第1骨间背侧肌神经肌蒂转移修复拇对掌肌功能临床解剖

发布时间：2018-04-26 16:08

本文选题：拇对掌肌 + 对掌功能　；参考：《南方医科大学》2010年硕士论文

【摘要】： 研究背景和目的拇指功能占手功能的36%-40%,而拇指对掌功能占拇指运动功能的60%。拇指对掌功能障碍主要是由周围神经损伤及手外伤所致,严重影响手的功能。由于拇对掌肌在拇指对掌运动中起主要作用,因此如何修复拇对掌肌功能成为临床治疗和研究的重点。对掌运动是多肌肉、多关节参与的复杂联合运动,要完成对掌动作需要外展、旋前、桡偏、屈曲四项活动,拇对掌肌是对掌运动中最重要的肌肉,第1掌指关节是最重要的关节。评价拇对掌功能重建术的效果,主要考虑术后拇指外展和旋前角度的大小,只有拇指充分的外展和旋前才能很好的完成捏持和抓握功能。拇对掌功能重建的方法目前主要有3类,即固定型重建术、肌腱转位术和各种显微外科方法。目前,临床应用最多的是各种肌腱转位修复拇对掌功能。国内、外对周围神经损伤修复的研究已有很大进展,但在促进神经再生、功能重建、异体神经移植、组织工程化神经应用等方面尚需进一步研究。但由于手外伤及周围神经损伤的复杂性,拇对掌功能的重建还没有一种标准术式。近年来一些学者在如何运用显微外科方法重建拇对掌功能的研究中做了大量的工作,主要研究方向是神经肌肉的带蒂／游离移植,取得了一定效果,但手术难度大,技术要求高,远期效果仍需进一步的观察。固定型重建术多采用骨性融合方式,第1、2掌骨间植骨固定术将拇指固定于对掌位,主要应用于影响对掌功能的骨关节病变,是在无合适动力肌腱选择转位情况下采用的一种术式。随着人工关节的临床应用和显微外科技术的进展,此项术式应用越来越少。临床应用最广泛的方法是腱转位拇对掌功能重建,目前几乎前臂大部分肌肉都被用来作为对掌功能重建的供区肌肉。腱转位拇对掌功能重建手术关键在于：转位肌腱的选择、是否重建滑车及滑车位置、转位腱的嵌入点。目前临床发现应用该术式后能大部分恢复拇指桡侧外展功能,但是拇指旋前不够而不能做充分的对掌动作,由此产生过多的侧向对掌或者对指成角,部分还伴有转位肌腱的粘连。因此更符合生物力学要求和生理功能的腱转位术式还在进一步探寻中。异体神经和组织工程化神经的研究近年来进展较快,国内、外已有少量报道,但距离临床大规模使用还有很长的路要走。随着显微外科的发展和成熟,各种显微外科方法重建拇指对掌功能也日益发展,主要有：①带血管神经蒂的小肌肉移植,如Huber小指展肌转位重建拇对掌肌功能：②运动神经移位修复鱼际肌支,如Schultz、朱盛修尺神经第3蚓状肌支、骨间前神经支转位修复鱼际肌支；③吻合血管神经的小肌肉移植,如朱盛修、庄永青先后采用了趾短伸肌、胸小肌作为供肌修复拇对掌功能。一些学者认为这种方法可以更好的恢复肌肉本身的生理功能,克服机械力学和牵引方法的弊端,但技术难度较高,长期临床效果尚待进一步观察。目前临床拇对掌功能重建治疗中存在的问题主要有：①不符合拇指对掌活动的生物力学,所形成的对掌往往是侧向对掌或对指成角,以致术后疗效不满意；②移位肌肉力量或者滑动幅度不够,不足以带动拇指做对掌动作或者对掌幅度不能满足功能要求；③损伤较重要的肌腱,而残存一定功能障碍；④需重建滑车或者需绕腕横韧带或某一肌腱的止点,移位肌腱必须克服成角活动造成的阻力,从而影响拇指对掌活动的灵活性,同时肌腱在滑车部位长期摩擦,易发生磨损,从而造成肌腱粘连或者断裂；⑤外形欠满意,不能达到医学美容学的要求。国内、外从很早就开始了神经肌蒂的研究,神经肌蒂转移技术已经在耳鼻喉、整形等临床科室应用,相关的基础及临床研究也在进行中。神经肌蒂是使用受区附近较小的运动神经分支连同末端的一小块肌组织移植到受植肌床内。肌蒂内被切断的神经分支依靠受区肌肉的去神经生物诱导作用,长入受植肌肉,并在其内发出枝芽,形成新生运动终板从而修复该肌的运动功能。神经肌蒂可以保留一定量的神经分支和运动终板,神经分支较易固定,与受区肌床的愈合良好,不仅可以结束肌肉的失神经萎缩状态,而且能使受植肌肉更快恢复功能。神经肌蒂转移的受植区一般为体积较小、功能重要的肌肉,这样才能保证肌蒂内的神经枝芽较快的长入整块肌肉,恢复其功能,同时也符合显微外科领域以次要部位组织修复重要部位组织的手术原则,这同我们修复拇指对掌肌的目的是一致的。临床上拇指对掌功能的丧失主要是由于支配鱼际肌的正中神经返支损伤导致,这种损伤常常是不可逆的。神经损伤后,造成鱼际肌的失神经萎缩,如果能够早期尽快恢复鱼际肌的神经再支配,无疑对拇指对掌功能的恢复起着重要作用。尺神经深支均为运动肌支,主要支配小鱼际肌、全部骨间肌、第3和4蚓状肌、拇收肌、拇短屈肌深头。我们的研究设想是通过显微外科解剖,观测尺神经深支的分布情况,探讨其在相关肌肉内的分布特点,为临床应用尺神经深支第1骨间背侧肌支神经肌肉蒂转移修复拇对掌肌功能提供解剖学依据。