近侧列腕骨间关节及韧带的应用解剖学观察

目的　对近侧列腕骨间关节及部分腕部韧带的解剖组织学特性进行详细观察。 方法　对成人腕关节标本的近侧列腕骨间关节及部分韧带进行解剖学观察、测量，并进行组织学观察。 结果　舟月及月三角骨间韧带各亚区中，近侧亚区最薄弱，掌、背侧亚区较粗壮。小多角骨－第2掌骨间背侧韧带长(3.13±0.28)mm，宽(9.12±0.35)mm，厚（3.28±0.25）mm，头状骨－第3掌骨间背侧韧带长（3.45±0.15）mm，宽（11.87±0.44）mm，厚（3.03±0.29）mm。舟月骨间韧带（SLIL）掌、背侧亚区韧带纤维间含较多血管神经束，近侧亚区则为乏血管区；SLIL与月三角骨间韧带（LTIL）有较高的穿孔率。 结论　小多角骨－第2掌骨间背侧韧带及头状骨－第3掌骨间背侧韧带均可作为舟月骨间韧带背侧亚区重建的供区材料；SLIL及　LTIL按组织结构及形态可分为掌、背、近侧3个亚区；SLIL及LTIL较高的穿孔率表明腕关节造影术不能准确判断关节内韧带是否损伤。     

手腕部不同载荷状态下舟月骨间韧带应力分布分析

目的　建立腕关节三维有限元模型研究腕关节舟月骨间韧带（Scapholunate interosseous ligament,SLIL）在腕部不同运动中的应力分布。 方法　选取正常腕关节CT数据,将其导入Mimics软件构建腕关节三维有限元模型,分析腕关节不同运动方向受力时的SLIL应力分布。 结果　随背伸角度增大,SLIL应力增大,背伸角度增加到 90°时,SLIL受到最大应力为1.3787 MPa。背伸角度为 30°时,腕关节掌屈时SLIL受到的最大应力为 0.1596 MPa,掌屈角度增加到 90°时,SLIL的最大应力降低至0.2452 MPa。桡偏 25°时,SLIL受到的最大应力为0.8145 MPa,尺偏 25°时,SLIL受到的最大应力为 0.1356 MPa。腕关节做桡侧受力 20N 时,SLIL受到的最大应力为 0.4465 MPa,尺侧受力 20N 时,SLIL受到的最大应力为 0.4635 MPa。 结论　腕关节三维有限元模型可以模拟SLIL在腕部不同运动中的受力情况。腕关节背伸角度达90°时,SLIL的应力最大。做尺偏、桡偏动作时,相同偏转角度下,SLIL桡偏时最大应力是尺偏最大应力的6倍左右。     

手舟骨月骨间韧带的解剖学及临床意义

目的：俾舟骨与月明间的舟月骨间韧带的解剖学结构和分布特点，探讨其对舟月骨间关节稳定性的作用。方法：采用２２只成人尸腐朽 标本，在解剖显微镜膛月骨间韧带的大体形态、长度变化、与腔囊内韧带的关系和在舟月骨上的附着点的位置及宽度。结果：舟月骨间韧带分成掌侧部、近仙部和背侧部，其掌背侧部以致密纤维结构为主，但近侧部显示有纤维软骨样成分。此韧 和桡舟头韧带、桡舟月专带及腔背侧横韧带有关系，舟月骨间韧带对舟，     

