microCT重建距骨骨内微小动脉三维结构的临床解剖学研究

目的获得距骨内微小动脉三维结构模型,对临床上不同分型的距骨骨折的预后做出更精确的解释和预测。方法对12例新鲜尸体下肢行股动脉插管并灌注铅造影剂。距骨取材,进行microCT扫描并且重建高精度模型,图像最终分辨率为52.30μm。最终获得距骨周围与距骨内血管在各个切面的图像,观察距骨表面动脉与骨内分支的走行和分布,并计数动脉的骨内分支数。结果距骨骨外血管集中分布于表面的韧带和关节囊内。距骨表面主要有4大血管分布区域,分别为跗骨管-跗骨窦区、距骨颈上表面、距骨体内侧面和后结节区。距骨颈周围血管环由跗骨管-跗骨窦区和距骨颈上表面的骨外血管连接而成(骨内分支数分别为5.1±1.3和5.6±1.9),是距骨的主要血供来源,分支分布于距骨头、距骨颈和大部分距骨体,并有丰富的吻合。此外,距骨体还接受距骨体内侧面(骨内分支3.2±1.4)和后结节区(骨内分支0.7±0.5)的骨内分支的血供。结论血管环是距骨的主要血供来源,骨内分支有丰富吻合。距骨颈骨折的坏死风险取决于该分型对血管环骨内分支和吻合的破坏程度。距骨体矢状面骨折和粉碎骨折对血管环的骨内分支的破坏较大,缺血坏死风险相对高。距骨头血供丰富,骨折时缺血坏死的可能小。     

肱骨近端粉碎性骨折人工肱骨头置换相关临床解剖因素分析

目的　探讨肱骨近端粉碎性骨折人工肱骨头置换术中假体安装中相关解剖因素及臂丛、旋肱后动脉的解剖特点和意义。 方法　对15例肱骨近端粉碎性骨折患者施行人工肱骨头置换术,术中保护好腋神经、旋肱后动脉并选用适当的假体后倾角、高度、肱骨头的直径正确安装假体。患者平均年龄63.5岁。术后随访并进行Constant评分。 结果　术后随访6~24个月,平均16.2个月,Constant评分平均为80.5分（61~89分）。 结论　人工肱骨头置换术是治疗肱骨近端粉碎性骨折的有效方法,术中掌握相关临床解剖结构特点,有利于减少术后并发症的发生,是临床获得满意疗效的关键。     

Proximal humerus fractures

Proximal humerus fractures are common injuries. Knowledge of local anatomy is paramount in the evaluation and treatment of these injuries. Information regarding humeral head vascularity, fracture patterns, bone quality, and overall geometry have direct implications for nonoperative treatment, internal fixation, and hemiarthroplasty. The ascending branch of the anterior circumflex artery perfuses most of the humeral head. When fractured, the greater tuberosity tends to displace posterosuperiorly, the lesser tuberosity and the shaft displace medially, and the head may be pulled by the attached tuberosity, impacted into valgus, or in more severe cases dislocated, impacted, or divided. Internal fixation of two-part, three-part, and selected four-part fractures may be compromised by local osteopenia; knowledge of the location of the strongest bone in the proximal humerus combined with the use of fixed-angle devices and occasionally bone graft or substitutes has improved the outcome of osteosynthesis. When the humeral head cannot be preserved, successful hemiarthroplasty requires tuberosity union and anatomic restoration of the overall geometry of the proximal humerus in terms of height, retroversion, and head-tuberosity relationships.     

The humeral head: A review of the blood supply and possible link to osteonecrosis following rotator cuff repair

Trauma, corticosteroid therapy and metabolic diseases are well established aetiologies of humeral head osteonecrosis; however, there is increasing evidence that arthroscopic rotator cuff surgery may be another possible cause. One of the reasons is that there may be inadvertent damage to the arterial blood supply to the humeral head during surgical intervention. The blood supply to the humeral head displays large amounts of variation with regard to origin, course and distribution. Therefore, to shed light on the pathogenesis, the blood supply of the humeral head is reviewed together with a summary of all reported cases of osteonecrosis of the humeral head that occurred following rotator cuff repair. Inconsistencies with regard to terminologies used and contradictions concerning arterial contributions from the anterior circumflex humeral artery and the posterior circumflex humeral artery towards humeral head supply are addressed. Moreover, variations in the course of the anterior circumflex humeral artery and its branches are summarized. The vascular anatomy of the humeral head is clinically relevant due to the close relationship of these blood vessels with the surgical repair sites for rotator cuff surgery and biceps tenotomies or tenodesis procedures. Potential sites of disruption of blood supply following arthroscopic rotator cuff surgery are discussed. Detailed knowledge of the course of the arteries supplying the humeral head may help to minimize the risk of vascular injury and subsequent osteonecrosis. Given the great interindividual variations of vascular anatomy, imaging procedures preceding arthroscopic rotator cuff surgery may be advisable.     

