TFCC神经分布的解剖和免疫荧光研究
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摘要
目的：
TFCC作为一个韧带软骨复合体,对维系远端尺桡关节的稳定性具有重要作用,其损伤是尺侧腕痛的常见病因,并影响尺腕关节功能。通过对10例成人上肢标本的解剖和免疫荧光染色技术,对腕关节TFCC的神经来源、内部神经分布进行观察,为尺侧腕痛提供病因基础,进而为其临床治疗提供解剖学依据。
方法：
分别对2例成人新鲜标本和8例10%福尔马林固定的成人上肢标本进行显微解剖,10倍显微镜下观察TFCC的神经来源、分布。用大鼠抗人单克隆PGP9.5抗体和Cy3标记的山羊抗大鼠IgG,通过免疫荧光染色技术,对TFCC内部神经分布行定量观察。同时对几个切片进行HE染色,观察TFCC的大体结构。
结果：
通过标本的显微解剖发现,尺神经手背支和前臂内侧皮神经神经均有分支到腕关节尺侧,其中5例前臂内侧皮神经发1个分支至TFCC表面,3例有2个分支至TFCC;1例尺神经手背支发1个分支至TFCC,3例有2个分支,3例3个分支,3例4个分支。尺神经手背支和前臂内侧皮神经可同时支配TFCC。免疫荧光染色发现TFCC内神经主要分布在IP,桡侧没有神经分布。
结论：
TFCC的神经可来自于前臂内侧皮神经和尺神经手背支,不受单一神经支配,其内部神经主要分布在尺侧,尤其是IP部分,顽固性尺侧腕痛可以行去神经支配术。
Objective:
As a ligamentous and cartilaginous complex, TFCC plays an important role on sustaining the stability of distal radioulnar joint (DRUJ),injuries to the triangular fibrocartilage complex are a common cause of ulnar-sided wrist pain and affect the function of the ulnocarpal joint.By the dissection of 10 adult upper-extremity specimens and immunofluorescence technique, the study examined the nervous origin and the distribution of the TFCC of the wrist, and provided the etiopathogenisis basis of ulnar-sided wrist pain, furthermore, provided a proof for clinical treatment of ulnar-sided wrist pain.
Methods:
Two fresh adult upper-extremity specimens and ten adult upper-extremity specimens fixed by 10% formaldehyde were separately studied by microdissection, and we observed the nervous origin and the contribution of the TFCC at 10×magnification. The quantitative study observed the innervation of TFCC via immunofluorescence technique with rat monoclonal antihuman PGP 9.5 antibody and Cy3-marked goat antirat IgG.To study the general structure of the TFCC, meanwhile, several frozen sections were stained with hematoxylin and eosin.
Results:
The microdissection study showed that the dorsal branch of the ulnar nerve and the medial antebrachial cutaneous nerve both had branch to the ulnar side of the wrist.The medial antebrachial cutaneous nerve had one branch to the surface of TFCC in five specimens,and it had two branchs to TFCC in another three specimens. In ten specimens,articular branches to the TFCC arose from the dorsal branch of the ulnar nerve, one branch in one specimen, two branches in three specimens, three branches in three specimens, and four branches in three specimens. TFCC could be simultaneously innervated by the dorsal branch of the ulnar nerve and the medial antebrachial cutaneous nerve. Immunofluorescence showed that IP of TFCC was chiefly innervated, and the radial aspects were not innervated.
Conclusion:
Articular branches to the TFCC can arise from the medial antebrachial cutaneous nerve and the dorsal branch of the ulnar nerve,not single innervation. And they are predominantly located on the ulnar side of the TFCC, especially in the IP.Refractoriness ulnar-sided wrist pain can be performed a operation of denervation.