两种治疗Ⅲb期月骨坏死术式的生物力学比较

目的 观察两种治疗Ⅲb期月骨坏死术式中腕关节桡舟、桡月关节间隙的生物力学变化,为临床治疗Kienbfck＆#39;s病提供生物力学依据.方法 选用成人新鲜冷冻上肢标本18侧,随机分为3组：正常腕关节组（A组）,舟骨、大小多角融合术组（B组）,头状骨、舟骨融合术组（C组）.在标本腕关节桡舟、桡月间隙处放置触觉压力传感器,将标本的近、远端分别固定在双轴液压材料测试系统（MTS）机上,与电脑I-scan压力测量系统连接,动态记录腕关节在中立位时各标本在100 N压力下、20 s内桡舟、桡月关节面间隙单位面积压力值.观察2种术式对腕关节桡舟、桡月关节间隙生物力学方面的影响.结果 腕关节中立位下,A组桡舟关节间负荷为（41.39 ± 6.93） N/cm2,桡月关节间负荷为（39.22±6.61） N/cm2;B组桡舟关节间负荷为（83.89±11.27） N/cm2,桡月关节间负荷为（22.55±11.27） N/cm2;C组桡舟关节间负荷为（86.45±8.10） N/cm2,桡月关节间负荷为（34.11±8.10）N/cm2.A组在腕中立位下,通过桡舟、桡月关节间隙的平均负荷十分均匀（P＞0.05）.B组和C组桡月关节间隙平均负荷均小于A组（P值均＜0.05）,而桡舟关节间隙平均负荷均明显大于A组（P值均＜0.05）,且B组桡月间隙平均负荷减少的更明显.结论 舟骨、大小多角融合术和头状骨、舟骨融合术均可使桡月间隙的受力得到明显缓解,且舟骨、大小多角骨融合术能更加有效地减轻月骨的负荷;在治疗Ⅲb期Kienbtock＆#39; s病的两种术式中,舟骨、大小多角融合术优于头状骨、舟骨融合术.     

带血管蒂头状骨移位替代月骨的应用解剖

目的：设计一种治疗晚期月骨无菌性坏死的手术方法。方法：对５０侧上肢标本解剖观测腕部血管的构成、走行、分支和腕骨的血供；对１００侧腕头状骨和月骨的外径、关节面的弧高、弧长，进行对比观测，经统计学处理。结果：头状骨和月骨的外径和关节面的弧高、弧长极其相近；头状骨血供以背侧为主，骨间掌侧动脉背侧支通过腕背动脉网可供给其充足的血运。结论：可以骨间掌侧动脉背侧支为蒂设计头状骨移位替代月骨，术式符合腕关节的功能解剖和生物力学传导，是治疗晚期月骨无菌性坏死的一种有效方法。     

新型导向器用于经皮螺钉固定治疗舟状骨骨折

背景：舟状骨骨折是临床上常见的腕部骨折，主要采用经皮螺钉治疗，首先闭合复位骨折端，然后将空心加压螺钉精准置于舟状骨轴心并加压固定骨折端，能够促进骨折愈合，使腕关节获得良好功能。目的：评价一种新型克氏针导向器辅助经皮空心加压螺钉治疗舟状骨骨折的临床疗效。方法：回顾性分析2015年1月至2020年12月河北医科大学第三医院手外科收治的15例舟状骨骨折患者的临床资料。所有患者均采用新型导向器辅助经皮空心加压螺钉固定治疗。统计患者的骨折愈合时间、手术时间、透视次数、重返工作的时间及并发症。术后12个月采用改良Mayo腕关节评分对腕关节功能进行评估，测量患侧及健侧腕关节掌屈、背伸、尺偏、桡偏活动度及握力。结果与结论：所有患者均完成了12个月随访。术后X射线片示：空心压力螺钉位于舟状骨轴心位置。所有舟状骨骨折均获骨性愈合，平均愈合时间10.0周。手术平均历时55.7 min，术中平均透视次数10.9次，平均10.3周重返工作岗位。腕关节功能：优9例，良5例，可1例，优良率93.3%。患侧及健侧的腕关节掌屈、背伸、尺偏、桡偏活动度及握力相比较，差异无显著性意义(P> 0.05)。所有患者均未发...     

