大圆肌重建肩肘功能的应用解剖及临床应用初步报告

Anatomical study and clinical application of teres major muscle for reconstruction of shoulder and elbow function

目的 对大圆肌进行应用解剖学研究 ,为临床应用大圆肌重建肩肘功能提供依据。方法 对 44侧陈旧性上肢标本 ,解剖并观察大圆肌的行径、血管神经蒂的长度及其入肌点。对 8例臂丛神经损伤者 ,行大圆肌移位重建肩外展功能 4例 ,伸肘功能 2例 ,屈肘功能 2例。结果 大圆肌肌腹上缘长 6～18cm ,下缘长 11～ 18cm。肌肉起点为肌性者占 63 .6% ,半腱半肌性者 3 6.4% ;肌肉止点为腱性者占79 .5 % ,半腱半肌性者 2 0 .5 %。神经血管蒂入肌处在肌肉上缘腹侧面中段 ,距止点距离 4.6～ 7.8cm。72 .7%的血供来自旋肩胛动脉 ,2 0 .5 %来自胸背动脉 ,6.8%来自肩胛下动脉。自起点至入肌点可分离长度 2 .1～ 7.6cm ,直径 1.0～ 2 .9mm。若分离至腋动脉 ,长度达 6.6～ 18.1cm。神经支配来自肩胛下神经下支 ,至入肌点的长度为 3 .43～ 10 .90cm ,直径 0 .86～ 2 .11mm。血管神经蒂呈多级分支。 4例重建肩外展功能者 ,外展由术前的 46.2 5°改善至 10 1.2 5° ;2例重建屈肘功能者 ,屈肘由术前 0°至术后 90° ;2例重建伸肘功能者 ,伸肘由术前 -65°至术后 0°。结论 大圆肌的血管神经蒂有足够的长度可供移位 ,以重建肩外展、屈肘、伸肘功能。

Objective To study the morphological characteristics of teres major muscle and provide anatomical basis for clinical application of teres major muscle transfer to reconstruct shoulder and elbow function. Methods 44 upper extremities of embalmed human cadavers were dissected. The anatomical features of teres major muscle, the length of the neurovascular pedicle and its course were observed and measured. Teres major muscle transfer was done in 8 cases of brachial plexus injuries to reconstruct shoulder abduction in 4 cases, elbow flexion in 2 cases, and elbow extension in 2 cases. Results The length of the upper part of the muscle belly was 6 to 18 cm, while that of the lower part 11 to 18 cm. The muscle was of muscular origin in 63.6 % of the dissected cadavers, and of semimuscular origin in 36.4 %. The insertion was tendinous in 79.5 %, and semitendinous in 20.5 %. The blood supply of the teres major muscle came from circumflex scapular artery in 72.7 %, from thoracodorsal artery in 20.5 %, and from subscapular artery in 6.8 %. The vascular pedicle had multi grade branches. The length of the vessel ranged from 2.1 cm to 7.6 cm, with diameter of 1.0 mm to 2.9 mm. If the vessel was dissected to the axillary artery, the length of the pedicle was 6.6 to 18.1 cm. The teres major muscle was innervated by lower subscapular nerve. The nerve accompanied the vessels and also had multi grade branches. The length of the nerve ranged from 3.4 cm to 10.9 cm, with diameter of 0.9 mm to 2.2 mm. The neurovascular pedicle entered the muscle at the mid portion of the ventral aspect. Follow up of the clinical cases showed that after muscle transfer, shoulder abduction improved from 46.25° to 101.25° in the 4 cases. In 2 cases of elbow flexion reconstruction, the range of motion increased from 0° preoperatively to 90° postoperatively. In 2 cases of elbow extension reconstruction, the preoperative 65° extension lag disappeared and the elbow could be fully extended. Conclusions The neurovascular pedicle of teres major muscle is long enough so that the muscle can be transferred for reconstruction of shoulder and elbow function.