Applied anatomy of recurrent branch of median nerve and microsurgical treatment of its compression syndrome / 中华显微外科杂志

Objective:To observe the anatomy of the recurrent branch of median nerve, summarize the injury mechanism of the recurrent branch of median nerve, and explore the surgical method and clinical effect of the compression.Methods:From February 2018 to October 2021, 12 fresh hand specimens were used in Department of Hand Surgery in the Second Hospital of Tangshan, including 6 male specimens, 3 left and 3 right hands, and 6 female specimens, 3 left and 3 right hands. Anatomy of the recurrent branch of median nerve and observation of its location, measurement of the length of each muscle branch innervating thenar muscle and the easy-to-jam position of the recurrent branch of median nerve in the course of running. The measurement results uses nonparametric test of statistical analysis by side and gender. P<0.05 was considered statistically significant. From January 2020 to January 2022, 21 patients with entrapment of the recurrent median nerve of wrist were treated, 14 males and 7 females. The age ranged from 31 to 65 years old, with an average of 46.2 years old. All patients developed thenar muscular atrophy. Before operation, the recurrent branch of median nerve was marked into the muscle point, and the thenar projection on palm surface was pressed, which caused fatigue and soreness. Electromyography examination: the motor latency of median nerve endings was more than 4.5 ms, and both fibrillation potential and positive potential appeared. The motor conduction velocity of all patients was less than 30 m/s, and the motor nerve amplitude was less than 10 mV. Surgical exploration of the recurrent branch of median nerve revealed that the trunk of the recurrent branch of median nerve made the tendon arch thickened at the starting point of the superficial head of flexor pollicis brevis, and there was compression between the deep layer of the palmar aponeurosis and the thenar musculocutaneous membrane, which was completely released during the operation to relieve the compression factor. All 21 patients had followed-up in outpatient. Results:Distance from the origin of the recurrent branch of median nerve to the distal edge of transverse carpal ligament. The distance from the origin of the recurrent branch of median nerve to the distal edge of transverse carpal ligament were (0.30, 0.31, 0.32) cm and (0.31, 0.32, 0.32) cm in male left and right groups, respectively, with no statistical significance ( Z=-0.943, P=0.346); The female left and right groups were (0.28, 0.28, 0.28) cm and (0.29, 0.30, 0.30) cm, respectively, and the difference was statistically significant ( Z=-2.121, P=0.034). The length and transverse diameter of the trunk of the recurrent branch of the median nerve, the length of the superficial head branch of flexor pollicis brevis and the length of the palmar muscle branch of the thumb had no significant difference between the left and right sides of males and females( P > 0.05). The length of abductor pollicis brevis muscle branch: the male left and right groups were (1.45, 1.27, 1.31) cm and (1.54, 1.38, 1.47) cm, respectively, and there was no statistical difference ( Z=-1.528, P = 0.127); The female left and right groups were (1.21, 1.18, 1.15) cm and (1.25, 1.24, 1.25) cm respectively, and the difference was statistically significant ( Z=-1.993, P=0.046). All the 21 patients were entered in follow-up for 9-24 (average 15) months. After operation, the wounds of all patients healed in the first stage, the soreness at thenar disappeared, and the thenar muscle was full in appearance. In 21 patients, the thumb abduction function returned to normal, the thumb to palm opposition returned to normal in 19 cases, and was slightly limited in 2 cases. After operation, thenar muscle strength recovered to grade 5 in 19 cases and grade 4 in 2 cases. At the last follow-up, electromyography showed that the motor latency of median nerve endings was less than 4.5 ms, and the motor conduction velocity was greater than 40 m/s; Motor nerve amplitudes were all greater than 10 mV. According to the functional evaluation standard of carpal tunnel syndrome recommended by Gu Yudong, 19 cases were excellent, 2 cases were good, and the excellent and good rate was 100%. Conclusion:The length of each nerve branch of the recurrent median nerve innervates thenar muscle is different, and there are many factors that cause the recurrent median nerve to get stuck. It is of high clinical value to master the anatomical structure of the recurrent median nerve and the mechanism of the entrapment, and to completely loosen vulnerable parts by surgery.