TFCC作为一个韧带软骨复合体,对维系远端尺桡关节的稳定性具有重要作用,其损伤是尺侧腕痛的常见病因,并影响尺腕关节功能。通过对10例成人上肢标本的解剖和免疫荧光染色技术,对腕关节TFCC的神经来源、内部神经分布进行观察,为尺侧腕痛提供病因基础,进而为其临床治疗提供解剖学依据。
方法：
分别对2例成人新鲜标本和8例10%福尔马林固定的成人上肢标本进行显微解剖,10倍显微镜下观察TFCC的神经来源、分布。用大鼠抗人单克隆PGP9.5抗体和Cy3标记的山羊抗大鼠IgG,通过免疫荧光染色技术,对TFCC内部神经分布行定量观察。同时对几个切片进行HE染色,观察TFCC的大体结构。
结果：
通过标本的显微解剖发现,尺神经手背支和前臂内侧皮神经神经均有分支到腕关节尺侧,其中5例前臂内侧皮神经发1个分支至TFCC表面,3例有2个分支至TFCC;1例尺神经手背支发1个分支至TFCC,3例有2个分支,3例3个分支,3例4个分支。尺神经手背支和前臂内侧皮神经可同时支配TFCC。免疫荧光染色发现TFCC内神经主要分布在IP,桡侧没有神经分布。
结论：
TFCC的神经可来自于前臂内侧皮神经和尺神经手背支,不受单一神经支配,其内部神经主要分布在尺侧,尤其是IP部分,顽固性尺侧腕痛可以行去神经支配术。
Objective:
As a ligamentous and cartilaginous complex, TFCC plays an important role on sustaining the stability of distal radioulnar joint (DRUJ),injuries to the triangular fibrocartilage complex are a common cause of ulnar-sided wrist pain and affect the function of the ulnocarpal joint.By the dissection of 10 adult upper-extremity specimens and immunofluorescence technique, the study examined the nervous origin and the distribution of the TFCC of the wrist, and provided the etiopathogenisis basis of ulnar-sided wrist pain, furthermore, provided a proof for clinical treatment of ulnar-sided wrist pain.
Methods:
Two fresh adult upper-extremity specimens and ten adult upper-extremity specimens fixed by 10% formaldehyde were separately studied by microdissection, and we observed the nervous origin and the contribution of the TFCC at 10×magnification. The quantitative study observed the innervation of TFCC via immunofluorescence technique with rat monoclonal antihuman PGP 9.5 antibody and Cy3-marked goat antirat IgG.To study the general structure of the TFCC, meanwhile, several frozen sections were stained with hematoxylin and eosin.
Results:
The microdissection study showed that the dorsal branch of the ulnar nerve and the medial antebrachial cutaneous nerve both had branch to the ulnar side of the wrist.The medial antebrachial cutaneous nerve had one branch to the surface of TFCC in five specimens,and it had two branchs to TFCC in another three specimens. In ten specimens,articular branches to the TFCC arose from the dorsal branch of the ulnar nerve, one branch in one specimen, two branches in three specimens, three branches in three specimens, and four branches in three specimens. TFCC could be simultaneously innervated by the dorsal branch of the ulnar nerve and the medial antebrachial cutaneous nerve. Immunofluorescence showed that IP of TFCC was chiefly innervated, and the radial aspects were not innervated.
Conclusion:
Articular branches to the TFCC can arise from the medial antebrachial cutaneous nerve and the dorsal branch of the ulnar nerve,not single innervation. And they are predominantly located on the ulnar side of the TFCC, especially in the IP.Refractoriness ulnar-sided wrist pain can be performed a operation of denervation.
引文
[1]Nagle DJ. Triangular fibrocartilage complex tears in the athlete[J]. Clin Sports Med.2001,20:155-166.
[2]费起礼,赵力.腕关节三角纤维软骨复合体损伤的诊治[J].中华骨科杂志,2003,23(8)：507-510.
[3]Palmer AK, Werner FW.The triangular fibrocartilage omplex of the wrist-anatomy and function[J]. J Hand Surg [Am].1981,6:153-162.
[4]洪光祥.中华骨科学手外科[M].北京市：人民卫生出版社,2010：66.
[5]Benjamin M, Evans EJ, Pemberton DJ. Histological studies on the triangular fibrocartilage complex of the wrist[J]. J Anat 1990;172:59-67.
