带前臂外侧皮神经的逆行筋膜皮瓣转移修复虎口皮肤缺损

1　临床资料1 .1　一般资料本组男 6例 ,女 3例 ;年龄 1 5～ 46岁。机器伤 6例 ,电灼伤 3例。虎口皮肤软组织缺损创面偏掌侧 5例、偏背侧 4例 ;9例均急诊手术。皮瓣切取范围约 4ｃｍ× 7ｃｍ× 1 0ｃｍ。1 .2　手术方法取前臂中立位 ,以桡骨茎突与肘窝肱二头肌腱外侧连线为轴心线 ,以桡骨茎突近侧 1 .5～ 2ｃｍ处为旋转点 ,在前臂中段桡侧设计皮瓣 ,前臂外侧皮神经及桡动脉的体表投影线均包含在皮瓣内 ,蒂宽 3～ 4ｃｍ ,皮瓣切取后通过皮下隧道或明道转移至虎口创面 ,在鼻咽窝处将皮瓣远端的前臂外侧皮神经与桡神经浅支吻合 ,缝合皮瓣与创缘…     

前置钢板微创固定治疗肱骨干中下段骨折的可行性研究

目的 评价采用微创前置钢板固定技术治疗肱骨干中下段骨折对桡神经、肌皮神经和肱二头肌功能的影响.方法 2004年5月至2007年12月,采用闭合复位、经上臂前侧远离骨折部位的小切口微创钢板固定技术(MIPO)置入4.5 mm窄动力加压钢板治疗20例肱骨十中、下段闭合性骨折患者.观察术后桡神经功能、肌皮神经功能、前后何肱骨干力线、骨折愈合时间和最后一次随访时肱二头肌肌力.结果 4例患者术后出现前臂外侧皮神经支配区麻小,无医源性桡神经麻痹患者.肱骨干前后位X线片示骨折远、近端0°成角7例,2例内翻成角达11°,内翻成角2°、3°、4°、5°、6°、7°和10°各1例.外翻成角3°,4°、6°和7°各1例.19例患者得到平均10.4个月(8～32个月)随访,骨折均获得愈合,平均骨折愈合时间13.4周(4～32用).伞部患者肱三头肌肌力均为5级.结论 采用前置钢板微创固定技术治疗肱骨巾、下骨折不会损伤桡神经和肱二头肌,但可能会干扰前臂外侧皮神经的功能.     

用MIPO技术治疗肱骨干中下段骨折的解剖及初步临床报告

目的探讨肱骨干中下段骨折的治疗方法。方法8具成人尸体上肢标本,经上臂近段前侧肱二头肌和三角肌间隙以及远端肘横纹近侧肱二头肌外侧缘的皮肤小切口,插入窄4．5 mm动力加压钢板置于肱骨干前侧,肱肌深面,两端分别用2枚螺钉固定,测定前臂旋后位桡神经在穿出外侧肌间隔以及冠状窝上缘水平与钢板外侧缘的距离。采用闭合复位、经皮前置钢板内固定技术治疗16例肱骨干中下段骨折。记录手术时间、术中失血量、术后平均住院时间、术后近期并发症、骨折愈合时间及肩、肘关节活动范围。结果经上臂小切口将钢板固定于肱骨干前侧后,钢板的近端位于肱二头肌长头腱和肌皮神经外侧。钢板大部分位于肱肌深面。前臂旋后位,桡神经在穿经外侧肌间隔和冠状窝上缘水平与钢板外侧缘之间的距离平均分别为16．5 mm(10．3～21．3 mm)和5．4 mm(3．7～7．7 mm)。钢板与桡神经之间间隔有肱肌肌腹。16例患者平均手术时间为120 min(90～150 min),术中失血量为50～200 ml,术后平均住院时间为4 d(3～5 d)。没有发生医源性桡神经麻痹的病例。无切口感染。术后随访7～24个月,骨折全部愈合,平均愈合时间为15．4周(12～32周)。肘关节屈曲135°～145°,伸直0°～5°,肩关节外展90°,上举150°～170°。结论采用MIPO技术治疗肱骨干中下段骨折可获得良好的结果。     

