前臂及腕部软组织功能重建中逆行肱桡肌皮瓣的应用解剖特征

目的：观察前臂及腕部软组织功能重建中逆行肱桡肌皮瓣的应用解剖特征，为设计逆行肱桡肌皮瓣提供解剖学依据。方法：实验于2002—03／2003—02在吉林大学第一医院手外科研究室完成。通过解剖20侧新鲜成人上肢标本（男16侧，女4侧，左右各半，家属知情同意）。①通过红色乳胶灌注后，分别测量肱桡肌的肌腹、肌腱的长度、宽度、厚度。②解剖并测量桡侧副动脉、桡侧返动脉及桡动脉向肱桡肌发出的肌支，观测上述组3组血管的起止、走行、外径、长度及进入肱桡肌的位置。③在手术显微镜下放大10倍，沿桡侧副动脉、桡侧返动脉及桡动脉向肱桡肌发出的肌支向肌内解剖，观察上述肌支在肱桡肌内的吻合情况。结果：①肱桡肌形态：肱桡肌是前臂桡侧最表浅的肌肉，起于肱骨外上髁上方及外侧肌间隔，止于桡骨茎窝基底，为一长而扁的梭形肌。②肱桡肌营养血管：肱桡肌由桡动脉发出的桡侧副动脉、桡侧返动脉及桡动脉直接肌支等供血。③肱桡肌肌内显微解剖：桡侧副动脉主要营养肱桡肌的中上部，其肌内分支与远侧桡侧返动脉发出的肌内分支在肱桡肌内形成广泛吻合，并具有明显吻合弓，同时其肌皮动脉在肱桡肌表面垂直穿出，供应其表面皮肤血运；桡侧返动脉是营养肱桡肌中下部的的主要血管，分为升支、横支及降支，在肌内除与桡侧副动脉分支有广泛吻合并发出皮支外，还与远侧的桡动脉肌支有广泛的吻合，在肌内形成明显的吻合弓，相互代偿，重叠供血。结论：①解剖学观测发现肱桡肌具有多重血供，其主要血管在肌内有广泛吻合，重叠供血，相互代偿，为设计逆行肱桡肌皮瓣奠定了解剖学基础。②设计了以桡侧返动脉及桡动脉肱桡肌肌支为蒂的逆行肱桡肌皮瓣，为前臂和腕部软组织修复及肌肉重建提供了一种新的手术方法。     

前臂背侧远端动脉穿支显微解剖与前臂后皮神经营养血管移植皮瓣的设计

背景:前臂后皮肤很适合手背侧修复,但对前臂后皮神经营养血管皮瓣的远端蒂动脉穿支缺少具体可操作性的研究,临床实际应用起来还较为困难。目的:研究前臂背侧远端的动脉穿支,为前臂后皮神经营养血管远端蒂皮瓣、复合瓣的合理设计提出解剖学理论。设计:单一样本观察。单位:解放军南京军区福州总医院军区骨科研究所临床解剖学研究中心材料:实验于2004-05/10在解放军南京军区福州总医院军区骨科研究所临床解剖学研究中心实验室完成。研究材料为33侧动脉灌注红色乳胶成人上肢标本(由南京军区福州总医院军区骨科研究所临床解剖学研究中心提供)。方法:将33侧经成人上肢标本,以尺、桡骨茎突为观测标志点进行显微解剖。主要观察指标:①前臂背侧远端的动脉穿支。②前臂后皮神经远端的营养血管。③营养血管与邻近肌、骨、皮的血供关系。结果:①以指总伸肌为中心,前臂背侧远端的动脉穿支主要循其两侧的肌间隙和腱间隙穿出,构成远端外侧与内侧2条纵向的吻合筋膜血管丛:即前臂背外侧血管丛,以外侧肌间隙为轴线,由骨间前动脉腕背支的外侧终支、桡侧骨皮穿支、骨间后动脉的桡侧骨皮穿支和桡动脉腕背支及其穿支组成;前臂背内侧血管丛:以内侧肌间隙为轴线,由骨间前动脉腕背支的内侧终支、尺侧骨皮穿支、骨间后动脉的尺侧骨皮穿支和尺动脉腕背支及其穿支组成。②上述动脉穿支发皮支、筋膜支和前臂后皮神经营养血管,形成皮神经干血管链以及深、浅筋膜血管网。骨间后动脉的肌骨膜支分布尺骨骨膜,其桡侧骨穿皮支与桡骨中下段裸区的骨膜血管吻合,是构成远端蒂复合瓣的解剖学基础。结论:前臂背侧远端的血供具有多源性、明显纵向性和营养血管同源性的解剖学特点,可以设计3种不同供血的前臂后皮神经营养血管远端蒂皮瓣或复合瓣,旋转轴点可达腕关节平面,适宜手背远侧的组织缺损修复。     

