close

Вход

Забыли?

вход по аккаунту

?

Functional gliding spaces of the dorsal side of the human hand.

код для вставкиСкачать
THE ANATOMICAL RECORD 267:242–251 (2002)
Functional Gliding Spaces of the
Dorsal Side of the Human Hand
PETRA THURMÜLLER,* MARKUS SCHUBERT, HOLGER BADE,
HANS-PETER NOTERMANS, JUTTA KNIFKA, AND JÜRGEN KOEBKE
Department of Anatomy, University of Cologne, Cologne, Germany
ABSTRACT
The clinical and functional importance of gliding spaces of the hand (e.g., their role in the
spread of infection or as a consideration in reconstructive surgery) has been repeatedly
emphasized. However, only a few studies have provided details regarding the connective
tissue spaces in the metacarpal region of the dorsal side of the human hand. The aim of the
present study was to analyze the morphology and elucidate the anatomic relation of functional gliding spaces in the metacarpal region on the dorsal side of the human hand in order
to provide a better understanding of function, and of clinical disorders and their treatment.
To delineate these spaces we used a plastic (Acrifix 90威) injection method. Twenty fixed and
unfixed cadaver hands were subcutaneously injected with Acrifix 90威 (a methacrylate) into
the metacarpophalangeal transitional region and into the tendon sheaths of the extensor
muscles. Different colors were used to distinguish one injected plastic solution from another.
The spreading pattern of the injected medium was analyzed by careful dissection. To delineate the exact bordering structures and the topography of the injected spaces, two hands were
plastinated using the E12/E6 technique (von Hagens et al., Anat Embryol 1987;175:411–
421), and one hand was injected and embedded in Technovit 7100威 for histological investigations. Injecting the plastic into the metacarpophalangeal transitional region of fingers
II–IV in a disto-proximal direction, the solution spreads along the surface of the separate
extensor tendons. It then coalesces 1–2 cm proximal to the injection points to form a
continuous plastic plate, which protrudes between and on top of the previous injected tendon
sheaths. In no case was a communication between the paratendinous tissue and the tendon
sheaths observed. Laterally, the injected solution is delimited at the radial side of the
extensor tendon of the second finger and at the ulnar side of the extensor tendon of the fourth
finger. Using the described technique at the fifth finger yields a plastic plate that extends
from the injection point to the tendon sheath. However, in two specimens a connection
between the plastic injected into the tendon sheath of the fifth finger, and the distal injected
solution was observed. Anat Rec 267:242–251, 2002. © 2002 Wiley-Liss, Inc.
Key words: anatomy; extensor apparatus; paratendinous connective tissue;
tendon sheath
With respect to its connective tissue architecture, the
dorsal side of the hand can be contrasted with the palm.
The connective tissue surrounding the extensor apparatus
forms loose structured layers, providing the dorsal connective tissue body with a high degree of mobility (Schmidt
and Lanz, 1992). On the dorsal side of the human hand the
extensor tendons are not covered by tendon sheaths in
their metacarpal part, but are surrounded by a multilamellary paratendinous connective tissue (Bade et al.,
1992), which is considered to have a specialized gliding
function for the tendons. The importance of the paratenon
to the supple movement of the extensor tendons is made
obvious by pathological alterations such as the paratendonitis crepitans that results from mechanical overloading or direct trauma. Moreover, insufficient posttraumatic
©
2002 WILEY-LISS, INC.
and postoperative regenerative processes or adhesions of
the paratenon often lead to secondary functional disturbance of neighboring tendinous elements of the dorsal
extensor apparatus. Contributing to frictionless motility
*Correspondence to: Petra Thurmüller, Institut II für Anatomie der Universität zu Köln, Joseph-Stelzmann-Stra␤e 9,
D-50931 Köln, Germany. Fax: ⫹49-221-4785318.