手法复位+经皮Herbert钉内固定治疗经舟骨月骨周围脱位

目的探讨手法复位+经皮Herbert钉内固定治疗经舟骨月骨周围脱位的疗效。方法回顾性分析自2009年3月~2013年6月18例经舟骨月骨周围脱位病例,均为背侧型脱位,臂丛麻醉下手法复位成功,经皮Herbert钉内固定舟骨骨折,术后采用腕舟骨支具外固定4周,然后行腕关节屈伸及旋转锻炼。术后每月定期随防行X光片检查评估骨折愈合情况,用Cooney评分标准评估腕关节功能,VAS评分评估腕关节疼痛并测量腕关节活动度及手的握力。结果本组18例患者获8~40月随访,平均34月,临床疗效满意。所有患者舟状骨均骨性愈合,时间2~8个月,平均3.6个月,采用Cooney评分标准,优9例,良9例。VAS评分结果:0分11例,1~3分5例,4~6分2例;腕关节掌屈40°(30~60°)、背伸平均57°(25~85°),分别为健侧的75%和80%;握力平均值为健侧的75.3%;13例患者恢复原工作岗位,5例重体力劳动患者更换工种。结论手法复位+经皮治Herbert钉内固定是治疗经舟骨月骨周围脱位的一种良好的方法。     

极限运动对舟-大-小多角骨融合体早期稳定性的影响

目的探讨极限运动对舟骨-大-小多角骨(Scaphotrapeziotrapezoid,STT)融合体稳定性的影响。方法6具新鲜尸体前臂标本,所有腕关节均先建立舟月骨分离并行STT融合术,在安全活动范围内从0o开始,每5o一个等级,每个等级分别作5万次屈、伸、尺偏和桡偏运动,每次运动前后均摄标准前后位及侧位片,测量舟骨长度、桡舟间距、桡舟角及克氏针松动、弯曲阳性率。所有腕关节均采用运动前后自身对照。结果当屈曲至50o、背伸至35o、桡偏至5o时,极限运动对融合体的稳定性无影响,未出现融合体解体,克氏针弯曲等征象。当屈曲至55o、背伸至40o、桡偏至10o时,融合体的稳定性开始受到影响,此时桡舟角、舟骨长度、桡舟间距及克氏针弯曲阳性率与对照组相比,均有统计学意义(P<0.05)。而尺偏运动过程中,融合体的稳定性始终未受到影响,上述各项指标的变化均无统计学意义(P>0.05)。结论腕关节在掌屈55o、背伸40o、桡偏10o范围以内活动时,融合体的稳定性无影响,但应避免环转运动。     

月骨滋养动脉应用解剖学研究及其临床意义

目的通过对手腕部血管进行灌注,研究月骨滋养动脉与月骨缺血性坏死之间的联系,为临床更好地预防、诊治月骨缺血性坏死提供依据。方法选用成人新鲜上肢标本8例,进行以下试验:(1)前臂血管灌注:在前臂近端断面解剖分离出肱动脉断端,将已经磨顿圆的针头插入肱动脉断端3~4 cm,冲洗血管内淤血,过氯乙烯乙酸乙酯溶液混合氧化铅填充剂分别隔2 h、4 h、6 h、8 h各补充灌注1次,灌注结束将标本置于4℃冰柜冷存24 h后,CT观察月骨滋养动脉分布情况。(2)尸体解剖:显微镜下解剖游离桡动脉发出的腕掌支,然后暴露尺动脉并向远侧追踪尺动脉掌深支,继续探查尺动脉末端与桡动脉掌浅支吻合成的掌浅弓,并拍照记录。解剖前臂背侧:显露掌背皮动脉及腕背浅层血管网,游离行走于其内的桡动脉,并向远端追踪其走行,显露桡动脉腕背支、尺动脉腕背支、骨间前动脉腕背支。(3)肉眼观察月骨血管孔的分布、数量,并测量血管孔的口径。标本主要血管解剖完成并且拍照后,根据滋养孔大小、位置分别做好记录以备数据整理及统计学分析。结果 (1)月骨的血供来源于腕掌、背侧动脉网。掌侧的动脉是月骨的主要血供来源;(2)月骨与周围腕骨多是关节软骨相接触,缺乏骨膜和肌腱附着,其血液供应主要依靠腕前韧带的滋养血管;(3)月骨掌侧面血管孔数为(2.13±1.13)个,背侧面为(2.00±0.76)个。结论 (1)月骨掌侧面大、中孔相对较多,背侧面小孔较多,且掌侧面血管孔多数分布于内侧区;(2)月骨骨折线越靠近掌侧极,其发生缺血性坏死可能性越高;(3)月骨骨折行切开复位内固定术时需避开月骨掌侧面内侧区。     

舟骨及月骨的滋养孔观察

利用50副完整成人骨骼标本观察100例舟骨及月骨的滋养孔情况;发现舟骨滋养孔最多集中在其腰部的背面,其次是在腰部的掌面,舟骨结节上也存有滋养孔存在,滋养孔平均最多数是在其腰部的中间部、月骨滋养孔最多处在其背面的远侧部,滋养孔最少处是在其背面的近侧部.     

