腋窝入路桡神经肱三头肌支转位移植修复腋神经的应用解剖

背景：上臂后上切口入路肱三头肌肌支转位移植修复腋神经牵拉三角肌时易损伤腋神经后支及锁骨上臂丛,探查和联合其他神经转位时需变更体位。 目的：分析腋窝入路桡神经肱三头肌支转位移植修复腋神经的可行性。 方法：取常规甲醛固定成人上肢标本10具20侧,于标本平卧,上肢外展外旋位,腋窝入路,对腋窝处神经血管进行显微解剖。测量腋神经起始处至分支处距离及其分支起始处的横径,肱三头肌各肌支起始处横径,各肌支由入肌点向近端进行无损伤分离长度。 结果与结论：腋神经肩胛下肌下缘分成前后两支,前支横径平均为2.5(1.6~3.4) mm。桡神经肱三头肌长头支,起点处横径为2.2(1.4-2.8) mm。桡神经与腋神经距离平均为18.2(10.2~30.0) mm。腋神经前支与桡神经肱三头肌支横径相似,距离短。表明腋窝入路可暴露和辨别腋神经前后分支,桡神经肱三头肌支在背阔肌腱表面水平靠近腋神经,可选择任一肌支转位移植修复腋神经。      

肩关节手术外侧入路与解剖

目的：为肩关节手术外侧入路和避免损伤腋神经提供解剖学依据。方法：对60侧成尸上肢标本，按照手术进路和层次进行解剖观测。结果：(1)三角肌起点弧长22.6±4．0cm，中线长15.3±2．3cm：(2)腋神经前支长2．9±0.7cm，分支主要支配三角肌前部和外侧部．(3)腋神经前支与肩峰至三角肌粗隆连线相交点，位于肩峰平面下方6.2±1．3cm，此段距离相当于三角肌上2／5份。结论：手术切口和分离三角肌纤维的远侧点均不应超过三角肌中线长的上2／5份，否则容易损伤腋神经前支。     

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。     

带臂外侧上皮神经及其营养血管筋膜皮瓣的应用解剖

目的:为带臂外侧上皮神经及其营养血管筋膜皮瓣提供解剖学基础.方法:32例经灌注红色乳胶的成人上肢标本,对臂外侧上皮神经及其营养血管等进行了较详细的应用解剖学研究.结果:臂外侧上皮神经在均由腑神经发出,起点横径为1.5±0.4mm,在三角肌深方斜向外下3.6±1.1cm从该肌后缘中1/3浅出肌间隔,分为上支和下支,分布于三角肌后部、外侧部和臂外侧上部.该神经的营养血管起源于旋肱后动脉,起点外径为0.9±0.4mm;其行程、分支和分布均同在神经,供血范因为14.8×9.8cm~2,并与周围的皮动脉存在丰富吻合.结论:带臂外侧上皮神经及其营养血管筋膜皮 瓣可视受区需要设计成游离瓣或旋转瓣,用于修复邻近部位、手或颌面部缺损.     

肱二头肌和三角肌肌支在臂丛的定位及其临床意义

目的：研究肱二头肌和三角肌肌支在臂丛中的定位。方法：通过对１０具尸体双侧肱二头肌及三角肌肌支的解剖，观察其纤维定位，并测定其截面积。结果：在腋部肱二头肌和三角肌肌支分别位于相应神经的外侧份，其截面积分别占主干截面积的３４％和５３％。在锁骨上，肱二头肌肌支位于上干前股的前正中和前外侧份，其截面积占上干前股的３４％，三角肌肌支位于上干后股的后正中和后外侧份，其截面积占上干后股的３７％。结论：在神经移植或移位手术中，应尽可能将动力神经缝接至肌支相应的神经束上，以提高疗效。     

