桡动脉与桡神经远端的解剖学研究
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摘要
目的：研究桡动脉与桡神经远端在鼻烟窝处的走形分布，以桡骨茎突及茎突平面为标志，测量鼻烟窝段桡动脉及桡神经的具体数据，以找出一个安全区域，为临床上以无头加压空心螺钉法治疗桡骨远端骨折提供解剖学依据。
材料与方法：解剖清理20具（共40例）尸体标本，年龄不详。其中男性13具，女性7具，手臂及腕部无破损，且排除腕部病变。暴露研究区域，对鼻烟窝段桡动脉及桡神经走形相关参数进行测量，并使用统计软件对数据进行处理。
结果：
（1）鼻烟窝外侧界为拇短伸肌腱，它与拇长伸肌腱融合点与桡骨茎突最凸处的距离为（69.50±5.34）mm，最大值为71.80mm，最小值为67.30mm。内侧界为拇长伸肌腱，它与拇短伸肌腱融合点距桡骨茎突平面与拇长伸肌腱交点的距离为（76.20±6.44）mm，最大值为78.16mm，最小值为74.40mm。拇长伸肌腱与拇短伸肌腱在桡骨茎突平面的距离为（21.08±2.14）mm，最大值为22.10mm，最小值为21.00mm。
（2）桡动脉从桡骨茎突的远端斜向内下，经拇短伸肌腱下方，走形于鼻烟窝内，行于拇长伸肌腱和拇短伸肌腱的深面，穿过拇长伸肌腱出鼻烟窝，至第一掌骨间隙，穿第一骨间背侧肌达手掌深部。桡动脉入鼻烟窝处距茎突的距离为（14.52±3.56）mm，最大值为17.70mm，最小值为11.88mm。出鼻烟窝处距茎突平面与拇长伸肌腱交点的距离为（43.80±4.36）mm，最大值为4.600mm，最小值为3.962mm。出鼻烟窝处距茎突的距离为（36.40±3.42）mm，最大值为39.00mm，最小值为34.40mm。桡动脉在鼻烟窝段内走形全长为22.18±2.14mm，最大值为24.00mm，最小值为20.00mm。
（3）鼻烟窝内桡动脉近侧段横径为（2.36±0.24）mm，最大值为2.66mm，最小值为2.20mm。远侧段横径为（1.86±0.18）mm，最大值为2.00mm，最小值为1.70mm。
（4）桡神经浅支常于鼻烟窝上部发出分支，斜过鼻烟窝内，与拇长伸肌腱有交点，与拇短伸肌腱无交点，鼻烟窝内走形长度为(32.10±2.14)mm，最大值为33.54mm，最小值为31.70mm。经茎突平面入鼻烟窝处距茎突的距离为（6.84±3.14）mm，最大值为9.92mm，最小值为4.42mm。出鼻烟窝处距茎突平面与拇长伸肌腱交点的距离为（34.52±4.04）mm，最大值为38.00mm，最小值为29.72mm。出鼻烟窝段距茎突的距离为（32.82±4.14）mm，最大值为35.50mm，最小值为31.30mm。
（5）鼻烟窝内近侧段桡神经横径为（2.56±0.22）mm，最大值为2.90mm，最小值为2.20mm。远侧段桡神经的横径为（1.50±0.14）mm，最大值为1.56mm，最小值为1.40mm。
（6）茎突最凸处距茎突最外侧的距离（AJ）为10.14±1.26mm，最大值为12.18mm，最小值为8.74mm。茎突最凸处距茎突最内侧的距离（AK）为13.26±1.42mm，最大值为15.10mm，最小值为11.90mm。茎突最凸处距茎突近侧端的距离（AH）为13.42±2.34mm，最大值为14.58mm，最小值为11.60mm。茎突最凸处距茎突远侧端的距离（AI）为9.58±1.04mm，最大值为10.18mm，最小值为7.86mm。茎突的最大宽度（JK）为17.56±2.84mm，最大值为19.98mm，最小值为16.50mm。茎突的长轴（HI）为21.80±2.62，最大值为24.32mm，最小值为19.60mm。
结论：
（1）鼻烟窝处，微创治疗桡骨远端骨折的“安全进针区域”为上界为茎突平面近端13mm，下界为桡动脉，外侧界为拇短伸肌腱，内侧界为桡神经浅支的尺侧支及拇长伸肌腱的一部分（EBCDH）。
（2）在C形臂的辅助下，以无头加压空心螺钉的固定方式于“安全区域”进针，可有效的减少桡神经的损伤概率，并能减少手术的窗口，并改善患者的预后。该术式可更好的治疗挠骨远端骨折
Objective：
Research radial artery and distal radial nerve’s distribution in the snuffbox,in order to stem tu and stem tu plane for mark, measuring snuffbox period ofradial radial nerve and specific data, in order to find a safe area, for clinicalheadless pressure in The Treatment of distal radial fractures using cannulatedheadless compression screw in minimally ivasive surgicalto provide theanatomical basis.
