正中神经返支血供的解剖学研究及其临床意义

目的:为修复正中神经返支提供带血管蒂神经桥接的理论基础和有关数据。方法:用体视学方法研究了60例灌注红色乳胶液的返支营养血管,观察其长度和内径、来源、进入神经干的方式。结果:营养动脉长度2.86±0.12mm,内径0.23±0.03mm,从返支主干的近1/3进入占88.8％,由神经的掌面,尺侧进入占74.5％。来源动脉起自掌浅弓凹侧的筋膜支,起占至“零点”的距离11.64±2.27mm,内径0.52±0.08mm,长度10.04±1.26mm。结论:返支营养动脉的来源动脉适宜做带血管蒂神经移植的受体血管。     

前臂后皮神经营养血管远端蒂复合瓣的应用解剖

目的:为前臂后皮神经营养血管远端蒂复合瓣设计提供解剖学基础。方法:30侧动脉灌注红色乳胶成人上肢标本,解剖观测前臂后皮神经营养血管的来源、分支、吻合及其与尺、桡骨膜血管的关系。结果:前臂后皮神经营养血管来自:桡侧副动脉皮支2～6支,外径(0.6±0.3) mm;骨间后动脉皮支6～9支,外径(0.7±0.3) mm;骨间前动脉腕背支皮支3~5支,外径(0.8±0.2) mm;尺、桡动脉腕背支皮支2~6支,外径(0.6±0.1) mm。尺骨中上段骨膜血管来自骨间后动脉的肌骨膜支6～8支,外径0.3～1.0 mm;骨间后动脉桡侧骨皮支与桡骨中段裸区骨膜血管吻合。上述支发出皮支、筋膜支、骨膜支和神经营养血管,形成皮神经干血管链以及深、浅筋膜和骨膜血管网。结论:前臂后皮神经营养血管与肌、骨、皮营养血管同源,其远端蒂复合瓣,旋转轴点在腕关节平面,适宜手背远处的组织缺损修复。     

正中神经掌皮支的应用解剖

目的:为预防腕、掌部手术损伤正中神经掌皮支和掌皮支损伤后修复提供解剖学资料。方法:对40侧成人上肢标本正中神经掌皮支的来源、走行、分支与分布进行解剖观测。结果:40侧标本均有掌皮支,在掌长肌腱桡侧距离远侧腕横纹中点(45.6±20.3)mm处发自正中神经桡侧,距离远侧腕横纹中点(19.3±11.6)mm处穿出前臂深筋膜,距离远侧腕横纹中点(8.2±3.5)mm处浅出掌腱膜。掌皮支长(49.4±24.8)mm,起点处宽(1.2±0.8)mm。掌皮支分3支者22例(占55%),分2支者12例(占39%),1支者6例(占15%)。掌皮支主要分布于鱼际区和掌中区。结论:掌皮支的来源、行程较恒定。腕、掌部手术应在掌长肌腱桡侧作纵行切口,可避免损伤掌皮支。     

前臂外侧皮神经-头静脉营养血管远端蒂复合瓣的应用解剖

目的为前臂外侧皮神经营养血管远端蒂复合瓣设计提供解剖学基础.方法30侧动脉灌注红色乳胶成人上肢标本,解剖观测前臂外侧皮神经下1/3段营养血管的来源、分支及其与桡骨膜血管的关系.结果前臂外侧皮神经下l/3段的营养血管来自桡动脉皮支6～11支,外径(0.7±0.3)mrn;掌浅支皮支2～6支,外径(0.5±0.3)mm;桡骨茎突返支皮支1～2支,外径(0.8±0.1)mm;鼻烟壶皮支1～2支,外径(0.6±0.2)mm.在桡骨茎突上8.0～15.0 cm之间,桡动脉肌间隙骨皮支1～3支,外径(1.1±0.2)mm,骨膜支分布桡骨体部中下段的裸露区,皮支外径(0.8±0.2)mm.上述穿支血管发皮支、筋膜支、骨膜支、神经--浅静脉营养血管,形成皮神经-头静脉血管链以及深、浅筋膜和骨膜血管网.结论前臂外侧皮神经-头静脉营养血管与肌、骨、皮营养血管同源,以桡动脉皮支为蒂前臂外侧皮神经营养血管远端蒂复合瓣,旋转轴点在腕关节平面,可用于手部远处组织缺损修复.     