三角肌神经入肌点定位及肌内神经分布的研究

目的　揭示三角肌神经入肌点和肌内神经分支分布 ,为其临床应用提供较为详尽的形态学资料。方法　①用经甲醛固定 2年以上的成人尸体 (2 0～ 5 0岁 ) 12具 (男 9,女 3)共 2 4侧。以肩峰后角为骨性标志 ,测量三角肌各亚部神经支入肌点的位置。②用经甲醛固定 1年以内的童尸 3具 (3～ 10岁 )及成人尸体 2具 (2 0、4 0岁 )完整取下三角肌 ,采用Sihler′s肌内神经染色法观察肌内神经分支分布。结果　①三角肌各亚部神经入肌点的体表投影 :三角肌前亚部、中亚部、后亚部的神经入肌点分别在距肩峰后角下方 (5 7± 0 7)cm、(5 9± 0 8)cm、(4 8± 0 5 )cm处的水平线上 ,距三角肌前缘外后方 (3 6± 0 4 )cm处及距三角肌后缘外前方 (3 5± 0 6 )cm、(2 3± 0 3)cm处 ,上述三点均在肌的中 1/3部。②肌内神经分布 :三角肌前、后亚部的肌内神经支在肌内为直接横过肌纤维中部 ,沿途再发出分支与肌纤维并行走行 ;而中亚部肌内神经支在各个羽内 ,与肌纤维相交 ,行向短肌纤维的起止端。结论　①三角肌的神经入肌部位及入肌形式与该肌的形态和功能有关联 ;②三角肌的肌内神经分支分布可能与该肌的肌纤维长度及肌纤维型有关 ;③三角肌中亚部的肌内神经吻合网较宽而致密 ,推测有着更精细的神经调节。     

模拟肩峰下前外侧扩展入路肱骨近端骨折复位内固定的解剖学特点

背景：临床用于肱骨近端骨折的常用入路主要有两种：前内侧入路、肩峰下前外侧入路,然而现有的手术入路存在一定局限性。 目的：分析臂部前外侧腋神经与肱骨上段及三角肌前、中亚部的解剖关系,为复位内固定治疗肱骨近端骨折寻找新入路提供解剖学依据。 方法：解剖12具成人(男7例,女5例)防腐上肢标本20侧,了解腋神经前支在三角肌前、外亚部中的走行,比较经过两亚部时跨越肌缝的神经分支形态。完成初步数据收集后,进行尸体上模拟复位内固定实验。 结果与结论：腋神经前支横向行走于三角肌肌腹深面中上1/3水平,距离肩峰外下缘(6.0±1.3) cm,前亚部仅有1支一级神经支支配,两亚部间为一连续的乏血管横越的肌缝,肌缝位于肩峰前角向下的延长线处,肉眼观为一白色结缔组织条带,腋神经通过肌缝时无分支,游离后跨缝段长度均大于1 cm,放置钢板后腋神经张力不高。通过肩峰下三角肌前、中亚部肌缝入路,显露腋神经支配前亚部的一级神经支并进行分离保护后,可以向下延伸切口,能够安全地暴露上段肱骨,在直视下进行骨折复位和金属植入物内固定等操作。     

The deep axillary artery

An aberrant axillary artery running deep to the brachial plexus during its course was observed. The brachial plexus in this case was formed by the fourth cervical nerve to the first thoracic nerve and the radial nerve received a small nerve bundle (accessory radial nerve root) from the posterior aspect of the lower trunk. The axillary artery passed between the lateral and the medial cords of the brachial plexus, the same as for an ordinary axillary artery. In addition, it passed between their posterior divisions, forming the posterior cord, and further ran between the radial nerve root and the accessory radial nerve root from deep to superficial. This axillary artery was recognized as the deep axillary artery, the same as the axillary artery we have reported previously. It was thought that the branches to the subscapularis and serratus anterior muscles, nutrient branch to the radial nerve root and the subscapular artery played important roles in its formation.     

