筋膜支、骨膜支、神经-浅静脉营养血管,形成皮神经-头静脉血管链以及深、浅筋膜和骨膜血管网。结论：前臂桡侧缘头静脉-皮神经营养血管与肌、骨、皮营养血管同源,以桡骨茎突返支为蒂的远端蒂复合瓣,旋转轴点在腕关节平面,可用于手部远处组织缺损修复。     

The innervation of deep muscles of the human forearm extensors]

The innervation of four deep muscles of the human forearm extensors (the abductor pollicis longus, the extensor pollicis brevis, the extensor pollicis longus, and the extensor indicis muscles) were investigated in 24 bodies (48 sides) from those used in the 1989 and 1990 student courses in gross anatomy dissection at the Iwate Medical University School of Medicine. The forearm extensor muscles and the deep branch of the radial nerve were dissected intensively in the student courses in gross anatomy and were removed afterwards. The four deep muscles of the human forearm extensors and the nerves innervating the muscles were observed while they were immersed in the water and with use of a stereomicroscope--with the assistance of which they were drawn. In six sides the intramuscular nerve supply was also examined carefully and drawn. The results were as follows. 1. The nerves to the four deep muscles of the forearm extensors arose usually from the deep branch of the radial nerve after emerging the supinator muscle and sending branches to superficial forearm extensors. In some cases a nerve or nerves to the superficial forearm extensors were observed arising from the deep branch of the radial nerve after sending one or more branches to the deep forearm extensor muscles, or from the branches to the deep muscles themselves. However they were split easily from the deep branch of the radial nerve and from the branches to the four deep forearm extensors proximally near to the emerging of the deep branch from the supinator muscle. Therefore, it was considered to be constant that the nerves to the four deep forearm extensors arose from the deep branch of the radial nerve after branching to the superficial forearm extensors. 2. The radial group of the deep forearm extensors (the abductor pollicis longus and the extensor pollicis brevis muscles) was innervated usually by one branch that arose from the deep branch of the radial nerve just after emerging from the supinator and giving off branches to the superficial forearm extensors. This branch ran on the dorsal (extensor) surface of the abductor pollicis longus muscle distally, sending many twigs to this muscle, and entered into the muscle at various distances from the origin (Figs. 1-6). The abductor pollicis brevis muscle was innervated by some twigs that ran usually inside but occasionally outside of the abductor pollicis longus muscle (Figs. 7-10).(ABSTRACT TRUNCATED AT 400 WORDS)     

以前臂内侧皮神经及营养血管为蒂的前臂内侧皮瓣的应用解剖

目的　为带前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 ,观测前臂内侧皮神经营养血管及其周围皮肤的血供情况。结果　前臂内侧皮神经近侧的血供来源于尺侧返动脉混合肌皮支 ,起始处外径为 0 .8mm ,穿出深筋膜前长度为 1.1cm ;中部主要来自尺动脉近中段和远中段的粗大皮支 ,起始处外径均为 0 .7mm ,穿出深筋膜前长度均为 1.0cm ;远侧有尺动脉腕上皮支 ,起始处外径为 0 .9mm ,穿出深筋膜前长度均为 1.0cm ;远侧有尺动脉腕上皮支 ,起始处外径为 0 .9mm ,穿出深筋膜前长为 2 .6cm。其神经旁血管网与神经皮穿支及神经内血管广泛吻合组成了皮神经血管轴。结论　可设计成带前臂内侧皮神经及营养血管为蒂筋膜上瓣 ,顺行或逆行转位修复邻近部位的软组织缺损。     

尺动脉腕上皮支下行支皮支链岛状皮瓣的应用解剖

目的　为尺动脉腕上皮支下行支皮支链岛状皮瓣修复前臂和手指缺损提供解剖学基础。方法　12侧肘关节以上部位截肢的上肢新鲜标本,10侧采用乳胶灌注肱动脉,2侧用乙酸乙酯和塑料灌注肱动脉制作铸型标本,解剖观测尺动脉腕上皮支下行支皮支的起始、走行、分布和吻合情况,并对其外径进行测量。  结果　以尺骨茎突尖端到手背尺侧第5掌指关节部位作为一个单位长度。尺动脉腕上皮支下行支发出的远段皮支2.3支,远段皮支血管聚集点约在第5掌骨颈部,到第5掌指关节的距离占总单位长度的(18.2±7.0)%; 近段皮支4.4支,近段皮支血管聚集点约在第5掌骨基底部,到第5掌指关节的距离占总单位长度的 (66.4±16.7)%。尺动脉腕上皮支下行支皮支在桡尺侧的分布无显著性差异。尺动脉腕上皮支下行支皮支在手背尺侧浅筋膜内相互吻合,形成与尺动脉腕上皮支下行支相平行的皮支链,并营养相应的皮肤。  结论　尺动脉腕上皮支下行支皮支链岛状皮瓣可用于修复手指或前臂较小的皮肤缺损,而且不损伤其主干血管。     