同种异体带血供肱骨移植的解剖学研究

目的为吻合血管同种异体肱骨移植提供解剖学依据。方法在40侧经动脉灌注红色乳胶的成人上肢标本上,着重观测肱骨上端及肱骨干滋养血管和骨膜血管的来源、分布、长度和外径;50根干燥成人肱骨,观察肱骨上端及肱骨干的滋养孔。结果肱骨上端外科颈周围平均有(7.7±2.0)个(4～12个)滋养孔,滋养支来自旋肱前动脉和旋肱后动脉。肱骨干滋养孔1～3个,主要位于肱骨中段前内侧面,距内上踝(11.7±2.2)cm(6.5～17.0cm)。滋养动脉主要来自肱动脉,长(2.6±0.7)cm(1.5～5.0cm),外径(1.3±0.6)mm(0.8～2.2mm)。结论选用旋肱前血管为蒂,可行肱骨上段移植,选用肱血管和肱深血管为蒂,可作肱骨中段移植。     

旋肱前血管外侧降支为蒂肱骨上段骨膜瓣的应用解剖

目的：为带旋肱前动脉外侧降支为蒂的肱骨上段外侧面骨膜瓣痊术提供解剖依据：方法：在３８侧经动脉环绕色乳胶的成人上肢标本上对旋肱前上侧降支的来源、走行、分布进行了了解剖学观测,并在４侧标本上不幕拟手术实验。结果：旋肱前动脉经 肱肌和肱二头肌短头深面,绒上科颈外进至结节间沟外侧缘分别分出升支和降支。升支上行分布于肱骨头和小结节部。降支有２条分别沿胸大肌止腱内、个侧紧贴骨膜下行,为内侧降支和外侧降支。外侧     

Presentation of the microscopic vascular architecture of the radial head using a sequential plastination technique

The purpose of this study was to demonstrate the peri- and intraosseous vascular architecture of the radial head and vascular interaction with surgical implants. Seventeen fresh human cadaveric elbows were sequentially plastinated beginning with arterial injection, followed by block and slice plastination of the whole elbow. With this technique, we obtained completely transparent cadaveric slices in which the peri- and intraosseous vascular architecture could be studied in its neutral position. In six of these elbows, radial head osteosynthesis was imitated with miniplates or fine threaded K-wires. Vascularization of the radial head occurred via branches of the radial recurrent artery on the ventral, lateral, and dorsal sides of the radial head and a branch of the ulnar artery--ramus periostalis ulnaris--medially and dorsomedially. Both arteries create a pericervical arterial ring around the radial neck. A branch of the interosseous artery--R. interosseous recurrence--supports the ventral and dorsal sides of the radial neck and the final branches of the nutrient artery support intraosseous vascularization. Vascular structures were damaged more severely by plates than by screws. The peri- and intraosseous vascularization of the radial head and the interaction between vascularization and the implants was shown. Plate fixation of radial head fractures leads to a higher level of implant-related destruction of the periosseous vascularization than screw fixation. Besides devascularization of the radial head due to the injury leading to a certain risk of fracture nonunion, additional implant-related injuries to the blood supply might increase the chance of radial head fracture non-union.     

带血管蒂肱骨中段骨膜瓣移位术的应用解剖

目的 :为带血管蒂肱骨中段骨膜瓣移位术提供解剖学依据。方法 :在 3 8侧经动脉灌注红色乳胶的成人尸体上肢标本上对肱骨中段前内侧面和部分前外侧面骨膜血管的来源、走行、分支、分布及吻合进行观测 ,并在 4侧标本上摹拟手术实验。结果 :旋肱前动脉主干行经喙肱肌和肱二头肌短头深面 ,绕肱骨外科颈外进至结节间沟外侧缘处分出升支和降支 ,升支上行分布于肱骨头及小结节部 ,降支有 2条分别沿胸大肌止腱内、外侧紧贴骨膜下行 ,为内侧降支和外侧降支。肱动脉肌间隙支自肱动脉发出后向外上走行至三角肌止端内侧发一升支即直接骨膜支上行连接旋肱前动脉的内侧降支。结论 :以旋肱前动脉内侧降支和肱动脉肌间隙支为蒂的肱骨中段骨膜瓣移位可用于修复肱骨头缺血性坏死和肱骨上、中段骨不连、骨缺损。     