E-mail: Petra.Thurmueller@uni-koeln.de
Received 21 October 1999; Accepted 14 March 2002
DOI 10.1002/ar.10113
Published online 10 June 2002 in Wiley InterScience
(www.interscience.wiley.com).
GLIDING SPACES OF THE DORSAL SIDE OF THE HAND
during tendon movement, (Feneis, 1935; Lang, 1960;
Dykyj and Jules, 1991; Rauber/Kopsch, 1998) the paratendinous connective tissue is rich in blood vessels and is
important to the vascular supply of the metacarpal part of
the extensor tendons between the distal end of the tendon
sheaths and the metacarpophalangeal joints (Lang, 1960;
Bade et al., 1992). The clinical and functional importance
of gliding and connective tissue spaces has been repeatedly emphasized, e.g., as regards their role in spread of
infection and as a consideration in reconstructive surgery.
However, only a few studies have investigated the connective tissue spaces (Mason and Koch, 1930; Kanaval, 1939;
Anson et al., 1945; Landsmeer, 1976; Bade et al., 1994) at
the dorsal side of the human fingers or hand. Kanaval
(1939) used injection experiments to demonstrate the morphology of tissue spaces. He correlated the anatomical
findings with his own clinical experience in relation to the
spread of infections following penetrating injuries. Mason
and Koch (1930) placed their emphasis on the dorsal side
of the metacarpophalangeal transitional region of the long
fingers, which deserves special attention because infections within these areas can spread not only on the dorsal
side of the fingers but also on the dorsal side of the hand.
They attempted to examine tissue spaces using injections
of a barium sulfate gelatin solution in fingers of human
cadavers, and analyzed the specimens by subsequent dissection and radiographs to determine the dispersion of the
solution. Nevertheless, the morphology of connective tissue spaces, and their relationship to the extensor apparatus and the tendon sheaths remain unclear. Because these
are potential spaces, they are often difficult to dissect and
therefore require special techniques for demonstration
purposes. In the present study, we used a plastic injection
method previously described by Schubert et al. (1994) for
delineation of these capillary spaces, and analyzed the
macroscopic topography and morphology of the connective
tissue spaces on the dorsal side of the human hand, with
preparation and plastination of the injected specimens. To
obtain detailed information about this topographically
and morphologically complex gliding system, which consists of multilamellary paratendinous connective tissue
and the tendon sheaths of the extensor apparatus, we
used the Technovit 7100威 (Kulzer GmbH, Wehrheim, Germany) resin embedding technique for histological investigations. Special attention was given to the small transition region of these gliding spaces. Bade et al. (1994) and
Schubert et al. (1996) investigated gliding spaces at the
dorsal side of the human finger using plastic injections,
and described very constant spaces. Bade et al. (1995)
examined the dorsal connective tissue body of the human
finger and described a deep lamellar system that covers
the aponeurosis dorsalis of the human finger. This system
of collagen lamellae separates the dorsal connective tissue
from the dorsal aponeurosis. Furthermore, Bade et al.
(1995) showed that the internal side of the deep lamellar
system is covered by a synovial-like epithelium. These
results identified the spaces between the dorsal hood and
the deep lamellar system as gliding spaces. Schubert et al.
(1996) reported that in some cases the gliding spaces at
the dorsal side of the fingers expand on the dorsal side of
the human hand. Kanaval (1939) injected a barium sulfate mixture into the dorsal side of the hand and found
that the solution dispersed widely. The aim of the present
study was to analyze the exact morphology, expansion,
and anatomical relation of functional gliding spaces on the
243
Fig. 1. Schematic representation of the injection sites (a and b)
marked by dots.
dorsal side of the human hand to provide an anatomical
basis for a better understanding of their function, and of
clinical disorders and their treatment.
