眶上裂及其周围结构的显微解剖和手术学意义

目的研究眶上裂及其周围结构的显微解剖,并分析其手术学意义,以期为相关手术入路、病理解剖和影像学研究提供显微解剖学资料。方法利用8具经福尔马林固定的成人头颅湿标本和5具成人头颅干标本,在显微镜下对眶上裂及其周围的骨性结构、硬膜结构、韧带、神经和血管进行解剖,并进行多角度观察、拍摄和描述。结果眶上裂的空间分成外侧部、中间部和下部;动眼神经、滑车神经、展神经、眼神经和眼上静脉从眶上裂的外侧部或中间部穿过;神经血管与软组织共同封闭眶上裂;眶上裂外侧韧带和直肌间韧带是重要的解剖标志。结论只有经过精细的显微解剖操作和观察才能全面掌握眶上裂及其周围结构的解剖知识,进而有助于临床手术操作。     

Anatomy of the Inferior Orbital Fissure: Implications for Endoscopic Cranial Base Surgery

Considering many approaches to the skull base confront the inferior orbital fissure (IOF) or sphenomaxillary fissure, the authors examine this anatomy as an important endoscopic surgical landmark. In morphometric analyses of 50 adult human dry skulls from both sexes, we divided the length of the IOF into three segments (anterolateral, middle, posteromedial). Hemotoxylin- and eosin-stained sections were analyzed. Dissections were performed using transnasal endoscopy in four formalin-fixed cadaveric cranial specimens (eight sides); three endoscopic approaches to the IOF were performed. IOF length ranged from 25 to 35 mm (mean 29 mm). Length/width of the individual anterolateral, middle, and posteromedial segments averaged 6.46/5, 4.95/3.2, and 17.6/ 2.4 mm, respectively. Smooth muscle within the IOF had a consistent relationship with several important anatomical landmarks. The maxillary antrostomy, total ethmoidectomy approach allowed access to the posteromedial segment of the fissure. The endoscopic modified, medial maxillectomy approach allowed access to the middle and posterior-medial segment. The Caldwell-Luc approach allowed complete exposure of the IOF. The IOF serves as an important anatomic landmark during endonasal endoscopic approaches to the skull base and orbit. Each of the three segments provides a characteristic endoscopic corridor, unique to the orbit and different fossas surrounding the fissure.     

Orbital apex syndrome associated with fractures of the zygoma and orbital floor

Summary The orbital apex syndrome can be caused by trauma. The patient presented was hit by an elbow in the right periorbital area with resulting fractures to the right zygoma and orbital floor. Examination revealed visual loss, total ophthalmoplegia, and ptosis of the right upper eyelid with hypoesthesia in the ophthalmic division of the trigeminal nerve. After a week of supportive therapy and observation, the orbital floor fracture was repaired by reducing the bone fragments, and the zygomatic fracture was reduced through a Gillies incision. Over the next six months, there was complete resolution of the ophthalmoplegia, the ptosis, the loss of sensation in the ophthalmic division of the trigeminal nerve, and the vision.     

Bilateral Orbital Metastases as the Presenting Finding in a Male Patient with Breast Cancer: A Case Report and Review of the Literature

Abstract: Breast cancer in men has traditionally been thought to be substantially different from that in women. As more becomes known about this relatively rare entity, the similarities between genders become more striking than the differences. Carcinoma of the male breast is an uncommon disease occurring in less than 1% of all breast cancers. Male breast carcinoma is staged similarly to female breast cancer using the American Joint Committee Clinical Staging System. As in women, axillary nodal status is the strongest predictor of outcome. Distant metastasis to bones, soft tissue, lungs, and liver have been widely reported in men with breast cancer. This case report provides a rather rare presentation of a man with breast carcinoma with bilateral orbital metastasis as an initial clinical presentation.     

Traumatic Hemipelvectomy: A Case Report and a Review of the Literature

Abstract Traumatic hemipelvectomy is a life threatening, devastating pelvic injury with very low survival rates. Excessive loss of blood, related systemic problems and additional injuries about the gastrointestinal and genitourinary systems increase mortality of this severe sort of injury. A young, male farmer injured violently by an agricultural heavy machine; a survivor of traumatic hemipelvectomy is described in this case report.     

The One-Piece Orbitozygomatic Approach: The MacCarty Burr Hole and the Inferior Orbital Fissure as Keys to Technique and Application

Summary  Objective. Use of the MacCarty keyhole burr hole and the inferior orbital fissure provides simplicity and safety to perform the one-piece frontotemporal orbitozygomatic (FTOZ1) approach.  Methods. We performed the FTOZ1 approach with its three subtypes (i.e., total, temporal, and frontal) in cadaveric head specimens in the Goodyear Laboratory and subsequently in surgical cases.  Results. The orbitozygomatic osteotomy, when added to a frontotemporal craniotomy, comprises the frontotemporal orbitozygomatic (FTOZ) approach, provides an expanded exposure to the anterior and middle cranial fossae, and enables the surgeon to create a window to the posterior cranial fossa. The MacCarty burr hole is used to facilitate orbital cuts, and the anterolateral portion of the inferior orbital fissure connects the orbital cuts to the zygomatic cuts. This allows the FTOZ1 craniotomy flap to be “out-fractured” with ease. The three types of FTOZ1 approach, i.e., the total, the temporal, and the frontal, are described step by step.  Conclusions. Understanding the MacCarty keyhole burr hole and the microsurgical anatomy of the inferior orbital fissure is essential to performing the FTOZ1 approach. The three types of FTOZ1 approach enable the surgeon to tailor the approach according to the surgical exposure needed for each lesion.     

