桡神经臂段卡压的解剖学基础

目的　研究桡神经臂段卡压综合征的解剖学因素 ,为临床诊治该病提供形态学依据。方法　对 2 0具 40侧成人上肢标本 ,肉眼观察桡神经在臂段的行径及其与周围结构的毗邻关系 ,并用游标卡尺测量数据。结果　 10 0 %的肱三头肌外侧头起始腱性部分紧贴桡神经 ,且 72 .5 %的腱性部分形成纤维弓 ,穿过该纤维弓时桡神经的周径为 [(0 .93± 0 .14 )cm , x±s,下同 ]。 77.5 %的外侧肌间隔有腱性组织包绕桡神经。 3 7.5 %的肱深动脉于肱骨内外上髁连线中点上方 (16.5 2± 1.2 4)cm处横跨桡神经。 3 5 0 %的肱肌和肱桡肌之间的纤维弓和桡神经直接接触。 7 5 %的肱肌腱性部分从前方压迫桡神经 ;2 5 %桡神经受到肱三头肌长头腱性部分的卡压 ,受压处神经变细。结论　桡神经在上臂行径中多处可受到卡压 ,卡压可来自多个方向 ,术中应尽可能松解已经存在和潜在的卡压结构。     

经皮电刺激促进桡神经损伤后神经再生的临床研究

目的 探讨经皮电刺激对上臂桡神经完全损伤后神经再生的促进作用,并对电刺激的参数、波形进行优化组合,以寻求最佳治疗方案.方法 对28例上臂段桡神经完全损伤患者,随机分为电刺激组和对照组,每组14例,在行桡神经缝合术后,各组同时服用神经营养药物治疗,电刺激组在术后4～6周石膏拆除后加用电刺激治疗.第1个月使用方波治疗,脉冲频率为2 Hz;第2个月使用变幅脉冲波治疗,脉冲频率为15 Hz;第3个月起继续使用变幅脉冲波治疗,脉冲频率为15Hz,同时每次附加肌肉训练波,脉冲频率为60 Hz;之后均使用变幅脉冲波+肌肉训练波,并适度增加肌肉训练波的治疗时间.术后随访内容:伸腕、伸指肌力,神经电生理检测.结果 电刺激组的临床伸腕、伸指肌力与肌电图结果均优于对照组,两组差异有统计学意义(P＜0.05).电刺激组的肌力恢复时间与肌电图恢复时间也明显短于对照组,两组差异有统计学意义(P＜0.05).结论 经皮电刺激治疗对促进上臂段桡神经损伤后神经再生的效果明显,在对电刺激仪的工作参数、电流波形进行优化组合后,可获得良好的疗效.     

Musculocutaneous nerve entrapment in the upper arm

Summary Wasting and weakness of the biceps and brachialis muscles can occur when the musculocutaneous nerve is compressed as it passes through the coracobrachialis muscle; there may also be impairment of sensation on the lateral aspect of the forearm. In our patient, symptoms appeared after strenuous exercise which included more than 500 pressups each day. Electromyography and telethermic examination confirmed the diagnosis. He was advised to stop his strenuous exercises and within 3 months muscle strength and sensation had returned.

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Résumé Le nerf musculo-cutané peut être comprimé lors de son passage dans le muscle coracobrachial. Les manifestations de l'atteinte du nerf sont longtemps discrètes mais la force musculaire du biceps et du brachial antérieur est diminuée de même que le réflexe bicipital. Un déficit sensitif est retrouvé à la face antéro-externe de l'avant-bras. Chez notre malade les symptômes sont apparus à la suite d'un entraînement intensif, comportant plus de 500 contractions par jour. L'EMG du membre supérieur mettait en évidence des anomalies au niveau du biceps et du brachial antérieur. Un examen téléthermographique montrait une hyperthermie de l'avantbras dans la zone innervée par le rameau cutané antibrachial externe du nerf musculo-cutané. L'arrêt de l'entraînement, le repos et une reprise progressive de l'activité ont été un traitement efficace. En l'espace de trois mois, le volume et la force des muscles ont été récupérés, ainsi que la sensibilité de l'avant-bras.