MATERIAL AND METHODS
Sixteen fixed and unfixed hands were injected with a
plastic solution at predefined points (Fig. 1a and b) and
the dispersion of the injected medium was analyzed by
subsequent dissection. The injection was performed immediately proximal to the metacarpophalangeal joints II–V
(Fig. 1a) with disto-proximal direction of dispersion. Prior
to this, an injection into the tendon sheath of the m.
extensor digitorum and the m. extensor indicis was performed (Fig. 1b) with proximo-distal dispersion of the injected plastic solution. Acrifix 90威 (Röhm GmbH, Darmstadt, Germany) was used as the injection plastic. Acrifix
90威 is a plastic based on acrylic acid and is used industrially as a plexiglas glue. We used Acrifix 90威 in the mixture
(see Table 1).
To avoid artifacts, the injection points were dissected in
a T-shape, with the horizontal bar oriented in the direction of dispersion. An open pouch was formed in the dispersion direction. The plastic was injected at these points
and was allowed to flow slowly into the capillary spaces. In
order to distinguish between the plastic solutions injected
at various locations, different colors were used. The injection was performed by a threaded, guided injection apparatus (Schlüter, 1961). The injection pressures were controlled by leaving an air bubble in the injection system as
a useful pressure indicator. This facilitated the use of low
injection pressures (Schubert et al., 1994). Following the
244
THURMÜLLER ET AL.
TABLE 2.
TABLE 1.
Injection mixture
Catalyst 20威
Thinner
Acrifix 90威
Coloring (Röhm GmbH 8076/8075)
%
3
1–3
93–95
1
Injection plastic
Parts
Biodur E20威
Biodur E2威
Biodur AT 10威
Coloring (Röhm GmbH 8076/8075)
100
42
20
2
TABLE 3.
Infiltration solution
injection, the hand was placed in a position that allowed
the plastic to drain slowly into the capillary spaces.
Two unfixed hands were examined by the technique of
block-plastination, which allowed the production of 1-mmthick serial sections using a diamond wire saw (type 6234,
Fa. Well). The hands were arterially perfused with physiological saline solution and a plastic solution was injected
at defined injection points (Fig. 1) by the technique described above. The contents of the injection plastic are
shown in Table 2.
It was necessary to use an acetone-insoluble injection
medium to prevent the injected substance from being dissolved by the acetone dehydration bath. After the plastic
was hardened, the hands were fixed with a 4% formaldehyde solution via the radial artery and placed in a formaldehyde solution for 14 days. The hands were plastinated
using the E6威/E12威 technique (von Hagens, 1985/1986),
which consists of three steps (described in detail by Schubert et al., 1996): 1) dehydration and fat removal, 2) forced
impregnation, and 3) hardening.
Histological Investigations
Another unfixed hand was arterially perfused with
physiological saline solution and injected with plastic at
defined injection points (Fig. 1) using Biodur E20®/E2® as
the injection solution. After hardening of the plastic, the
hand was fixed via the radial artery with a 4% formaldehyde solution. After fixation, the hand was frozen to –25°C
and cut into 1-cm-thick slices with a diamond wire saw
(type 6234, Fa. Well). The slices were placed in a formaldehyde solution for 14 days. Dehydration and fat removal
of the specimens was performed in acetone baths of increasing concentrations (90%, 98%, and 99%). The tissue
slices were decalcified using EDTA, and the calcium remnants of the bone were examined radiographically. The
embedding technique (Technovit 7100威) had to be modified to handle these large specimens. The preinfiltration
step was not used, and the specimens were put directly
into the infiltration solution (see Table 3).
During acetone extraction and infiltration, the specimens were kept in a vacuum environment for 3 hr. To
prevent elevation of temperature caused by heat of reaction in such large objects, the Harder II (10 ml/100 ml
infiltration solution; Heraeus Kulzer, Wehrheim, Germany) was mixed with the infiltration solution at –25°C.
The polymerization was initiated at –25°C. Step by step
the polymerization was continued at slowly increasing
temperatures, and it reached room temperature in 14
days. After hardening, sections (5–10 ␮m thick) were
made using a hard microtome. The sections were stained
with toluidine blue. Another hand was treated in the
described manner, without injection of plastic.
