骨盆骨折血管损伤的解剖学基础

目的：探讨骨盆骨折血管损伤的机制。方法：20具新鲜成年国人骨盆标本，采用前后双侧入路解剖，观察髂内外血管的走行特点、分型与骨盆韧带、骶丛神经的关系，观察血管在骨盆壁上的投影位置，测量每一根血管到骨壁的垂直距离，观察各动脉间的侧支吻合情况。结果：骨盆动脉血管根据口径可分为3类：(1)小口径动脉，直径小于3．0mm。(2)中等口径动脉，直径3．0～5．0mm。(3)大口径动脉，直径大于5．0mm。据血管距骨壁的距离可分为靠近骨壁的血管(平均距离小于10．0mm)及远离骨壁的血管(平均距离大于10．0mm)。阴部内动脉与骨壁关系不明显。骨盆动脉分支间有广泛的吻合支。结论：骨盆动脉解剖学特点决定了在骨盆骨折中损伤的机率，骨盆动脉有广泛吻合支是骨盆动脉出血止血困难的原因。     

闭孔动脉吻合支的解剖学研究及其临床意义

目的 :为骨盆创伤止血提供解剖学基础。方法 :在 3 0个防腐固定的成年骨盆标本 ,仔细解剖观察双侧闭孔动脉的来源、分支及其吻合情况。同时通过 5个盆部血管铸型标本 ,观察闭孔动脉与髂外动脉及髂内动脉系统的侧支吻合情况。结果 :闭孔动脉起源分散 ,可分为盆内段和盆外段 ,其分支分布至盆腔脏器和骨盆。 86.7%的闭孔动脉与旋股内动脉浅支间存在直径 ( 1.2 8± 0 .2 2 )mm的血管吻合 ,3 6.7%与对侧闭孔动脉间存在直径 ( 1.12± 0 .0 8)mm的血管吻合 ,2 6.7%与腹壁下动脉 (或髂外动脉 )间有直径( 1.0 2± 0 .3 2 )mm的吻合血管 ,11.7%与旋股内动脉深支有直径 ( 1.5 6± 0 .3 4)mm的血管吻合。此外 ,闭孔动脉分支的终末毛细血管与髂腰动脉、旋髂深动脉、第四腰动脉、阴部内动脉、膀胱上、下动脉和前列腺动脉 (或子宫动脉 )等动脉之间存在广泛、固定的毛细血管吻合网。结论 :闭孔动脉与髂内动脉其他分支及髂外动脉之间存在广泛的血管吻合 ,主要吻合类型为终末支直接吻合和终末支网状血管吻合。在骨盆创伤骨折需阻断出血动脉时 ,应特别注意终末支直接吻合的存在。     

骶髂关节骨折脱位前路手术的应用解剖

目的　为临床前路手术治疗骶髂关节骨折脱位提供解剖学依据。 方法　成年防腐盆部标本20具（40侧）,解剖观察髂内动静脉、髂腰动静脉与骶髂关节的位置关系,测量L4、5神经前支及腰骶干与骶髂关节的毗邻关系。 结果　髂内动脉横跨骶髂关节处的外径左侧为(5.92±0.7)mm,右侧为(5.38±　0.7)mm,起始处距骨壁距离左侧为(11.91±2.4)mm,右侧为(12.52±2.9)mm,髂腰动脉横跨骶髂关节处的外径为(2.54±0.39)mm,起始处距骨壁的距离为(2.50±0.41)mm。骶髂关节从后上到前下的不同平面到L4、5神经前支及腰骶干的距离逐渐减小,L4神经根前支距离骶骨翼骨面的垂直距离亦逐渐减小,L5神经根出椎间孔后,几乎紧贴骶骨翼骨面行走。 结论　骶髂关节骨折脱位前路手术要特别注意医源性血管神经的损伤,L5神经根易受损伤,安全放置钢板的位置是骶骨翼中上部,距骶骨翼边缘20 mm以内。     