Anatomical variations of the cords of brachial plexus and the median nerve

The variations in formation, location, and courses of the cords of brachial plexus and the median nerve were studied in both axillae of 172 cadavers. The total prevalence of variation was 12.8% (CI, 7.6-17.4) and it was found in 13.2% (CI, 7.5-18) of male and in 10.7% (CI, -0.6-19.6) of female cadavers. These variations were divided into three groups. The first group was abnormal location of the cords, which was either posterolateral or anteromedial in relation to the axillary artery in 2.3% (CI, 0.1-4.5) cadavers. The lateral cord and the medial root of the median nerve had received communicating branches from the posterior cord in most of the cases of this group. The second group was absence of the posterior cord in 3.5% (CI, 0.7-6.1) of cadavers. The lateral and medial cords of this group were connected with the communicating branches, which had a course in front of the axillary artery. The third group was abnormal formation and course of the median nerve in 7% (CI, 3.1-10.6) of cadavers. In all cases of this group the medial root received communicating branch/branches either from the lateral or posterior cord. In eight (4.7%) cadavers, both roots of the median nerve were joined on medial side of the axillary artery to form a median nerve, which traveled medial to the artery. In four (2.3%) cadavers the roots of the median nerve did not join and both traveled separately anteromedial to the axillary and brachial arteries. This study indicates that all three cords and median nerve vary considerably in levels of origin, location and course in relation to the axillary artery and these variable cases were joined with the communicating branch/branches. The observed variations are of anatomical and clinical interest. These kinds of variations are more prone to injury in radical neck dissection and in other surgical operation of the axilla.     

三角肌注射部位的选择及应用解剖研究

目的：为三角肌不同部位安全注射提供解剖学依据。方法：分别以经过!肱骨小结节和肩峰后外侧角垂线为标志,将三角肌分为前部、外侧部和后部三部分。按照三角肌注射的部位及深度在30具（60侧）成人尸体上进行解剖观测。结果：三角肌起点前端与肩峰外侧角间距为（73．4±6．9）mm,后端与肩峰外侧角间距为（97．7±8．4）mm,止点与肩峰外侧角间距为（148．7±7．2）mm。前、后部较薄,外侧部较厚。外侧部深面横过的血管神经束上下径为（18．0±4．8）mm,此束上缘与外侧部中垂线交点到肩峰平面垂直距离为（51．8±7．2）mm。后部深面腋神经后支入肌点到肩峰平面垂直距离为（49．6±8．3）mm,与三角肌后缘垂直距离为（26．7±6．1）mm;在后部深面有桡神经向下行走,桡神经与大圆肌下缘交界处距肩峰平面垂直距离为（72．6±6．5）mm处。结论：三角肌注射首选部位为外侧部,此处肌肉较厚,操作安全方便,有利用药液吸收。     

The gross anatomy of the extrathoracic course of the intercostobrachial nerve

Recent reports emphasize the importance of preserving the intercostobrachial nerve (ICBN) during surgical procedures (i.e., mastectomy, axillary clearance). However, a limited number of scientific reports explore the surgical anatomy of this nerve. We dissected 100 adult human formalin-fixed cadavers (200 axillae). In all the cadavers the ICBN was present with variant contributions from intercostal nerves T1, T2, T3, and T4. The arrangements of the ICBN were typed as I through VIII. The components of Type I (45% or 90 of our specimens) included a branch to the posterior antebrachial cutaneous nerve, a branch to the anterior and lateral parts of the axilla, a branch to the medial side of the arm, and a branch to the medial antebrachial cutaneous nerve. Type II (25%) describes the ICBN arising from T2 and giving off a branch to the brachial plexus. In Type III (10%), lateral cutaneous branches of T2 and T3 fuse as a common trunk and then split immediately after exiting the intercostal space to form an ICBN. In type IV (5%), T2 and T3 join distally to form an ICBN that ends as its terminal branches. Type V (5%): T3 joins T2 from the same intercostal space proximally, with Type VI (3%) showing a very proximal branching of the sensory terminal nerves. Type VII (5%) displayed a contribution from T3 and a branch to the brachial plexus with multiple terminating branches. A contribution from T3 and T4 and a branch to the brachial plexus with multiple branches of termination comprised Type VIII (2%).     