Materials and Methods：
clean up with20(40cases) body specimens, age is not known. With13ofmen, women with7, arm and wrist without damage, and ruled out wrist lesions.Exposure to area, and to snuffbox period of radial and radial nerve concernedparameters are measured, and the use of statistical software processing of data.
Results:
（1）The lateral boundary for thumb nest snuff out short tendon, it andthumb long stretch tendon fusion point and stem the convex place at thedistance to (69.50±5.34) mm, a maximum of71.80mm, minimum value of67.30mm. For the world long thumb out tendons, it and thumb short tendonfusion point out from the stem axon plane and thumb long stretch the distanceof the intersection of tendon for (76.20±6.44) mm, a maximum of78.16mm,minimum value of74.40mm. Thumb long stretch and thumb short stretchhamstring tendon in at the distance to stem the plane (21.08±2.14mm, amaximum of22.10mm, minimum value of21.00mm.
（2）Radial stem from her in the far end inclined to, and after thumb shortstretch tendon lower part, walk to snuff in the nest, line in long thumb tendonand thumb short stretch out the tendon deep surface, through long stretch out thumb tendon snuff nest, to first metacarpal space, wear the first bone dorsalmuscles of palm between deep. Radial into the nest from ashdod stem in snuffthe distance to (14.52±3.56) mm, a maximum of17.70mm, minimum value of11.88mm. Out in the sudden stem from the nest snuff plane and thumb longstretch the distance of the intersection of tendon for (43.80±4.36)mm, amaximum of4.600mm, minimum value of3.962mm. Out in the nest fromstem axon snuff the distance to (36.40±3.42) mm, a maximum of39.00mm,minimum value of34.40mm. In snuff nest in radial for walking,(22.18±2.14)mm, a maximum of24.00mm, minimum value of20.00mm.
（3）Snuffbox in near side radial section diameter for (2.36±0.24) mm, amaximum of2.66mm, minimum value of2.20mm. The far side period ofdiameter for (1.86±0.18) mm, a maximum of2.00mm, minimum value of1.70mm.
（4）The radial nerve with shallow used to snuff out the upper nest branch,a snuff in the nest, and the thumb long stretch a tendon intersect, and thumbshort tendon no stretch intersect, snuff in length is walking nest (32.10±2.14)mm, a maximum of33.54mm, minimum value of31.70mm. The plane intothe nest at stem from the stem in snuff running distance to (6.84±3.14) mm, amaximum of9.92mm, minimum value of4.42mm. Out in the sudden stemfrom the nest snuff plane and thumb long stretch the distance of the intersectionof tendon for (34.52±4.04) mm, a maximum of38.00mm, minimum value of29.72mm. A snuff nest from her for stem distance for (32.82±4.14) mm, amaximum of35.50mm, minimum value of31.30mm.
（5）Snuff nest near side in radial neural diameter for (2.56±0.22) mm, amaximum of2.90mm, minimum value of2.20mm. The far side radial neuraldiameter for (1.50±0.14)mm, a maximum of1.56mm, minimum value of1.40mm.
