带感觉支指背侧岛状皮瓣的应用解剖学研究

目的 探讨含指掌侧固有神经背侧支的指背岛状皮瓣的应用解剖学，以提高皮瓣的修复疗效。方法 在20具40侧成人上肢标本上解剖观测指掌侧固有神经背侧支的起点和走行。另对4具8侧成人上肢进行血管铸型制作，观察指掌侧固有动脉及手指静脉的分布范围。结果 示、中、环指的指掌侧固有神经在掌指关节附近恒定发出1较大的背侧支，小指尺侧未见背侧支出现；小指桡侧背侧支缺如者占82．5％。指掌侧固有神经背侧支在近节指骨中下1／3处恒定地和指掌侧固有动脉相交，在该处神经跨过动脉上方的占69．17％，另30．83％走行在动脉下方。结论 示、中、环指的背侧支有较为恒定的蒂部，可以包含在指背侧岛状皮瓣中。其体表投影为近节指骨基底掌侧部中外1／3至近侧指问关节背外侧，以及其和甲根外侧缘的连线。小指桡侧的指掌侧固有神经背侧支缺如率较高，不宜设计成背侧支指背皮瓣。     

带指固有神经背侧支的指背筋膜逆行岛状皮瓣修复指腹缺损

目的应用以指背筋膜为蒂、带指固有神经背侧支的指背筋膜逆行岛状皮瓣修复指腹缺损。方法根据指背皮肤的血供特点,于手指近节中、远段及近节指间关节背侧设计皮瓣,皮瓣侧缘不超过手指侧中线,轴点位于远侧指间关节背桡侧或背尺侧,轴心线与手指纵轴平行。切取的皮瓣内含带指固有神经背侧支,在皮瓣转位后将其与创面指固有神经断端吻合。1997年11月～2001年4月,应用该术式修复手指指腹缺损27例28指。急诊手术24例,择期手术3例。皮瓣面积为1.8cm×1.5cm～2.5cm×2.2cm,蒂长1.5～2.2cm。结果皮瓣全部成活。随访7～32个月,平均21个月。修复后的指腹外观良好,质地柔软、耐磨,无明显触痛,静止两点辨别觉达3.5～6.5mm。供区无明显并发症,指间关节活动正常。结论此术式不损伤手指主要血管、神经,简单、安全,一次完成,不妨碍其他手指活动,重建的指腹感觉恢复满意。     

指背血管的应用解剖

为探讨指痛旗形皮瓣的血供方式,对２０只成人手标本行细致的解剖学观测,结果：（１）手指背侧的皮肤主要由指掌侧固有动脉的背侧分支供应,指背动脉短小,只参与指痛近节皮肤的血液供血。（２）手指背侧的静脉系统丰富,常吻合成网,在无 ,近侧指间关节及近节指中份形成第一、二三级静脉弓。（３）第三级静脉弓粗大,近侧弯向指根部形成桡、尺侧指背静脉网。（４）桡、尺侧静脉干之间的区域,几乎无静脉可见,可称为指背的“乏静     

双重神经支配的示指交指皮瓣或岛状皮瓣修复拇指缺损

已经证明,交指皮瓣是修复拇指指腹缺损的可靠方法。它对供指创伤小,缺点是两点分辨党恢复较差。作者发现掌指关节以远到示指的桡神经背侧感觉支差异较大,示指背侧感觉支配很不恒定。在大多数情况下,仅支配示指背侧近1/3皮肤,远侧2/3指背皮肤则多由示指掌面桡侧指神经的背侧支支配。标本解剖示这一神经分支是恒定的,在掌中纹的桡侧和示指近侧指横纹之间发出。桡侧指神经背侧支单独分支支配近节远侧2/3皮肤者占92％,8％在更远处分出,对近节指背皮     

指背筋膜逆行岛状皮瓣修复指腹缺损

目的 介绍指背筋膜逆行皮瓣修复指腹、指尖缺损的手术方法及临床效果。方法 在手指近节中远段及近侧指间关节背倒设计皮瓣，皮瓣边缘不超过手指侧正中线，轴点位于远侧指间关节背桡侧或尺背侧，指背侧缘为轴心线。切取的皮瓣内含有指固有神经背侧支，转移后与创面指固有神经断端缝合。结果 本组16例皮瓣全部成活，随访5～18个月，外形美观，质地柔软、耐磨，指腹两点辨别觉为4mm—7．5mm。供区无并发症发生。结论 该皮瓣具有不损伤主要动脉、神经，操作简便，质地良好，血供可靠等优点，重建的指腹感觉恢复满意，是修复指腹缺损的较好方法。     