     

The treatment of distal upper arm fractures

The treatment of fractures of the distal humerus is very well standardized. The classification according to Müller allows for easy differentiation between the many types of fractures, helps in the determination of therapeutic guidelines and contributes to an objective comparison of results of treatment. Fractures in group A/B are treated either conservatively or with comparatively simple instrumentation using K-wires, screws, and plates. Injuries falling in group C demand a high standard of operative skill. The underlying principle of internal fixation aims primarily at reconstruction of the articular surface. The next operative step consists in the realignment of the reconstructed articular block with the proximal humeral fragment by osteosynthesis. Autologous cancellous bone is used to give a solid counterbalance for screw fixation and to re-establish osseous continuity. Sound assessment of concomitant injury to the soft tissue demands wide clinical experience. This is necessary for essential decision as to whether primary osteosynthesis, delayed, secondary reconstruction of the joint following recovery of the soft tissue or conservative treatment is indicated.     

Spontaneous bilateral median nerve compressions in the distal arm

A case of bilateral median nerve compressions in the distal arm is described. The patient was seen initially with the spontaneous onset of paresis of the anterior interosseous nerve innervated muscles, as well as more proximal median nerve innervated muscles. There was no shoulder-girdle weakness or sensory abnormality. No systemic symptoms were identified. Surgical exploration in each extremity revealed enlarged communicating veins directly compressing the median nerve in the distal arms. Clinical improvement began 6 months after operation and was complete by 18 months.     

Radial nerve paresis during expansion in the upper arm

Summary A case report is presented in which a tissue expander was used to correct a burn scar in the upper arm. During the expansion period the inflated expander caused a paresis of the radial nerve. The paresis recovered gradually after removal of the expander. Problems concerning tissue expansion in the upper extremities are discussed in this paper.     

Fascicular torsion in the median nerve within the distal third of the upper arm: three cases of nontraumatic anterior interosseous nerve palsy

Three patients with nontraumatic anterior interosseous nerve palsy are presented. All patients also had paralysis of the pronator teres, flexor carpi radialis, and/or palmaris longus. One patient also had sensory disturbance and palsy of the thenar muscles. An hourglass-like constriction was seen within a 7-cm section of the nerve fascicles (2-9 cm proximal from the medial epicondyle of the humerus) in the median nerve trunk. All constrictions exhibited approximately 30 degrees of fascicular torsion. Because this nerve section is anatomically proximal to the branching point for the earlier mentioned motor branches and the anterior interosseous nerve, the nerve fascicles may have been structurally twisted before the onset of palsy. Structural abnormalities causing inflammation and edema of nerve fascicles as well as factors such as compression from surrounding small vessels may have maximized torsion, resulting in the formation of constrictions.     

The significance of nerve damage in upper arm fractures

Lesions of the nerves are a relatively frequent complication after humeral shaft fractures, the nerve most commonly affected being the radial nerve. In the case of proximal fractures of the humerus, particularly dislocation fractures and luxated fractures, lesion of the axillary nerve and irritation of the plexus, are most frequent. In distal humeral fractures the ulnar nerve is most frequently first place and shows a serious complication. The therapy of the fracture must differ in most of these cases from conventional procedure. We believe that primary paresis of the radial nerve is a relative indication for surgery and secondary paresis of the radial nerve, an absolute indication for operation. When we find a subcapital humeral shaft fracture with rare paresis of the nervus axillaris we wait with an operation, but if remission does not occur within approximately 8 weeks a revision should be done. Fracture luxations with irritation of the plexus are an acute indication for operation, because repositioning or displacement of the head fragment can afford relief.     

超声检查在上臂桡神经炎中的应用

目的:探讨超声检查在上臂桡神经炎诊治中的意义.方法:选取2005年12月至2011年7月患者10例,男6例,女4例;年龄20～40岁,平均32岁;病程4个月～2年.患者上臂外侧疼痛,体格检查发现神经扣击试验阳性,伸腕伸指肌力减退.根据临床体征和体格检查诊断为上臂桡神经炎.所有患者采用B超检查,并进行电生理、病理检查.将超声影像学表现与术中所见的桡神经形态进行对比研究,同时将B超检查结果与电生理、病理检查结果进行对比分析.结果:B超显示患肢桡神经平均直径(0.29±0.04) cm,平均面积(0.23±0.05) cm2,均大于健侧.超声影像学表现与术中所见的桡神经病变一致,而且B超检查结果和病理检查结果一致.结论:B超检查为上臂桡神经炎的诊断和治疗提供了形态学依据.     