Effectiveness on treatment of metacarpal avulsion fracture with Kirschner wire buckling combined with bone fixation / 中国修复重建外科杂志

OBJECTIVE@#To summarize the effectiveness of Kirschner wire buckling combined with bone fixation in the treatment of metacarpal avulsion fracture.@*METHODS@#The clinical data of 35 patients of metacarpal avulsion fracture admitted between March 2017 and June 2022 were retrospectively analyzed. There were 22 males and 13 females; the age ranged from 20 to 55 years, with an average of 31.6 years. There were 17 cases of the second metacarpal avulsion fracture, 6 cases of the fourth metacarpal avulsion fracture, and 12 cases of the fifth metacarpal avulsion fracture. The causes of injury included 21 cases of strangulation, 8 cases of sprain, and 6 cases of sports injury. X-ray film examination showed that the size of the avulsion fracture of metacarpal bone ranged from 0.30 cm×0.20 cm to 0.55 cm×0.45 cm. The total active motion (TAM) of the injured finger before operation was (154.00±17.38)°. The time from injury to operation was 3-10 days, with an average of 5.8 days. Follow-up regularly after operation, X-ray film and CT examination were performed to evaluate fracture healing and TAM of injured finger was measured. The finger function was evaluated by the trial standard of upper limb function evaluation of Hand Surgery Society of Chinese Medical Association.@*RESULTS@#All the incisions healed by first intention. All 35 patients were followed up 9-36 months, with an average of 28 months. All metacarpal avulsion fractures achieved bony healing, and the healing time was 4-6 weeks, with an average of 4.8 weeks. The metacarpophalangeal joint of the patient was stable, without stiffness, and the flexion and extension activities were good. At last follow-up, the TAM of the injured finger reached (261.88±6.23)°, which was significantly different from that before operation ( t=-35.351, P<0.001). The finger function was evaluated according to the trial standard of upper limb function evaluation of the Society of Hand Surgery of Chinese Medical Association, and 33 cases were excellent and 2 cases were good, with an excellent and good rate of 100%.@*CONCLUSION@#The treatment of metacarpal avulsion fracture with Kirschner wire buckling combined with bone fixation has the advantages of less trauma, firm fixation, and less interference to the soft tissue around metacarpophalangeal joints, which is a good alternative method for the metacarpal avulsion fracture.

Index finger porximal dosal island flap supplied by the second dosal metacarpal artery in repair of the soft tissue defect of thumb / 中华显微外科杂志

Objective:To investigate the method and outcome of reconstruction of thumb soft tissue defect by index finger proximal dorsal island flap supplied by the second dorsal metacarpal artery (SDMA).Methods:From August, 2015 to December, 2017, 12 cases of thumb soft tissue defect were treated by index finger proximal dorsal island flap supplied by SDMA. The site of defect ranged from 2.0 cm×2.4 cm to 5.5 cm×3.0 cm, and the flap area ranged from 2.2 cm×2.6 cm to 6.0 cm×3.3 cm. The donor site was repaired by split-thickness skin graft from the forearm of the injured limb. All patients received regular outpatient follow-up after surgery. The appearance, texture, sensory recovery and donor site of the flap were observed.Results:All the 12 flaps had 5-16 (8.8 in average) months follow-up and survived, the donor site and wounds healed in primary stage. The appearance, sensory and function of the flaps were good. There were no scar contracture on the donor sites, and no pain and limitation of motion in the joints. At the last follow-up, according to the Criteria for Function Assessment of Upper Limbs by the Branch of Hand Surgery of Chinese Medicine Association, the thumb functions were excellent in 11 cases and good in 1 case.Conclusion:Index finger proximal dorsal island flap supplied by SDMA is easy to operate, and has constant blood supply, improved rotation angle of the flap vessel base. It is a good method to repair the soft tissue defect of thumb.