我们的研究主要分以下两个部分：第一章第1骨间背侧肌神经肌蒂转移修复拇对掌肌功能的临床解剖目的：探讨尺神经深支第1骨间背侧肌远端肌支神经肌蒂转移修复拇对掌肌功能术式的可行性,为临床应用提供解剖学基础。方法：固定手部标本20例,在手术显微镜下解剖观测尺神经第1骨间背侧肌支及其营养血管的分支、分布情况,据此设计带血管的第1骨间背侧肌远端肌支神经肌蒂转移修复拇对掌肌功能的手术方式。新鲜手部标本5例,进行手术模拟。结果：尺神经深支第1骨间背侧肌支进入肌肉前分出2个分支,分别于肌肉的上、下1／3处进入肌肉；远端肌支横径(1.5±0.2)mm,可无损伤分离长度为(2.82±0.24)cm,可无损伤分离长度与神经肌蒂转移需要的距离经两独立样本t检验,证明其长度足以到达受区(P0.01)。其营养血管发自第1或第2掌心动脉,起始处直径为(0.6-0.9)mm。结论：带血供的尺神经第1骨间背侧肌远端肌支神经肌蒂转移修复拇指对掌肌功能的术式具有可行性,该术式的实用性、有效性有待临床进一步验证。第二章第1骨间背侧肌神经血管解剖学研究目的：为临床带血供的第1骨间背侧肌远端肌支神经肌蒂转移修复拇对掌功能手术提供供区肌肉神经、血管相关解剖学依据,评估切取该肌远端肌支对供区的影响。方法：10例手部固定标本,采用显微解剖方法,观察第1骨间背侧肌形态、血供和神经支配情况。通过再改良Sihler's染色法对第1骨间背侧肌进行肌内神经染色。将所取固定标本用去离子水浸泡,5%氢氧化钾浸泡除色素,Sihler'sⅠ溶液进行脱钙,Sihler'sⅡ溶液染色,根据染料配制的情况不同,再次浸入Sihler'sⅠ溶液脱色,然后去离子水浸泡10min,0.05%碳酸锂溶液,最后将标本依次放入40%、70%、100%梯度甘油中透明。剔除肌肉筋膜,X线观片箱下观察拍照。结果：第1骨间背侧肌的血供背侧主要以第一掌背动脉为主,掌侧由示指桡侧动脉和第1掌心动脉营养。第1骨间背侧肌支神经来源于尺神经深支,在进入第1骨间背侧肌前分成两支。其中近端分支主要分布于肌腹的上2／3,远端分支主要分布在肌腹的下1／3。结论：切取第1骨间背侧肌远端肌支神经肌蒂转位修复拇对掌肌的功能是可行的,其对供区肌肉的影响较小。
[Abstract]:Background and purpose of research
The thumb function accounts for the 36%-40% of the hand function, and the thumb opposite of the thumb function accounts for the thumb motor function of the thumb. The function of the thumb against the thumb is mainly caused by peripheral nerve injury and hand injury, which seriously affects the function of the hand. The function of the thumb against the palmar muscle is the main function of the thumb against the palmar palmar muscle. The focus of the study.
The movement of the palmar is a complex combined movement involving multiple muscles and multiple joints. In order to complete the action of the palmar movement, the most important muscle in the movement of the palmar is the most important muscle in the movement of the palmar, and the first metacarpophalangeal joints are the most important joints. The effect of the thumb abduction and the pronation angle after the operation is mainly considered. Only the thumb fully abduction and pronation can complete the function of grasping and grasping.
