长伸肌瓣的解剖学基础

在30个成人下肢标本上观察了长伸肌的形态、血供和神经支配。测得肌长23.1cm。该肌由7-17支胫前动脉横向分支供应,肌下份有腓动脉穿支发出补充,动脉主要从肌的内侧入肌。腓深神经约发出2支分支分布该肌,也是从肌内侧进入肌内。根据观察结果我们认为长仲肌瓣倒置治疗小腿中下份慢性骨髓炎及开放性胫骨骨折,似为较理想的供肌。     

The distal hindlimb musculature of the cat

Summary Chronic recordings were made of electromyographic (EMG) activity, tension, and length of distal hindlimb muscles in six cats performing a variety of normal motor tasks. Muscles studied thoroughly or in part were medial gastrocnemius, lateral gastrocnemius, plantaris, soleus, flexor digitorum brevis, flexor digitorum longus, flexor hallucis longus, tibialis posterior, tibialis anterior, extensor digitorum longus, peroneus longus, and peroneus brevis. Postural and locomotor activities were examined, as well as jumping, landing, scratching, and paw shaking. In general, muscles could be assigned to traditional groupings (e.g. extensor, flexor) related to the demands of the motor task. Patterns of muscle activity were most often consistent with current understanding of muscle mechanics and neural coordination. However, purely functional distinctions between flexor digitorum longus and flexor hallucis longus (anatomical synergists) were made on the basis of activity patterns. Likewise, the activity of plantaris and flexor digitorum brevis, which are attached in series, was differentiated in certain tasks. The rhythmical oscillatory patterns of scratching and paw shaking were found to differ temporally in a manner consistent with the limb mechanics. In several cases, mechanical explanations of specific muscle activity required length and force records, as well as EMG patterns. Future efforts to study motor patterns should incorporate information about the relationships between muscle activation, tension, length and velocity.Abbreviations EDL extensor digitorum longus - FDB flexor digitorum brevis - FDL flexor digitorum longus - FHL flexor hallucis longus - LG lateral gastrocnemius - MG medial gastrocnemius - PB peroneus brevis - PL peroneus longus - PLT plantaris - SOL soleus - TA tibialis anterior - TP tibialis posterior Limbs A ankle - K knee - LF left forelimb - LH left hindlimb - RF right forelimb - RH right hindlimb Step Cycle Phases E₁ first extension, late swing phase prior to footfall - E₂ second extension, early stance phase - E₃ third extension, late stance phase - F flexion, early swing phase     

The consistent presence of the human accessory deep peroneal nerve

Twenty-four human legs were dissected macroscopically to study the morphological details of the accessory deep peroneal nerve. This nerve arose from the superficial peroneal nerve and descended in the lateral compartment of the leg, deep to peroneus longus along the posterior border of peroneus brevis. Approaching the ankle joint, this nerve passed through the peroneal tunnels to wind around the lateral malleolus; it then crossed beneath the peroneus brevis tendon anteriorly to reach the dorsum of the foot. The accessory deep peroneal nerve was found in every case examined and constantly gave off muscular branches to peroneus brevis and sensory branches to the ankle region. In addition, this nerve occasionally had muscular branches to peroneus longus and extensor digitorum brevis, and sensory branches to the fibula and the foot. The anomalous muscles around the lateral malleolus were also innervated by this nerve. Neither cutaneous branches nor communicating branches with other nerves were found. The present study reveals that the accessory deep peroneal nerve is consistently present and possesses a proper motor and sensory distribution in the lateral region of the leg and ankle. It is not an anomalous nerve as has previously been suggested.     

The distal hindlimb musculature of the cat. Patterns of normal use

Chronic recordings were made of electromyographic (EMG) activity, tension, and length of distal hindlimb muscles in six cats performing a variety of normal motor tasks. Muscles studied thoroughly or in part were medial gastrocnemius, lateral gastrocnemius, plantaris, soleus, flexor digitorum brevis, flexor digitorum longus, flexor hallucis longus, tibialis posterior, tibialis anterior, extensor digitorum longus, peroneus longus, and peroneus brevis. Postural and locomotor activities were examined, as well as jumping, landing, scratching, and paw shaking. In general, muscles could be assigned to traditional groupings (e.g. extensor, flexor) related to the demands of the motor task. Patterns of muscle activity were most often consistent with current understanding of muscle mechanics and neural coordination. However, purely functional distinctions between flexor digitorum longus and flexor hallucis longus ("anatomical synergists") were made on the basis of activity patterns. Likewise, the activity of plantaris and flexor digitorum brevis, which are attached in series, was differentiated in certain tasks. The rhythmical oscillatory patterns of scratching and paw shaking were found to differ temporally in a manner consistent with the limb mechanics. In several cases, mechanical explanations of specific muscle activity required length and force records, as well as EMG patterns. Future efforts to study motor patterns should incorporate information about the relationships between muscle activation, tension, length and velocity.     