Hollow screw in treatment of basilar part fracture of hamate hook / 中国修复重建外科杂志

Objective: To explore the effectiveness of hollow screw for the treatment of basilar part fracture of hamate hook. Methods: Five patients with basilar part fracture of hamate hook, aged 24-47 years (mean, 31 years) were treated with open reduction and hollow screw fixation between June 2015 and February 2019. There were 4 males and 1 female. The causes of injury were athletic injury in 3 cases, falling injury in 1 case, and crushing injury in 1 case. Among them, 1 case was combined with sensory disturbance of one and a half fingers on the ulnar side of the palm. The grip strength of the affected side was significantly decreased when compared with that of the healthy side in all patients. The intervals between injury and surgery were 3-8 days (mean, 4.2 days). Postoperative follow-up was conducted regularly to measure the grip strength of the affected and healthy fingers and the total motion of ring and little fingers of the affected side. Darrow criteria was used to evaluate the effectiveness. Results: All the incisions healed by primary intention. All the patients were followed up 6-32 months (mean, 16 months). X-ray films showed that the basilar part fracture of hamate hook reached bony union, and the healing time was 2.0-3.5 months (mean, 2.2 months). At last follow-up, the grip strength of the affected side was (35.80±3.76) kg, showing no significant difference when compared with healthy side [(36.00±4.94) kg] ( t=0.094, P=0.930); and the total motion of ring and little fingers of the affected side was (529.0±8.9)°, which was significantly different from that before operation [(232.0±34.7)°] ( t=18.108, P=0.000). In 1 patient with ulnar nerve injury, the two-point discrimination of the innervation area was 4 mm, and the pain sensation and temperature sensation returned to normal. Assessed by Darrow criteria, the results were excellent in 4 cases and good in 1 case. Conclusion: For the basilar part fracture of hamate hook, hollow screw fixation can obtain secure reduction and fixation and provide sustained compression and counter-rotation for the broken end of fracture, thus allowing early joint motion and promoting fracture healing and recovery of wrist function. It is a relatively good method for the treatment of basilar part fracture of hamate hook.

Application of ipsilateral digital proper artery dorsal branch flap to repair mid-phalanx degloving injury with distal segment finger defect / 中国修复重建外科杂志

Objective: To investigate the effectiveness of ipsilateral digital proper artery dorsal branch flap to repair mid-phalanx degloving injury with distal segment finger defect. Methods: Between February 2013 and July 2016, 11 cases (11 fingers) of mid-phalanx degloving injury with distal segment finger defect were treated. There were 9 males and 2 females with an average age of 33.6 years (range, 18-59 years). The injury caused by twisting in 8 cases and crushing in 3 cases. The injury located at index finger in 3 cases, middle finger in 6 cases, and ring finger in 2 cases. The skin avulsion was from proximal interphalangeal joint in 1 case, proximal 1/4 of mid-phalanx in 6 cases, and 1/2 of mid-phalanx in 4 cases. The area of wounds ranged from 4.0 cm×1.7 cm to 6.2 cm×2.6 cm. The interval between injury and operation was 2.5-6.0 hours (mean, 4.5 hours). All defects were repaired with the ipsilateral digital proper artery dorsal branch flaps. The size of flaps ranged from 4.4 cm×1.9 cm to 7.0 cm×2.9 cm. Nerve anastomose was carried between digital proper nerve dorsal branch in the flap and digital proper nerve stump in the wound. The donor sites were repaired by skin grafting. Results: Tension blisters of the flap and partial necrosis occurred in 1 case, and healed after dressing change. The other flaps and skin grafting survived, and wounds healed by first intention. All patients were followed up 6-18 months (mean, 16 months). The texture and appearance of all the flaps were satisfactory. At 6 months after operation, two-point discrimination of flaps ranged from 7 to 10 mm (mean, 8.5 mm). At last follow-up, according to the functional assessment criteria of upper limbs by the Branch of Hand Surgery of Chinese Medicine Association, the results were excellent in 10 cases and good in 1 case, with the excellent and good rate of 100%. Conclusion: The ipsilateral digital proper artery dorsal branch flap is a good method to repair mid-phalanx degloving injury with distal segment finger defect for the advantages of simple operation, less damage in donor site, high survival rate of the flap, and good feeling recovery of the finger.

