本文選題：拇對掌肌 + 對掌功能　； 參考：《南方醫(yī)科大學》2010年碩士論文

【摘要】： 研究背景和目的 拇指功能占手功能的36%-40%,而拇指對掌功能占拇指運動功能的60%。拇指對掌功能障礙主要是由周圍神經(jīng)損傷及手外傷所致,嚴重影響手的功能。由于拇對掌肌在拇指對掌運動中起主要作用,因此如何修復拇對掌肌功能成為臨床治療和研究的重點。 對掌運動是多肌肉、多關(guān)節(jié)參與的復雜聯(lián)合運動,要完成對掌動作需要外展、旋前、橈偏、屈曲四項活動,拇對掌肌是對掌運動中最重要的肌肉,第1掌指關(guān)節(jié)是最重要的關(guān)節(jié)。評價拇對掌功能重建術(shù)的效果,主要考慮術(shù)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。 拇對掌功能重建的方法目前主要有3類,即固定型重建術(shù)、肌腱轉(zhuǎn)位術(shù)和各種顯微外科方法。目前,臨床應用最多的是各種肌腱轉(zhuǎn)位修復拇對掌功能。國內(nèi)、外對周圍神經(jīng)損傷修復的研究已有很大進展,但在促進神經(jīng)再生、功能重建、異體神經(jīng)移植、組織工程化神經(jīng)應用等方面尚需進一步研究。但由于手外傷及周圍神經(jīng)損傷的復雜性,拇對掌功能的重建還沒有一種標準術(shù)式。近年來一些學者在如何運用顯微外科方法重建拇對掌功能的研究中做了大量的工作,主要研究方向是神經(jīng)肌肉的帶蒂／游離移植,取得了一定效果,但手術(shù)難度大,技術(shù)要求高,遠期效果仍需進一步的觀察。 固定型重建術(shù)多采用骨性融合方式,第1、2掌骨間植骨固定術(shù)將拇指固定于對掌位,主要應用于影響對掌功能的骨關(guān)節(jié)病變,是在無合適動力肌腱選擇轉(zhuǎn)位情況下采用的一種術(shù)式。隨著人工關(guān)節(jié)的臨床應用和顯微外科技術(shù)的進展,此項術(shù)式應用越來越少。臨床應用最廣泛的方法是腱轉(zhuǎn)位拇對掌功能重建,目前幾乎前臂大部分肌肉都被用來作為對掌功能重建的供區(qū)肌肉。腱轉(zhuǎn)位拇對掌功能重建手術(shù)關(guān)鍵在于：轉(zhuǎn)位肌腱的選擇、是否重建滑車及滑車位置、轉(zhuǎn)位腱的嵌入點。目前臨床發(fā)現(xiàn)應用該術(shù)式后能大部分恢復拇指橈側(cè)外展功能,但是拇指旋前不夠而不能做充分的對掌動作,由此產(chǎn)生過多的側(cè)向?qū)φ苹蛘邔χ赋山?部分還伴有轉(zhuǎn)位肌腱的粘連。因此更符合生物力學要求和生理功能的腱轉(zhuǎn)位術(shù)式還在進一步探尋中。異體神經(jīng)和組織工程化神經(jīng)的研究近年來進展較快,國內(nèi)、外已有少量報道,但距離臨床大規(guī)模使用還有很長的路要走。 隨著顯微外科的發(fā)展和成熟,各種顯微外科方法重建拇指對掌功能也日益發(fā)展,主要有：①帶血管神經(jīng)蒂的小肌肉移植,如Huber小指展肌轉(zhuǎn)位重建拇對掌肌功能：②運動神經(jīng)移位修復魚際肌支,如Schultz、朱盛修尺神經(jīng)第3蚓狀肌支、骨間前神經(jīng)支轉(zhuǎn)位修復魚際肌支；③吻合血管神經(jīng)的小肌肉移植,如朱盛修、莊永青先后采用了趾短伸肌、胸小肌作為供肌修復拇對掌功能。一些學者認為這種方法可以更好的恢復肌肉本身的生理功能,克服機械力學和牽引方法的弊端,但技術(shù)難度較高,長期臨床效果尚待進一步觀察。 目前臨床拇對掌功能重建治療中存在的問題主要有：①不符合拇指對掌活動的生物力學,所形成的對掌往往是側(cè)向?qū)φ苹驅(qū)χ赋山?以致術(shù)后療效不滿意；②移位肌肉力量或者滑動幅度不夠,不足以帶動拇指做對掌動作或者對掌幅度不能滿足功能要求；③損傷較重要的肌腱,而殘存一定功能障礙；④需重建滑車或者需繞腕橫韌帶或某一肌腱的止點,移位肌腱必須克服成角活動造成的阻力,從而影響拇指對掌活動的靈活性,同時肌腱在滑車部位長期摩擦,易發(fā)生磨損,從而造成肌腱粘連或者斷裂；⑤外形欠滿意,不能達到醫(yī)學美容學的要求。 國內(nèi)、外從很早就開始了神經(jīng)肌蒂的研究,神經(jīng)肌蒂轉(zhuǎn)移技術(shù)已經(jīng)在耳鼻喉、整形等臨床科室應用,相關(guān)的基礎(chǔ)及臨床研究也在進行中。神經(jīng)肌蒂是使用受區(qū)附近較小的運動神經(jīng)分支連同末端的一小塊肌組織移植到受植肌床內(nèi)。