本文選題：指淺屈肌肌支 + 神經(jīng)移位�。� 參考：《河北醫(yī)科大學(xué)》2008年碩士論文

【摘要】： 目的:為正中神經(jīng)指淺屈肌肌支移位修復(fù)尺神經(jīng)運(yùn)動(dòng)支,恢復(fù)手內(nèi)在肌功能的臨床應(yīng)用提供解剖學(xué)基礎(chǔ)。尺神經(jīng)運(yùn)動(dòng)支(深支)支配小魚際肌、骨間肌、拇收肌及第3、4蚓狀肌,功能非常重要,當(dāng)尺神經(jīng)損傷后,將導(dǎo)致尺神經(jīng)所支配的手內(nèi)在肌麻痹,使手失去靈活的運(yùn)動(dòng)功能,對(duì)手功能影響很大。對(duì)高位的尺神經(jīng)損傷用傳統(tǒng)的神經(jīng)修復(fù)方法縫接,由于縫接點(diǎn)至神經(jīng)運(yùn)動(dòng)終板的再生距離長(zhǎng),細(xì)小的手內(nèi)在肌在再生神經(jīng)纖維長(zhǎng)入神經(jīng)運(yùn)動(dòng)終板之前,即發(fā)生廢用性肌肉萎縮和機(jī)化,手術(shù)效果差;而前臂近端尺神經(jīng)損傷,由于尺神經(jīng)在此段內(nèi)以感覺(jué)纖維為主,神經(jīng)直接吻合后,有可能發(fā)生不同功能束的錯(cuò)接,使再生神經(jīng)纖維迷失方向,長(zhǎng)入感覺(jué)纖維膜管內(nèi),使手內(nèi)在肌功能難以恢復(fù)。指淺屈肌肌支發(fā)自正中神經(jīng)主干,是以運(yùn)動(dòng)纖維為主的神經(jīng)分支,位于指淺屈肌的深面,位置恒定,變異少,易于尋找,以此肌支修復(fù)尺神經(jīng)運(yùn)動(dòng)支是肌支對(duì)肌支的縫接,功能束對(duì)位準(zhǔn)確,再生的神經(jīng)纖維通過(guò)一個(gè)縫接口,可以最短的距離長(zhǎng)入神經(jīng)運(yùn)動(dòng)終板內(nèi),使手內(nèi)在肌在最短的時(shí)間內(nèi)重新獲得神經(jīng)支配,能有效防止其廢用性肌肉萎縮,使手內(nèi)在肌功能恢復(fù)良好。本課題通過(guò)對(duì)正中神經(jīng)指淺屈肌肌支及尺神經(jīng)相關(guān)研究,為臨床上選擇性修復(fù)尺神經(jīng)運(yùn)動(dòng)支提供解剖學(xué)依據(jù)。 方法:選用10側(cè)近期經(jīng)福爾馬林浸泡固定的成人上肢標(biāo)本,肩外展90°伸直位,解剖暴露前臂段正中神經(jīng)主干以及尺神經(jīng)主干,顯露正中神經(jīng)指淺屈肌各肌支,先觀察記錄肌支數(shù),然后用游標(biāo)卡尺、規(guī)尺等測(cè)量工具測(cè)量指淺屈肌肌支的發(fā)出部位、入肌部位、橫徑、前后徑、肌支從主干的起始點(diǎn)至入肌點(diǎn)間可自然分離的長(zhǎng)度以及尺神經(jīng)運(yùn)動(dòng)支和感覺(jué)支間自然分束無(wú)損傷分離長(zhǎng)度。模擬操作:以適合移位的指淺屈肌肌支模擬吻合尺神經(jīng)運(yùn)動(dòng)支(深支),修復(fù)手內(nèi)在肌的功能。取指淺屈肌該肌支作橫斷面組織學(xué)切片,切片染色后置于光學(xué)顯微鏡下觀察:高倍視野下測(cè)量5個(gè)隨機(jī)視野的有髓神經(jīng)纖維數(shù)目,求出神經(jīng)纖維密度;低倍視野下測(cè)量肌支橫斷面神經(jīng)束面積,最終計(jì)算出指淺屈肌該肌支有髓神經(jīng)纖維數(shù)目。 結(jié)果:1指淺屈肌肌支:2-4支,1支型未發(fā)現(xiàn),2支型1例占10%,3支型1例占10%,4支型8例占80%。對(duì)于其中的四支型,第一支發(fā)出部位距離橈骨莖突和尺骨莖突連線:200.5±12.2mm,入肌部位距離橈骨莖突和尺骨莖突連線:166.8±10.3mm,可分離長(zhǎng)度:33.7±8.4mm,橫徑:1.0±0.1mm,前后徑:0.6±0.1mm;第二支發(fā)出部位距離橈骨莖突和尺骨莖突連線:155.6±10.2mm,入肌部位距離橈骨莖突和尺骨莖突連線:113.9±10.5mm,可分離長(zhǎng)度:40.4±6.4mm,橫徑:0.9±0.1mm,前后徑:0.6±0.1mm;第三支發(fā)出部位距離橈骨莖突和尺骨莖突連線:90.9±2.8mm,入肌部位距離橈骨莖突和尺骨莖突連線:61.7±1.3mm,可分離長(zhǎng)度:29.2±3.1mm,橫徑:0.8±0.1mm,前后徑:0.6±0.1mm;第四支發(fā)出部位距離橈骨莖突和尺骨莖突連線:48.4±2.4mm,入肌部位距離橈骨莖突和尺骨莖突連線:21.4±1.8mm,可分離長(zhǎng)度:27.1±1.2mm,橫徑:1.2±0.2mm,前后徑:0.7±0.1mm。尺神經(jīng)運(yùn)動(dòng)支和感覺(jué)支間自然分束無(wú)損傷分離距離為:7.1±0.7cm。2選擇最適合移位的指淺屈肌肌支(第四肌支),經(jīng)指淺屈肌深面轉(zhuǎn)位模擬修復(fù)尺神經(jīng)運(yùn)動(dòng)支獲得成功。3正中神經(jīng)指淺屈肌第四肌支的有髓神經(jīng)纖維數(shù)為:1378.9±107.9條,滿足為恢復(fù)有效的手內(nèi)在肌功能所需要的有效生長(zhǎng)神經(jīng)纖維數(shù)目。 結(jié)論:1正中神經(jīng)指淺屈肌肌支有足夠的長(zhǎng)度、橫徑以及有髓神經(jīng)纖維數(shù)量,可以修復(fù)尺神經(jīng)的運(yùn)動(dòng)支、恢復(fù)手內(nèi)在肌的功能。該研究為正中神經(jīng)指淺屈肌肌支移位修復(fù)尺神經(jīng)運(yùn)動(dòng)支的臨床應(yīng)用打下了良好的解剖學(xué)基礎(chǔ)。2切取部分指淺屈肌肌支后,由于保留了部分指淺屈肌的肌支以及指深屈肌具有足夠的屈指功能,所以對(duì)手指的屈指功能影響較小。3正中神經(jīng)指淺屈肌肌支的位置表淺,手術(shù)時(shí)的難度及其風(fēng)險(xiǎn)相對(duì)較小,且第四肌支距離被修復(fù)的尺神經(jīng)運(yùn)動(dòng)支所支配的神經(jīng)運(yùn)動(dòng)終板較近,可有效防止手內(nèi)在肌萎縮。