改良Thompson切口治疗桡骨近段骨折

目的 探讨一种既能安全显露桡骨近段又能方便进行骨折固定的手术入路.方法 收治桡骨近段骨折14例,其中6例合并尺骨骨折,3例合并桡神经深支损伤.手术采用改良Thompson切口显露桡神经深支,经桡侧腕伸肌与指伸肌间隙进人进行骨折固定.结果 平均随访1年,骨折愈合率达100%,无一例出现桡神经深支损伤.3例合并桡神经深支损伤者术后3个月均恢复,拇指背伸功能、前臂旋转及肘关节功能正常.结论 改良Thompson切口能较好地显露桡神经深支,从而避免损伤,又能方便进行骨折复位及固定.     

前臂后外侧穿支皮瓣游离移植修复手指中、大面积皮肤缺损的解剖学研究

目的介绍前臂后外侧穿支皮瓣游离移植修复手指中、大面积皮肤缺损的应用解剖学基础。方法对36例成人尸体上肢标本,手术显微镜下进行前臂后外侧局部解剖,观测前臂后外侧皮肤的营养动脉、回流静脉、神经支配来源。结果自桡骨lister结节至肱骨外侧髁连线中点附近指伸肌和桡侧腕伸肌肌间隔内有一恒定的皮支动脉营养前臂后外侧皮肤,该动脉有两条伴行静脉,神经支配为前臂后侧皮神经分支,游离移植可切取血管蒂长度为(4.12±0.26) cm,血管起始处外径为(0.91±0.07) mm,是与指动脉口径相仿的穿支皮瓣。结论前臂后外侧皮肤可制成以桡骨lister结节至肱骨外侧髁连线中点附近的指伸肌和桡侧腕伸肌肌间隔皮肤动脉穿支为蒂的游离穿支皮瓣移植修复手指皮肤缺损。     

伸直型肱骨髁上骨折并桡神经损伤二例比较

本院于 1 997和 2 0 0 0年分别收治 2例伸直型肱骨髁上骨折并桡神经损伤患者。报告如下。1　临床资料例一 :男 ,1 1岁。学骑自行车摔倒挫伤右肘部 4h来院 ,查右肘部明显肿胀 ,畸形 ,异常活动 ,骨擦感阳性 ,右手伸腕、伸指功能障碍 ;摄X线片示 :右肱骨髁上伸直桡偏型骨折 ,重叠移位 3cm。经术前准备急症行桡神经探查 ,骨折克氏针内固定术 ,术中见桡神经于肘上外侧绕肱骨干后走向骨折近端尺侧缘近侧经近端尺缘上方绕向背侧 ,位置固定 ,张力增高 ,探查困难 ,神经桡掌侧肱肌及肱桡肌部分肌组织挫断 ,形成腔隙 ,而尺侧肌肉无明显挫伤。例二 :女 …     

不显露骨间后神经治疗桡骨中上段骨折

前臂上段手术致前臂骨间后神经损伤的报道屡见不鲜,自2003年本院采用后侧显露途径,自桡侧腕长短伸肌间进入,不显露骨间后神经进行切开复位内固定,取得良好效果。1临床资料1.1一般资料本组30例,男25例,女5例;年龄6~70岁,平均31岁;单纯桡骨骨折16例,尺桡骨双骨折14例;粉碎性骨折4例,横行形骨折8例,短斜形骨折12例,长斜形骨折6例;开放性骨折7例,闭合性骨折23例。1.2手术方法采用桡骨后侧显露途径,尺骨骨折另作切口显露。切口与传统手术相同,前臂外展旋前,自肱骨外上髁后上侧沿桡骨外侧向下,朝向腕背中心,切开皮肤、皮下及筋膜层,显露肌肉,仔细…     

臂丛神经损伤合并多神经损伤

我院收治2例臂丛神经损伤同时合并多神经损伤。例1男性,20岁。因左上肢卷入机器内受伤3天入院。检查:左肩关节活动正常;肘、腕、手指各关节均无主动活动。肱二头肌、肱三头肌肌力0级。前臂以下仅尺侧腕屈肌肌力Ⅲ级。经观察3周后无明显恢复。行正中,尺、桡神经松解术。术中发现神经外膜增厚,与周围组织粘连。术后4个月复查,感觉、运动功能部分恢复。再行左臂丛神经     