肌蒂內(nèi)被切斷的神經(jīng)分支依靠受區(qū)肌肉的去神經(jīng)生物誘導作用,長入受植肌肉,并在其內(nèi)發(fā)出枝芽,形成新生運動終板從而修復該肌的運動功能。神經(jīng)肌蒂可以保留一定量的神經(jīng)分支和運動終板,神經(jīng)分支較易固定,與受區(qū)肌床的愈合良好,不僅可以結(jié)束肌肉的失神經(jīng)萎縮狀態(tài),而且能使受植肌肉更快恢復功能。神經(jīng)肌蒂轉(zhuǎn)移的受植區(qū)一般為體積較小、功能重要的肌肉,這樣才能保證肌蒂內(nèi)的神經(jīng)枝芽較快的長入整塊肌肉,恢復其功能,同時也符合顯微外科領(lǐng)域以次要部位組織修復重要部位組織的手術(shù)原則,這同我們修復拇指對掌肌的目的是一致的。臨床上拇指對掌功能的喪失主要是由于支配魚際肌的正中神經(jīng)返支損傷導致,這種損傷常常是不可逆的。神經(jīng)損傷后,造成魚際肌的失神經(jīng)萎縮,如果能夠早期盡快恢復魚際肌的神經(jīng)再支配,無疑對拇指對掌功能的恢復起著重要作用。尺神經(jīng)深支均為運動肌支,主要支配小魚際肌、全部骨間肌、第3和4蚓狀肌、拇收肌、拇短屈肌深頭。我們的研究設(shè)想是通過顯微外科解剖,觀測尺神經(jīng)深支的分布情況,探討其在相關(guān)肌肉內(nèi)的分布特點,為臨床應用尺神經(jīng)深支第1骨間背側(cè)肌支神經(jīng)肌肉蒂轉(zhuǎn)移修復拇對掌肌功能提供解剖學依據(jù)。 我們的研究主要分以下兩個部分： 第一章第1骨間背側(cè)肌神經(jīng)肌蒂轉(zhuǎn)移修復拇對掌肌功能的臨床解剖 目的：探討尺神經(jīng)深支第1骨間背側(cè)肌遠端肌支神經(jīng)肌蒂轉(zhuǎn)移修復拇對掌肌功能術(shù)式的可行性,為臨床應用提供解剖學基礎(chǔ)。 方法：固定手部標本20例,在手術(shù)顯微鏡下解剖觀測尺神經(jīng)第1骨間背側(cè)肌支及其營養(yǎng)血管的分支、分布情況,據(jù)此設(shè)計帶血管的第1骨間背側(cè)肌遠端肌支神經(jīng)肌蒂轉(zhuǎn)移修復拇對掌肌功能的手術(shù)方式。新鮮手部標本5例,進行手術(shù)模擬。 結(jié)果：尺神經(jīng)深支第1骨間背側(cè)肌支進入肌肉前分出2個分支,分別于肌肉的上、下1／3處進入肌肉；遠端肌支橫徑(1.5±0.2)mm,可無損傷分離長度為(2.82±0.24)cm,可無損傷分離長度與神經(jīng)肌蒂轉(zhuǎn)移需要的距離經(jīng)兩獨立樣本t檢驗,證明其長度足以到達受區(qū)(P0.01)。其營養(yǎng)血管發(fā)自第1或第2掌心動脈,起始處直徑為(0.6-0.9)mm。 結(jié)論：帶血供的尺神經(jīng)第1骨間背側(cè)肌遠端肌支神經(jīng)肌蒂轉(zhuǎn)移修復拇指對掌肌功能的術(shù)式具有可行性,該術(shù)式的實用性、有效性有待臨床進一步驗證。 第二章第1骨間背側(cè)肌神經(jīng)血管解剖學研究 目的：為臨床帶血供的第1骨間背側(cè)肌遠端肌支神經(jīng)肌蒂轉(zhuǎn)移修復拇對掌功能手術(shù)提供供區(qū)肌肉神經(jīng)、血管相關(guān)解剖學依據(jù),評估切取該肌遠端肌支對供區(qū)的影響。 方法：10例手部固定標本,采用顯微解剖方法,觀察第1骨間背側(cè)肌形態(tài)、血供和神經(jīng)支配情況。通過再改良Sihler's染色法對第1骨間背側(cè)肌進行肌內(nèi)神經(jīng)染色。將所取固定標本用去離子水浸泡,5%氫氧化鉀浸泡除色素,Sihler'sⅠ溶液進行脫鈣,Sihler'sⅡ溶液染色,根據(jù)染料配制的情況不同,再次浸入Sihler'sⅠ溶液脫色,然后去離子水浸泡10min,0.05%碳酸鋰溶液,最后將標本依次放入40%、70%、100%梯度甘油中透明。剔除肌肉筋膜,X線觀片箱下觀察拍照。 結(jié)果：第1骨間背側(cè)肌的血供背側(cè)主要以第一掌背動脈為主,掌側(cè)由示指橈側(cè)動脈和第1掌心動脈營養(yǎng)。第1骨間背側(cè)肌支神經(jīng)來源于尺神經(jīng)深支,在進入第1骨間背側(cè)肌前分成兩支。其中近端分支主要分布于肌腹的上2／3,遠端分支主要分布在肌腹的下1／3。 結(jié)論：切取第1骨間背側(cè)肌遠端肌支神經(jīng)肌蒂轉(zhuǎn)位修復拇對掌肌的功能是可行的,其對供區(qū)肌肉的影響較小。
[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.