肘前内侧血管神经间隙入路的临床解剖学

目的　对肘前内侧血管神经等相关结构进行解剖研究,为肘关节相关手术提供更佳的手术入路。 方法　 福尔马林防腐动脉灌注红色乳胶成人尸体上肢标本20侧,按层次解剖,从肱桡肌及旋前圆肌间隙进入,通过正中神经与肱、尺动脉之间的血管神经间隙,显露肘前侧解剖结构。观察肱动脉、桡动脉和尺动脉向内、外侧的分支,测量分支到桡、尺动脉分叉处的距离,分支管径;观察正中神经及分支走行情况,测量神经与血管伴行无相互交叉分支距离。 结果　血管神经无互相交叉分支伴行长度平均为6.04 cm,两者之间无重要分支相交叉,易于向两侧分开,能够清楚地提供肘关节相应部位的暴露。动脉向内侧分支较向外侧分支少且细,易于向外侧牵拉。神经肌支,基本上向内侧发出,以极小的锐角从主干发出,几乎与主干平行,易于向内侧牵拉。 结论　肘前内侧血管神经间隙入路,可保护血管神经,能清楚显露肘关节前侧解剖结构,易于操作。     

桡,尺动脉肌,皮支的解剖学研究

目的:为手外科提供桡、尺动脉分出的肌、皮支.材料和方法:用福尔马林常规固定的成尸上肢69(男61,女8)侧,解剖观测桡、尺动脉分支的部位、支数及外径.主要结果:从尺、桡动脉壁两侧发出分支,大部分为不对称性分支间距不等,平均(3.0～15.0)mm.桡动脉平均分出15.8支,其中肌支10.3支,筋膜皮支5.5支.尺动脉平均分出12.4支,其中肌支7.6支,筋膜皮支4.8支.结论:桡、尺动脉分出肌、皮支,皮支为前臂筋膜瓣、皮瓣的血管蒂.     

以前臂内侧皮神经及营养血管为蒂筋膜皮瓣的应用解剖

目的:为带前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,观测前臂内侧皮神经营养血管及其周围皮肤的供血情况。结果:前臂内侧皮神经近侧的血供来源于尺侧返动脉混合肌皮支,起始处外径为0.8mm,穿出筋膜前长度为1.1cm;中段主要来自尺动脉近中段和远中段的粗大皮支,起始处外径均为0.7mm,穿出深筋膜前长度均为1.0cm;远侧有尺动脉腕上皮支,起始处外径为0.9mm,穿出深筋膜前长为2.6cm。其神经旁血管网与神经皮(穿)支及神经内血管广泛吻合组成了皮神经血管轴。结论:可设计成带前臂内侧皮神经及营养血管为蒂筋膜皮瓣,顺行或逆行转位修复邻近部位的软组织缺损。     

Applied anatomy of the superficial branch of the radial nerve

The superficial branch of the radial nerve (SBRN) is highly vulnerable to trauma and iatrogenic injury. This study aimed to map the course of the SBRN in the context of surgical approaches and identify a safe area of incision for de Quervain's tenosynovitis. Twenty-five forearms were dissected. The SBRN emerged from under brachioradialis by a mean of 8.31 cm proximal to the radial styloid (RS), and remained radial to the dorsal tubercle of the radius by a mean of 1.49 cm. The nerve divided into a median of four branches. The first branch arose a mean of 4.92 cm proximal to the RS, traveling 0.49 cm radial to the first compartment of the extensor retinaculum, while the main nerve remained ulnar to it by 0.64 cm. All specimens had branches underlying the traditional transverse incision for de Quervain's release. A 2.5-cm longitudinal incision proximal from the RS avoided the SBRN in 17/25 cases (68%). In 20/25 specimens (80%), the SBRN underlay the cephalic vein. In 18/25 (72%), the radial artery was closely associated with a sensory nerve branch near the level of the RS (SBRN 12/25, lateral cutaneous nerve of the forearm (LCNF) 6/25.) A longitudinal incision in de Quervain's surgery may be preferable. Cannulation of the cephalic vein in the distal third of the forearm is best avoided. The close association between the radial artery and first branch of the SBRN or the LCNF may explain the pain often experienced during arterial puncture. Particular care should be taken during radial artery harvest to avoid nerve injury.     