Technovit 7100威 (GMA with Co-Catalyst XLC)
Harder I (Dibenzoylperoxid)
100 ml
1g
RESULTS
Topography and Morphology of the Gliding
Tissue Spaces of the M. extensor digitorum and
the M. extensor indicis, Analyzed by Injection
and Subsequent Dissection
Injection of the plastic solution into the metacarpophalangeal transition region of fingers II–IV in disto-proximal
direction led to a dispersion of the solution on the surface
of the extensor tendons (Fig. 2). The solution spread along
the surface of the extensor tendons, and then coalesced to
form a continuous plastic plate 1–2 cm proximal to the
injection points. This plate protruded between and over
the previously injected tendon sheaths of the M. extensor
digitorum and the M. extensor indicis. In no case was a
communication between the plastic solution injected into
the multilamellary paratendinous connective tissue and
the plastic solution injected into the tendon-sheaths observed. Laterally, the injected solution was delimited at
the radial side of the extensor tendon of the second finger
and at the ulnar side of the extensor tendon of the fourth
finger (Fig. 2). The dorsal surface of the plastic plate was
covered by an always demonstrable connective tissue
membrane. This membrane forms a roof for the gliding
compartment, which is occupied by the extensor tendons
and their enveloping coats and separates the loose, areolar, subcutaneous tissue of the dorsum of the hand from
the delineated gliding spaces. This connective tissue membrane is non-fatty and very strong, and contains clearly
visible fibers that contribute to its appearance as a weaker
aponeurosis. It dips at the ulnar side of the extensor
tendon of the fourth finger and at the radial side of the
extensor tendon of the second finger volarwards to become
continuous with the equivalent infratendinous membrane, which itself forms the palmar surface of the gliding
tissue spaces of the M. extensor digitorum and the M.
extensor indicis. These marginal attachments of both connective tissue membranes can be regarded as the cause of
the precise bordering of the injected plastic plate at the
ulnar and the radial side of these tendons. In no case did
the injected plastic plate reach the extensor tendon of the
first or the fifth finger. Around the free edges of the second
and fourth extensor tendons, the infratendinous and supratendinous layers are not distinct. Conjoined, they become continuous with the connective tissue of the extensor
tendon of the first and fifth fingers. In the proximal direction, the supratendinous connective tissue membrane is in
close contact with the tendon sheaths and continues into
Fig. 2. Acrifix mold of the paratendinous connective tissue space
occupied by the extensor tendons (blue color) and the previously injected synovial tendon sheaths (yellow color) following injection (see the
injection points marked with dots a and b in Fig. 1) and dissection.
Fig. 4. Multilamellary paratendinous connective tissue space (red color)
of the M. extensor digitorum and the M. extensor indicis in the region of the
middle of the metacarpus (Technovit 7100姞, toluidine blue, 7 ␮m, ⫻7, line
1 (Fig. 3)). The enlargement of this section shows the localization of the
injection medium between the supratendinous (arrowheads) and infratendinous (arrows) membranes bordered laterally by a thin lamella at the free
edges of the fourth (IV) and second (II) extensor tendons. The division of the
paratendinous connective tissue space into lesser spaces by intertendinous
networks of loose connective tissue is shown.
Fig. 5. Transverse section through the common tendon sheath of the
M. extensor digitorum, lying immediately under the retinaculum extensorum
(Technovit 7100姞, toluidine blue, 7 ␮m, ⫻5, line 5 (Fig. 3)). The extensor
tendons are completely surrounded by the yellow injected tendon sheath
(arrow), which is closely adherent to the retinaculum extensorum without
any loose intervening connective tissue of the paratenon. The tendon
sheath of the M. extensor carpi radialis brevis is marked by an arrowhead.
246
THURMÜLLER ET AL.
the retinaculum extensorum and the fascia antebrachii.