正中神经的血供

本文在25具(男14女11)专供科研用的成人尸体上,用显微外科解剖技术,解剖和测量了50侧正中神经的来源动脉、营养动脉的长度和外径等。共解剖出营养动脉365条。来源动脉和营养动脉的长度、口径分别为25.44±3.30mm,9.81±0.71mm,0.40±0.02mm,1.61±0.06mm。营养动脉主要发自肱动脉(82侧22.46±5.90％);正中动脉(80侧21.92±5.85％);桡动脉(37侧10.13±4.26％)。     

桡神经浅支的血供

观察了15具(30例)成人尸体的桡神经浅支的营养动脉及其来源动脉的数目、外径等。平均每条神经有3.47±0.22支营养动脉,外径平均0.23±0.07毫米。营养动脉的来源动脉,直接由桡动脉发出者占17.31±3.71%;间接从桡动脉的分支发出者(主要是桡侧返动脉、桡侧伸腕肌支和桡动脉的皮支等)占82.69±3.71%。除桡动脉外,其余来源动脉的外径平均为0.64±0.03毫米。观察结果表明,以来源动脉为蒂,作为桡神经浅支移植的吻接血管是可行的。     

季肋—腹部皮瓣的应用解剖学

在68侧成人尸体上,对腹上外侧部T_(10)T_(11)T_(12)神经血管的外侧皮支的前支进行了解剖学研究。以肋间后血管外侧皮支的前支为蒂,可以构成一个新的皮瓣供区。第十肋间动脉外侧皮支的前支在背阔肌前缘外径0.9±0.3mm,第十一肋间后动脉外侧皮支的前支为0.9±0.3mm,肋下动脉的外侧皮支的前支为0.8±0.3mm。     

以前臂内侧皮神经及营养血管为蒂筋膜皮瓣的应用解剖

目的:为带前臂内侧皮神经及其营养血管筋膜皮瓣提供形态学基础。方法:在32侧成人上肢标本上,观测前臂内侧皮神经营养血管及其周围皮肤的供血情况。结果:前臂内侧皮神经近侧的血供来源于尺侧返动脉混合肌皮支,起始处外径为0.8mm,穿出筋膜前长度为1.1cm;中段主要来自尺动脉近中段和远中段的粗大皮支,起始处外径均为0.7mm,穿出深筋膜前长度均为1.0cm;远侧有尺动脉腕上皮支,起始处外径为0.9mm,穿出深筋膜前长为2.6cm。其神经旁血管网与神经皮(穿)支及神经内血管广泛吻合组成了皮神经血管轴。结论:可设计成带前臂内侧皮神经及营养血管为蒂筋膜皮瓣,顺行或逆行转位修复邻近部位的软组织缺损。     

以胫前返血管为蒂腓骨上段移植的应用解剖

目的:为胫前返血管蒂腓骨瓣的设计提供解剖学基础。方法:30侧经动脉红色乳胶灌注的成人下肢标本,解剖观测胫前返动脉的起始、走行、分支及分布。结果:胫前返动脉始于胫前动脉,起始点距腓骨头尖下(4.5±0.7)cm(3.0～6.0cm),动脉主干长(0.5±0.2)cm(0.2～1.2cm),外径(2.0±0.4)mm(1.3～3.0mm),伴行静脉2条,外径为(2.1±0.5)mm(1.5～3.0mm)和(2.6±0.4)mm(1.7～3.2mm)。胫前返动脉腓骨头支1～2支,外径(1.7±1.3)mm(0.6～2.1mm),分布于腓骨头的前内侧面骨膜,并与其它来源的腓骨上段骨膜支构成动脉网。腓骨头支起始点至胫前返动脉起始点长度为(1.0±0.4)cm(0.3～1.8cm),其中长度≥1.0cm者占46.7%。腓骨头支起始点以远1.5cm处的胫前返动脉外径为(1.4±0.5)mm(0.8～2.1mm)。结论:胫前返血管蒂腓骨瓣的的设计具有可行性,为临床带血管腓骨上段移植提供一种新的可供选择的血管蒂。     