[6]Lewis OJ, Hamshere RJ, Bucknill TM. The anatomy of the wrist joint[J]. J Anat.1970; 106,539-52.
[7]Nakamura T,Yabe Y.Histological anatomy of the triangular fibroca-rtilage complex of the human wrist[J]. Ann Anat 2000; 182,567-72.
[8]Palmer AK. Triangular fibrocartilage complex lesions:a classification [J]. J Hand Surg [Am].1989;14:594-606.
[9]Adams BD, Holley KA. Strains in the articular disk of the triangular fibrocartilage complex:a biomechanical study[J].J Hand Surg[Am].1993; 18A:919-925.
[10]Kauer JMG. The distal radioulnar joint; anatomic and functional considerations[J]. Clin Orthop Rel Res.1992;275:37-45.
[11]汤锦波,徐燕,侍德.腕关节盘的解剖学研究及临床意义[J].中国临床解剖学杂志,2000,18(1)：16-18.
[12]黄继锋,钟世镇,徐达传.三角纤维软骨复合体的解剖学研究[J].中国临床解剖学杂志,2001,19(2)：115-119.
[13]Moritomo H. Advantages of Open Repair of a Foveal Tear of the Triangular Fibrocartilage Complex Via a Palmar Surgical Approach[J]. Tech Hand Surg.2009;13:176-181.
[14]Chidgey LK.Histologic anatomy of the triangular fibrocartilage[J]. Hand Clin.1991;2:249-262.
[15]Cober SR,Trumble TE:Arthroscopic repair of triangular fibrocartilage complex injuries[J]. Orthop Clin North Am.2001;30:279-294.
[16]Bednar MS, AmoczkySP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex:its clinical significance[J]. J Hand Surg(Am). 1991;16:1101-1105.
[17]Mikic Z. The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk disk[J]. Clinical Orthopaedics & Related Research.1992; 275:19-28.
[18]于胜吉,蔡锦方.腕关节外科[M].北京市：人民卫生出版社,2002：29-35.
[19]David J,et al.Triangular Fibrocartilage Complex Repair Through Bone Tunnels (Palmer Type 1D) [J].Oper Tech Sports Med.2010; 18:173-180.
[20]Fukumoto K, Kojima T, Kinoshita Y et al. An anatomical study of the innervation of the triangular fibrocartilage complex[J]. J Jpn Soc Surg Hand.1991;8,598-601 (in Japanese with English abstract).
[21]Gupta R, Nelson, SD, Baker J,et al. The lnnervation of the triangular fibrocartilage complex:nitric acid maceration rediscovered [J]. Plastic &Reconstructive Surgery.2001;107(1):135-139.
[22]Ohmori M, Azuma H.Morphology and distribution of nerve endings in the human triangular fibrocartilage complex[J]. J Hand Surg Br.1998; 23(4):522-525.
[23]Cavalcante ML, Rodrigues CJ, Mattar R. Mechanoreceptors and nerve endings of the triangular fibrocartilage in the human wrist [J]. J Hand Surg Am.2004;29(3):432-435.
[24]Shigemitsu T, Tobe M, Mizutani K,et al.Innervation of the triangular fibrocartilage complex of the human wrist:quantitative immunohistochemical study [J]. Anat Sci Int.2007; 82(3):127-132.
[25]Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears:a rwiew[J]. Bull NYU Hosp Jt Dis.2006;64(3-4):114-118.
[26]Palmer AK, Werner FW, Glisson RR, et al. Partial excision of the triangular fibrocartilage complex [J].J Hand Surg.1988; 13A:391-394.
[27]Adams BD. Partial excision of the triangular fibrocartilage complex articular disk:a biomechanical study [J].The Journal of Hand Surgery.1993; 18(2):334-340.
[28]黄继锋,徐永年,钟世镇.三角纤维软骨复合体损伤的诊断和治疗研究进展.中国实用手外科杂志,2001,15(4)：231-232.
[29]黄继锋,钟世镇.桡尺远侧关节稳定结构的生物力学分析.中华手外科杂志,2001,17(2)：125-127.