桡外侧入路手术治疗桡骨中上段骨折效果分析

目的 评价桡外侧手术入路治疗桡骨中上段骨折对比传统手术入路的治疗优势.方法 对桡骨骨折92例予以手术治疗,分别采用桡外侧入路(A组)34例,掌侧入路(B组)26例,背侧入路(C组)32例.结果 桡外侧手术入路操作简单,可缩短手术时间,远期骨折愈合及前臂功能情况与传统术式比较,差异无统计学意义.结论 桡外侧手术入路治疗桡骨中上段骨折,具有暴露术野快捷、不易损伤重要血管神经,且远期效果与传统术式相当.     

肘部和前臂段桡神经解剖特征及损伤修复

目的 观察肘部和前臂段桡神经的解剖学特征及损伤修复的方法.方法 36侧成人上肢标本,于肘外侧做"S"形切口,从肱肌和肱桡肌间隙内解剖出桡神经肘段,沿桡神经干向远端追踪,找出桡神经深支出旋后肌的各个分支,测量深支各肌支的发出点、入肌点距肱骨髁上水平的距离和长度.逆行分离各分支,观察各分支的神经纤维在桡神经干内的分布定位特征.对12例肘部桡神经损伤的患者,采用桡神经定位缝合和不定位缝合的方法进行修复.结果 12例获得平均2.4年的随访.根据桡神经深支支配的运动区肌腱肌力恢复情况,神经定位缝合6例,术后有效率为83.3%.非定位缝合6例,有效率为50.0%.桡神经定位缝合组的有效率明显高于不定位缝合组.结论 前臂背侧距肱骨外上髁10～15cm范围内的锐器伤,伸拇困难者应考虑有骨间背神经肌支的损伤.运动支的神经纤维在桡神经干的内侧,对肘部桡神经断裂伤修复时重点应缝合内侧部分.显微定位缝合技术修复肘部和前臂段桡神经损伤是有效的方法.     

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。     

Influence of the pronator quadratus and supinator muscle load on DRUJ stability

PURPOSE: To determine the effects of altering the load contributions of the pronator quadratus and supinator muscles on in vitro distal radioulnar joint (DRUJ) stability during pronation and supination and before and after ulnar head excision. METHODS: Multiple pronation trials were conducted with incremental loading of the pronator quadratus relative to the pronator teres muscle; supination trials were similarly conducted with incremental loading of the supinator relative to the biceps muscle. All trials were conducted using an upper-limb apparatus capable of simulating muscle/tendon loading and displacement. Stability measurements included dorsal-volar translations of the radius relative to the ulna and DRUJ diastasis and convergence. RESULTS: Increased pronator quadratus loading did not affect intact DRUJ stability but effects were noted after ulnar head excision when the forearm was positioned between neutral and full pronation. Incremental loading of the supinator muscle did not modify DRUJ stability in the intact or ulnar head excised state. CONCLUSIONS: Pronator quadratus muscle activity aggravates forearm instability after ulnar head excision. Immobilization of the forearm in mid- to full supination should minimize pronator quadratus activity and optimize soft-tissue healing. This information may be useful to develop in vitro muscle-loading scenarios and analytical forearm models.     

Surgical exposures of the radius and ulna

The forearm contains many muscles, nerves, and vascular structures that change position on forearm rotation. Exposure of the radial shaft is best achieved with the Henry (volar) or Thompson (dorsal) approach. The volar flexor carpi radialis approaches are used increasingly for exposure of the distal radius. Although the dorsal approach is a safe utilitarian option with many applications, its use for managing fracture of the distal radius has waned. Potential complications associated with radial exposure include injury to the superficial branch of the radial nerve, the lateral antebrachial cutaneous nerve, and the cephalic vein. Dorsal and ulnar proximal radial exposures are associated with increased risk of injury to the posterior interosseous nerve. With surgical exposure of the ulna, care is required to avoid injuring the dorsal cutaneous branch of the ulnar nerve.     