副神经的应用解剖及斜方肌的功能重建

副神经为胸锁乳突肌和斜方肌的主要支配神经早已为学术界所公认,但在颈丛神经是否也参与斜方肌的运动支配及两者对斜方肌支配的具体部位等问题上仍存在颇多争议.创伤、根治性颈淋巴清扫术等原因可致副神经损伤和连续性中断,引起一系列肩部综合征,影响患者的生活质量.目前重建斜方肌功能的手术方式很多,如神经的端端吻合,游离神经移植,神经移位移植等.对于可直接施行无张力吻接的病例,修复治疗的效果较为满意,但对于缺损长度较大的副神经损伤,创伤小且疗效确切的手术治疗方式尚不多见.     

椎动脉起始段的显微解剖及临床意义

【目的】积累椎动脉形态学资料 ,为临床治疗提供解剖学基础。【方法】15具成人尸体标本 ,解剖观察椎动脉起始段形态 ,测量椎动脉长度、外径。【结果】椎动脉起始段全部走行于斜角肌椎体三角内 ,左侧椎动脉外径 (4 .0 4± 0 .4 4 )mm ,右侧 (3.6 7± 0 .78)mm ;椎动脉进入C6横突孔者 2 8支 ,进入C5横突孔者 2支 ;椎动脉起始段分为弯曲型 (17支 )和平直型 (13支 )。【结论】椎动脉起始段存在较大变异 ,术前详细的血管造影极为必要 ;对于椎动脉起始段的粥样硬化 ,血管重建比内膜切除术安全、简单。     

椎动脉第三段及枕下区的显微外科解剖

目的积累椎动脉第三段的形态学资料,为临床应用提供解剖学依据。方法15例(30侧)成人尸体标本,解剖观察椎动脉第三段形态及枕下区结构,测量椎动脉和枕动脉长度、外径。结果椎动脉第三段有明显而连续的多个弯曲,椎动脉第三段全长(55.77±10.02)mm,枕动脉长(86.51±11.06)mm,与椎动脉距离(15.36±0.75)mm。结论椎动脉第三段的连续弯曲可适应头颈部复杂的运动,椎动脉第三段的显露常采用侧方入路,偶尔可采用颈前入路。显露椎动脉第三段可进行血管结扎、内膜切除和血管重建操作。枕下区有如下解剖标志:上枕下三角和颈1神经后支,下枕下三角和颈2神经前支,颈1横突,颈1后弓,椎静脉丛。     

阴股沟移植皮瓣的应用显微解剖学基础

目的:明确阴股沟移植皮瓣的动脉、静脉及神经的显微解剖基础。方法:实验于2004-04/09于解放军第二军医大学解剖教研室完成。取成人尸体11具,男性6具,女性5具,均为捐献遗体。模拟临床皮瓣切取方式,对22侧成人尸体阴股沟皮瓣区包含的血管、神经进行观测,并进行深部组织解剖,追溯血管、神经来源并记录。结果:阴股沟区动脉血液供应充足,静脉回流丰富,具有丰富的血管吻合网,位置比较恒定,动脉尤以阴部外动脉最为恒定。神经来源及支配区域较恒定。结论:阴股沟移植皮瓣血运丰富,解剖简便易行,切取方便,供区隐蔽,是一种值得推广的方法。     

盆底自主神经丛的解剖及临床意义

笔者通过对48具成人盆部标本解剖学观察，旨在了解盆底神经丛及其分支的解剖学结构和位置走向，为临床直肠癌根治手术提供科学依据，避免术中误伤其他组织。 1材料和方法 1．1材料取48具经过10％甲醛防腐固定的成人盆部标本（男30例，女18例），质地良好，外观无畸形。     

人膝关节前、后交叉韧带解剖研究及临床意义

【目的】对国人前交叉韧带(ACL)、后交叉韧带(PCL)的解剖结构进行观察研究,掌握更为详细的解剖资料,为临床治疗提供参考。【方法】对42例人膝关节标本的交叉韧带进行观察,测量其长度、宽度和厚度以及附着区的形态;应用显微外科技术对14具新鲜冷冻PCL标本进行解剖,并行组织学观察,掌握其微观结构,其结果与国外文献资料比较。【结果】国人PCL长31.0~37.0(33.8±1.3)mm,两端粗大,最窄处位于中间。ACL长25.0~36.0(29.6±1.1)mm,前、后交叉韧带均为不可分割的完整韧带,由许多纤维组成并发生扭转,纤维束相互穿插融合。病理切片示PCL近端和远端纤维分布松散,中段紧密。【结论】前、后交叉韧带是完整的韧带,对维持膝关节稳定有一定作用。国人交叉韧带长度可能短于西方人。     