Innervation of metacarpophalangeal joint and distal interphalangeal joint: an anatomical and histological study

Using 131 fingers for the metacarpophalangeal (MP) joint and 124 fingers for the distal interphalangeal (DIP) joint obtained from 30 hands of human cadavers, the innervation of the MP and DIP joints was investigated anatomically in detail. Two articular branches developing from a dorsal branch of the ulnar nerve and a superficial branch of the radial nerve, and entering the dorsal side of the MP joint from the ulnar side and radial side, respectively, were found in every finger. In addition, articular branches from the deep branch of the ulnar nerve were found in every middle, ring and little finger. However, articular branches from the proper palmar digital nerve were found to exist in 62.7% of the fingers. Articular branches developing from the proper palmar digital nerve and going towards the DIP joint were found in every case, and 97.3% of 244 branches developed directly from the proper palmar digital nerve, while some of the remaining branches were from a dorsal branch of the proper palmar digital nerve and others developed neural loop penetration. Articular branches ran parallel to the distal transverse artery and entered the joint, and some of them went towards the volar plate, dorsal joint capsule, and tendon sheath. Many nerve endings existed in the surface layer of the articular capsule and arthrosynovial membranes in the form of Pacinian corpuscles and corpuscles of Ruffini. The existence of a neural loop in the finger should be taken notice of during somatoscopy in patients with neurovascular symptoms in the fingertip or surgical operation on a vascular pedicular island flap. Further, it was suggested that injury of the articular branch of the DIP joint could induce Heberden nodes due to its anatomical characteristics.     

肘关节前方入路切口“安全区域”的解剖学研究

目的 解剖学观察肱二头肌腱和前臂内、外侧皮神经之间的解剖位置关系,为肘关节前方入路手术切口设计提供理论依据。方法 解剖30例成人肘关节标本,均无外伤、畸形、肿瘤、骨折。其中新鲜冰冻标本8例(性别不详,左5例、右3例),经10%甲醛溶液浸泡的标本22例(男12例、女10例,左11例、右11例)。仔细观察肘关节前方的肱二头肌腱和前臂内、外侧皮神经,并测量前臂内、外侧皮神经穿出深筋膜的位置,及其与肱二头肌肌腱之间的解剖位置关系。结果 前臂外侧皮神经走行于肘关节的前方偏桡侧,与肱二头肌腱相毗邻,在肱骨外上髁平面下方(20.5±2.5)mm处穿出深筋膜,穿出点与肱二头肌腱桡侧缘之间的水平距离为(12.6±0.9)mm;前臂内侧皮神经沿肱动脉下行,在肱骨内上髁上方约5 cm处穿出深筋膜,在肱骨内上髁平面处,后支与肱二头肌腱尺侧缘之间的水平距离为(33.1±2.7)mm。两者之间的安全宽度约为40 mm。结论 距肱二头肌腱两侧缘之间约40 mm的宽度为肘关节前方入路的相对安全区域,以肱二头肌腱为参照设计切口,可以减少医源性前臂内、外侧皮神经损伤的发生。     

第1掌骨背桡侧岛状皮瓣的应用解剖

目的　提供第1掌骨背桡侧岛状皮瓣的应用解剖依据。 方法　解剖 20具防腐固定成人手标本,观测第1掌背桡侧皮支血管链的起源、外径、长度及吻合。1例新鲜成年手标本动脉造影。 结果　在拇长展肌腱止点深面可见一条粗大皮支起始,39侧来源自桡动脉浅支,1侧来源于桡动脉主干。该皮支主干沿拇短伸肌腱桡侧向远端走行,相距2 mm。在掌指关节平面,与指掌侧动脉穿支吻合。 结论　以第1掌骨背桡侧该皮支为轴心血管设计轴线,切取岛状皮瓣修复手部皮肤软组织缺损在解剖上具有可行性。     