[Abstract]:Objective: the median nerve superficial flexor muscle transposition to repair the ulnar nerve, and provide anatomical basis for clinical application to restore the function of intrinsic muscle of hand. The ulnar nerve motor branch (deep branch) dominates hypothenar muscles, interosseous muscle, adductor pollicis and 3,4 lumbricalis, function is very important, when the ulnar nerve injury that will lead to the ulnar nerve innervation of the hand intrinsic muscle paralysis, the hand lose flexible movement function, greatly affect the opponent function. The traditional method of using neural repair joint of high ulnar nerve injury, because the regeneration distance seam point to nervimotion end plate long before the intrinsic muscle of hand small nerve endplate ingrowth in the regeneration of nerve fibers, the disuse muscle atrophy and metaplasia, the operation effect is poor; and the proximal forearm ulnar nerve injury, because this period is dominated by ulnar nerve sensory fibers, nerve anastomosis, might have different functions of beam Wrong connection, make the nerve fiber regeneration lost, long into the sensory fibers of the membrane tube, so that the function of intrinsic muscle of hand. It is difficult to restore superficial flexor muscle from the median nerve trunk, nerve branches to motor fibers mainly located, refers to the deep layer of the superficial digital flexor constant position, less variation, easy to find, in order to muscle a repair of ulnar nerve muscular branches of muscular branches is the joint function, beam accurate positioning of the regenerated nerve fibers through a joint interface, can be the shortest distance into the long nerve endplate, the intrinsic muscle re innervation in the shortest period of time, can effectively prevent the atrophy with muscle, the intrinsic muscle recovery is good. The superficial flexor muscle and ulnar nerve of the median nerve, for clinical selective repair of ulnar nerve to provide the anatomical basis.
Methods: the recent 10 sides of adult upper limb specimens soaked by formalin fixed, shoulder abduction 90 degrees extension, forearm median nerve trunk were exposed and ulnar nerve trunk revealed median nerve superficial flexor muscle branches, first recorded muscle count, and then use the vernier caliper measuring tool gauge measurement of flexor digitorum superficialis a part of the muscular branches, into muscle, transverse diameter, anteroposterior diameter, muscular branches from the starting point of the trunk to the entrance point of diaphragm between natural separation length and the ulnar nerve and sensory branches between the natural splitting no damage separation length. Simulation of operation: for displacement of the superficial flexor muscle simulating anastomosis ulnar nerve motor branch (deep branch), repair of hand intrinsic muscle function. The superficial flexor muscle branch of the cross section for histological staining, observed under optical microscope: at high magnification measurement of 5 random fields of the number of myelinated nerve fibers The nerve fiber density was calculated, and the area of the transverse section of the muscle branch was measured in the low magnification field, and the number of the nerve fibers of the muscle branch of the finger flexor muscle was calculated.
緇撴灉:1鎸囨祬灞堣倢鑲屾敮:2-4鏀，

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