Distally, the supratendinous connective tissue membrane
fuses with the capsular tissue of metacarpophalangeal
joints II–IV, with the periosteum on either side of each
extensor tendon and with the infratendinous membrane
at the clefts between metacarpal bones II–III and III–IV,
to form a crenated margin at each of the interdigital
concavities. The described fusion of the supra- and infratendinous membranes forms a definite circumscribed compartment, which contains the extensor tendons. This
structural detail of the connective tissue body of the M.
extensor digitorum and the M. extensor indicis was seen
in all specimens examined, except in two cases. In these
two cases the injected solution became continuous with
the paratendinous apparatus of the fingers and lay upon
the dorsal aponeurosis between the dorsal hood and a
covering membrane. This membrane covers the dorsal
aponeurosis and separated the solution from the subcutaneous tissue.
After the supratendinous connective tissue membrane
and the plastic plate were removed, some particles of the
injected plastic solution remained between the fascicle of
the tendons.
Dissection of the fifth finger and the respective tendon
showed that the injected solution surrounded the tendon
completely. The injected plastic and the tendon were completely covered by a thin connective tissue membrane.
Proximally, the solution protruded onto the previous injected tendon sheath. However, in two cases it appeared
that the two different injected spaces communicated.
Topography and Morphology of the Gliding
Tissue Spaces of the M. extensor digitorum and
the M. extensor indicis, Analyzed by Injection
and Plastination
Transverse sections of the dorsum of the hand displayed
a definite circumscribed paratendinous gliding space
formed by the described supra- and infratendinous membranes, and confirmed the results regarding the morphology of the gliding tissue spaces of the M. extensor digitorum and the M. extensor indicis established by injection
and preparation. The tendons of the M. extensor digitorum and M. extensor indicis, with their surrounding tissue (which envelops each tendon and stretches between
the extensor tendons over the intermetacarpal spaces),
divide this connective tissue space incompletely into two
spaces lying on the dorsal and palmar surfaces of the
tendons. The dorsal aspect of the described space is subdivided by a vertical lamella, which continues from the
palmar side of the supratendinous membrane to the infratendinous membrane at the ulnar side of the third
extensor tendon. This vertical lamella separates the paratendinous connective tissue space into lesser spaces—a
closed space for the extensor tendon of the fourth finger,
and a common space for the extensor tendons of the second
and third fingers. At the radial side of the second, and the
ulnar side of the fourth extensor tendon, the injected solution followed the supratendinous membrane to the conjunction with the infratendinous membrane. Therefore, a
thin layer of plastic solution reached the palmar side of
the extensor tendons. However, this thin solution did not
continue to form a continuous plastic plate, so that the
palmar side of the extensor tendon of the third finger was
never covered by the injected plastic solution.
Fig. 3. Topographic localization of the histologically investigated
cross sections in the region of the metacarpus and carpus, marked by
lines 1–5.
Histological Investigations of Injected
Specimens
The topographic localization of the histologically investigated cross sections in the region of the metacarpus and
carpus is marked by lines 1–5 in Fig. 3. The paratendinous
connective tissue of the M. extensor digitorum and the M.
extensor indicis is characterized by the above-described
supra- and infratendinous membranes, which formed the
dorsal and palmar borders of the red-injected connective
tissue body (Fig. 4). The supratendinous membrane is
highly populated with fibrocytes. Their cytoplasm often
displayed metachromatic granules in the toluidine-blue
stain as a sign of increased activity. The fibrocytes form a
loose layer at the dorsal border of the depicted gliding
space. At the ulnar side of the extensor tendon of the
fourth finger and at the radial side of the extensor tendon
of the second finger, a thin connective tissue lamella originates from the inner surface of the supratendinous membrane, dips volarwards, and fuses with the infratendinous
membrane, resulting in a clearly defined gliding space
containing the extensor tendons (Fig. 4). Between the
supratendinous and infratendinous membrane, the intertendinous spaces of the extensor tendons are filled by a
loose network of fatty areolar connective tissue, which
contains many small vessels and separates the connective
tissue body into lesser spaces. Connecting the several
extensor tendons, small vessels could be seen coursing
through these areolar sleeves toward the tendons at frequent, regular intervals. Between the fourth and third
extensor tendons, the loose intertendinous connective tis-
GLIDING SPACES OF THE DORSAL SIDE OF THE HAND
sue is adherent to the supra- and infratendinous membranes, whereas the connective tissue network between
the third and second extensor tendons is in close contact
with the infratendinous membrane. The expansion of the
injected plastic solution (red color) demonstrated that
these differences in the intertendinous connective tissue
body led to a closed gliding space for the extensor tendon
of the fourth finger, and a common gliding space for the
extensor tendons of the second and third fingers (Fig. 4).