[30]Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint[J].J Anat.1978; 126:367.
[31]Schweitzer ME, Brahme SK, Hodler J, et al:Chronic wrist pain: Spinecho and short tau inversion recovery MR imaging and conventionaland MR arthrography[J]. Radiology.1992; 182:205-211.
[32]Potter HG, Asnis-Ernberg L, Weiland AJ, et al:The utility of highresolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist[J]. J Bone Joint Surg Am.1997; 79:1675-1684.
[33]Ruegger C, Schmid MR, Pfirrmann CW, et al:Peripheral tear of the triangular fibrocartilage:Depiction with MR arthrography of the distal radioulnar joint[J]. Am J Radiol.2007;188:187-192.
[34]Coleman HM. Injuries of the anticular disc at the wrist[J]. J Bone Joint Surg Br.1960;42:522-529.
[35]Kessler L, Silberman Z. An experimental studv of the radiocarpal joint by arthrography[J]. Surg Cynecol Obst.1961;112:33-40.
[36]Hajek PC, Sartoris DJ, Neumanm CH, et al. Potential contrast agents for MR arthrography:in vitro evaluation and pratical observations [J]. AJR. 1987;149:97-104.
[37]Andrew H, Mark E, william B, et al. Interal derangement of the wrist:indirect MR arthrography versus unenhanced MR imaging [J].Radiology. 2003;227:701-707.
[38]Andrew H, Mark E, william B, et al. Limitations of MR imaging in the diagnosis of peripheral tears Of the triangular fibrocartilage of the wrist[J]. AJR.2002;178:419-422.
[39]Bowers WH. Problems of the distal radioulnar joint [A].Williams, Advances in orthopaedic surgery[J]. Baltimore.1998.939-989.
[40]Palmer AK. The distal radioulnar joint [J]. Orthop Clin North (Am). 1984; 15:321-335.
[41]Melone CP, Nathan R. Traumatic disruption of the triangular fibrocartilage complex:pathoanatomy[J]. Clin Orthop.1992;275:65-74.
[42]Hermansdorfer JD, Kleinman WB. Management of chronicperipheral tears of the triangular fibrocartilage complex[J]. JHand Surg Am. 1991;16:340-346.
[43]Trumble TE, Vedder N. Isolated tears of the triangularfibrocartilage: management by early arthroscopic repair[J]. JHand Surg Am.1997;22:57-65.
[44]Millants P, De Smet L, Van Ransbeeck H. Outcome studyof arthroscopic suturing of ulnar avulsions of the triangularfibrocartilage complex of the wrist[J]. Chir Main.2002;21:298-300.
[45]Chou CH, Le TS. Peripheral tears of the triangular fibrocartilage complex:results of primary repair[J]. Int Orthop.2001;25:392-395.
[46]Haugstvedt JR, Husby T. Results of repair of peripheraltears in the triangular fibrocartilage complex using an arthroscopic suture technique[J]. Scand J Plast Reconstr SurgHand Surg.1999;33:439-447.
[47]BotteMJ,CohenMS,LaverniaCJ,et al.The dorsal branch of the ulnar nerve:A nanatomic study[J].J Hand Surg Am.1990; 15:603-607.
[48]Wilkinson KD. Regulation of ubiquitin-dependent processes by deubiquinating enzymes[J]. Fed Am Soc Exp Biol.1997;11:1245-56.
[49]Caballero OT, Resto V, Patturajan M, Meerzaman D, Guo MZ, Engles J,Yochem R, Ratovitski E, Sidransky D, Jen J. Interaction andcolocalization of PGP9.5 with JAB1 and p27Kip1[J]. Oncogene.2002;21:3003-10.
[2]费起礼,赵力.腕关节三角纤维软骨复合体损伤的诊治[J].中华骨科杂志,2003,23(8)：507-510.
[3]Palmer AK, Werner FW.The triangular fibrocartilage omplex of the wrist-anatomy and function[J]. J Hand Surg [Am].1981,6:153-162.
[4]洪光祥.中华骨科学手外科[M].北京市：人民卫生出版社,2010：66.