人工肱骨头置换治疗肱骨近端复杂性骨折

目的探讨肱骨近端复杂性骨折应用人工肱骨头置换治疗以及肩关节功能恢复的效果。方法对12例肱骨近端复杂性骨折患者采取人工肱骨头置换手术治疗。结果12例患者经5-15个月随访,无重大手术并发症发生,仅1例发生肱骨头半脱位现象。患肩功能恢复基本满意,生活可自理。结论人工肱骨头置换治疗复杂性肱骨近端骨折,术后肩关节功能恢复基本满意,能满足解除疼痛、稳定关节、重建运动功能的要求,是一种切实有效的治疗方法。     

长型肱骨近端锁定钢板治疗肱骨近端并肱骨干骨折

背景：国内外均有文献报道证实长型肱骨近端内固定锁定钢板用于治疗肱骨近端骨折疗效显著。 目的：总结应用长型肱骨近端内固定锁定钢板手术治疗肱骨近端合并肱骨干骨折的临床疗效。 方法：纳入应用长型肱骨近端内固定锁定钢板治疗肱骨近端合并肱骨干骨折患者16例。其中男7例,女9例,年龄45-83岁,平均71岁。肱骨近端Neer分型,2部分骨折5例,3部分骨折8例,4部分骨折3例;肱骨干骨折AO分型A1型5例,B1型6例,B2型2例,C1型2例,C3型1例。内固定后肩关节功能采用Constant-Murley肩关节评分标准对患者两侧肩关节进行评分,同时计算评分百分比并作相应评价。肘关节采用改良HSS评分标准评估。 结果与结论：16例患者均获随访,随访时间12-24个月,平均14.9个月。所有患者骨折均愈合,时间8-17周,平均12.1周。2例患者出现伤口脂肪液化,换药后均愈合。1例患者治疗后出现桡神经麻痹症状,1例患者出现肩峰撞击综合征,治疗后好转。无内固定松动、螺钉切割及肱骨头缺血坏死等并发症发生。治疗后12个月按Constant-Murley评分标准为65-90分,平均76.87分。与健侧百分比为71.4%-93.8%,平均83.41%。优良15例,满意1例。改良HSS肘关节评分优13例,良3例,优良率100%。说明长型PHILOS钢板治疗肱骨近端合并肱骨干骨折固定可靠,并发症少,疗效满意。     

The arterial supply of the long head of biceps tendon: Anatomical study with implications for tendon rupture

Zones of hypovascularity are thought to exist in several tendons of the shoulder, contributing to localized tendon weakness and subsequent rupture in clinical practice. Although these zones have been demonstrated in many frequently ruptured tendons, the existence of a similar area in the often ruptured long head of biceps (LHB) tendon is largely unknown. Twenty cadaveric upper limb specimens were dissected after injection with either a radio‐opaque lead oxide/milk mixture or India ink, followed by histological sectioning of the tendons. The LHB tendon was consistently supplied via its osteotendinous and musculotendinous junctions by branches of the thoracoacromial and brachial arteries respectively. In two specimens, additional branches from the anterior circumflex humeral artery travelling in a mesotenon vascularized the midsection of tendon. These source arteries divided the LHB tendon into either two or three vascular territories, depending upon the presence of the mesotenon‐derived vascular supply. A zone of hypovascularity was consistently found in the region of the LHB tendon most frequently prone to rupture. This zone covered an area 1.2–3 cm from the tendon origin, extending from midway through the glenohumeral joint to the proximal inter‐tubercular groove. This hypovascular region occurred on the border of two adjacent vascular territories, where reduced caliber choke vessels provide limited arterial supply. While it is probable that the limited arterial supply contributes to the susceptibility of this area to rupture, similar to other tendons the true pathogenesis is likely to be a combination of both vascular and mechanical factors. Clin. Anat. 23:683–692, 2010. © 2010 Wiley‐Liss, Inc.     