创伤修复中桡神经深支前臂段深层肌支自身比例的定位

目的:观察桡神经肌支自身比例定位关系,为前臂部创伤修复及肌瓣移植提供形态学依据.方法:实验于2003-01/2004-12在暨南大学医学院人体解剖学实验室完成.采用解剖剥离测量方法,对25具(共50侧)成人上肢标本桡神经深支发出的前臂后区深层肌支进行自身比例定位分析.结果:①桡神经深支发出的各肌支以1支型出现率最多.②桡神经深支发出的各肌支集中于上肢的6段.③桡神经深支发出的各肌支进入各肌门的区位,均有倾向于以神经干为轴心近距离分布的规律.结论:确定了桡神经深支肌支的危险区段和危险区位,有利于开展带神经血管蒂肌瓣移植时肌支类型的选择.     

带蒂超长下斜方肌肌皮瓣修复头颈部组织缺损

目的报道诺蒂超长下斜万肌肌皮瓣修复头颈部组织缺损。方法在对斜方肌及其血供进行显微外科解剖学研究的基础上利用颈横动脉浅降支为蒂设计超长下斜方肌肌皮瓣,其远端可达肩胛下角下17cm处,单侧皮瓣最大面积为36cm×13cm,双侧皮瓣总面积可超过700cm2,皮瓣转移可覆盖颅项、颌面及颈部缺损。结果临床应用修复头颈部组织缺损8例,其中2例采用双侧肌皮瓣转移,10块皮瓣均完全成活。结论超长下科方肌肌皮瓣是修复头颈部组织缺损的较好方法。     

Perforator-based reverse radial forearm flap to reconstruct multiple third-degree burn defects of the fingers.

Adequate soft-tissue coverage is a cornerstone for successful hand reconstruction in burn patients allowing for hand mobilization and rehabilitation. Multiple finger injuries that involve separate soft-tissue defects with complex wounds challenge the reconstruction dilemma. In this case report, a modified application of reverse radial forearm flap for the simultaneous reconstruction of multiple separate finger defects for burn cases is presented. A 23-year-old heavy industry worker is presented with a history of third-degree electrical burn of left index and middle fingers. The proximal interphalangeal (PIP) joint of the both fingers were exposed. A distally based radial forearm flap with a dimension 7.5 x 6 cm was planned. The flap was transposed to the distal defect and splitted. The bilobed flap was inset. A tendon graft is used to span the gap of extensor apparatus before insetting the flaps in both fingers. The donor defect was closed primarily. A satisfactory coverage is observed in the recipient areas. Finger functions including full range of motion of the metacarpophalangeal and PIP joints of the index and PIP and distal interphalangeal joints of long fingers were observed. The technique presented here is advantageous as it is easy to perform, covers multiple finger defects simultaneously, avoids long-term immobilization, saves the operative time, avoids microsurgery. Donor site is closed primarily and finally this approach ensures a simultaneous repair of complex wounds with multiple vital anatomical structures i.e. bone, tendon, joint, and soft tissue.     

Role of the wrist cuff in forearm plethysmography.

1. To determine whether a wrist cuff is necessary to measure the forearm blood flow correctly, we studied the effects of wrist cuff inflation to supra-venous and supra-systolic pressure values over a large range of forearm blood flow values: in the basal state, during post-occlusive hyperaemia of the hand, and during heating of the hand with warm air. Eleven healthy men participated, and the study was carried out at two different ambient temperatures of 20 and 25 degrees C. 2. In the basal state, the measured forearm blood flow was lowest with the wrist cuff at supra-systolic pressure. With the wrist cuff at supra-venous pressure the forearm blood flow was also lower than with an uninflated cuff, but only significantly so when the basal forearm blood flow was higher (at a room temperature of 25 degrees C). 3. During post-occlusive hyperaemia, inflating the wrist cuff to supra-systolic pressure produced the lowest forearm blood flow value at both room temperatures. In addition, with the wrist cuff at supra-venous pressure, forearm blood flow values were lower than with the uninflated cuff, but the supra-venous cuff pressure was clearly less efficient in excluding the hand blood flow than the supra-systolic cuff pressure. 4. During heating of the hand, both supra-systolic and supra-venous cuff pressures were effective in excluding the hand blood flow at both room temperatures. The forearm blood flow measured with the wrist cuff at supra-systolic pressure was lower than that measured with the wrist cuff at supra-venous pressure, but the difference was only significant at a room temperature of 20 degrees C. 5. In conclusion, we have demonstrated that a wrist cuff at supra-systolic pressure is most appropriate for the exclusion of the hand circulation in order to measure the forearm blood flow correctly.     