肋间臂神经的解剖及其临床意义

目的：为乳癌腋清扫术中保留肋间臂神经(ICBN)提供解剖学基础。方法：对25具成人尸体的50侧腋区进行了解剖，对肋间臂神经及上下相邻皮神经的走行、分支、支配、粗细等情况进行解剖观察。结果：ICBN可分为缺如型、单干型、单干分支型、双干型及3干型；84％的臂内侧皮神经与ICBN上支、上干相交通；34％的第3肋间神经外侧皮支可发支支配腋窝底；3侧第1肋间神经外侧皮支主干进入上臂内侧。结论：肋间臂神经为第2肋间神经外侧皮支的分支，通常为上支或上干，与臂内侧皮神经联合构成，可有第3或第1肋间神经的外侧皮支参与。其损伤可造成乳房切除术后疼痛综合征，乳癌腋清扫术中经胸小肌后方或经腋静脉下方能顺利找到该神经并加以保护。     

Anatomy and quantitation of the subscapular nerves

Information regarding branches of the brachial plexus can be of utility to the surgeon for neurotization procedures following injury. Sixty-two adult cadaveric upper extremities were dissected and the subscapular nerves identified and measured. The upper subscapular nerve originated from the posterior cord in 97% of the cases and in 3% of the cases directly from the axillary nerve. The upper subscapular nerve originated as a single nerve in 90.3% of the cases, as two independent nerve trunks in 8% of the cases and as three independent nerve trunks in 1.6% of the cases. The thoracodorsal nerve originated from the posterior cord in 98.5% of the cases and in 1.5% of the cases directly from the proximal segment of the radial nerve. The thoracodorsal nerve always originated as a single nerve from the brachial plexus. The lower subscapular nerve originated from the posterior cord in 79% of the cases and in 21% of the cases directly from the proximal segment of the axillary nerve. The lower subscapular nerve originated as a single nerve in 93.6% of the cases and as two independent nerve trunks in 6.4% of the cases. The mean length of the lower subscapular nerve from its origin until it provided its branch into the subscapularis muscle was 3.5 cm and the mean distance from this branch until its termination into the teres major muscle was 6 cm. The mean diameter of this nerve was 1.9 mm. The mean length of the upper subscapular nerve from its origin to its termination into the subscapularis muscle was 5 cm and the mean diameter of the nerve was 2.3 mm. The mean length of the thoracodorsal nerve from its origin to its termination into the latissimus dorsi muscle was 13.7 cm. The mean diameter of this nerve was 2.6 mm. Our hopes are that these data will prove useful to the surgeon in surgical planning for potential neurotization procedures of the brachial plexus.     

Does the motor branch of the long head of the triceps brachii arise from the radial nerve?

Anatomy textbooks say that the motor branch of the long head of the triceps brachii (LHT) arises from the radial nerve. Some clinical observations of traumatic injuries of the axillary nerve with associated paralysis of the LHT have suggested that the motor branch of the LHT may arise from the axillary nerve. This anatomic study was performed, using both cadaver anatomical dissections and a surgical study, to determine the exact origin of the motor branch of the LHT. From the adult cadaver specimens (group I), 20 posterior cords were dissected from 10 subjects (eight embalmed, two fresh) using 3.5× magnification. The axillary nerve was followed from its onset to the posteromedial part of the surgical neck of the humerus and the radial nerve. We looked for the origin of the proximal branch of the LHT by a meticulous double anterior and posterior dissection. From the surgical group (group II), 15 posterior cords were dissected from 15 patients suffering from a C5-C6 injured paralysis, without paralysis of the LHT. During the surgical procedure, we looked for the origins of the motor branch of the LHT with a nerve stimulator. In group I, the motor branch of the LHT arose in 13 cases from the axillary nerve near its origin, in five cases from the terminal division of the posterior cord itself, and in two cases from the posterior cord 10 mm before its terminal division into the radial and axillary nerves. In no case did we find the motor branch of the LHT arising from the radial nerve. In eight cases, we found some accessory branches that arose near the principal branch. In group II, the motor branch of the LHT arose in 11 cases from the axillary nerve near its origin and in four cases from the terminal division of the posterior cord itself. The motor branch of the LHT never originated from the radial nerve. In four cases, we found some accessory branches that arose near the principal branch of the LHT. These results reveal that the motor branch of the LHT seems to originate most often from the axillary nerve. This contribution could be relevant for surgical treatment of traumatic nerve injuries.     