The adhesions of the intertendinous connective tissue
lamellae with the infratendinous membrane to both sides
of the extensor tendon of the third finger explain why the
injected plastic solution was never seen at the palmar side
of this tendon, whereas at the free sides of the extensor
tendons of the second and fourth fingers the injected solution followed the supratendinous membrane and expanded on the palmar surface of the tendons (Fig. 4). The
injection of the plastic solution into the tendon sheaths
(yellow color) of the M. extensor digitorum and the M.
extensor indicis, 1 cm proximal of the retinaculum extensorum, showed that their morphology is not uniform
throughout their entire course. Only in their proximal
aspect, under the retinaculum extensorum, were the tendons completely enclosed by the yellow injected tendon
sheaths (Fig. 5). Distally, after splitting of the common
synovial sheath of the M. extensor digitorum and the M.
extensor indicis into the separate recesses at the distal
margin of the retinaculum extensorum, the synovial tendon sheaths continue only on the dorsal aspect of the
respective tendon with a size comparable to that of a
bursa, and do not surround the entire tendon surface (Fig.
6). The distal termination of the synovial tendon sheaths
appeared as small clefts surrounded by the paratendinous
connective tissue of the extensor tendons. The transitional
region of the injected tendon sheaths (yellow color) and
the injected multilamellary, paratendinous connective tissue space (red color) of the M. extensor digitorum and M.
extensor indicis showed a close engagement of these two
different gliding spaces. In any case, they are completely
separated by connective tissue lamellae. The distal termination of the tendon sheath of the fourth finger is enclosed
by the supratendinous membrane and is located at the
dorsal aspect of the paratendinous connective tissue without contact with the respective tendon (Fig. 7). The gap
between the tendon sheath and the tendon is filled by the
paratendinous connective tissue (red color). In the proximal direction, the synovial tendon sheath becomes adherent to the dorsal aspect of the tendon, so that the tendon
of the fourth finger is partially surrounded by the clearly
defined paratendinous connective tissue (red color) and
the synovial tendon sheath (yellow color) (Fig. 6). The
distal recesses of the tendon sheath of the third and second fingers lie immediately on the dorsal surface of the
respective tendon. Their size is comparable to that of a
bursa covered by a thin layer of paratendinous connective
tissue (Figs. 6 and 8). As observed at the fourth finger, the
tendons of the third and second fingers are also, in a
proximal direction, surrounded more and more completely
by the respective tendon sheath. The tendons of the M.
extensor digitorum and the M. extensor indicis are enclosed by their tendon sheaths only in their proximal part,
immediately beneath and under the retinaculum extensorum (Fig. 5). At this point, the tendon sheath is closely
adherent to the supratendinous membrane and the retinaculum extensorum, without any loose intervening con-
247
nective tissue of the paratenon. Distally, the tendon
sheaths lose their intimate connection with the supratendinous membrane; thus the paratendinous connective tissue is situated between the top of the sheath and the
supratendinous membrane.