There are 3 main methods for the reconstruction of the function of the thumb to the palmar function, that is, fixation reconstruction, tendon transposition and various microsurgical methods. At present, the most clinical application is the repair of the thumb and the palmar function by various tendon transposition. Further research is still needed in the transplantation of tissue engineered nerve applications. However, due to the complexity of hand injury and peripheral nerve injury, there is no standard operation for the reconstruction of the thumb palmar function. In recent years, some scholars have done a lot of work in the study of how to reconstruct the thumb palmar function by using microsurgical methods. It is a pedicle / free transplantation of nerves and muscles. It has achieved certain results, but the operation is difficult and the technical requirements are high. The long-term effect needs further observation.
Bone fusion is mostly used in fixed reconstruction. 1,2 metacarpal intermetacarpal bone fixation is used to fix the thumb on the palmar position. It is mainly applied to the bone and joint lesions that affect the function of the palmar. It is an operation under the condition of no appropriate dynamic tendon selection. With the clinical application of artificial joints and the progress of microsurgical technique, this operation is performed. The most widely used method of clinical application is the reconstruction of the tendon transposition of the thumb to the palmar function. Most of the muscles in the forearm are currently used as the donor muscle for the reconstruction of the palmar function. The key to the reconstruction of the palmar function of the tendon transposition is: the selection of the transposition tendons, the reconstruction of the position of the trochlear and the trochlear, the insertion point of the transposition tendon. At present, it is found that most of the clinical application can restore the function of the radial abduction of the thumb after the operation, but the thumb is not enough to make full action of the palmar, resulting in excessive lateral palmar or contralateral angle, and the adhesion of the transposition tendons in part. Therefore, the tendon transposition that is more in line with the requirements of biological mechanics and physiological function is still in the form of tendon transposition. In the further exploration, the research of allogenic nerve and tissue engineering nerve has been progressing rapidly in recent years. There have been a few reports in domestic and abroad, but there is still a long way to go from the large scale of clinical use.
With the development and maturity of microsurgery, various microsurgical methods have also been developed for the reconstruction of thumb palmar function, including: (1) small muscle transplantation with vascular and nerve pedicle, such as Huber small finger abductor transposition to reconstruct the function of the thumb to the palmar muscle: (2) the repair of the interosseous muscle by the displacement of the motor nerve, such as Schultz, the third vermis of the ulnar nerve in Zhu Sheng, and the interosseous muscle The anterior nerve branch transposition for the repair of the thenar muscle branch and the small muscle transplantation that anastomosed vascular nerve, such as Zhu Shengxiu and Zhuang Yongqing, used the extensor digitalis and the pectoralis minor as the donor to repair the function of the thumb. Some scholars believe that this method can better restore the physiological function of the muscle itself and overcome the disadvantages of mechanical mechanics and traction methods. The technical difficulty is high, and the long-term clinical effects need to be further observed.
The main problems in the reconstructive treatment of hallux palmar function are: (1) not conforming to the biomechanics of the thumb to the palmar activity, and the formation of the palms often are lateral to the palm or to the angle of the finger, so that the effect of the operation is not satisfactory; (2) displacing the muscle strength or the amplitude of the slipping is not enough to drive the thumb to do the action of the palm or the palm. The degree can not meet the functional requirements; (3) the damage of the more important tendons, and residual disability; (4) the need to rebuild the trochlear or the need to wound the wrist or a tendon or a tendon. The displacement of the tendon must overcome the resistance caused by the angular activity, thus affecting the flexibility of the thumb movement, and the tendon is frictional for a long time in the part of the trochlear, and it is easy to occur. Wear, resulting in tendon adhesion or breakage. 5. The shape is not satisfactory enough to meet the requirements of medical cosmetology.