（6）the most convex place at stem from the outside of the stem axon distance (AJ) is10.14±1.26mm, maximum of12.18mm, minimum of8.74mm.Stem from the convex place at the inside of the stem axon distance (AK) is13.26±1.42mm, a maximum of15.10mm, minimum value of11.90mm. Stemfrom the convex place at the near side at stem from (AH) is13.42±2.34mm, amaximum of14.58mm, minimum value of11.60mm. Stem from the convexplace at the far side of ashdod stems from (AI) is9.58±1.04mm, a maximumof10.18mm, minimum value of7.86mm. Her biggest stem width (JK) is17.56±2.84mm, a maximum of19.98mm, minimum value of16.50mm. Stemaxon long axis (HI) is21.80±2.62, a maximum of24.32mm, minimum valueof19.60mm.
Conclusion:
(1) snuff nest place, minimally invasive treatment distal radialfractures’safe needle into the area for the upper bound for Stem axon planeproximal10mm, lower bound for radial artery, the lateral boundary for thumbshort stretch tendon, inside bound for the radial nerve shallow branch of thefeet long and collateral thumb out part of the tendons (HEBD).
(2) in the c-arm help to pressure the headless hollow bolt fixed way in"safe area" into the needle, can effectively reduce the probability of injury tothe radial nerve, and can reduce the operation of the window, and to improvethe prognosis of patients. This operation can be better treatment NaoGu remotefracture
材料与方法：解剖清理20具（共40例）尸体标本，年龄不详。其中男性13具，女性7具，手臂及腕部无破损，且排除腕部病变。暴露研究区域，对鼻烟窝段桡动脉及桡神经走形相关参数进行测量，并使用统计软件对数据进行处理。
结果：
（1）鼻烟窝外侧界为拇短伸肌腱，它与拇长伸肌腱融合点与桡骨茎突最凸处的距离为（69.50±5.34）mm，最大值为71.80mm，最小值为67.30mm。内侧界为拇长伸肌腱，它与拇短伸肌腱融合点距桡骨茎突平面与拇长伸肌腱交点的距离为（76.20±6.44）mm，最大值为78.16mm，最小值为74.40mm。拇长伸肌腱与拇短伸肌腱在桡骨茎突平面的距离为（21.08±2.14）mm，最大值为22.10mm，最小值为21.00mm。
（2）桡动脉从桡骨茎突的远端斜向内下，经拇短伸肌腱下方，走形于鼻烟窝内，行于拇长伸肌腱和拇短伸肌腱的深面，穿过拇长伸肌腱出鼻烟窝，至第一掌骨间隙，穿第一骨间背侧肌达手掌深部。桡动脉入鼻烟窝处距茎突的距离为（14.52±3.56）mm，最大值为17.70mm，最小值为11.88mm。出鼻烟窝处距茎突平面与拇长伸肌腱交点的距离为（43.80±4.36）mm，最大值为4.600mm，最小值为3.962mm。出鼻烟窝处距茎突的距离为（36.40±3.42）mm，最大值为39.00mm，最小值为34.40mm。桡动脉在鼻烟窝段内走形全长为22.18±2.14mm，最大值为24.00mm，最小值为20.00mm。
（3）鼻烟窝内桡动脉近侧段横径为（2.36±0.24）mm，最大值为2.66mm，最小值为2.20mm。远侧段横径为（1.86±0.18）mm，最大值为2.00mm，最小值为1.70mm。
（4）桡神经浅支常于鼻烟窝上部发出分支，斜过鼻烟窝内，与拇长伸肌腱有交点，与拇短伸肌腱无交点，鼻烟窝内走形长度为(32.10±2.14)mm，最大值为33.54mm，最小值为31.70mm。经茎突平面入鼻烟窝处距茎突的距离为（6.84±3.14）mm，最大值为9.92mm，最小值为4.42mm。出鼻烟窝处距茎突平面与拇长伸肌腱交点的距离为（34.52±4.04）mm，最大值为38.00mm，最小值为29.72mm。出鼻烟窝段距茎突的距离为（32.82±4.14）mm，最大值为35.50mm，最小值为31.30mm。
（5）鼻烟窝内近侧段桡神经横径为（2.56±0.22）mm，最大值为2.90mm，最小值为2.20mm。远侧段桡神经的横径为（1.50±0.14）mm，最大值为1.56mm，最小值为1.40mm。
（6）茎突最凸处距茎突最外侧的距离（AJ）为10.14±1.26mm，最大值为12.18mm，最小值为8.74mm。茎突最凸处距茎突最内侧的距离（AK）为13.26±1.42mm，最大值为15.10mm，最小值为11.90mm。茎突最凸处距茎突近侧端的距离（AH）为13.42±2.34mm，最大值为14.58mm，最小值为11.60mm。茎突最凸处距茎突远侧端的距离（AI）为9.58±1.04mm，最大值为10.18mm，最小值为7.86mm。茎突的最大宽度（JK）为17.56±2.84mm，最大值为19.98mm，最小值为16.50mm。茎突的长轴（HI）为21.80±2.62，最大值为24.32mm，最小值为19.60mm。
结论：
（1）鼻烟窝处，微创治疗桡骨远端骨折的“安全进针区域”为上界为茎突平面近端13mm，下界为桡动脉，外侧界为拇短伸肌腱，内侧界为桡神经浅支的尺侧支及拇长伸肌腱的一部分（EBCDH）。
（2）在C形臂的辅助下，以无头加压空心螺钉的固定方式于“安全区域”进针，可有效的减少桡神经的损伤概率，并能减少手术的窗口，并改善患者的预后。该术式可更好的治疗挠骨远端骨折
Objective：