Anatomic basis of a pedicled extensor digitorum brevis muscle flap

The vascularization of the extensor digitorum brevis is ensured on its deep aspect by branches of the anterior tibial artery, but also by a lateral arterial arch anastomosing with these branches. The lateral vascular arch of the extensor digitorum brevis was constantly found in 37 anatomic specimens: 17 formolized and 20 fresh. This arch derives from the perforating peroneal branch, the terminal anterior branch of the peroneal artery. Its variable caliber, assessed by arteriography of the foot, seemed adequate for the peroneal artery to serve as a pedicle for the extensor digitorum brevis without interruption of the anterior-tibial axis.     

Dimensions of the anterior tarsal tunnel and features of the deep peroneal nerve in relation to clinical application

Background The aim of this study was to demonstrate anatomical features of the anterior tarsal tunnel and the deep peroneal nerve and to discuss the importance of these structures for the anterior tarsal tunnel syndrome and some other surgical approaches to minimize the injury risk. Methods Lower limbs of 18 formalin fixed cadavers were examined. The limbs showed no evidence of pathology or trauma. Results The lateral length of the tunnel was 21.7 ± 4.3 mm and the medial length of the tunnel was 55.0 ± 9.0 mm. The width of the tunnel at the inferior border between the extensor hallucis longus and extensor digitorum longus tendons was 12.6 ± 2.1 mm. The location of the deep peroneal nerve bifurcation was in the anterior tarsal tunnel in 31 specimens (86.1%) and distal to the tunnel in two specimens (5.6%). In three specimens (8.3%) there was no bifurcation because of the absence of the medial terminal branch of the deep peroneal nerve. In these three specimens, the superficial peroneal nerve distributed to the adjacent sides of the great and second toes. Bifurcation above the tunnel was not observed in our specimens. There was connection between the deep peroneal nerve and the superficial peroneal nerve in 10 specimens (27.8%) in the first interdigital space. During the observations, the presence of a fibrous band over the nerve and vessel was noted in 22 specimens (61.1%). Conclusions We believe that a detailed anatomic knowledge of the anterior tarsal tunnel and the deep peroneal nerve will be of help during surgical approaches to this area and the diagnosis of the problems related to the peripheral nerves on the dorsum of the foot. This study was presented on the 4th Asian-Pacific International Congress of Anatomists (APICA 2005) in Kusadasi, Turkey on 7-10 September 2005.     

Correlation between the size of the compound muscle and sensory nerve action potentials recorded from the foot in distal axonopathy

Nerve conduction study was performed on 71 diabetic patients with distal sensorimotor axonopathy. Of 76 lower limbs studied, 46.1% showed no recordable sural compound sensory nerve action potential (CSNAP), and 55.3% no superficial peroneal CSNAP. Only 2.6% revealed no recordable compound muscle action potential (CMAP) from the abductor hallucis (AH) muscle, and 9.2% showed no obtainable CMAP from the extensor digitorum brevis (EDB) muscle. There were fairly good positive correlations between the amplitudes of the sural CSNAPs and AH CMAPs (r = 0.66), and between the superficial peroneal CSNAP and EDB CMAP amplitudes (r = 0.63). There were no instances in which a CSNAP could be obtained from the sural or superficial peroneal sensory nerve, but a CMAP could not be recorded from the AH or EDB muscle. If the CMAP amplitudes of the AH and EDB muscles were reduced to less than 0.3 mV, usually a CSNAP could longer be recorded from the sural and superficial peroneal sensory nerves. The size of the CSNAP is a more sensitive measure compared to the CMAP in revealing the presence of distal sensorimotor axonopathy.     

Intramuscular innervations of lower leg skeletal muscles: applications in their clinical use in functional muscular transfer

Purpose

This study aims to investigate nerve distribution patterns of human lower leg skeletal muscles using a modified Sihler’s staining method.

Methods

Sixteen lower leg from eight fresh adult cadavers were used in this study and all the skeletal muscles were dissected. The muscle specimens were classified according to Lim’s classification. The specimens were then stained by further modified Sihler’s staining technique. Data were analyzed according to research results.