Applied anatomy for upper limb nerve blocks

The brachial plexus derives from C5, C6, C7, C8 and T1 nerves. It is made up of five roots, between the scalene muscles, three trunks (upper, middle and lower) lying in the posterior triangle, each of which divide into anterior and posterior divisions behind the clavicle to form lateral, medial and posterior cords in the upper axilla. The plexus gives rise to the definitive motor and cutaneous nerve supply to the upper limb. The plexus can be blocked by local anaesthetic infiltration at its root/trunk level in the fascial sheath compartment between the scalenes, or as it crosses the first rib. Block can also be performed around the axillary artery. Peripherally, the nerves may be blocked at the elbow, wrist or finger level.     

Applied anatomy for upper limb nerve blocks

The brachial plexus derives from C5, C6, C7, C8 and T1 nerves. It is made up of five roots, between the scalene muscles, three trunks (upper, middle and lower) lying in the posterior triangle, each of which divide into anterior and posterior divisions behind the clavicle to form lateral, medial and posterior cords in the upper axilla. The plexus gives rise to the definitive motor and cutaneous nerve supply to the upper limb. The plexus can be blocked by local anaesthetic infiltration at its root/trunk level in the fascial sheath compartment between the scalenes, or as it crosses the first rib. Block can also be performed around the axillary artery. Peripherally, the nerves may be blocked at the elbow, wrist or finger level.     

Neurolysis of the distal superficial radial nerve for dysaesthesia due to nerve tethering

The subcutaneous course of the superficial radial nerve over the radial border of the wrist and hand renders it very susceptible to injury. Both traumatic and iatrogenic injury can produce tethering of this nerve, presenting as dysaesthesia. This study was designed to evaluate the efficacy of neurolysis of the distal superficial radial nerve for this condition. Twenty-five cases of tethered superficial radial nerves underwent neurolysis. At final follow-up (mean 3.5 years), fourteen cases reported symptomatic resolution while eleven continued to experience dysaesthesia. Intra-operatively, evidence of external abnormality, scarring, or compression was identified in only six cases, and its presence did not correlate with symptomatic outcome. Although the majority of patients were improved postoperatively, the success rate was lower than anticipated. Therefore, while neurolysis of the superficial radial nerve offers the opportunity for pain relief, it does not reliably produce success.     

The radial recurrent fasciocutaneous flap: reverse upper arm flap

We have recently designed and developed a radial recurrent fasciocutaneous flap based on the radial recurrent artery. This artery supplies the supinator, brachialis and elbow joint, ascending to the fascia, subcutaneous tissues and skin over the lateral aspect of the upper arm, and anastomoses with the radial collateral artery. We describe the use of this fasciocutaneous flap in the repair of elbow lesions.     

严重自体压迫性桡神经损伤的疗效分析

目的 评价严重自体压迫性上臂桡神经损伤的手术疗效.方法 对2005年3月至2009年8月收治的8例自体压迫性桡神经损伤患者进行回顾性总结.8例中有5例是由于醉酒后致腕指下垂畸形,3例由外伤昏迷所致.发病距手术时间为2～6个月,平均3.6个月.手术探查发现上臂桡神经主干及深支上有受压病变,5例出现腊肠样改变,其中3例有2处呈腊肠样改变.3例行神经外膜松解术;5例将病变段神经切除,其中2例直接缝合,3例取腓肠神经移植修复.结果 术后随访9个月至3年,6例伸腕、伸指、伸拇肌力恢复至M3～M4,2例效果较差.根据中华医学会手外科学会上肢功能评定试用标准评定:优4例,良2例,可2例.结论 严重自体压迫性桡神经损伤手术治疗大部分患者可取得良好的疗效.     

Superficial radial nerve injury during standard K-wire fixation of uncomplicated distal radial fractures

This study determines the incidence of superficial radial nerve injury after Kirchner wire insertion. An experienced orthopedic surgeon inserted the K-wires into the radii of 92 adult cadavers. Subsequent dissection of the area exposed the superficial radial nerve and any observed nerve injury was documented. It is clear from the results that nerve injury may still occur as a result of K-wire insertion; however, the current method of K-wire insertion still proves to be a reliable and safe procedure for fixation of distal radial fractures.     

Medial upper arm skin flap: vascular anatomy and clinical applications

We present the use of a medial arm free flap with the superior ulnar collateral artery as the arterial supplier in 8 patients. The flaps succeeded in 7 cases. In addition, by cadaver dissections the vascular anatomy of this flap was reevaluated. We found that the direct cutaneous arterial branches other than the superior ulnar collateral artery could be used for vascular anastomosis, in case the latter artery is not available.