Research radial artery and distal radial nerve’s distribution in the snuffbox,in order to stem tu and stem tu plane for mark, measuring snuffbox period ofradial radial nerve and specific data, in order to find a safe area, for clinicalheadless pressure in The Treatment of distal radial fractures using cannulatedheadless compression screw in minimally ivasive surgicalto provide theanatomical basis.
Materials and Methods：
clean up with20(40cases) body specimens, age is not known. With13ofmen, women with7, arm and wrist without damage, and ruled out wrist lesions.Exposure to area, and to snuffbox period of radial and radial nerve concernedparameters are measured, and the use of statistical software processing of data.
Results:
（1）The lateral boundary for thumb nest snuff out short tendon, it andthumb long stretch tendon fusion point and stem the convex place at thedistance to (69.50±5.34) mm, a maximum of71.80mm, minimum value of67.30mm. For the world long thumb out tendons, it and thumb short tendonfusion point out from the stem axon plane and thumb long stretch the distanceof the intersection of tendon for (76.20±6.44) mm, a maximum of78.16mm,minimum value of74.40mm. Thumb long stretch and thumb short stretchhamstring tendon in at the distance to stem the plane (21.08±2.14mm, amaximum of22.10mm, minimum value of21.00mm.
（2）Radial stem from her in the far end inclined to, and after thumb shortstretch tendon lower part, walk to snuff in the nest, line in long thumb tendonand thumb short stretch out the tendon deep surface, through long stretch out thumb tendon snuff nest, to first metacarpal space, wear the first bone dorsalmuscles of palm between deep. Radial into the nest from ashdod stem in snuffthe distance to (14.52±3.56) mm, a maximum of17.70mm, minimum value of11.88mm. Out in the sudden stem from the nest snuff plane and thumb longstretch the distance of the intersection of tendon for (43.80±4.36)mm, amaximum of4.600mm, minimum value of3.962mm. Out in the nest fromstem axon snuff the distance to (36.40±3.42) mm, a maximum of39.00mm,minimum value of34.40mm. In snuff nest in radial for walking,(22.18±2.14)mm, a maximum of24.00mm, minimum value of20.00mm.
（3）Snuffbox in near side radial section diameter for (2.36±0.24) mm, amaximum of2.66mm, minimum value of2.20mm. The far side period ofdiameter for (1.86±0.18) mm, a maximum of2.00mm, minimum value of1.70mm.
（4）The radial nerve with shallow used to snuff out the upper nest branch,a snuff in the nest, and the thumb long stretch a tendon intersect, and thumbshort tendon no stretch intersect, snuff in length is walking nest (32.10±2.14)mm, a maximum of33.54mm, minimum value of31.70mm. The plane intothe nest at stem from the stem in snuff running distance to (6.84±3.14) mm, amaximum of9.92mm, minimum value of4.42mm. Out in the sudden stemfrom the nest snuff plane and thumb long stretch the distance of the intersectionof tendon for (34.52±4.04) mm, a maximum of38.00mm, minimum value of29.72mm. A snuff nest from her for stem distance for (32.82±4.14) mm, amaximum of35.50mm, minimum value of31.30mm.