腓肠神经营养血管蒂岛状皮瓣的应用解剖

目的 :为带腓肠神经营养血管蒂岛状皮瓣的临床应用提供解剖学依据。方法 :在 3 8侧经动脉灌注红色乳胶成人下肢标本上解剖观测腓肠神经及营养血管的起始、走行、分支分布、吻合及外径 ,2侧成人新鲜下肢标本墨汁灌注观察营养血管的墨染范围。结果 :腓肠神经由腓肠内侧皮神经与腓神经交通支汇合而成 ,其汇合点在外踝上 12 .7± 3 .7cm ,腓肠神经沿窝中点至外踝与跟腱中点连线下行 ,外踝上 12 .6± 3 .4cm处穿出深筋膜。其营养血管主要来源于窝中间皮动脉和腓动脉肌间隔穿支 ,上段起始部外径 0 .6± 0 .1mm ,下段距外踝上 6.7± 1.6cm处与腓动脉穿支恒定吻合 ,吻合支外径 0 .6± 0 .1mm ,沿途发出众多筋膜皮支营养小腿后部皮肤。结论 :以腓肠神经及其营养血管为蒂可设计切取顺行或逆行岛状皮瓣。     

第9、10肋间神经外侧皮支营养血管皮瓣的解剖与临床应用

目的：为季肋部皮神经营养血管皮瓣提供解剖学基础。方法：在17例34侧成人躯干标本上，观察了第9、10肋间神经外侧皮支及其营养血管的来源、走行及分布规律；在临床上，应用第9肋间神经外侧皮支皮神经营养血管皮瓣修复组织缺损2例。结果：第9、10肋间神经外侧皮支从腋中线前后相应肋间穿出深筋膜，分为前、后支，呈节段性、重叠性分布于侧胸腹部皮肤。皮神经营养血管相互间形成丰富的吻合。临床应用取得了满意的疗效。结论：以第9、10肋间神经外侧皮支营养血管为蒂，可以设计皮神经营养血管皮瓣。     

The retrograde neurocutaneous island flap of the dorsal branch of the ulnar nerve: anatomical basis and clinical application

It is well known that a cutaneous artery is constantly located near a cutaneous peripheral nerve, forming a vascular plexus around it. This vascular axis can be either a true artery or an interlacing network, ensuring the vascularization of the nerve and giving off several neurocutaneous perforators to the skin. The anatomy of the accompanying arteries of the dorsal branch of the ulnar nerve (DBUN) and their relationships with the dorsal branch of the ulnar artery (DBUA) were investigated in 22 fresh upper limbs injected with colored neoprene latex. A constant perineural vascularization of the terminal branch of the DBUN was observed in the fourth web space, connected distally with the corresponding dorsal metacarpal or palmar digital arteries. Our findings therefore provide anatomical bases for a new neurocutaneous island flap. Moreover, they allow us to describe a precise surgical technique in order to raise this flap over the larger branch of the DBUN, in the fourth intermetacarpal space. The flap is harvested on the medial aspect of the dorsum of the hand, and its point of rotation is located in the fourth web space, 1 cm proximal to the metacarpophalangeal joint. It is supplied by a reversed flow originating from distal anastomoses of the perineural vessel with the dorsal metacarpal and digital palmar arteries in the fourth web space. This flap does not involve in its pedicle the distal course of the DBUA. It represents a pure neurocutaneous flap.     

Biometric study of the relationships between palmar neurovascular structures, the flexor retinaculum and the distal wrist crease