[5]Benjamin M, Evans EJ, Pemberton DJ. Histological studies on the triangular fibrocartilage complex of the wrist[J]. J Anat 1990;172:59-67.
[6]Lewis OJ, Hamshere RJ, Bucknill TM. The anatomy of the wrist joint[J]. J Anat.1970; 106,539-52.
[7]Nakamura T,Yabe Y.Histological anatomy of the triangular fibroca-rtilage complex of the human wrist[J]. Ann Anat 2000; 182,567-72.
[8]Palmer AK. Triangular fibrocartilage complex lesions:a classification [J]. J Hand Surg [Am].1989;14:594-606.
[9]Adams BD, Holley KA. Strains in the articular disk of the triangular fibrocartilage complex:a biomechanical study[J].J Hand Surg[Am].1993; 18A:919-925.
[10]Kauer JMG. The distal radioulnar joint; anatomic and functional considerations[J]. Clin Orthop Rel Res.1992;275:37-45.
[11]汤锦波,徐燕,侍德.腕关节盘的解剖学研究及临床意义[J].中国临床解剖学杂志,2000,18(1)：16-18.
[12]黄继锋,钟世镇,徐达传.三角纤维软骨复合体的解剖学研究[J].中国临床解剖学杂志,2001,19(2)：115-119.
[13]Moritomo H. Advantages of Open Repair of a Foveal Tear of the Triangular Fibrocartilage Complex Via a Palmar Surgical Approach[J]. Tech Hand Surg.2009;13:176-181.
[14]Chidgey LK.Histologic anatomy of the triangular fibrocartilage[J]. Hand Clin.1991;2:249-262.
[15]Cober SR,Trumble TE:Arthroscopic repair of triangular fibrocartilage complex injuries[J]. Orthop Clin North Am.2001;30:279-294.
[16]Bednar MS, AmoczkySP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex:its clinical significance[J]. J Hand Surg(Am). 1991;16:1101-1105.
[17]Mikic Z. The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk disk[J]. Clinical Orthopaedics & Related Research.1992; 275:19-28.
[18]于胜吉,蔡锦方.腕关节外科[M].北京市：人民卫生出版社,2002：29-35.
[19]David J,et al.Triangular Fibrocartilage Complex Repair Through Bone Tunnels (Palmer Type 1D) [J].Oper Tech Sports Med.2010; 18:173-180.
[20]Fukumoto K, Kojima T, Kinoshita Y et al. An anatomical study of the innervation of the triangular fibrocartilage complex[J]. J Jpn Soc Surg Hand.1991;8,598-601 (in Japanese with English abstract).
[21]Gupta R, Nelson, SD, Baker J,et al. The lnnervation of the triangular fibrocartilage complex:nitric acid maceration rediscovered [J]. Plastic &Reconstructive Surgery.2001;107(1):135-139.
[22]Ohmori M, Azuma H.Morphology and distribution of nerve endings in the human triangular fibrocartilage complex[J]. J Hand Surg Br.1998; 23(4):522-525.
[23]Cavalcante ML, Rodrigues CJ, Mattar R. Mechanoreceptors and nerve endings of the triangular fibrocartilage in the human wrist [J]. J Hand Surg Am.2004;29(3):432-435.
[24]Shigemitsu T, Tobe M, Mizutani K,et al.Innervation of the triangular fibrocartilage complex of the human wrist:quantitative immunohistochemical study [J]. Anat Sci Int.2007; 82(3):127-132.
[25]Ahn AK, Chang D, Plate AM. Triangular fibrocartilage complex tears:a rwiew[J]. Bull NYU Hosp Jt Dis.2006;64(3-4):114-118.
[26]Palmer AK, Werner FW, Glisson RR, et al. Partial excision of the triangular fibrocartilage complex [J].J Hand Surg.1988; 13A:391-394.
[27]Adams BD. Partial excision of the triangular fibrocartilage complex articular disk:a biomechanical study [J].The Journal of Hand Surgery.1993; 18(2):334-340.