（5）Snuff nest near side in radial neural diameter for (2.56±0.22) mm, amaximum of2.90mm, minimum value of2.20mm. The far side radial neuraldiameter for (1.50±0.14)mm, a maximum of1.56mm, minimum value of1.40mm.
（6）the most convex place at stem from the outside of the stem axon distance (AJ) is10.14±1.26mm, maximum of12.18mm, minimum of8.74mm.Stem from the convex place at the inside of the stem axon distance (AK) is13.26±1.42mm, a maximum of15.10mm, minimum value of11.90mm. Stemfrom the convex place at the near side at stem from (AH) is13.42±2.34mm, amaximum of14.58mm, minimum value of11.60mm. Stem from the convexplace at the far side of ashdod stems from (AI) is9.58±1.04mm, a maximumof10.18mm, minimum value of7.86mm. Her biggest stem width (JK) is17.56±2.84mm, a maximum of19.98mm, minimum value of16.50mm. Stemaxon long axis (HI) is21.80±2.62, a maximum of24.32mm, minimum valueof19.60mm.
Conclusion:
(1) snuff nest place, minimally invasive treatment distal radialfractures’safe needle into the area for the upper bound for Stem axon planeproximal10mm, lower bound for radial artery, the lateral boundary for thumbshort stretch tendon, inside bound for the radial nerve shallow branch of thefeet long and collateral thumb out part of the tendons (HEBD).
(2) in the c-arm help to pressure the headless hollow bolt fixed way in"safe area" into the needle, can effectively reduce the probability of injury tothe radial nerve, and can reduce the operation of the window, and to improvethe prognosis of patients. This operation can be better treatment NaoGu remotefracture
引文
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[1]姜保国,张殿英,傅中国,徐海林.桡骨远端Barton骨折的手术治疗[J].中华手外科杂志.2004(01)
[2] P. Wiemer,G. K ster,J. Felderhoff,U. Weber. Fractures of the distal radius.Changing therapeutic strategies[J],1999
[3]卡纳尔.坎贝尔骨科手术学.第3卷[M].第9版.卢世璧译.济南:山东科学技术出版社，2001:2294.
[4]朱晓红,陆春才,吴宝金,戴松茂,吴洪海.以桡动脉鼻烟窝段为蒂岛状皮瓣的应用解剖[J].中国临床解剖学杂志.1997(01)
[5]徐达传,谭新萌,钟世镇,于立新,白喜文,杨铁城.以鼻烟窝区血管作动静脉内瘘血液透析的应用解剖[J].中国临床解剖学杂志.1991(03)
[6]杨胜波,李名杨,张宏.桡动脉鼻咽窝段的若干测量[J].四川解剖学杂志.2000(01)
[7] Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch ofthe radial nerve [J]. Clin Anat,2008,21(1):38-45.
[8]陈一心,郑欣,邱勇,朱亚文,詹朝双,董平.微创治疗桡骨远端骨折时避免克氏针损伤桡神经浅支的研究[J].中国临床解剖学杂志.2009(05)
[9] Glanvill R, Boon JM, Birkholtz F, et al. Superficial radial nerve injuryduring standard K-wire fixation of uncomplicated distal radial fractures [J].Orthopedics,2006,29(7):639-641.
[10]Habernek H, Weinstabl R, Fialka C, et al. Unstable distal radius fracturestreated by modified Kirschner wire pinning: anatomic considerations,technique, and results [J]. J Trauma,1994,36(1):83-88.
[11]Singh S, Trikhaa P, Twymanb R. Superficial radial nerve damage due tokirschner wiring of the radius[J]. Injury,2005,36(2):330-332.
[12]Ruschel PH, Albertoni WM. Treatment of unstable extra-articular distalradius fractures by modified intrafocal Kapandji method [J]. Tech HandUp Extrem Surg,2005,9(1):7-16.
[13]Hochwald NL, Levine R, Tornetta P, et al. The risk of kirschner wireplacement in the distal radius: a comparison of techniques [J]. J Hand SurgAm,1997,20(4):580-584.