肱骨近端骨折手术安全区的解剖学研究和临床意义

目的　测量旋肱前动脉和腋神经解剖学数据,为寻求肱骨近端骨折手术安全区提供必要的解剖学依据。 方法　20具成人尸体标本,用游标卡尺测量肱骨近端旋肱前动脉、腋神经相对于手术切口和骨性标志的距离。 结果　肩峰锁骨端下缘与旋肱前动脉上缘垂直距离为(5.1±0.2) cm(4.6~5.5 cm)、小结节顶点与旋肱前动脉上缘垂直距离为(2.5±0.2)cm(2.0~3.0 cm)、旋肱前动脉的横径为(2.6±0.2)mm　(2.2~3.1 mm)、旋肱前动脉与肱骨干长轴的夹角为（14±4）°(5~22°)、肩峰前下缘与腋神经上缘的垂直距离为(6.3±0.5)cm(5.2~7.0 cm)、大结节顶点与腋神经上缘的垂直距离为(3.5±0.2)cm(3.2~4.1 cm)、腋神经与肱骨干长轴垂线的夹角为(22±7)°(8~37°)、三角肌前外1/3间隙处腋神经横径为(4.2±0.8)mm(3.7~5.5 mm)。 结论　本研究得出了旋肱前动脉和腋神经上方相对于手术切口和骨性标志的安全区,以避免在肱骨近端骨折手术时损伤旋肱前动脉和腋神经。     

Lateral arm flap: analysis of its anatomy and modification using a vascularized fragment of the distal humerus

Soft tissue injuries with associated bone defects are difficult to manage and often require prolonged treatment with repeated interventions. Frequently, a free flap is applied as a first step and bone grafting is carried out in a second procedure. Ideally, these two procedures are combined in one operation, utilizing a soft tissue flap with an attached vascularized bone fragment. The lateral arm flap can provide such an osteoseptocutaneous flap and has been utilized clinically with success; however, the vascular anatomy of the flap, especially the humeral fragment, has not been described in detail previously, and there is broad disagreement concerning its innervation. In this study, the arteries and nerves of 24 fresh cadaver arms were dissected after injection of colored latex. The levels of origin of the periosteal arteries of the humerus were also documented. The lateral arm flap has a consistent arterial supply from three septocutaneous perforating branches that are arranged in a predictable pattern. The lateral supracondylar ridge of the humerus is vascularized by direct branches of the posterior branch of the radial collateral artery and by arteries that arise from muscular branches supplying adjacent muscles. The innervation of the lateral arm flap is by the inferior lateral cutaneous nerve of the arm. Knowledge of the consistent vascular anatomy of the lateral humerus and soft tissue of the donor site allows an osteoseptocutaneous flap to be raised safely with an appropriate technique. We recommend use of the lateral arm flap with a humeral fragment for the treatment of combined soft tissue and bone defects when a single step surgical solution is indicated.     

肩胛—侧胸联合皮瓣移植的解剖学基础

在36侧从动脉灌注红色乳胶的成人尸体标本上,解剖观测了肩胛—侧胸皮瓣的血管类型、分支和分布等.本文观察结果,83.3％可以肩胛下血管为蒂,带旋肩胛血管和胸背血管,形成肩胛—侧胸联合皮瓣.文中对皮瓣的设计、切取方法等有关的解剖学进行了讨论.     

人工肱骨头置换中使用胸骨针行肱骨近端骨折肩袖重建

背景：越来越多的粉碎、移位严重而无法重建的肱骨近端骨折患者需要行人工肱骨头置换,但此类患者肩袖的重建直接影响治疗效果,置换过程中往往需要良好的肩袖重建。 目的：探讨胸骨针在肱骨近端骨折人工肱骨头置换肩袖重建中的应用体会。 方法：34例肱骨近端四部分骨折患者行人工肱骨头置换时使用胸骨针修复肩袖,年龄67-78岁。人工肱骨头置换时未过分剥离骨折块与肩袖组织,保留肩袖组织与骨块相连,将胸骨针沿着肩袖大小结节表面肌腱-骨结合部环形缝合备用,可用多根,假体置入后,将肱骨大、小结节及碎骨块解剖复位,收紧胸骨针,大小结节及肩袖附着的碎骨块均原位贴在人工肱骨头下方。术中应尽可能将残余的肩袖和肌肉组织损伤进行缝合修复,并要注意缝合后的动力平衡。采用Neer标准对人工肩关节功能的恢复情况进行评价。 结果与结论：34例患者均获随访,随访时间1-3年,24例优,10例良,2例可;无关节脱位、半脱位等关节不稳情况,未见感染、神经损伤及假体松动病例。提示人工肱骨头置换过程中使用胸骨针进行肩袖修复及大小结节固定能使肩袖和大小结节接近解剖位置,并且比常规的涤纶线强度高,固定牢靠,能满足人工肱骨头置换后康复训练的需要,对肩关节的稳定性及功能恢复有重要作用。     