Can palmar creases serve as landmarks for the deeper neuro-vascular structures?

Purpose

The aim of this study was the examination of the superficial anatomy of palmar creases and their relation to deeper neuro-vascular structures.

Methods

Four creases: distal wrist flexion crease, thenar crease, proximal palmar crease and distal palmar crease were evaluated with reference to the following structures: palmar cutaneous branch of median nerve, palmar cutaneous branch of ulnar nerve, the nerve of Henle, transverse palmar branches from ulnar nerve, recurrent motor branch of median nerve, radial proper palmar digital nerve to the index and the ulnar proper palmar digital nerve to the thumb, Berrettini’s communicating branch, ulnar nerve and artery, superficial palmar arch. We performed dissections of 20 cadaveric upper limbs derived from a homogenous Caucasian group. In our study we measured the location of surgically important structures with reference to palmar skin creases.

Results

Among the other observations we noticed that the palmar cutaneous branches of the median and ulnar nerves were located at least 0.5 cm away from the thenar crease. The superficial palmar arch was found between the thenar and proximal palmar crease and never crossed the proximal or distal palmar creases.

Conclusions

These anatomical dissections will provide reference material for further ultrasound studies on the arrangements of neuro-vascular structures in reference to superficial palmar creases.     

微创治疗桡骨远端骨折安全进针区域的解剖学研究

目的　测量桡骨茎突在腕关节不同角度时与周围肌腱、血管的距离,探讨手法复位经皮闭合穿针内固定术微创治疗桡骨骨折经桡骨茎突的相对安全进针区域。 方法　20侧成人前臂标本,以腕部外固定支架固定腕部,分别在腕关节掌屈0°、20°、40°、60°和尺偏0°、30°等8个位置,测量桡骨茎突最高点与桡侧腕长伸肌腱、拇短伸肌腱的最短距离,桡骨茎突最高点与桡侧腕长伸肌腱、拇长伸肌腱、拇短伸肌腱、桡动脉各交点的距离。 结果　腕关节掌屈、尺偏运动引起桡骨茎突周围肌腱相对位置规律性地变化,腕关节在尺偏30°掌屈0°~20°范围内时,桡骨茎突的相对安全进针区域最大。 结论　以桡骨茎突最高点为体表标志,当腕关节在尺偏30°掌屈0°~20°范围内,桡骨茎突最高点周围一定距离范围内,经皮克氏针固定桡骨骨折,能最大限度降低对肌腱及血管的损伤率。     

Muscle variations and abnormal branching and course of the ulnar nerve in the forearm and hand

During dissection of the right forearm of a 27-year-old female cadaver, variations in the form and insertion of the palmaris longus muscle were observed. The tendon of the palmaris longus muscle, which demonstrated a centrally placed belly, split into two tendons: one inserted into the palmar aponeurosis and the other into the proximal part of the flexor retinaculum. Additionally, we found an accessory muscle extending between the flexor retinaculum and the tendon of the abductor digiti minimi muscle. This accessory muscle was located deep to the ulnar artery but superficial to the superficial and deep branches of the ulnar nerve at the wrist. Finally, an aberrant branch of the ulnar nerve was identified in the forearm; it traveled distally alongside the ulnar artery and in the palm demonstrated communications with common palmar digital nerves from the ulnar and the median nerves. No variations were observed in the contralateral upper limb.     