髂内动脉及其主要分支的观察

观察了320侧成人的髂内动脉及其主要分支。髂内动脉的起点多平第五腰椎和腰骶椎间盘的高度(80.94％),在左、右侧之间,多数是右高于左;在男、女性之间,有男高于女的趋势。依髂内动脉发出臀上、臀下和阴部内动脉三大分支的情况,将髂内动脉的分支型式分为五大型共10个分型。各型中,以先发出臀上动脉,后发出臀下阴部干的(Ⅰ型)最多,占55.94％。髂内动脉三大分支与骶丛的主要位置关系是:臀上动脉多数穿过腰骶干与第一骶神经之间(79.06％);臀下动脉以经骶丛前方出盆的较多(51.65％);阴部内动脉绝大多数经骶丛前方出盆(94.69％)。髂腰动脉只有一支的占65.62％,有二支的占30％,有三支的占4.38％。髂腰动脉多数直接起于髂内动脉或臀上动脉。骶外侧动脉的支数为1—6支不等,其以有二支的为最多,占63.74％。骶外侧动脉多数起自臀上动脉。闭孔动脉起于髂内动脉系的占80％,起于髂外动脉系的占17.19％,起于髂内、外动脉系的占2.81％。直肠中动脉以起于阴部内动脉的较多。子宫动脉多数只有一支,有11例标本有两支子宫动脉,这些动脉多发自髂内动脉的脐动脉段。副阴部动脉的出现率颇高,占24.37％,该动脉经耻骨联合下方出盆,分布于阴茎或阴蒂。     

髂骨螺钉骨性通道毗连血管及神经的解剖学研究

目的　探讨经髂后上棘到髂前下棘髂骨螺钉通道附近的血管、神经分布,为临床手术提供参考。 方法　采用12具防腐骨盆标本,模拟手术操作,从后向前沿骨盆经髂后上棘到髂前下棘骨性通道钻入3.5 mm 钢针,观察盆腔内重要的血管神经和钢针空间关系,找出在放置髂骨螺钉时血管神经易损伤区域。 结果　髂骨翼后部,血管、神经与髂骨之间有腰大肌相隔开,进行放置螺钉操作中不易损伤;骨盆壁侧方,闭孔血管和闭孔神经距离盆壁都很近,在进行内固定操作时,如果导针或螺钉进钉角度偏小,对这些结构就有可能造成医源性损伤;髋臼及腹股沟区,因髂前下棘与旋髂深动脉距离最近,所以此动脉损伤几率最大。 结论　由后向前植入髂骨螺钉时,髂骨翼后部较为安全,但骨盆壁侧方和髋臼及腹股沟区较危险,闭孔血管、神经和旋髂深动脉容易受到损伤。     

骨盆后环骨折神经损伤的临床解剖学研究

目的：了解骨盆后环骨折易损神经的相对解剖位置及其与骨折的关系。方法：解剖20具骨盆标本，神经外膜下置管造影CT扫描5例，测量腰区各神经的走行特点、与骨盆壁和骶髂关节的距离。结果：腰4腰骶干支、腰5神经和腰骶干与骶骨翼的距离不超过1cm，距离骶髂关节不超过2．5cm。闭孔神经、股神经、股外侧皮神经与骨壁的距离依次渐远。CT测量结果和人工测量结果无显著性差异。结论：腰4腰骶干支、腰5神经和腰骶干是与骨盆壁和骶髂关节的关系最为紧密的神经，它们在骨盆后环骨折及其治疗时最易受损。     

骶丛的血供分布特点及临床意义

目的探讨骶丛的动脉来源、分布的解剖学特点及其临床意义.方法(1)3具成人新鲜尸体标本,采用明胶-氧化铅微血管显影法观察骶丛的动脉分布.(2)选择15具灌注红色乳胶的防腐固定成人尸体标本,手术显微镜下解剖观察骶丛的动脉来源和分布.结果骶丛根部的血供主要来源于骶髂腰动脉系统(sacral Iliac lumbar artery system,SILAS)、臀上动脉和臀下动脉.各动脉的分支之间互相吻合.L4根部血供以第4腰动脉为主;L5根部血供以髂腰动脉为主,L5 ～S3,由骶外侧动脉分支供应,血管平均为(2.2±1.4)支(1～4支).坐骨神经臀段出骨盆处,以臀下动脉、阴部内动脉以及梨状肌肌支供血为主,营养支动脉有(5.3±1.2)支(3～7支).结论骶丛的血供主要来自于SILAS,每一个动脉分支从不同方向进入骶丛后分为升支和降支,在骶丛内相互吻合.相邻血管区域的血供可以代偿,为骶丛损伤的外科救治提供了解剖学基础.     