【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2010
【分類號】：R322.74

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2 劉建國;張付祥;王樹國;付宜利;;偽主動式人手康復方法及其信息庫的研究[J];哈爾濱工程大學學報;2009年02期

3 李玉成,宮輝,何殿友;小指展肌移位拇指對掌功能重建術(shù)[J];黑龍江醫(yī)學;2000年06期

4 唐詩天;腱轉(zhuǎn)位重建拇對掌功能[J];華西醫(yī)學;2003年02期

5 朱盛修，王巖，，黃鋼;骨間前神經(jīng)轉(zhuǎn)移修復魚際肌支傷恢復手內(nèi)肌功能的實驗研究及臨床應用[J];解放軍醫(yī)學雜志;1994年03期

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7 薛洪光;謝仁國;任鳳禮;李軍;陳福生;;創(chuàng)傷修復后肌性拇指對掌功能障礙原因分析及修復術(shù)式探討[J];交通醫(yī)學;2007年03期

8 沈業(yè)彤;畢鄭鋼;;帶蒂小指展肌轉(zhuǎn)位重建拇外展對掌功能的解剖研究及臨床應用[J];齊齊哈爾醫(yī)學院學報;2006年14期

9 劉濤,王斌全,皇甫輝,夏立軍,張念祖;P物質(zhì)在神經(jīng)肌蒂移植治療聲帶麻痹的臨床應用[J];山西醫(yī)科大學學報;2005年01期

10 唐休發(fā),溫玉明,王大章;舌下神經(jīng)頦舌肌蒂植入失神經(jīng)胸大肌瓣的實驗研究[J];實用口腔醫(yī)學雜志;2001年05期

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