General innervation pattern and sensory corpuscles in the scapholunate interosseous ligament

The scapholunate interosseous ligament (SLIL) is biomechanically important in maintaining wrist motion and grip strength in the hand, but its possible sensory role in the dynamic muscular stability of the wrist joint has not been examined. The aim of this study was to use immunohistochemical methods to analyze the general innervation and the possible existence of sensory corpuscles in the SLIL. The ligament was excised in its entirety from 9 patients. Antibodies against the low-affinity p75 neurotrophic receptor (p75) were used to reveal sensory corpuscles as well as general innervation. Furthermore, antibodies against the general nerve marker protein gene product 9.5 (PGP 9.5) and the glial marker S-100 were used to additionally depict innervation and corpuscular structures. Blood vessels occurred in areas interspersed throughout the homogeneous collagenous structure. In these vascularized areas, the SLIL was found to be supplied with nerve fascicles and sensory corpuscles of both the Ruffini and lamellated type. p75 immunoreactivity (IR) was detected in association with the nerve fascicles and the corpuscles, particularly in their capsule. S-100 IR was found in the Schwann cells in the central regions of the corpuscle, and PGP 9.5 IR marked the axonal structures in the corpuscles. New information on neurotrophin receptor distribution in ligaments has been obtained here. The presence of nerve fascicles and particularly sensory corpuscles in the SLIL suggests that the ligament has a proprioceptive role in the stability of the wrist. The marked p75 IR further indicates that neurotrophins play a part in a proprioceptive system in the ligament, given the importance of neurotrophins in maintaining sensory function.     

MIPO治疗掌侧Barton骨折

目的 观察微创接骨板固定技术(MIPO)治疗掌侧Barton骨折的近期临床疗效。方法 对2016年1月至2018年8月收治的22例掌侧Barton骨折患者,男9例,女13例,年龄30～68岁,平均56岁,术前掌倾角13.6°±4.1°,尺偏角15.7°±2.8°,均采用桡骨远端掌侧纵行小切口闭合复位微创接骨板固定技术置入锁定钢板手术治疗。结果 随访6～18个月(平均12个月),骨折均愈合,术后1个月复查X线片掌倾角10.3°±3.2°,尺偏角20.5°±4.6°,与术前比较差异具有统计学意义(P0.01)。腕关节功能按照Gartland-Werley功能评估标准:优16例,良4例,可2例,优良率90.9%。结论 采用MIPO治疗掌侧Barton骨折,复位固定牢靠,能早期功能锻炼,创伤小,临床效果良好。     

Variation of the ulnar variance with powerful grip

Causal relationships between ulnar variance and wrist disorders are known. Gripping and pronation cause proximal translation of the radius with respect to the ulna, leading to a statistically significant increase in ulnar variance. The purpose of this study was to investigate variation of the ulnar variance with powerful grip. A total of 41 male volunteers aged between 19 and 25 years (mean, 21.2+/-1.7 years) were studied. Posteroanterior X-ray films of all wrists were taken in the standardized position. After neutral posteroanterior X-ray films had been taken, subjects were asked to grip a Takei hand dynamometer with maximum force while repeated standardized posteroanterior X-ray films were obtained. Ulnar variance values were measured using the perpendicular method. Mean maximum grip force was 38.1 kg (range, 26.6-47.9 kg). Mean values of force-free (neutral) and forced ulnar variances were 0.06+/-0.21 mm and 1.87+/-0.23 mm, respectively. The difference in ulnar variance between the two groups was statistically significant ( P<0.001). The increase in ulnar variance with grip observed varied between 0.00 mm (minimum) and 3.97 mm (maximum), with a mean of 1.81 mm. Gaining an understanding of normal limits of ulnar variance modification with grip may be helpful in planning surgical treatment.     

Multiple arterial variation of the human upper limb

A case report of multiple variations involving the arteries of the upper limb in a single cadaver is presented. In addition to the proximal origin of the arteries unusual arterial patterns on both the right and left sides were present. On the right side, the subscapular artery gave rise to a large posterior circumflex humeral artery in addition to the thoracodorsal and circumflex scapular arteries. On the left side, the radial and ulnar arteries arose from the brachial artery at the level of arm, with their origins being opposite to the usual arrangement. There was an arciform anastomosis between the radial and ulnar arteries, with the radial recurrent artery arising from the concavity of the arch. The course of both the radial and ulnar arteries was normal at the wrist and hand, except for the absence of the first palmar metacarpal artery and an early bifurcation of the second palmar metacarpal artery. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0011.