Results

After the staining, we found four patterns of nerve distribution in human lower leg muscles: (1) Type 1: single nerve pattern in which the nerve branches into two either running parallel to each other or radiating in a spray pattern (such as the extensor digitorum longus, extensor hallucis longus, fibularis brevis and flexor hallucis longus). (2) Type 2: double nerve pattern, one being proximal and the other being distal (such as the extensor digitorum longus, flexor digitorum longus, flexor hallucis longus). (3) Type 3: multiple branch pattern (such as the tibialis anterior, fibularis longus, gastrocnemius, soleus, tibialis anterior and popliteus).

Conclusion

Our modified Sihler’s staining method is useful for research of large muscles and intramuscular nerves in human. These findings might provide guidance for clinicians for muscle reconstruction surgery.

     

Accessory peroneal nerves in the human

The Nervus peroneus profundus accessorius was described by Ruge (1878) in the lower mammals and for the first time identified by Bryce (1897) in man. It is an accessory terminal branch of the superficial peroneal (musculocutaneous) nerve which winds round the lateral malleolus beneath the tendons of the peronei muscles and reaches the dorsum of the foot; there it often supplies the lateral portion of the extensor digitorum brevis muscle. In further investigations this nerve has been traced in 21.2% of subjects resp. in 13.5% of legs. This nerve, however, is not the only accessory branch of the common peroneal nerve: In 14 out of 140 subjects (10%) resp. in 22 out of 280 legs (7.9%) a Nervus peroneus superficialis accessorius has been found. This nerve pierces the anterior crural intermuscular septum either in common with deep peroneal (anterior tibial) nerve or at a lower point. Then it descends in front of the septum rarely giving off muscular branches to the extensor digitorum longus and peroneus tertius muscles; in the lower half of the leg it pierces the crural fascia, passes in front of the ankle joint and becomes the medial cutaneous nerve of the dorsum of the foot. This accessory superficial peroneal nerve may be of importance in surgery of the leg and foot.     

Nerve conduction velocity to different muscles in peroneal pressure neuropathy.

The variability inherent in nerve conduction velocity (NCV) studies suggests that multiple measurements may yield more information than a single measurement. To test this hypothesis, three motor nerve conduction velocities (NCVs) of the peroneal nerve were measured: to the extensor digitorum brevis muscle over the fibular head and in the lower leg, and to the tibialis anterior muscle over the fibular head. Three groups were studied: controls, polyneuropathy cases and peroneal pressure neuropathy cases. Over the fibular head, NCVs recorded from the tibialis anterior were consistently higher than those from the extensor digitorum brevis, and showed a higher number of abnormalities. Differences between NCVs, their Z-scores and Mahalanobis distances were compared to study the influence of variance differences and covariances. The best compromise between true and false positives was found to be a comparison between NCVs over the fibular head recorded from the tibialis anterior and the leg segment recorded from the extensor digitorum muscle. Z-scores are more useful than Mahalanobis distances in this respect.     

Restoration of motor function of the deep fibular (peroneal) nerve by direct nerve transfer of branches from the tibial nerve: an anatomical study

Traction injuries of the common fibular (peroneal) nerve frequently result in significant morbidity due to tibialis anterior muscle paralysis and the associated loss of ankle dorsiflexion. Because current treatment options are often unsuccessful or unsatisfactory, other treatment approaches need to be explored. In this investigation, the anatomical feasibility of an alternative option, consisting of nerve transfer of motor branches from the tibial nerve to the deep fibular nerve, was studied. In ten cadaveric limbs, the branching pattern, length, and diameter of motor branches of the tibial nerve in the proximal leg were characterized; nerve transfer of each of these motor branches was then simulated to the proximal deep fibular nerve. A consistent, reproducible pattern of tibial nerve innervation was seen with minor variability. Branches to the flexor hallucis longus and flexor digitorum longus muscles were determined to be adequate, based on their branch point, branch pattern, and length, for direct nerve transfer in all specimens. Other branches, including those to the tibialis posterior, popliteus, gastrocnemius, and soleus muscles were not consistently adequate for direct nerve transfer for injuries extending to the bifurcation of the common fibular nerve or distal to it. For neuromas of the common fibular nerve that do not extend as far distally, branches to the soleus and lateral head of the gastrocnemius may be adequate for direct transfer if the intramuscular portions of these nerves are dissected. This study confirms the anatomical feasibility of direct nerve transfer using nerves to toe-flexor muscles as a treatment option to restore ankle dorsiflexion in cases of common fibular nerve injury.     

Lateromedial and dorsoplantar borders among supplying areas of the nerves innervating the intrinsic muscles of the foot.