[28]黄继锋,徐永年,钟世镇.三角纤维软骨复合体损伤的诊断和治疗研究进展.中国实用手外科杂志,2001,15(4)：231-232.
[29]黄继锋,钟世镇.桡尺远侧关节稳定结构的生物力学分析.中华手外科杂志,2001,17(2)：125-127.
[30]Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint[J].J Anat.1978; 126:367.
[31]Schweitzer ME, Brahme SK, Hodler J, et al:Chronic wrist pain: Spinecho and short tau inversion recovery MR imaging and conventionaland MR arthrography[J]. Radiology.1992; 182:205-211.
[32]Potter HG, Asnis-Ernberg L, Weiland AJ, et al:The utility of highresolution magnetic resonance imaging in the evaluation of the triangular fibrocartilage complex of the wrist[J]. J Bone Joint Surg Am.1997; 79:1675-1684.
[33]Ruegger C, Schmid MR, Pfirrmann CW, et al:Peripheral tear of the triangular fibrocartilage:Depiction with MR arthrography of the distal radioulnar joint[J]. Am J Radiol.2007;188:187-192.
[34]Coleman HM. Injuries of the anticular disc at the wrist[J]. J Bone Joint Surg Br.1960;42:522-529.
[35]Kessler L, Silberman Z. An experimental studv of the radiocarpal joint by arthrography[J]. Surg Cynecol Obst.1961;112:33-40.
[36]Hajek PC, Sartoris DJ, Neumanm CH, et al. Potential contrast agents for MR arthrography:in vitro evaluation and pratical observations [J]. AJR. 1987;149:97-104.
[37]Andrew H, Mark E, william B, et al. Interal derangement of the wrist:indirect MR arthrography versus unenhanced MR imaging [J].Radiology. 2003;227:701-707.
[38]Andrew H, Mark E, william B, et al. Limitations of MR imaging in the diagnosis of peripheral tears Of the triangular fibrocartilage of the wrist[J]. AJR.2002;178:419-422.
[39]Bowers WH. Problems of the distal radioulnar joint [A].Williams, Advances in orthopaedic surgery[J]. Baltimore.1998.939-989.
[40]Palmer AK. The distal radioulnar joint [J]. Orthop Clin North (Am). 1984; 15:321-335.
[41]Melone CP, Nathan R. Traumatic disruption of the triangular fibrocartilage complex:pathoanatomy[J]. Clin Orthop.1992;275:65-74.
[42]Hermansdorfer JD, Kleinman WB. Management of chronicperipheral tears of the triangular fibrocartilage complex[J]. JHand Surg Am. 1991;16:340-346.
[43]Trumble TE, Vedder N. Isolated tears of the triangularfibrocartilage: management by early arthroscopic repair[J]. JHand Surg Am.1997;22:57-65.
[44]Millants P, De Smet L, Van Ransbeeck H. Outcome studyof arthroscopic suturing of ulnar avulsions of the triangularfibrocartilage complex of the wrist[J]. Chir Main.2002;21:298-300.
[45]Chou CH, Le TS. Peripheral tears of the triangular fibrocartilage complex:results of primary repair[J]. Int Orthop.2001;25:392-395.
[46]Haugstvedt JR, Husby T. Results of repair of peripheraltears in the triangular fibrocartilage complex using an arthroscopic suture technique[J]. Scand J Plast Reconstr SurgHand Surg.1999;33:439-447.
[47]BotteMJ,CohenMS,LaverniaCJ,et al.The dorsal branch of the ulnar nerve:A nanatomic study[J].J Hand Surg Am.1990; 15:603-607.
[48]Wilkinson KD. Regulation of ubiquitin-dependent processes by deubiquinating enzymes[J]. Fed Am Soc Exp Biol.1997;11:1245-56.
[49]Caballero OT, Resto V, Patturajan M, Meerzaman D, Guo MZ, Engles J,Yochem R, Ratovitski E, Sidransky D, Jen J. Interaction andcolocalization of PGP9.5 with JAB1 and p27Kip1[J]. Oncogene.2002;21:3003-10.
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