拇展肌肌皮瓣修复足跟恶性黑色素瘤软组织缺损的临床应用

目的探讨拇展肌肌皮瓣修复足跟恶性黑色素瘤软组织缺损的临床疗效。方法采用带血管神经蒂的拇展肌肌皮瓣修复足跟部恶性黑色素瘤广泛切除术的软组织缺损18例,其中伴有溃疡出血者7例。皮肤缺损面积(2～6)cm×(5～9)cm,肌皮瓣切取面积(4～8)cm×(7～11)cm,深层拇展肌肌肉面积3cm×7cm,供区均采用中厚皮片游离植皮,并进行随访。结果术后18例肌皮瓣完全存活,创面Ⅰ期愈合;随访时间7～36个月,平均25个月,局部无复发;肌皮瓣质地优良,外观满意,未出现行走异常,皮肤感觉恢复良好。结论拇展肌肌皮瓣血液供应可靠,转移方便,是修复足跟部位恶性黑色素瘤广泛切除软组织缺损的良好选择。     

The recovery characteristics of soft tissues following repeated loading

Pressure relief at the patient support interface is important to avoid tissue breakdown by ischemia, particularly with debilitated subjects. However, there are still few guidelines to indicate the level of relief required for specific tissue areas. This paper examines the nature of the tissue recovery to repeated loading in compression. Loading was produced by (1) external application using an experimental system attached to the sacrum and (2) ischial support on a dynamic cushion. In both cases, the interface pressures applied for a prescribed time were related to changes in transcutaneous gas tension, the latter being an index of tissue viability. Results indicate two distinct responses to repeated loading. The normal response provides rapid and complete tissue recovery to unloaded values of transcutaneous oxygen tension. This was observed with all normal subjects and some of the debilitated subjects. There was also a group of debilitated subjects who demonstrated impaired and delayed tissue recovery. It is proposed that they are at most risk of developing tissue breakdown.     

逆行第二掌背动脉皮瓣及肌腱皮瓣修复手指皮肤软组织缺损27例

目的:观察应用逆行第二掌背动脉皮瓣、肌腱皮瓣修复手指皮肤软组织缺损的临床效果.方法:1994-2008年,共采用逆行第二掌背动脉皮瓣或肌腱皮瓣修复手指皮肤软组织缺损27例.其中合并伸指肌睫缺损6例,男21例,女6例,年龄17～34岁,平均27岁.结果:术后随访1～24个月,平均6个月,27例皮瓣中23例全部成活,1例坏死,3例远端皮缘坏死,伤指外形及功能满意.结论:第二掌背动脉逆行皮瓣操作是修复手指皮肤软组织缺损或合并伸指肌腱缺损的理想方法,操作简单,成活率高,损伤小.     

Measurement of angular wrist neutral zone and forearm muscle activity

OBJECTIVES: To determine the forearm muscles activity in different wrist deviated positions and wrist neutral zone, and to assess the self-selected resting position without visual feedback. BACKGROUND: Wrist deviation occurs in almost all industrial and office jobs. This has been deemed hazardous for carpal tunnel syndrome. Proper resting wrist position is likely to decrease the hazard for carpal tunnel pressure. METHODS: Twenty blindfolded subjects without history of hand/forearm musculoskeletal disorders participated in the study. The EMG of the forearm muscles (flexor carpi radialis, flexor carpi ulnaris, extensor carpi radialis and, extensor carpi ulnaris) in deviated and neutral wrist postures was recorded at a sampling rate of 1 kHz. Also, wrist neutral zone at rest was measured using a custom-made calibrated uniaxial electrogoniometer. One-way ANOVA with repeated measures was used in order to find the impact of wrist deviation on muscles activity. RESULTS: The participants positioned their wrist in rest at 7 degrees -9 degrees extension and 5 degrees -7 degrees ulnar deviation. Significantly higher EMG activity was recorded for each muscle in the wrist deviated postures when compared to neutral position (P < 0.001). CONCLUSIONS: Self selected wrist neutral posture decreased the muscle activity significantly. Placement of wrists in neutral zone is expected to reduce risk of injuries.     

下斜方肌肌皮瓣解剖学特点及在头面颈部缺损修复中的移植应用前景

下斜方肌肌皮瓣移植的临床应用广泛,尤其是超长下斜方肌肌皮瓣移植大大扩展了其临床应用范围.斜方肌有多支营养血管,下斜方肌的主要营养血管是颈横动脉浅降支和颈横动脉深支,位置恒定,解剖简单.副神经是斜方肌的支配神经,下斜方肌肌皮瓣的切取一般不会损伤副神经.下斜方肌肌皮瓣的临床应用灵活,可以设计成超长下斜方肌肌皮瓣,扩大其临床应用范围.下斜方肌肌皮瓣血流动力学的研究有"超灌注学说"和"血管网学说",但其可切取的末端位置还不明确.下斜方肌肌皮瓣的适应证及优缺点可以指导临床应用.随着血流动力学的进一步研究,下斜方肌肌皮瓣必将有广阔的临床应用前景.