Clinical observation of combined skin flap and abdominal flap for repair of distal finger degloving injury / 中华显微外科杂志

Objective To compare the clinical effect and operation difficulty of the combined skin flap with reversed proper palmar digital arterial dorsal branch island flap and cross-finger flap and the abdominal flap in the treatment of distal finger degloving injury.Methods Inclusion criteria:①Soft tissue defect far beyond the level of distal interphalangeal joints.②The inured finger was from second to fifth.③Single finger injury.④ Iniury time within 8 h.Exclusive criteria:①With tendon injury.② Multiple finger injuries.③Followed-up time within 6 months.Between February,2009 and September,2016,52 patients (52 fingers) with distal finger degloving injury were reviewed,there were 32 males and 20 females,aged from 18 to 60 (36.02±11.00) years.The time from injury to operation was 2.5-8.0 (4.81±1.28) h.Affected fingers included index finger in 15 cases,middle finger in 22 cases,ring finger in 10 cases,and little finger in 5 cases.Twenty patients (20 fingers) were treated by combined skin flap with reversed digital arterial dorsal branch island flap and cross-finger flap(group combined-flap).The cubital skin was grafted onto the donor sites.Thirty-two patients (32 fingers) were treated by abdominal flap (group abdominal-flap).Results The patients were followed-up 6-25 (9.25±3.97) months.The operation time:group combined-flap was 80-130 (98.46±8.34) min and group abdominal-flap was 85-125(107.84±8.63)min.There was no significant difference in two groups (P＞0.05).Pedicle division time:group combined-flap was 15-24 (16.75±1.74) d and group abdominal-flap was 24-45 (28.31±5.12) d.There was a significant difference in two groups (P＜0.05).And the pedicle division time in group combined-flap was much shorter than in group abdominal-flap.Flap function at last follow-up,the excellent and good rate of the flap in group combined-flap and group abdominal-flap was 90.00％ and 59.38％,respectively.There was a significant difference in two groups (P＜0.05),and the flap function in group combined-flap was much better than in group abdominal-flap.Affected finger function at last follow-up,the excellent and good rate of the affected fingers was 95.00％ and 71.88％.There was a significant difference in two groups (P＜0.05),and the affected finger function in group combined-flap was much better than in group abdominal-flap.Conclusion The combined skin flap with reversed digital arterial dorsal branch island flap and cross-finger flap is a simple and high-survival-rate flap,whose texture,appearance and clinical outcome for repair of distal finger degloving injury are much better than traditional abdominal flap.

Repair of soft tissue defects at middle or distal part of 2nd ～ 5th finger and donor site with relaying reversed perforator flaps / 中华显微外科杂志

Objective To investigate the clinical effectiveness of the reversed flaps pedicled with lateral vas-cular chain of dorsal branch of digital artery and perforating branch of the dorsal metacarpal artery for relaying repair of soft tissue defects at middle-distal part of the 2nd ～ 5th finger and donor site. Methods From June, 2014 to May, 2016, a total of 18 cases (11 male and 7 female) with soft tissue defects at middle-distal part of 2nd～5th fin-ger were treated with the reversed flap pedicled with lateral vascular chain of dorsal branch of digital artery. The donor site was repaired with the reversed flap pedicled with the perforating branch of the dorsal metacarpal artery. The aver-age age at the time of reconstruction was 41 years. The right hand was involved in 12 cases and the left in 6 cases. The etiologies of injury were avulsion (n=5) , crush (n=6), and saw-cut injury (n=7). There were 15 cases with soft tissue defect at the distal phalanx and 3 cases with loss of distal and middle phalanx. All these cases were exposed with bone or tendon. The defect size ranged from 1.0 cm × 1.8 cm to 2.0 cm × 3.0 cm. And the dimension of the re-versed flaps pedicled with lateral vascular chain of dorsal branch of digital artery and perforating branch of the dorsal metacarpal artery ranged from 1.2 cm × 2.0 cm to 2.3 cm × 3.3 cm, and 1.4 cm × 2.3 cm to 2.6 cm × 3.6 cm, respec-tively. Postoperative follow-up was done termly. Results All flaps survived uneventfully with primary healing at donor site. The mean of followed-up time was 11 months (ranged from 6 to 15 months). The appearance and texture of the flaps were satisfactory and similar to the surrounding tissue. There was only some linear scar left at the dorsum of the palm. On the basis of the MHQ, 16 patients were strongly satisfied (score 5) with the appearance of the flap, and the remaining 2 patients was satisfied (score 4) with the appearance. The static 2-point discrimination of the flaps at the middle-distal part of 2nd～5th finger was 5-9 mm. Based on TAM assessment, the function of the injured finger was graded as excellent in 15 cases, good in 3 cases. Conclusion The relaying reversed flaps pedicled with lat-eral vascular chain of dorsal branch of digital artery and perforating branch of the dorsal metacarpal artery can be applied for repair of soft tissue defects at middle-distal part of 2nd～5th finger and donor site with easy procedure, reliable blood supply, satisfactory results, good appearance as well as less complications at donor sites.