Anatomy and intracompartmental pressure measurement technique of the pronator quadratus compartment

The compartment of the pronator quadratus muscle in 25 cadaver specimens is described. Defined by the radius, ulna, and distal interosseous membrane dorsally and the pronator quadratus fascia on the palmar side, the osteofibrous walls of the compartment confine the pronator quadratus muscle within a noncompliant space. A safe and reliable location for compartment pressure measurement was defined at a site 4 cm proximal to the scaphoid tubercule, on the radial side of the flexor carpi radialis tendon and on the ulnar side of the radial artery. These clear anatomic definitions might be useful in diagnosis of compartment syndrome of the pronator quadratus; a clinical investigation may be justified on the basis of pressure measurements made using this technique.     

Occurrence and fate of palmar type of median artery

BACKGROUND: The median artery represents a persistent part of the embryonic arterial axis of the upper extremity. It appears mainly as two types: an antebrachial type and a palmar type. The palmar type is of major clinical significance. METHOD: This study was undertaken to investigate the incidence and fate of the palmar type of the median artery in 19 cadavers. The occurrence was 15.8% and of this two incidences (5.2%) were on the right side and four (10.6%) were on the left side. On the right side, the artery originated from the ulnar and joined with the superficial palmar arch or anterior interosseous artery and communicated with the radial artery. CONCLUSIONS: This study concludes that palmar type of median artery is found at a higher incidence than the antebrachial type and that it may be involved in the pronator teres syndrome, carpal tunnel syndrome and anterior interosseous syndrome.     

Influence of distal radioulnar joint subluxation on restricted forearm rotation after distal radius fracture

PURPOSE: To analyze the influence of subluxation of the distal radioulnar joint (DRUJ) on restricted forearm rotation after distal radius fracture. METHODS: Twenty-two cases of healed unilateral distal radial fracture with restricted forearm rotation were included in the study. The subluxation of the DRUJ was evaluated using helical computed tomography scan at neutral, maximum pronation, and maximum supination and presented as the percent displacement of the ulnar head in both the injured and uninjured sides. The radiographic parameters of palmar tilt, radial inclination, dorsal shift, radial shift, and ulnar variance were measured on plain x-ray films and the rotational deformity of the distal radius was evaluated from the computed tomography scan. The differences of each radiographic parameter from the uninjured side were calculated. The relationships between the restricted forearm rotation and the percent displacement of the ulnar head and each of the radiographic parameters were analyzed statistically. RESULTS: When forearm pronation was restricted the ulnar head was located palmarly at neutral, maximum supination, and maximum pronation with severe dorsal tilt of the distal radius. When supination was restricted the ulnar head was located dorsally at maximum supination with severe ulnar-positive variance. CONCLUSIONS: The subluxation of the DRUJ was related to restricted forearm rotation. The radiographic parameters of palmar tilt and ulnar variance showed an adverse influence on the position of the ulnar head at the DRUJ, which might lead to restricted forearm rotation after distal radial fracture.     

Arthroscopic release for lateral epicondylitis: a cadaveric model.

At least 10 different surgical approaches to refractory lateral epicondylitis have been described, including an arthroscopic release of the extensor carpi radialis brevis tendon. The advantages of an arthroscopic approach include an opportunity to examine the joint for associated pathology, no disruption of the extensor mechanism, and a rapid return to premorbid activities with possibly fewer complications. A cadaveric study was performed to determine the safety of this procedure. Ten fresh-frozen cadaveric upper extremities underwent arthroscopic visualization of the extensor tendon and release of the extensor carpi radialis brevis tendon. The specimens were randomized with regard to the use of either a 2.7-mm or a 4.0-mm 30 degree arthroscope through modified medial and lateral portals. Following this, the arthroscope remained in the joint, and the portal, cannula track, and surgical release site were dissected to determine the distance between the cannula and the radial, median, ulnar, lateral antebrachial, and posterior antebrachial nerves, and the brachial artery and the ulnar collateral ligament. No direct lacerations of neurovascular structures were identified; however, the varying course of the lateral and posterior antebrachial nerves place these superficial sensory nerves at risk during portal placement. As in previous reports, the radial nerve was consistently in close proximity to the proximal lateral portal (3 to 10 mm: mean, 5.4 mm). The ulnar collateral ligament was not destabilized. Arthroscopic release of the extensor carpi radialis brevis tendon appears to be a safe, reliable, and reproducible procedure for refractory lateral epicondylitis. Cadaveric dissection confirms these findings.     