During surgical exposure of the carpal tunnel it is possible to injure the neurovascular structures closely related to the flexor retinaculum, such as the superficial palmar arch and the communicating branch between the ulnar and median nerves. Because of the importance of these structures and with the purpose of increasing knowledge of anatomical details concerning to their location, a biometric study was performed on the retinaculum and the communicating branch, and between the communicating branch and the distal wrist crease, as well as between the retinaculum and the superficial palmar arch. We dissected 56 hands from 28 Brazilian formalin‐preserved cadavers of both sexes (24 male) at the Federal University of São Paulo–Escola Paulista de Medicina, Brazil. The communicating branch was observed in 96.4% of cases and the superficial palmar arch in 78.6%. The communicating branch was found between the common palmar digital nerve of the 4th interosseous space (from the ulnar nerve) to the homonymous nerve of the 3rd interosseous space (from the median nerve). In males, the distance between the distal wrist crease and the site where the communicating branch originates from the ulnar component had an average of 33.9±5.5 mm on the right side and 30.2±8.2 mm on the left. The distance between the distal wrist crease and the junction of the communicating branch with the common palmar digital nerve of the 3rd interosseous space was 43.6±6.9 mm on the right and 40.2±6.2 mm on the left side. Conversely, in 14.8% of cases (1 female), the communicating branch was observed to emerge from the common palmar digital nerve of the 3rd interosseous space. The distance between the retinaculum and the superficial palmar arch in the axial line of the 4th metacarpal bone was on average 7.3±4.3 mm on the right and 8.3±3.5 mm on the left side. At the same level, the distance between the retinaculum and the communicating branch was 6.2±3.7 mm on the right side and 5.1±2.8 mm on the left. These results can be used as a reference during surgical procedures in the palmar region.     

前臂桡侧头静脉-皮神经的营养血管的解剖学

目的：为前臂桡侧头静脉-皮神经营养血管远端蒂复合瓣设计提供解剖学基础。方法：动脉灌注红色乳胶成人上肢标本,解剖观测头静脉-前臂外侧皮神经下1/3段营养血管的来源、分支及其与桡骨膜血管的关系。结果：头静脉-前臂外侧皮神经下1/3段的营养血管来自：桡动脉皮支,掌浅支皮支,桡骨茎突返支皮支和桡动脉肌间隙骨皮支。上述诸支血管发皮支、筋膜支、骨膜支、神经-浅静脉营养血管,形成皮神经-头静脉血管链以及深、浅筋膜和骨膜血管网。结论：前臂桡侧缘头静脉-皮神经营养血管与肌、骨、皮营养血管同源,以桡骨茎突返支为蒂的远端蒂复合瓣,旋转轴点在腕关节平面,可用于手部远处组织缺损修复。     

喉返神经喉外分支的显微解剖及临床意义

目的探讨甲状腺手术区域喉返神经(RLN)的解剖特点和方法。方法运用大体解剖的方法,对48例成人标本甲状腺手术区域的RLN及其周围毗邻结构进行了观测。结果 48例96侧成人标本中,29%RLN主干穿过环咽肌肌束至致密结缔组织膜下缘,71%RLN主干走行在环咽肌深面。69%RLN在距离甲状软骨下角尖端(15.2±5.5)mm处分为前、后两支,前支多于环状软骨侧方下缘距离甲状软骨下角尖端(5.9±1.8)mm处穿过结缔组织膜,后支入喉点距甲状软骨下角尖端(4.8±2.1)mm;31%RLN未见分支。结缔组织膜下缘RLN与甲状腺下动脉(ITA)分支的关系为:66%(63/96)RLN位于ITA前方,27%(32/96)位于ITA后方。结论大多数RLN具有喉外分支,在以甲状软骨下角作为标志寻找RLN时,要同时找寻RLN及喉外分支的入喉点。ITA与RLN的关系复杂多变,ITA不作为RLN定位的首选。     

桡神经臂部血供的显微解剖

目的为临床中修复桡神经长段缺损及利用该神经修复其他神经损伤提供形态学基础。方法对35侧经腋动脉灌注带色乳胶的成人上肢标本,解剖观察供给桡神经营养血管的来源、分布、微血管构筑、营养动脉的外径。结果桡神经接受的营养血管来源分为四种类型;营养血管分布在臂部中段较多;营养动脉起始处外径平均为(0.37±0.03)mm,入神经干处外径平均为(0.28±0.02)mm。结论35侧成人上肢的桡神经全段血供形式可分为3型。在臂部桡神经中,肱深动脉、桡侧返动脉为供给神经血液的主要血管,且大部分集中于中、下1/3段。     