指背血管的应用解剖

为探讨指背旗形皮瓣的血供方式，对２０只成人手标本行细致的解剖学观测。结果：①手指背侧的皮肤主要由指掌侧固有动脉的背侧分支供应，指背动脉短小，只参与指背近节皮肤的血液供应。②手指背侧的静脉系统丰富，常吻合成网，在远侧、近侧指间关节及近节指中份形成第一、二、三级静脉弓。③第三级静脉弓粗大，近侧弯向指根部形成桡、尺侧指背静脉干，注入手背静脉网。④桡、尺侧静脉干之间的区域，几乎无静脉可见，可称为指背的“乏静脉区”。⑤静脉干至指中轴线的距离，在指背近节中份平面为４．１±０．１ｍｍ，掌指关节平面为５．２±０．２ｍｍ。由此对指背旗形皮瓣的解剖特点、设计原则及存活机理做了阐述     

吻合神经的手指中节C型皮瓣修复指腹创面

手部重要功能部位的软组织缺损 ,需采用能重建感觉功能的皮瓣予以修复。我们自 1997年 4月起 ,采用吻合指固有神经背侧支的手指中节Ｃ型皮瓣修复拇指、食指及中指指腹创面 2 5例 ,获得满意效果。1　应用解剖　手指中节Ｃ型皮瓣的血供来源于指固有动脉 ,在行进途中发出背侧支和掌侧支 ,分别营养指背和指腹皮肤。同时两侧指固有动脉的分支在中线处有广泛的吻合支 ,使得皮瓣可跨越中线 ,而无血供障碍之虞[1 ] ,其血液回流依赖皮瓣蒂所带的筋膜组织中的小静脉。手指中节背侧感觉由指固有神经背侧支支配。指固有神经位于固有动脉内侧 ,在近节指近…     

指背侧岛状皮瓣在手指皮肤缺损中的临床应用

目的 探讨以手指背侧微血管网为血管蒂的手指近、中节背侧皮瓣逆行修复手指不同平面皮肤缺损的临床效果.方法 2007年1月-2011年12月,以近节及中节手指桡、尺背侧的手指背侧微血管网为血管蒂,逆行修复手指近指间关节掌侧,及其以远指体掌背侧及侧方皮肤缺损60例78指,皮瓣大小为1.2 cm×2.0 cm～2.5 cm×3.5 cm.结果 术后随访6～36个月,73指皮瓣成活,5指中节指背皮瓣远端部分坏死,经换药后创面愈合.术后皮瓣两点辨别觉8～10 mm,指间关节活动功能好.结论 该皮瓣具有操作简单、不损伤指固有动脉及指固有神经等优点.近节指背皮瓣面积大、血管蒂长、旋转弧大、成功率高.中节指背皮瓣血管蒂短,可用于修复末节甲根及甲中段平面背侧及指侧方皮肤缺损.     

六种含感觉神经皮瓣修复桡侧三指指腹缺损

目的介绍6种含感觉神经皮瓣修复拇、示、中指指腹缺损的手术方法及临床效果。方法分别采用桡神经拇指尺背支营养血管皮瓣、手背U-I型血管蒂岛状皮瓣、示指背岛状皮瓣、带指神经背侧支的指动脉逆行岛状皮瓣、躅趾腓侧趾腹皮瓣及环指尺侧神经血管蒂岛状皮瓣修复桡侧三指指腹缺损43例。结果皮瓣除l例坏死外，其余全部成活。经6个月～2年随访，皮瓣血运、质地好，指腹两点辨别觉平均为：桡神经拇指尺背支营养血管皮瓣12mm、手背U-I型血管蒂岛状皮瓣11mm、示指背岛状皮瓣8mm、指动脉逆行岛状皮瓣8mm、踇趾腓侧趾腹皮瓣8mm，环指尺侧神经血管蒂岛状皮瓣5mm。结论6种带感觉神经的皮瓣可恢复指腹良好的感觉及饱满的外形，但各有优缺点，应灵活掌握适应证。     