肘关节镜三种远端前外侧入路对周围神经损伤风险比较

目的：比较肘关节镜3 种远端前外侧入路穿刺后对前臂外侧皮神经及桡神经（ 深支）的影响。 方法：选用 新鲜冰冻的成人肘关节标本,关节镜下对3 种入针点（ 肱骨外上髁远端3 cm,前方1 cm ;肱骨外上髁远端2 cm, 前方2 cm ;肱骨外上髁远端1 cm,前方1 cm）进行定位、穿刺克氏针,并在肘关节屈曲90°时,解剖、测量与 前臂外侧皮神经及桡神经（ 深支）的最短距离。结果：3 种入路距前臂外侧皮神经的最短距离分别为（18.51±2.07） mm、（19.14±1.53）mm、（21.95±1.83）mm,距桡神经（ 深支）的最短距离分别为（7.18±1.17）mm、（7.59±0.88） mm、（9.22±1.51）mm。后一入路点（ 肱骨外上髁远端1 cm,前方1 cm）距2 条神经的距离为最短,且与前2 者 的差异具有统计学意义。结论：肘关节镜前外侧入路（ 肱骨外上髁远端1 cm,前方1 cm）距前臂外侧皮神经及桡 神经（ 深支）的最短距离最远,建立远端前外侧入路时选此入路穿刺比较安全。     

Report of a rare human variation: absence of the radial artery

A case of unilateral absence of the radial artery is reported. The arterial system of the specimen was developmentally primitive with the anterior interosseous artery the chief blood supply to the forearm and hand. A "superficial ulnar artery" of small caliber supplemented the supply of the hand. Three large branches of the anterior interosseous artery supplied the hand with the lateral terminal branch replacing the radial artery distal to the wrist. The superficial palmar arch was formed by an anastomosis of the media and lateral terminal branches of the anterior interosseous artery. No deep palmar arch was present, but three palmar metacarpal arteries arose from a perforating artery which branched from a large dorsal branch of the anterior interosseous artery. The median artery was of small caliber and could not be traced beyond the midforearm. Based on this specimen and a review of other forearm and hand arterial variations, it is postulated that the ulnar artery may developmentally precede the median artery.     

Vascular branches from cutaneous nerve of the forearm and hand: Application to better understanding raynaud's disease

Cutaneous nerves have branches called vascular branches (VBs) that reach arteries. VBs are thought to be involved in arterial constriction, and this is the rationale for periarterial sympathectomy as a treatment option for Raynaud's disease. However, the branching patterns and distribution areas of the VBs remain largely unclear. The aim of the present study was to investigate the anatomical structures of the VBs of the cutaneous nerves. Forty hands and forearms were examined to assess the branching patterns and distribution areas of the VBs of the superficial branch of the radial nerve (SBRN), the lateral antebrachial cutaneous nerve (LACN), the medial antebrachial cutaneous nerve (MACN), and the palmar cutaneous branch of the ulnar nerve (PCUN). VBs reaching the radial and ulnar arteries were observed in all specimens. The branching patterns were classified into six types. The mean distance between the radial styloid process and the point where the VBs reached the radial artery was 34.3 ± 4.8 mm in the SBRN and 38.5 ± 15.8 mm in the LACN. The mean distance between the ulnar styloid process and the point where the VBs reached the ulnar artery was 60.3 ± 25.9 mm in the MACN and 43.8 ± 26.0 mm in the PCUN. This study showed that the VBs of the cutaneous nerves have diverse branching patterns. The VBs of the SBRN had a more limited distribution areas than those of the other nerves. Clin. Anat. 31:734–741, 2018. © 2017 Wiley Periodicals, Inc.     