The branching patterns of nerves supplying the intrinsic muscles of the foot were analyzed as a basis to confirm the muscle layer structure. Thirty-eight feet of 20 Japanese cadavers were examined in detail in this study. The first dorsal interosseus was innervated by a branch from the deep peroneal nerve as well as a branch of the lateral plantar nerve in 92.1%, the second dorsal interosseus in 10. 5% and the third dorsal interosseus in 2.6%. In three specimens, branches from the deep peroneal nerve innervated the oblique head of the adductor hallucis or the lateral head the flexor hallucis brevis. In addition, branches from the medial and lateral plantar nerves and the deep peroneal nerve formed communication loops in three specimens. The first dorsal interosseus, the oblique head of the adductor hallucis and the lateral head of the flexor hallucis and their innervating nerve branches are closely related within the first intermetatarsal space. Since the tibial part of the first interosseus muscle primordium is occupied in the space during development, the variations of innervation patterns and formation of the communicating nerve loops may be explained by various combinations of the part and the other muscle primordia.     

Central representation of the hindlimb muscles supplied by the common peroneal nerve. A retrograde horseradish peroxidase study in the dog

Motoneurons supplying the common peroneal nerve in the dog were identified by the retrograde horseradish peroxidase method. They were distributed within two discrete cell columns (columns 2 and 2') in the 6th and 7th lumbar segments. The extensor digitorum longus muscle was represented in the dorsolateral part of column 2; the peroneus longus muscle in the ventrolateral part and the tibialis cranialis muscle in the intermediate lateral part. The medial half of column 2 contained motoneurons supplying the superficial peroneal nerve. Column 2', which was situated dorsomedially to column 2, contained motoneurons innervating the extensor digitorum brevis muscle.     

Lateromedial and dorsoplantar borders among supplying areas of the nerves innervating the intrinsic muscles of the foot

The branching patterns of nerves supplying the intrinsic muscles of the foot were analyzed as a basis to confirm the muscle layer structure. Thirty‐eight feet of 20 Japanese cadavers were examined in detail in this study. The first dorsal interosseus was innervated by a branch from the deep peroneal nerve as well as a branch of the lateral plantar nerve in 92.1%, the second dorsal interosseus in 10.5% and the third dorsal interosseus in 2.6%. In three specimens, branches from the deep peroneal nerve innervated the oblique head of the adductor hallucis or the lateral head the flexor hallucis brevis. In addition, branches from the medial and lateral plantar nerves and the deep peroneal nerve formed communication loops in three specimens. The first dorsal interosseus, the oblique head of the adductor hallucis and the lateral head of the flexor hallucis and their innervating nerve branches are closely related within the first intermetatarsal space. Since the tibial part of the first interosseus muscle primordium is occupied in the space during development, the variations of innervation patterns and formation of the communicating nerve loops may be explained by various combinations of the part and the other muscle primordia. Anat Rec 255:465–470, 1999. © 1999 Wiley‐Liss, Inc.     

足底中间群肌和足背肌肌内神经整体分布模式及意义

目的 揭示足底中间群和足背肌的肌内神经整体分布模式，探讨其意义。 方法 取下12具经福尔马林固定的成人尸体足底中间群肌和足背肌，改良的Sihler’s染色法显示肌内神经整体分布模式。 结果 接受足底内侧神经支配的趾短屈肌、第1和第2蚓状肌的神经支，分别从肌的内侧深面和浅面入肌；接受足底外侧神经支配的足底方肌、第3和第4蚓状肌的神经支从肌止端走向起端；骨间足底肌和骨间背侧肌的神经支从肌起端走向止端。趾短伸肌和母短伸肌的神经支共干。蚓状肌、第1和第2骨间足底肌、第1骨间背侧、母短伸肌和趾短伸肌仅在肌腹中部形成1个肌内神经密集区；趾短屈肌、足底方肌、第3骨间足底肌以及第2~4骨间背侧肌有2个肌内神经密集区，位于肌腹两侧，这些肌可分为2个神经肌亚部。 结论 这些结果可为外科手术免于神经损伤、肌移植的选材匹配，以及注射肉毒毒素A阻滞这些肌的痉挛提供形态学指导。     

Quantification of electromyographic activity during REM sleep in multiple muscles in REM sleep behavior disorder