Neuromuscular pedicle studies have been started very early in the country. Neural pedicle transfer technology has been used in clinical departments such as otolaryngology and plastic surgery. The related basic and clinical studies are also in progress. The nerve pedicle is transplanted into the implant bed with a small muscle branch near the area and the end of the muscle tissue. The nerve branch, which is cut off, depends on the denervation of the muscle of the region, and grows into the implanted muscle and sends out the branch buds in it to form a new motor endplate to repair the motion function of the muscle. The nerve pedicle can retain a certain amount of nerve branches and motor endplates, the nerve branch is more easily fixed, and the healing of the muscle bed in the recipient is good, It can only end the state of denervation and atrophy of the muscles, and can make the implanted muscles recover faster. The implant areas of the nerve pedicle transfer are generally small, functional muscles, so as to ensure that the sprouts in the Muscular Pedicles grow rapidly into the whole muscle, restore their power, and meet the needs of the microsurgical areas. The operation principle of tissue repair of important parts of the tissue is consistent with the purpose of repairing the thumb to the palmar muscles. The loss of the function of the thumb to the palmar is mainly due to the injury of the median nerve back branch of the thenar muscle, which is often irreversible. After nerve injury, it causes the atrophy of the thenar muscle, if it can be damaged. The restoration of the nerve redominance of the thenar muscle early as soon as possible will undoubtedly play an important role in the restoration of the function of the thumb palmar. The deep branch of the ulnar nerve is a moving muscle branch, which dominates the small interosseous muscle, the all interosseous muscles, the third and fourth vermis, the adductor pollicis, and the deep flexor of the flexor pollicis. In order to provide an anatomical basis for the function of the deep branch of the ulnar nerve for the clinical application of the deep branch of the ulnar nerve, the neuromuscular pedicle of the muscular branch of the dorsal interosseous branch of the first bone was used to repair the function of the thumb muscle.
Our research is divided into two parts:
Chapter one first clinical anatomy of the musculus hallucis metacarpalis muscle pedicled with dorsal interosseous nerve pedicle
Objective: To explore the feasibility of repairing the function of the muscle function of the thumb to the palmar muscle of the deep branch of the ulnar nerve and the distal interosseous muscle of the first interosseous muscle of the interosseous interosseous, and to provide the anatomical basis for clinical application.
Methods: 20 cases of hand specimens were fixed, and the branches of the dorsal lateral muscular branches of the ulnar nerve and their nutrient vessels were observed under the operation microscope, and the distribution of the branches of the nutrient vessels in the first bone of the ulnar nerve was observed. According to this, the operation method of repairing the function of the thumb against the palmar muscle was designed by the transfer of the nerve pedicle of the distal muscle branch of the dorsal lateral muscle of the first interosseous interosseous. The surgical simulation was performed in the fresh hand specimens in 5 cases.
Results: the deep branch of the ulnar nerve was divided into 2 branches before the first interosseous branches of the interosseous interosseous, respectively, on the muscles, 1 / 3, and the distal diameter (1.5 + 0.2) mm, with no injury separation length (2.82 + 0.24) cm, and the distance between the length of the injury and the need for the transfer of the nerve pedicle was tested by the two independent sample t test, proving its length. It is enough to reach the recipient area (P0.01). The nutrient vessels originate from the first or second metacarpal arteries, with a diameter of (0.6-0.9) mm. at the beginning.
Conclusion: it is feasible to transfer the pedicle of the distal interosseous muscle of the ulnar nerve with blood supply to the distal interosseous muscle of the interosseous muscle of the first bone to repair the function of the thumb to the palmar muscle. The practicability and effectiveness of this type of operation need to be further verified in clinical.
Second chapter first anatomy of nerves and vessels of interosseous dorsal muscles
Objective: to provide the muscle nerve and vascular related anatomical basis for the repair of the thumb palmar function by transferring the distal muscle branch of the dorsal interosseous muscle of the first interosseous interosseous muscle to repair the palmar function, and evaluate the effect of the distal muscle branch of the muscle on the donor area.
Methods: 10 cases of hand fixed specimens were used to observe the morphology, blood supply and nerve innervation of the dorsi of the first interosseous interosseous muscles by microdissection. Through the modified Sihler's staining, the intramuscular nerve of the dorsi interosseous muscles of the first interosseous was stained. The fixed specimens were soaked with deionized water, 5% potassium hydroxide soaked in pigment, and Sihler's I solution was decalcified. Sihler's II solution was dyed, according to the different conditions of the preparation of the dye, soaked in Sihler's I solution and decolorized again, then dionized water to soak 10min, 0.05% lithium carbonate solution. Finally, the specimens were placed in 40%, 70%, 100% gradient glycerol in turn. Remove the muscle fascia and observe and take photos under the X-ray film box.
Results: first the main dorsal lateral muscle of the interosseous muscle was mainly the first dorsal metacarpal artery, the palmar lateral radial artery and the first palmar artery were nourishment. First the dorsal lateral muscular nerve of the interosseous was derived from the deep branch of the ulnar nerve and was divided into two branches in the dorsal lateral muscle of the first interosseous interosseous. The proximal branches were mainly distributed on the upper 2 / 3 of the muscle abdomen, and the distal branches were mainly divided into two branches. The cloth is 1 / 3. below the muscle belly.
Conclusion: it is feasible to repair the function of the hallux metacarpal muscle by transposition of the musculocutaneous branch of the distal intermuscular muscle of the first dorsal interosseous muscles.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2010
【分类号】：R322.74

【参考文献】