右侧闭孔动脉、静脉变异1例

<正>我们在解剖1具成年男性尸体时,发现其闭孔动脉起点及行程有较大变异,为积累资料及为临床提供参考,报道如下:右髂总动脉沿腰大肌内侧斜向外下,在骶髂关节前方分为髂内动脉(外径5.05mm)和髂外动脉(外径6.02mm;图1)。髂内动脉主干沿     

骶1螺钉固定毗邻结构的应用解剖

目的 :探讨骶骨毗邻结构与骶骨螺钉并发症的关系。方法 :在 5 8具骨盆标本上 ,对第 1骶前孔及骶管结构进行了观测。在 10具标本上 ,模拟骶骨进钉方法的手术过程 ,观察钉道位置与骶骨周围结构的关系。结果 :骶交感干、第 1骶神经与腰骶干围成一个三角形区域 ,在其内侧部无重要结构紧贴骨面走行 ,外侧区有臀上血管走行。此三角前方有髂动、静脉相邻。第 1骶神经粗 (11.0± 2 .8)mm (6.0～ 17.0mm) ,腰骶干粗 (7.6± 2 .2 )mm (3 .0～ 12 .0mm)。当螺钉与矢状面呈向内 0°～ 10°进钉时较为安全。第 1骶后孔可见小血管 ,骶骨外侧沟内有第 5腰椎血管后内侧支走行 ,是术中出血的原因。结论 :骶骨螺钉有损伤骶神经、髂血管的可能 ,5点 7点进钉方法较为安全。     

骶髂关节周围腰骶丛神经的解剖学研究及其临床意义

目的　对腹直肌外侧入路显露骶髂关节周围重要结构的位置关系进行测量及描述,探讨入路的安全性及安全操作空间。 方法 选取新鲜成人完整尸体标本,对每具骨盆标本经双侧腹直肌入路逐层解剖,观察腹膜、髂外血管、髂腰肌、闭孔神经等重要组织结构的位置关系,重点观测L4、L5、S1神经与闭孔神经位置,测量分析神经至骶髂关节的距离。 结果　腹直肌外侧入路可清楚显露骶髂关节、腰骶干、S1神经根、骶骨翼等结构。 L5神经前支出椎间孔处与骶髂关节距离左侧为(23.56±4.30)mm,右侧为(23.69±3.41)mm,L4神经前支与骶髂关节在L5神经前支出椎间孔处的距离左侧为(17.97±1.58)mm,右侧为(17.49±1.49)mm,腰骶干外缘在其形成汇合点平面与骶髂关节的水平距离左侧为(14.34±2.51)mm,右侧为(13.81±2.21)mm,平骶岬处腰骶干外缘与骶髂关节的水平距离左侧为(12.19±1.98)mm,右侧为(12.22±1.55)mm。 结论　腹直肌外侧入路可用于复位固定骶髂关节周围骨折脱位,具有安全的操作空间,且经该入路的操作为骶髂关节复合体损伤引起的神经损伤提供了探查松解的新思路。     

Systematic study of the internal iliac artery in llama (Lama glama).

The aim of this research was to determine the origins of the parietal and visceral branches of the internal iliac artery of the llama and to match those with the known types and classifications in the human being and domestic animals. The internal iliac artery divides at the level of the third sacral vertebra into the caudal gluteal and internal pudendal arteries corresponding to an intermediate long iliac type. It gives off the following collateral branches: umbilical, cranial gluteal, obturator and iliolumbar arteries. The intrapelvic visceral branches, vaginal or prostatic arteries, arise from the internal pudendal artery as occurs in carnivores. This is an important difference in relation to the distribution in characteristic long iliac and artiodactyla types. The origins of the parietal and visceral branches of internal iliac artery in the llama have characteristics in common with the domestic cat, which belongs to the carnivores. In relation to the Adachi classification, the internal iliac artery of the llama will be included in the IVa type. We believe that this study is a contribution of a new aspect in teaching and research in comparative anatomy.     