骨间后神经穿桡管远端处的解剖特点及其临床意义

目的：了解骨间后神经穿旋后肌后可能的卡压位置及临床意义,方法：在2倍放大镜下解剖骨间后神经穿旋后肌后的行程,分支,可能卡压位置以及前臂活动对其影响。结果：骨间后神经穿旋后肌后恒定地分尺仙支和桡侧支;旋后肌远侧缘和拇短伸肌,拇长展肌浅面的腱性肌纤维结构可能是致卡压的解剖结构,前臂伸肌群的活动可 诱发上述结构卡压骨间后神经,结论：在桡管远端同样存在卡坟骨间后神经的解剖结构,必要时应手术探查,松解。     

尺神经手背支营养血管皮瓣修复小指指腹创面的解剖及临床

目的:报道尺神经手背支营养血管逆行皮瓣修复小指指腹皮肤缺损的解剖基础及方法。方法:根据尺神经手背支及其营养血管的解剖规律,设计逆行皮瓣,修复小指指腹皮肤缺损。结果:患者7例,术后平均随访5～20个月,皮瓣全部成活,其中优3例,良3例,可1例,疗效优良率86%。结论:尺神经手背支营养血管逆行皮瓣血运丰富,修复小指皮肤缺损,覆盖完全,容易成活,优良率高,手术简单。     

Case report of a new variant of double incomplete superficial palmar arch

A rare, unique and previously non-described form of duplicated incomplete superficial palmar arch is reported in the right hand of a male cadaver. The two incomplete arches were formed from the continuation of two terminal palmar branches of the ulnar artery in the distal third of forearm that were connected by a small transverse artery superficial to the flexor retinaculum. Both arches had no contribution from the radial artery. The palmar digital branches from the lateral arch supplied the lateral two-and-a-half fingers, while those from the medial arch supplied the medial two-and-a-half fingers. The thumb and index had additional blood supply from the princeps pollicis and radialis indicis branches of radial artery. The deep palmar arch was entirely formed by the radial artery with no contribution from the ulnar artery. Previous reports on various patterns of superficial palmar arch are highlighted, and the anatomical and clinical importance of the new pattern are discussed.     

Can palmar creases serve as landmarks for the deeper neuro-vascular structures?

Purpose

The aim of this study was the examination of the superficial anatomy of palmar creases and their relation to deeper neuro-vascular structures.

Methods

Four creases: distal wrist flexion crease, thenar crease, proximal palmar crease and distal palmar crease were evaluated with reference to the following structures: palmar cutaneous branch of median nerve, palmar cutaneous branch of ulnar nerve, the nerve of Henle, transverse palmar branches from ulnar nerve, recurrent motor branch of median nerve, radial proper palmar digital nerve to the index and the ulnar proper palmar digital nerve to the thumb, Berrettini’s communicating branch, ulnar nerve and artery, superficial palmar arch. We performed dissections of 20 cadaveric upper limbs derived from a homogenous Caucasian group. In our study we measured the location of surgically important structures with reference to palmar skin creases.

Results

Among the other observations we noticed that the palmar cutaneous branches of the median and ulnar nerves were located at least 0.5 cm away from the thenar crease. The superficial palmar arch was found between the thenar and proximal palmar crease and never crossed the proximal or distal palmar creases.

Conclusions

These anatomical dissections will provide reference material for further ultrasound studies on the arrangements of neuro-vascular structures in reference to superficial palmar creases.     

The Muscular Branching Patterns of the Ulnar Nerve to the Flexor Carpi Ulnaris and Flexor Digitorum Profundus Muscles

The branching pattern of the ulnar nerve in the forearm is of great importance in anterior transposition of the ulnar nerve for decompression after neuropathy of cubital tunnel syndrom and malformations resulting from distal end fractures of the humerus. In this study, 37 formalin-fixed forearms were used to demonstrate the muscular branching patterns from the main ulnar nerve to the flexor carpi ulnaris muscle (FCU) and ulnar part of the flexor digitorum profundus muscle (FDP). Eight branching patterns were found and classified into four groups according to the number of the muscular branches leaving the main ulnar nerve. Two (Group I) and three (Group II) branches left the main ulnar nerve in 18 and 17 forearms respectively. The remaining two specimens had four (Group III) and five (Group IV) branches each. Usually one or two branches were associated with the innervation of the FCU. However, in 2 cases, three and in one, four branches to FCU were observed. The FDP received a single branch in all cases, except in four, all of which had two branches. In six forearms, a common trunk was observed arising from the ulnar nerve to supply the FCU and FDP. The distribution of the muscular branches to the revealed muscles was outlined in figures and the distance of the origin of these branches from the interepicondylar line was measured in millimeters. The first muscular branch leaving the main ulnar nerve was the FCU-branch in all specimens. The terminal muscular branch of the ulnar nerve to the forearm muscles arose at the proximal 1/3 of the forearm in all specimens. In 7 forearms, Martin-Gruber anastomosis in form of median to ulnar was observed.