指背血管的应用解剖

为探讨指背旗形皮瓣的血供方式,对20只成人手标本行细致的解剖学观测。结果:①手指背侧的皮肤主要由指掌侧固有动脉的背侧分支供应,指背动脉短小,只参与指背近节皮肤的血液供应。②手指背侧的静脉系统丰富,常吻合成网,在远侧、近侧指间关节及近节指中份形成第一、二、三级静脉弓。③第三级静脉弓粗大,近侧弯向指根部形成桡、尺侧指背静脉干,注入手背静脉网。④桡、尺侧静脉干之间的区域,几乎无静脉可见,可称为指背的“乏静脉区”。⑤静脉干至指中轴线的距离,在指背近节中份平面为4.1±0.1mm,掌指关节平面为5.2±0.2mm。由此对指背旗形皮瓣的解剖特点、设计原则及存活机理做了阐述。     

Anatomic variations in sensory innervation of the hand and digits

Anatomic dissections under microscopic magnification were performed on 30 fresh cadaveric hands to depict the course and interconnections of the sensory nerves to the digits. The dissections included the median nerve, the ulnar nerve, the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, and the dorsal branch of the proper digital nerve. The communicating branches between the median and ulnar nerves in the palm were found in 20 of the 30 (67%) specimens. The dorsal branch of the proper digital nerve was found to arise at or proximal to the A1 pulley zone in 62% of the long digits, more proximally than previously reported. The dorsal sensory nerves (the terminal branch of radial or ulnar sensory nerves) extending to the nail bed area were found in 46% of the digits, thus confirming that sensory supply to the dorsum of the distal phalanx and nail bed also arises from the dorsal sensory nerves. Four types of palmar-dorsal interconnections, located in the middle of the proximal phalanx, were found in the digits but not in the thumb. The presence of these branches indicates dual innervation of the dorsal and palmar side of the distal areas of the digits. These anatomic findings may help hand surgeons interpret discrepancies in sensory loss after either dorsal or palmar injuries.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.     

游离足底内侧皮瓣修复腕掌尺侧皮肤神经缺损

目的 探讨修复腕掌尺侧皮肤神经同时缺损的新方法.方法 2000年4月至2009年8月,应用游离足底内侧皮瓣修复腕掌尺侧皮肤并神经缺损5例.足拇趾胫侧趾底固有神经修复小指尺掌侧固有神经缺损1例;桡神经浅支修复尺神经及其深浅支缺损2例,修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例;尺神经手背支修复尺神经浅支、第4指掌侧总神经及小指尺掌侧固有神经缺损1例.足底内侧血管与尺血管吻合.供区取同侧大腿皮片移植修复.结果 术后皮瓣及移植皮片全部成活.5例获得6个月至4年的随访,皮瓣质地好、外观满意,无手内肌萎缩和爪形手畸形,皮瓣和手指感觉恢复达S3～S3+,皮瓣两点辨距觉为7～10 mm.尺神经深浅支缺损病例术后综合评价均为优.结论 游离足底内侧皮瓣是修复腕掌尺侧皮肤神经缺损的有效方法.

Abstract：

Objective To explore a new method for repair of concurrent skin and nerve defect at palm and carpal on ulnar side. Methods From April 2000 to August 2009, five cases with concurrent skin and nerve defect at palm and carpal on ulnar side were reconstructed with free medial plantar flaps.Palmar nervous proprii defect at ulnar side of little finger was repaired by the first toe tibia nervous proprii in one case. The superficial branch of radial nerve was applied to repair the defect of ulnar nerve, as well as its deep or superficial branch in two cases. The superficial branch of radial nerve was also used to repair the defect of superficial branch of ulnar nerve, common palmar digital nerve of the fourth finger, Little finger ulnar palmar nervous proprii in one case. The dorsal branch of ulnar nerve was applied to repair the defect of superficial branch of ulnar nerve, common palmar digital nerve of the fourth finger, little finger ulnar palmar nervous proprii in one case. The vascular bundle of medial plantar flap was anastomozised with ulnar vascular bundle. The wounds at donor sites were covered with free skin grafts which were obtained from upper leg. Results All the flaps and skin grafts were survived completely. The five patients were followed up for six months to four years with no muscular atrophy or claw hand deformity. The esthetic result was satisfied. The Sensory of flaps and fingers recovered to S3 to S3+. The two-point discrimination distance on flaps was range from 7 mm to 10 mm. The postoperative comprehensive evaluation was excellent in the cases whose superficial and deep branches of ulnar nerve were repaired.Conclusions Free medial plantar flap is an effective method to repair concurrent skin and nerve defect at palm and carpal on the ulnar side.     