Morphology of the middle rectal arteries

The middle rectal arteries were studied in 30 cadavers of adult and older individuals (29 Caucasians and one Negro) of both sexes (15 males and 15 females). The middle rectal artery was present in 56.7% of the cases, bilaterally (36.7%) or unilaterally (20%), originating from the internal pudendal (40%), inferior gluteal (26.7%), internal iliac (16.8%), and less frequently from other pelvic branches. The average external diameter of the middle rectal artery was found to be 1.7 mm, its average length about 7 cm, and the point of penetration in the rectal wall about 6 cm (average) superior to the anus. The most frequent sites of the rectal wall pierced by the middle rectal arteries were the anterior (50% of the cases) and posterior (45%) quadrants of the rectum, whether isolated or combined (43.3%). These anatomical features justify, when needed and possible, the preservation of the middle rectal artery in surgical interventions on related organs. The term middle rectal arteries in Nomina Anatomica should be changed to inferior rectal arteries and indented under internal pudendal artery; the current term inferior rectal arteries should be changed to anal arteries to follow the already adopted division of the terminal intestine into rectum and anal canal.     

Ring formation of the internal iliac artery

We observed an arterial ring communicating the superior and inferior gluteal arteries in the left half of the pelvis of an 88-year-old male. Although many previous studies have shown variations in the internal iliac artery, there has been no literature describing the fenestration. Therapeutic embolization is commonly performed for intractable bleeding in pelvic region. Surgeons should be aware of the arterial ring formation because of possible danger in the intravascular treatments. In patients with similar arterial rings, embolization of the anterior trunk of the internal iliac artery could be insufficient when blood runs through the circle of the arterial ring.     

明胶海绵粉末栓塞犬髂内动脉

背景：明胶海绵已成为骶骨肿瘤术前栓塞的首选材料,但针对小颗粒明胶海绵对栓塞效果及栓塞后并发症的影响未见明确报道。 目的：观察小颗粒明胶海绵栓塞犬双侧髂内动脉后手术出血量变化和并发症情况。 方法：用直径为50-150 μm明胶海绵粉末对15只犬行双侧髂内及骶正中动脉栓塞,分别于栓塞后1,2,3 d模拟骶骨肿瘤手术测量出血量变化;病理观察栓塞区膀胱、直肠、臀部肌及坐骨神经变化。 结果与结论：栓塞后第3天出血量高于第1,2天(P < 0.05),栓塞后第1天与第2天出血量差异无显著性意义(P > 0.05)。在运用直径为50-150 μm明胶海绵粉末栓塞犬双侧髂内及骶正中动脉时,最小动脉是50 μm的微动脉,但主要集中在100-200 μm小动脉,数字减影血管造影下显示栓塞双侧髂内及骶正中动脉近端血管级别为其一级分支,此时犬盆腔脏器组织无明显变化。     

Rare case of femoral artery ramification and origin of the obturator artery

We observed two rare patterns of femoral artery ramification in the bilateral thighs of an 83-year-old male cadaver. In the right thigh, the lateral circumflex femoral and deep circumflex iliac arteries formed a common trunk, while in the left, the medial circumflex femoral, inferior epigastric, and obturator arteries formed a common trunk. In the left pelvis, the obturator artery comprised branches from the inferior epigastric, superior gluteal, and inferior gluteal arteries. We describe this rare case and discuss the genesis and clinical significance of these variations.     

Where and what arteries are most likely injured with pelvic fractures?