带桡神经浅支及其营养血管筋膜皮瓣的应用解剖

目的:为带桡神经浅支及其营养血管筋膜皮瓣的临床应用提供形态学基础.方法:在32例成人上肢标本上,观测了桡神经浅支浅段及其营养血管、以及该血管与筋膜皮肤的供血关系.结果:桡神经浅交浅段的血供主要来自桡动脉的肌皮支或皮支,其中以桡动脉显露段的粗大皮支,鼻咽壶段的茎突返支及虎口区的皮动脉较为恒定,起点外径分别为0.8mm、0.7mm及0.6mm:穿出深筋膜前长分别为0.8cm、1.1cm及0.5cm.皮动脉的神经支在神经旁或神经干内相互沟通形成纵向链状血管网,并借吻合支与皮动脉筋膜皮支构成的皮下血管网、筋膜血管网等连接.结论:可设计成带桡神经浅支及其营养血管的顺行或逆行筋膜皮瓣,转位修复邻近部位的软组织缺损.     

正中神经返支卡压及易损伤部位的解剖学基础

目的：探讨腕管综合征术后大鱼际功能恢复不良的原因与返支易损伤部位。方法：对20侧成人新鲜上肢标本进行显微解剖，观测正中神经返支走行中存在的卡压因素以及易损伤部位。结果：(1)拇短屈肌浅头尺侧存在腱弓及腱纤维束结构，对正中神经返支形成卡压；(2)住屈肌支持带远侧返支与掌腱膜关系密切，在此部位掌腱膜可对返支形成卡压或术中易误伤返支；(3)走行中返支与拇长屈肌腱和示指屈肌腱存在交叉走行关系。结论：(1)返支走行中存在易卡压因素，治疗腕管综合征时应常规探查松解返支；(2)涉及拇长屈肌腱，示指屈肌腱和掌腱膜手术时，应注意防止损伤返支。     

Anatomic study of the superficial sural artery and its implication in the neurocutaneous vascularized sural nerve free flap

Combined extended nerve and soft tissue defects of the upper extremity require nerve reconstruction and adequate soft tissue coverage. This study focuses on the reliability of the free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap within this indication. An anatomical study was performed on 26 cadaveric lower extremities that had been Thiel fixated and color silicone injected. Dissection of the fasciocutaneous posterior calf flap involved the medial sural nerve and superficial sural artery (SSA) with its septocutaneous perforators, extended laterally to include the lateral cutaneous branch of the sural nerve and continued to the popliteal origin of the vascular pedicle and the nerves. The vessel and nerves diameter were measured with an eyepiece reticle at 4.5× magnification. Length and diameter of the nerves and vessels were carefully assessed and reported in the dissection book. A total of 26 flaps were dissected. The SSA originated from the medial sural artery (13 cases), the popliteal artery (12 cases), or the lateral sural artery (one case). The average size of the SSA was 1.4 ± 0.4 mm. The mean pedicle length before the artery joined the sural nerve was 4.5 ± 1.9 cm. A comitant vein was present in 21 cases with an average diameter of 2.0 ± 0.8 mm, in 5 cases a separate vein needed to be dissected with an average diameter of 3.5 ± 0.4 mm. The mean medial vascularized sural nerve length was 21.2 ± 8.9 cm. Because of inclusion of the vascularized part of the lateral branch of the sural nerve (mean length of 16.7 ± 4.8 cm), a total of 35.0 ± 9.6 cm mean length of vascularized nerve could be gained from each extremity. The free vascularized sural nerve graft combined with a fasciocutaneous posterior calf flap pedicled on the SSA offers a reliable solution for complex tissue and nerve defect. Clin. Anat. 26:903–910, 2013. © 2012 Wiley Periodicals, Inc.     

颞浅动脉额支的观测及其临床意义

目的为颞动脉活检提供颞浅动脉额支相关的解剖学资料。方法对16具防腐成人尸体标本进行解剖,对颞浅动脉额支进行相关的解剖学观测、测量。结果①颞浅动脉额支在起点和末梢分叉点之间的长度为(45.93±7.29)mm;②颞浅动脉额支在起点和末梢分叉点的坐标值分别为(22.95±3.81,17.32±4.54)mm和(59.93±8.94,37.48±5.37)mm;③颞浅动脉额支在起点和末梢分叉点之间直线相关,直线回归方程为y赞=7.06+0.50X,相关系数r=0.68,P<0.001。结论深入了解颞浅动脉额支的解剖学特点及其与周围结构的解剖学关系,有利于颞动脉活检中颞浅动脉额支的定位及防止周围结构的损伤。