Bilateral double axillary artery: embryological basis and clinical implications

An unusual bilateral variation in the arterial pattern of the axilla was observed in an embalmed cadaver. Each axilla contained two axillary arteries of similar origins but different patterns of branching and fate. The first part of each axillary artery was a single vessel as is the norm. It gave off a supreme thoracic artery and then bifurcated into two medium-sized arteries hence referred to as regular and variant. The variant artery ran in an antero-medial course, partly covered by the one axillary vein. The regular artery gave off the thoracoacromial and two posterior branches from its second part, the anterior and posterior humeral circumflex arteries from its third part, and then continued as the brachial artery with all the usual branches except the profunda brachii on the right side. The variant gave off five arteries from the second part, a thoracoacromial artery, two separate long thoracic arteries each with a branch that ran along the intercostobrachial nerve to the arm, and two posterior branches. In the third part of the variant, the subscapular artery arose with its usual branches plus a common origin for two additional humeral circumflex arteries. The variant terminated as the profunda brachii artery to the right side while on the left side it terminated in muscular branches to the triceps. Hence, the arterial blood supply to the upper limb, and the axillary region in particular, was shared on both sides by two major arteries instead of one. These two arteries emanated from the first part of the axillary artery and may represent persisting branches of the capillary plexus of the developing limb buds. The findings have an embryological basis and clinical relevance considering the frequency of procedures in this region.     

肱骨近端锁定钢板置入结合Osteoset人工骨治疗肱骨近端骨折随访：22例

背景：螺钉、克氏针张力带钢丝、髓内钉、三叶草钢板等置入内固定肱骨近端骨折的疗效欠佳,常出现螺钉固定不牢或松动等现象,影响肱骨头血运与肩关节外展功能。 目的：观察肱骨近端锁定钢板置入内固定结合Osteoset人工骨植入治疗肱骨近端骨折的临床效果。 方法：应用肱骨近端锁定钢板置入内固定结合Osteoset人工骨植入治疗22例肱骨近端骨折病例。 结果与结论：所有病例随访12~24个月均骨性愈合,根据Neer疗效评分标准,优13例,良7例,可2例,差0例,优良率为91%;治疗后X射线显示所有肱骨近端骨折及肩关节脱位均获得了满意复位。说明肱骨近端锁定钢板置入内固定结合Osteoset人工骨植入治疗肱骨近端骨折疗效肯定。     

A method to quantify and visualize femoral head intraosseous arteries by micro‐CT

We describe a technique for perfusing a barium sulphate suspension into the intraosseous artery. Following the perfusion of abarium sulphate suspension into 14 fresh lower limbs of Chinese cadavers, micro‐CT scanning was applied to digitize, quantify and visualize the intraosseous arteries in the human femoral heads. Then, the femoral heads were removed and subjected to micro‐CT scanning. The data were imported into the amira and mimics programs to reconstruct and quantify the intraosseous arteries. The femoral head intraosseous artery lengths, areas, volumes, and femoral head bone volumes were quantified. The artery densities and artery ratios were calculated and analysed with independent‐samples t‐tests. The intraosseous vasculature volume renderings were displayed as screenshots and videos made with amira . Many intraosseous artery study technologies were compared. The barium sulphate suspension was milky white in colour. The perfusion of the barium sulphate suspension followed by micro‐CT scanning provided a good representation of the intraosseous artery. The femoral head intraosseous artery lengths, areas and volumes, and the femoral head bone volumes were displayed as the . No differences were observed between the left and right femoral head intraosseous arteries in terms of the artery densities or artery ratios. The volume renderings and 3‐D orthogonal projections displayed the overall distributions of the intraosseous arteries. The videos clearly demonstrated the entry sites of the nutrition‐carrying arteries, their courses and branches, and the intraosseous arterial anastomoses. Our technique is the simplest and least time‐consuming method of producing accurate vascular three‐dimensional reconstructions. The perfusion of a barium sulphate suspension into intraosseous arteries combined with micro‐CT scanning can deliver high‐resolution 3‐D digitized data and images of intraosseous arteries. This technique does not require bone decalcification or bone dissection and thus significantly shortens the time required to quantify and display intraosseous arteries. This method provides a simple and rapid technique for quantifying and visualizing human intraosseous arteries.     

肱骨近端解剖钢板治疗肱骨外科颈骨折36例临床分析

目的评价应用肱骨近端解剖型钢板治疗肱骨外科颈骨折的方法及疗效。方法回顾性分析肱骨近端解剖型钢板治疗肱骨外科颈骨折36例临床资料。结果本组手术过程顺利,无神经、血管损伤,住院期间无感染等并发症发生。36例中31例获门诊随访,随访时间6～24个月,平均12个月,获得随访的患者骨折术后均I期愈合,按Neer肩关节评价标准,优及满意率为93.5%。结论肱骨近端解剖型钢板治疗肱骨外科颈骨折是一种有效的方法。