Fibromuscular Dysplasia of the Superior Mesenteric Artery-Case Report and Review of the Literature

Fibromuscular dysplasia is a multifactorial arteriopathy most commonly affecting the renal and carotid arteries. In this report we present a case of visceral artery involvement, causing occlusion of the superior mesenteric artery and celiac trunk and resulting in visceral ischemia. Treatment consisted of superior mesenteric artery reimplantation. Visceral artery FMD can present as occlusive or aneurysmal disease and treatment depends on patient characteristics and symptoms.     

Blunt Left Extrahepatic Bile Duct Injury: Case Report and Literature Review

Background  Extrahepatic biliary tract injuries following blunt abdominal trauma are very rare and pose a diagnostic and therapeutic challenge. Case Report  We report a case of blunt liver injury with left extrahepatic duct transection following a motor vehicle collision. Technetium 99m dimethyliminodiacetic acid scan confirmed a bile leak and endoscopic retrograde cholangiopancreatography (ERCP) diagnosed the injury of the left extrahepatic duct. Management was initially conservative, consisting of external drainage along with trials of stent placement. Ultimately, partial left hepatectomy was required to definitively treat the injury. Conclusion  In the setting of suspected biliary tract injury, early ERCP is essential to localize a leak and guide management decisions. In the event of a confirmed bile leak, a trial of nonoperative management consisting of endoscopic ductal decompression along with percutaneous drainage may initially be warranted although is not always successful.     

Pseudoaneurysm of the Dorsalis Pedis Artery: Case Report and Literature Review

Aneurysms and pseudoaneurysms of the dorsalis pedis artery are rare vascular entities usually caused by traumatic injury or iatrogenic intervention, producing a focal soft pulsatile tissue mass in the dorsal foot. Gradual expansion of the fibrous capsule can produce secondary physical signs through the pressure exerted on surrounding structures. We report the case of a 57-year-old male with an idiopathic pseudoaneurysm of the dorsalis pedis artery. A focused history found a low-grade blunt trauma to the dorsal foot that had occurred 2 years previously. The diagnosis of a pseudoaneurysm was confirmed by ultrasound examinations and computed tomography angiograms. The pseudoaneurysm was treated with resection, and a short reversed great saphenous vein interposition graft was placed. He recovered well after surgery and remained free of symptoms 18 months postoperatively. The literature review of this uncommon vascular pathologic entity and the diagnosis and management are discussed.     

Avulsion Fracture of the Calcaneal Tuberosity: Case Report and Literature Review

Avulsion fractures of the calcaneal tuberosity are predominantly seen in patients with poor bone quality, the commonly used lag screw fixation might not be strong enough even with bony fragments of sufficient size. We present a case of a closed displaced avulsion fracture of the calcaneal tuberosity due to blunt trauma to the calf in a 74-year-old female. Open reduction and internal fixation with two 3.5-mm cannulated cortical screws with washers was performed, and anatomic reduction was achieved. Without further trauma, secondary displacement of the fracture occurred on day 3. Revision was performed with a single 3.5-mm cortical screw and transosseous fixation with 2 suture anchors, followed by partial weightbearing for 6 weeks. At 12 weeks postoperative, the fracture had completely healed, and she was doing well at 16 months after the revision surgery. Transosseous suture anchor fixation of an osteoporotic avulsion fracture of the calcaneal tuberosity seems to provide better and stronger fixation than that using lag screws.     

Orbital Infantile Myofibroma: a Case Report and Clinicopathologic Review of 24 Cases from the Literature