Effect of simulated muscle activity on distal radioulnar joint loading in vitro.

This study investigated the relationship between simulated forearm muscle loads and the joint reaction force in the distal radioulnar joint using an in vitro model. Seven fresh frozen cadaveric specimens were mounted in an upper extremity joint simulator capable of applying pneumatic loads to various (muscle) tendons while restraining the forearm in the three positions of pronation, supination, and neutral rotation. Loads were applied to model four forearm muscles (biceps, pronator teres, pronator quadratus, and supinator) in 10 N increments ranging from 10 N to 80 N for the biceps and pronator teres and in 10 N increments from 10 N to 50 N for the pronator quadratus and the supinator. Distal ulnar arthroplasty was performed on each specimen with a custom instrumented ulnar head replacement implant that quantified loads (via strain gauge instrumentation). The relationship between increasing muscle load and joint load was found to be positive and quasilinear in most cases. The biceps had the greatest influence on the distal radioulnar joint reaction force with a joint force in the range of 8% to 33% of the applied muscle load. The pronator teres, supinator, and pronator quadratus were less influential with a joint reaction force ranging between 6% to 19%, 4% to 9% and 2% to 10% of the applied muscle load, respectively.     

Lateral antebrachial cutaneous neuropathy following the long head of the biceps rupture

Lateral antebrachial cutaneous neuropathies present as purely sensory lesions, manifesting as elbow pain or dysesthetic pain over the lateral forearm. Classically, entrapment of the lateral antebrachial cutaneous nerve has been documented at the lateral edge of the biceps tendon as it exits the deep fascia in the antecubital fossa. We report a case of lateral antebrachial cutaneous nerve traction neuritis, rather than entrapment, resulting from a rupture of the long head of the biceps. The biceps displaced the nerve laterally, resulting in sensory loss and severe allodynia. The patient's symptoms were relieved with proximal biceps tenodesis.     

尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤的手术治疗

目的探讨尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤的手术治疗方法及临床疗效。 方法回顾性分析2011年4月至2014年7月四川省骨科医院收治且获完整随访的9例尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤患者临床资料。其中男6例,女3例;年龄20~62岁,平均41岁。致伤原因：跌伤3例,自行车伤1例,电动自行车伤3例,交通事故伤2例。均为新鲜闭合骨折;无神经、血管损伤。受伤至手术时间4~12 d,平均7.2 d。均为O'Driscoll分型2型,其中1亚型1例,2亚型5例,3亚型3例。其中肘关节外侧副韧带肱骨外髁止点撕脱骨折4例,其余5例术中证实肘关节外侧副韧带肱骨外髁止点撕脱。伴有尺骨鹰嘴骨折或为肘关节恐怖三联征患者未纳入本组。经肘关节前侧或内侧入路复位,以支撑钢板、缝合锚、螺钉固定冠状突骨折及修复前侧关节囊。经后外侧入路,以缝合锚修复外侧副韧带。 结果术后切口均Ⅰ期愈合,无血管神经损伤。随访时间12~48个月,平均25.6个月,X线片示骨折均愈合。随访期间无内固定物失效、肘关节不稳定、创伤后骨关节炎等并发症发生。末次随访时患肘关节活动范围：伸肘0~10°,平均1.1°;屈肘110~135°,平均128.9°;前臂旋前40~70°,平均61.1°;旋后80~90°,平均88.9°。Broberg和Morrey肘关节功能评分为82~100分,平均95分;优6例,良3例,优良率100%。疼痛视觉模拟评分为0~2分,平均0.7分。 结论重视和识别尺骨冠状突前内侧面骨折伴肘关节外侧副韧带损伤,对于存在肘关节内翻后内侧旋转不稳定者,根据冠状突骨折块的大小、部位及形态,经肘关节前侧或内侧入路复位,以支撑钢板、缝合锚及螺钉固定,修复前侧关节囊,经肘关节后外侧入路,以缝合锚修复外侧副韧带,术后早期活动锻炼,可获得满意疗效。