STUDY OBJECTIVES: The aim of our study was to determine which muscle or combination of muscles (either axial or limb muscles, lower or upper limb muscles, or proximal or distal limb muscles) provides the highest rates of rapid eye movement (REM) sleep phasic electromyographic (EMG) activity seen in patients with REM sleep behavior disorder (RBD). SETTING: Two university hospital sleep disorders centers. PARTICIPANTS: Seventeen patients with idiopathic RBD (n = 8) and RBD secondary to Parkinson disease (n = 9). INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Patients underwent polysomnography, including EMG recording of 13 different muscles. Phasic EMG activity in REM sleep was quantified for each muscle separately. A mean of 1459.6 +/- 613.8 three-second REM sleep mini-epochs were scored per patient. Mean percentages of phasic EMG activity were mentalis (42 +/- 19), flexor digitorum superficialis (29 +/- 13), extensor digitorum brevis (23 +/- 12), abductor pollicis brevis (22 +/- 11), sternocleidomastoid (22 +/- 12), deltoid (19 +/- 11), biceps brachii (19 +/- 11), gastrocnemius (18 +/- 9), tibialis anterior (right, 17 +/- 12; left, 16 +/- 10), rectus femoris (left, 11 +/- 6; right, 9 +/- 6), and thoraco-lumbar paraspinal muscles (6 +/- 5). The mentalis muscle provided significantly higher rates of excessive phasic EMG activity than all other muscles but only detected 55% of all the mini-epochs with phasic EMG activity. Simultaneous recording of the mentalis, flexor digitorum superficialis, and extensor digitorum brevis muscles detected 82% of all mini-epochs containing phasic EMG activity. This combination provided higher rates of EMG activity than any other 3-muscle combination. Excessive phasic EMG activity was more frequent in distal than in proximal muscles, both in upper and lower limbs. CONCLUSION: Simultaneous recording of the mentalis, flexor digitorum superficialis, and extensor digitorum brevis muscles provided the highest rates of REM sleep phasic EMG activity in subjects with RBD.     

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)     

Estimation of nerve conduction velocity using surface multielectrode.

The nerve conduction velocity (NCV) was measured by using the multichannel surface EMG technique. The subjects were 7 healthy volunteers (20-49 years). The evoked responses were recorded from the tibialis anterior muscle when electrically stimulating the common peroneal nerve. The distribution and propagation pattern of the nerve action potentials (NAPs) preceding M-waves could be obtained by the multichannel surface EMG. The NCV of the fastest nerve fibers could be estimated from the time delays of the latencies of the NAPs. The average NCV (ANCV) of active nerve fibers could be also estimated from the time delays of the peak latencies of the NAPs. In 4 of 7 normal subjects, the shortest latencies and the fastest NCVs were obtained with threshold stimulation. The mean values of the NCV and the ANCV with supramaximal stimulation in 7 normal deep peroneal nerves calculated by this method were 55.9 +/- 6.5 m/s and 43.3 +/- 3.2 m/s respectively.     

An unique variation of the peroneus tertius muscle

Peroneus tertius (fibularis tertius) is a muscle unique to humans. It often appears to be a part of extensor digitorum longus, and might be described as its "fifth tendon". Although its insertion variation has been reported by many authors, variations of its origin points are not common. A variation of the peroneus tertius muscle was found during routine dissection of a 75-year-old male cadaver. The muscle originated from the extensor hallucis longus. The muscle belly of the extensor hallucis longus arose from the middle two-fourths of the medial surface of the fibula, medial to the extensor digitorum longus, and anterior surface of the interosseous membrane. It lay under the extensor digitorum longus, and lateral to the tibialis anterior muscle. The muscle belly of the extensor hallucis longus divided into medial and lateral parts 17 cm below its origin point. The lateral part, named as peroneus tertius, continued downward to reach the medial part of the dorsal surface of the base of the fifth metatarsal bone. The medial part ran also downward and divided into two tendons reaching the dorsal surface of the base of the distal phalanx of the great toe. This kind of variation may be important during foot or leg surgery.     

踝关节外侧韧带和距下关节韧带修复重建的应用解剖

目的 :为踝关节外侧韧带和距下关节韧带损伤修复重建提供解剖学基础。方法 :在 3 2侧经防腐固定、8侧冷藏新鲜标本上解剖观测踝关节外侧韧带和距下关节韧带及小趾趾长伸肌腱、第 3腓骨肌腱、腓骨短肌腱、伸肌下支持带 ,在新鲜标本上摹拟修复术。结果 :小趾趾长伸肌腱、第 3腓骨肌腱、腓骨短肌腱、伸肌下支持带解剖位置恒定 ,与踝关节外侧韧带和距下关节韧带相毗邻 ,具有一定的长、宽、厚度 ,可形成移植供体。结论 :①陈旧性踝关节外侧韧带和距下关节韧带的损伤 ,原位修复较难 ,用肌腱转位修复是一种可行的方法 ;②可用腓骨短肌腱修复距腓前和跟腓韧带损伤 ,小趾趾长伸肌腱和第 3腓骨肌腱转位修复距下关节韧带 ,伸肌下支持带可用作加强缝合 ,术式经标本摹拟具有可行性。