Comparative study of the effect of innervated reverse digital artery island flap and the digital artery island flap with dorsal branches for fingertip repair / 中华整形外科杂志

Objective@#To compare the clinical effect of innervated reverse digital artery island flap and the digital artery island flap with dorsal branches in the repair of fingertip defects.@*Methods@#From January 2014 to June 2015, a total of 43 cases (50 fingers) with fingertip defects in 2-5 fingers were randomly treated with reverse digital artery island flaps (23 cases) or the digital artery island flaps with dorsal branches (20 cases). All cases underwent emergency surgery. The operative time, patient satisfaction of appearance for the reconstructed fingers, the static 2-point discrimination of the flaps, active motion of the injured finger joints and postoperative appearance on donor site were compared respectively.@*Results@#All flaps survived primarily. The follow-up period ranged from 12-18 months. No significant differences were found in operative time and active motion of the injured finger joints between the two groups (P>0.05). Patient satisfaction of appearance and the static 2-point discrimination of the flaps in reverse digital artery island flap group were better than those in the digital artery dorsal branch island flap group (P<0.05). For the donor site, the texture of donor site in reverse digital artery island flap was soft without significant Scar contracture and pigmentation. There were 5 cases with mild scar contracture in donor site at the digital artery island flap with dorsal branches.@*Conclusions@#The reverse digital artery island flap and the digital artery island flap with dorsal branches are all suitable for the repair of fingertip defects. Compared with the digital artery island flap with dorsal branch, the reverse digital artery island flap can provide better fingertip sense and appearance.

Designing a dorsal branches flap of the proper palmar digital artery to repair pediatric middle-phalanx skin defects / 中华显微外科杂志

Objective To discuss a design of flap of dorsal branches of the digital proper artery to repair pediatric middle phalanx skin defects and its effect.Methods From October,2013 to March,2015,antegrade flaps were used to treat 9 pediatric patients with skin defect in middle phalanx,the dorsal branches of the digital proper artery were used as the pedicel.The dorsal branch of digital proper nerve carried by flap was sutured with digital proper nerve in wound surface of middle phalanx,flap cutting area was 3.5 cm × 1.2 cm-2.5 cm × 0.8 cm,the donor site of flap was repaired by full thickness skin graft.Results All the 9 flaps survived,and primary healing in the wound of donor and recipient site.The 9 patients were followed up for 6-12 months,with an average of 8 months.All the flaps had soft texture and full shape,the two-point discrimination was 5-9 mm,6.5 mm on average.Conclusion To repair skin defect in the middle phalanx with flap using the dorsal branches of the digital proper artery as the pedicel and sutured the dorsal branch of digital proper nerve,combine advantages of the simplicity,high skin flap survival rate,good postoperative appearance and sensation recovery.