Unusual anatomic variation of palmar sensory branches of the ulnar nerve: a case report.

Variant sensory branches of the ulnar nerve were encountered during a routine dissection of the palmar aspects of a cadaver hand. The variant branches were distributed to the ulnar half of the index, ulnar half of the middle, and radial half of the ring fingers. The communicating branch between the superficial ulnar branch and the third common digital branch of the median nerve was absent. Distribution of the median nerve sensory branches was normal. The clinical significance of this variation is discussed.     

Innervated boomerang flap for finger pulp reconstruction

The boomerang flap originates from the dorsolateral aspect of the proximal phalanx of an adjacent digit and is supplied by the retrograde blood flow through the vascular arcades between the dorsal and palmar digital arteries. To provide sensation of the boomerang flap for finger pulp reconstruction, the dorsal sensory branch of the proper digital nerve and the superficial sensory branch of the corresponding radial or ulnar nerve are included within the skin flap. After transfer of the flap to the injured site, epineural neurorrhaphies are done between the digital nerves of the pulp and the sensory branches of the flap. We used this sensory flap in five patients, with more than 1 year follow-up, and all patients achieved measurable two-points discrimination. The boomerang flap not only preserves the proper palmar digital artery but also provides an extended and innervated skin paddle. It seems to be an alternative choice for one-stage reconstruction of major pulp defect.     

Reversed dorsal digital and metacarpal island flaps supplied by the dorsal cutaneous branches of the palmar digital artery

The dorsal digital and metacarpal island flaps have been described for use in a variety of clinical situations. On the basis of the authors' previous angiographic studies, these two skin flaps were planned on the dorsum of the proximal phalanx or intermetacarpal space based on the vascular anastomoses between the proximal dorsal cutaneous branches of the palmar digital artery and the dorsal digital branches of the dorsal metacarpal artery at the level of the proximal phalanx. The authors present a series of 13 patients using these flaps. To reconstruct the injured finger pulp, the reverse dorsal digital flap was used in 5 patients, and the reverse dorsal metacarpal flap was used in 8 patients. Most of the 13 patients sustained a work-related injury. Associated injuries of bone, joint, or tendon occurred in most patients. In all patients, the skin defect was located distal to the proximal interphalangeal joint. The skin paddle was taken from the dorsal aspect of the middle and ring fingers or the first, second, third, and fourth metacarpal area. All flaps survived completely. Two patients who had the dorsal branch of the sensitive radial nerve anastomosed to the digital nerve recovered 6-mm two-point discrimination in the reverse dorsal digital flap. The results of this anatomic study and the authors' clinical experience confirm the reliability of the dorsal digital and metacarpal island flaps.     

伤指背筋膜岛状皮瓣修复手指软组织缺损

目的 介绍以伤指指背筋膜为蒂，带指固有神经背侧支的岛状皮瓣顺行或逆行转移修复指腹或指背软组织缺损的方法。方法 在手指近、中节背侧沿指固有神经背侧支走行方向设计并切取筋膜蒂皮瓣，切取皮瓣时蒂部带一矩形皮瓣，以减轻转位后皮瓣蒂部的张力。皮瓣顺行转移不需缝合神经，逆行转移时与受区神经缝合。皮瓣切取范围不超过手指侧中线，切取面在腱周浅层，皮瓣转移轴线沿指固有神经背侧支走向。结果 本组17例22指皮瓣全部成活。结论 采用伤指指背筋膜蒂岛状皮瓣转移修复指腹或指背皮肤缺损是一种简单安全，行之有效的手术方法。