A rare variation of posterior cord brachial plexus branching coexisting with the intercalated ectopic muscle

During a dissection of the brachial plexus we found a rare variation of left posterior cord branching coexisting with an unusual intercalated ectopic muscle. This muscle originated from the shoulder joint capsule at the lesser tubercle on insertion of the subscapularis then pierced between the brachial plexus, enclosed by two roots of the radial nerve, and inserted into the upper part of the latissimus dorsi muscle. The variant posterior cord divided into two roots; a thin lateral and thick medial root. The lateral root gave off the thoracodorsal nerve that penetrated and also innervated the ectopic muscle. The medial root gave off five nerve branches; two upper subscapular, one lower subscapular, one axillary and one terminal branch. A terminal branch fused with the lateral root to form a loop enclosing the ectopic muscle then continued as the radial nerve. This type of variation may be useful to interpret unexplained clinical signs and symptoms and provided additional knowledge to surgeons who perform brachial plexus surgery.     

人三角肌的肌内神经分布与亚部划分及其临床意义

目的：研究三角肌肌内神经分支分布为三角肌的肌肉移植提供详尽的解剖学基础。方法：用经甲醛固定1年以内的童尸3具(3～10岁)及成人尸体2具，完整取下三角肌，采用Sihler’s肌内神经染色法观察肌内神经分支分布。结果：三角肌前、中、后亚部内的肌内神经分支分布相互独立，彼此间未见明显的神经吻合。中亚部内的肌内神经吻合较前、后亚部为密集。结论：根据肌内神经分支分布，进一步证实三角肌可分为前、中、后3个亚部。前、后亚部可单独取材用于肌移植。三角肌中亚部内的神经吻合较致密，在三角肌活动中起着重要作用，不能单独用于肌移植。     

面神经下颌缘支的应用解剖

目的了解面神经下颌缘支的正常层次解剖位置,为涉及面侧区和颌下区的美容外科手术提供临床应用解剖学资料。方法解剖33具（共66例）成人尸体标本的头颈部标本,观察了面神经下颌缘支的分支类型、走行、与面动脉的位置关系以及穿出腮腺处和与面动脉的交叉处的体表位置。结果面神经下颌缘支为1-2支,以单干型居多,约占58%,大多行于下颌骨下缘上方约占44%,行于骨下缘下方者占5%。未发现面神经下颌缘支不与面动脉交叉,位置在均下颌角下缘上、下方约0.5-1 cm范围内。面神经下颌缘支经过面动脉的浅面和深面者分别占89%和6%;面神经下颌缘支穿出腮腺处的体表位置分别在下颌角上方和下颌支后缘前方1 cm交点附近,面神经下颌缘支与面动脉交处距下颌支后缘约4 cm,距下颌骨下缘约1 cm。结论面神经下颌缘支的毗邻和行程关系较为复杂,了解其与周围结构的重要位置关系,可以减少美容外科手术因神经损伤造成下唇及口角功能障碍的发生。     

Position of the axillary nerve in the deltoid muscle.

The relationship of the anterior branch of the axillary nerve to the deltoid muscle was studied on both sides in 66 adult cadavers. The nerve runs a course on the deep surface of the deltoid muscle about 2.2 cm above the midpoint on the vertical plane of the muscle.