Application of external fixator in vascular injuries to the knee and calf / 中华骨科杂志

Objective To investigate the effect of external fixator on repairing the vascular injuries in the knee and calf.Methods From May 2004 to October 2010,208 patients (234 sides) with vascular injuries in knee and calf,treated with external fixation,were retrospectively analyzed,including 192 males (217 sides) and 16 females (17 sides) with an average age of 39.6 years (range,14-67).Blood vessel damage:the popliteal artery injury in 84 patients (86 sides),the anterior tibial artery injury in 36 (46),the posterior tibial artery injury in 41(49),the anterior tibial artery and the posterior tibial artery injury in 47 (53).Complete ischemic of the injured distal limb existed in 129 patients(141 sides),incomplete ischemia in 79 patiets (93 sides).All patients underwent emergency surgery.The AO external fixators were used in 164 patients,the chuangsheng inlaid external fixators in 37,and the hybrid external fixators in 7.The injured vessels were anastomosed directly,or indirectly with great saphenous vein.The wounds were treated with phase Ⅰ bandage,skin grafts,flap transplantation or VSD suction.Results One hundred and ninty four patients obtained successful limb salvage; but 14 patients underwent amputation owing to serious damage of limb and poor general condition.One hundred and twenty seven patients underwent the second stage debridement combined with skin graft or flap transplantation; 24 patients underwent the first stage free skin graft or flap transplantation;wound cicatrized by oneself in 43 patients.One hundred and forty eight patients were followed up for 8 months to 3 years.External fixators were removed after an average of 7.2 months (range,1-18).The average healing time of fracture in 102 patients was 5.6 months (range,3-13).Forty patients suffered bone nonunion or bone defect; after treated by fracture fixation,bone graft or bone transport,all of them got bone union.Conclusion The external fixation can shorten operation time as well as the time of limb ischemia,which is an effective option on repairing vascular injuries in knee and calf.

Imaging anatomic study of deep branch of ulnar nerve / 中华显微外科杂志

Objective To dissect and observe the course of the deep branch of the ulnar nerve and its'distribution of the muscular branch,to provide imaging and anatomical basis for early diagnosis and treatment of the wrist deep branch of ulnar nerve injury in clinical. MethodsFrom October 2008 to August 2010,dissected 16 fresh and 4 antiseptic samples, with the most bump of the hook of the hamate bone as the origin O,set the axis over the O point.The distance from O to the intersection point of the X axis and the deep branch of ulnar nerve was OE ; the distance from O to the intersection point with the ulnaris of hook of hamate bone was OF; the distance from O to the proximal deep branch of ulnar nerve intersection point of the Y axis was OG; the distance from O to the distal deep branch of ulnar nerve respectively was OH.Named the head of the metacarpal bone and the palm side of the center of the basal of the 2nd to the 5th metacarpal bone, through these two points,the measure related data from the deep branch of the ulnar nerve and the metacarpal bone in the sagittal plane.Having a CT scan image data,the Barium Sulfate ( Ⅱ ) dry suspension was uniformly smeared onto the surface of the deep branch of ulnar nerve, the data obtained was analyzed using SPSS 13.0.ResultsThe length of OE was ( 4.96 ± 0.11 ) mm,CT result was (5.02 ± 0.12 ) mm; the length of OF was (3.69 ± 0.12 ) mm,CT result was(3.75 ± 0.12)mm; the length of OG was(10.55 ± 1.07)mm,CT result was(10.48 ± 0.84)mm;the length of OH was (7.23 ± 0.85)mm,CT result was (7.29 ± 0.84)mm; the length of EF was (1.27 ± 0.15 )mm,CT result was( 1.17 ± 0.16)mm.The measure related data from the deep branch of the ulnar nerve and the metacarpal bone in the sagittal plane. Each data set of the anatomical results and CT results had been tested by T,P values were more than 0.05. ConclusionsThere is no significant difference between anatomic and CT observations of deep branch of ulnar nerve, CT observations can be regarded as a clinical reference directly.Anatomic and CT observations can be seen as a guide for clinical work in the diagnosis and treatment of deep branch of ulnar nerve injury.