Isolated orbital infantile myofibroma are rare tumors in the head and neck. The mass-like clinical presentation and variable histologic features result in frequent misdiagnosis and potentially inappropriate clinical management. There are only a few reported cases in the English literature. Twenty-four patients with orbital infantile myofibroma or myofibromatosis were compiled from the English literature (Medline 1960–2011) and integrated with this case report. The patients included 14 males and 10 females, aged newborn to 10 years (mean, 34.8 months), who presented with a painless mass in the infra- or supraorbital regions, usually increasing in size andassociated with exophthalmos (n = 5). Females were on average older than their male counterparts (38.9 vs. 31.9 months, respectively; P = 0.71). The tumors were twice as frequent on the left (n = 16) than right (n = 8). Patients experienced symptoms for an average of 2.7 months before clinical presentation. The tumors involved the bone (n = 17) or the soft tissues (n = 7) of the orbit, with extension into the nasal or oral cavity (n = 3). The mean size was 3.0 cm, with a statistically significant difference between males and females (mean: 3.9 vs. 1.82; P = 0.0047), but without any differences based on age at presentation (P = 0.25), duration of symptoms (P = 0.66), or bone or soft tissue involvement (P = 0.51). Grossly, all tumors were well-circumscribed, firm to rubbery, homogenous, and white–grey. Histologically, the tumors were biphasic, showing whorled and nodular areas of fusiform cells with extracellular collagen, mixed with a population of small, primitive-appearing, darkly staining cells. Necrosis was not present, but mitoses could be seen. Tumors with immunohistochemistry performed showed strong and diffuse smooth muscle actin and vimentin immunoreactivity, but were negative with muscle specific actin, desmin, MYOD1, myogenin, S100 protein, GFAP, keratin, CD31, 34, Factor VIIIR-Ag, and CD45RB. The principle histologic differential diagnosis includes juvenile hyaline fibromatosis, fibrous hamartoma of infancy, fibromatosis coli, leiomyoma, infantile hemangiopericytoma, infantile fibrosarcoma, Ewing sarcoma/primitive neuroectodermal tumor, and lymphoma. All patients were managed with surgery. Recurrences developed in two patients at 4 and 6 months, respectively. Follow-up data was available on all but two patients (n = 22). These patients were either alive without evidence of disease (n = 18), alive but with disease (n = 3), or had died unrelated to this disease (i.e., neuroblastoma, n = 1). Orbital infantile myofibroma is a rare tumor, presenting in infancy as an enlarging mass of the orbit, with characteristic histomorphologic and immunophenotypic features. Orbital disease is usually isolated rather than part of systemic disease, and shows an excellent long-term prognosis, making appropriate separation from other conditions important.     

Complete Cuboid Dislocation With Associated Lisfranc Injury: A Case Report and Review of the Literature

Cuboid dislocations are rare midfoot injuries that usually occur in the setting of high-energy trauma. Diagnosis can be challenging and optimal treatment remains unknown. This case report and review aims to summarize the recent literature on this topic.     

Endoscopic-assisted Fascial Decompression for Forearm Exertional Compartment Syndrome: A Case Report and Review of the Literature

A case of chronic exertional compartment syndrome of the forearm treated with endoscopic-assisted fascial decompression is presented. The diagnosis of exertional compartment syndrome of the forearm was confirmed by direct measurement of intracompartmental pressures. Following endoscopic-assisted fascial decompression, the patient was able to begin rehabilitation therapy within 2 weeks. There were no wound-related complications. The patient reported no recurrence of symptoms after returning to work requiring heavy lifting, and morbidity associated with open decompression was avoided. Endoscopic release is not an option in traumatic compartment syndrome, but a minimally invasive approach may be considered in cases of exertional compartment syndrome. Reports of endoscopic-assisted fascial decompression in exertional compartment syndrome of the forearm are relatively scarce. Confirmation of the safety and efficacy of these evolving techniques in the hand surgery literature remains important.     

Superior Vena Cava Thrombosis after In Vitro Fertilization: Case Report and Review of the Literature

Ovarian hyperstimulation syndrome (OHSS) is a rare complication of fertility medication. A 33 year old female with OHSS with thrombosis of the right internal jugular vein, subclavian vein, and superior vein cava underwent in vitro fertilization following stimulation with a GnRH analog with successful implantation. The patient developed abdominal distention and dyspnea, with persistent symptoms that resulted in a 20 lb weight loss. As pregnancy progressed, edema, pain, and tingling sensations developed by the ninth week at which time a CT scan confirmed thrombus with the right internal jugular and subclavian vein and a free floating tip in the superior vena cava. Following treatment with intravenous heparin therapy and subcutaneous low-molecular weight heparin until delivery her symptoms improved. While optimal treatment remains unclear, treatment strategies remain conservative. Identifying the risk factors that lead to the development of OHSS including the identification of those patients at risk for developing OHSS, more extensive investigation of potential underlying coagulopathy in severe or recurrent cases, and consideration of prophylactic subcutaneous heparin or IV albumin supplementation, will facilitate prevention in the high risk population.     

Simultaneous Dislocation of Both Joints of the Thumb with a Fracture Involving the Interphalangeal Joint. A Case Report and a Review of the Literature

Combined dislocation of the metacarpophalangeal and interphalangeal joints of the thumb is uncommon, only five cases having been previously reported. In this case report, a previously unreported case characterized by volar-ulnar dislocation of the metacarpophalangeal joint and dorsal dislocation of the interphalangeal joint, associated with a unicondilar open fracture of the proximal phalanx, is presented.

Only open reduction for the interphalangeal joint was needed and both (metacarpophalangeal and interphalangeal) joints were treated with K-wire fixation after reduction. Internal fixation of the phalangeal fracture was not performed because of the size of the bone fragment.

Although the diagnosis of dislocation of the interphalangeal joint is obvious, a simultaneous dislocation of the metacarpophalangeal joint can be easily overlooked, which is a fact that underlines the importance of this article. It is therefore recommended to examine the whole hand.