Blood vessels passing through pelvic region come into intimate contact with pelvic bone and can be injured by the sharp edges of the dislocated fracture fragments. The aim of the study was to evaluate the influence of localization, shape, and dislocation of individual pelvic ring bones' fractures on arterial injuries. The study group consisted of 474 patients enrolled in a 1‐year prospective multicenter study. The pattern of pelvic fracture lines was characterized and recorded on a planar diagram of the subjected side of the pelvis. The diagram was subdivided into 11 designated areas. Frequency of injury at each 11 areas was recorded. The course of individual arteries in the 11 areas was also recorded in relation to each type of pelvic fractures. Out of the 474 investigated patients, the highest proportion of fractures occurred in the areas of the superior (62%) and inferior (59%) ramus of the pubis as well as in the lateral part of the sacrum (19%). These locations can be associated with injuries of the external iliac, obturator, internal iliac, and aberrant obturator arteries. The highest risk of arterial injuries was associated with vertically displaced fractures in the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and in the vicinity of the ventral part of the sacroiliac joint, where the artery runs at a distance of less than 1 cm from the bone. Clin. Anat. 32:682–688, 2019. © 2019 Wiley Periodicals, Inc.     

髋臼周围动脉的解剖学研究及其临床意义

目的：探讨髋臼周围动脉的解剖学特点,为临床髋臼骨折手术治疗提供解剖学基础。方法：在15具成年男性尸体标本30侧髋臼上对髋臼周围动脉的形态学特点及毗邻关系进行观测。结果：臀上动脉、阴部内动脉以及臀下动脉贴近髂骨外骨板走行,臀上动脉距离坐胃大切迹顶点最近,侧卧化时髂后上棘、坐骨火切迹顶点、大粗隆顶点三者之间的连线体表投影构成以坐骨大切迹顶点为顶点的等腰三角形,臀上动脉位于三角形顶角区。结论：涉及坐骨大切迹顶点的髋臼骨折易损伤臀上动脉及变异的臀下动脉,侧卧位时依其等腰三角形可改进髋臼骨折手术人路,减少术中出血。     

成年男性脐动脉的应用解剖

目的 研究男性标本脐动脉的解剖学特点,为临床膀胱癌切除术中结扎脐动脉提供理论依据。 方法 随机选用福尔马林液固定的成年男性尸体19具（38侧）,解剖观测脐动脉的起点、走行、起始端外径及分支,结果进行统计学分析。 结果 脐动脉均起自髂内动脉。脐动脉起始端外径为（3.02±0.30）mm。脐动脉均发出膀胱上动脉,其分支有5种类型：数支膀胱上动脉型,占总标本量的52.6%（20侧）;数支膀胱上动脉和1支膀胱下动脉型,占28.9%（11侧）;2支膀胱上动脉、1支膀胱下动脉与闭孔动脉的共干动脉型,占5.3%（2侧）;数支膀胱上动脉和1支闭孔动脉型,占7.9%（3侧）;2支膀胱上动脉和1支精囊动脉型,占5.3%（2侧）。 结论 脐动脉起始位置固定,起始端外径狭小,分支数目变异较多,对膀胱手术有重要意义。     

Arterial supply to the sciatic nerve in the gluteal region

The arterial supply to the sciatic nerve was investigated in 20 human lower limbs (10 right, 10 left) from 20 cadavers (14 females, aged 84 +/- 9.6 years, range 66-95 years: 6 males, aged 80 +/- 8.2 years, range 70-90 years). In all limbs examined at least 1 sciatic artery could be identified supplying the sciatic nerve in the gluteal region. In total 28 sciatic arteries were identified, of which 14 arose from the medial circumflex femoral artery, 11 from the inferior gluteal artery, 2 from the first perforating artery, and 1 from the internal pudendal artery. In 5 limbs, 2 sciatic arteries were observed, being independent branches from the medial circumflex femoral and inferior gluteal arteries in 4 limbs and separate branches of the medial circumflex femoral artery in 1 limb. In 1 limb, 4 sciatic arteries were observed: 1 from the inferior gluteal artery, 2 from the medial circumflex femoral artery, and 1 from the first perforating artery. In the remaining 14 limbs a single sciatic artery was observed, which in one case arose from the internal pudendal artery, a previously unreported observation.