DISCUSSION
Different methods for analyzing the morphology and
topography of connective tissue spaces have been reported
in the literature. Anson et al. (1945) studied the dorsal
layers of the hand exclusively by careful dissection of
several specimens to demonstrate regional differences in
texture and attachment. Kanaval (1939) based his observations on injection studies using a barium sulfate solution injected in the dorsal connective tissue body. He used
different injection pressures and completed his studies
with the examination of 1-cm-thick cross sections through
the metacarpus. Mason and Koch (1930) used a gelatin
barium solution and documented the expansion of the
injection mass with x-rays.
By combining the injection and GMA-embedding techniques, it has been possible to analyze connective tissue
spaces of capillary character and their bordering structures in greater detail. The applied method of combined
injection and plastination used by Bade et al. (1994) and
Schubert et al. (1996) to analyze gliding spaces nearly
closes the gap between macroscopic and microscopic observations. To identify even single collagen fibers bordering the injected spaces, we have introduced a combination
of injection and histological embedding which has made it
possible to investigate even the small transitional region
of the extensor tendon sheaths and the multilamellary
paratendinous connective tissue body in detail. A frequent
criticism of injection techniques is that injection itself
destroys fine connective tissue structures and leads to
erroneous results. Using the described technique we have
been able to show that the injected solution spread along
very fine collagen lamella without destroying them.
The clinical and functional importance of connective
tissue spaces has been repeatedly commented upon, especially as regards their role in the spread of hemmorhage or
infection (Mason and Koch, 1930; Kanaval, 1939; Grodinsky and Holyoke, 1941; Anson et al., 1945; Rieger and
Brug, 1992; Schubert et al., 1996). The connective tissue
spaces on the palmar side of the human hand have been
extensively investigated by Garlock (1924), Kanaval
(1939), Grodinsky and Holyoke (1941), and Flynn (1942).
However, only a few studies have analyzed the connective
tissue body in the metacarpal region of the dorsal side of
the human hand (Mason and Koch, 1930; Kanaval, 1939;
Anson et al., 1945; Landsmeer, 1976).
Mason and Koch (1930), Kanaval (1939), and Landsmeer (1976) described a dorsal subcutaneous space lying
on the dorsal surface of the extensor tendons. Mason and
Koch (1930) and Landsmeer (1976) observed a defined
compartmentalization of the subcutaneous space by fascial structures. Kanaval (1939) described an extensive
area of loose tissue without defined boundaries in which
pus can spread over the entire dorsum of the hand. Kanaval made his observations by means of injection experiments employing a high degree of injection force to obtain
expansion of the injection mass equally over the entire
dorsum of the hand. In the present study we demonstrated
the dorsal multilamellary, paratendinous connective tissue space of the extensor tendons to be a gliding space of
248
THURMÜLLER ET AL.
clearly defined pattern. This space is separated from the
subcutaneous fat by the supratendinous membrane,
which was previously described by Anson et al. (1945),
who named this membrane the “supratendinous fascia.”
They showed by subsequent dissection that this membrane forms the roof of a compartment containing the
extensor tendons. The bottom of this extensor compartment is formed by the infratendinous membrane. At the
free edges of the second and the fourth extensor tendons,
the two membranes fuse and complete a close extensor
compartment. We demonstrated that the extensor tendons occupying this compartment are surrounded by a
definite gliding space. Anson et al. (1945) described a
subsequent division of the extensor compartment into a
supra- and infratendinous part, defined by the extensor
tendons and their intertendinous fascia, which enclosed
the tendons and attached medially and laterally to the
compartment wall. In our study, we demonstrated that
the tendons are not enclosed by an intertendinous fascia,
but are surrounded by a loose network of fatty areolar
connective tissue. This tissue fills the intertendinous
spaces and contains many small vessels, separating the
connective tissue body into lesser spaces, but it does not
attach to the compartment walls laterally. Therefore, the
supra- and infratendinous spaces are not completely separated.
Schubert et al. (1996) identified a connective tissue
space lying between the dorsal hood and a bordering membrane of the human finger. He showed that, in some cases,
an injected solution expanded in a proximal direction over
the metacarpophalangeal joints on the dorsal aspect of the
respective extensor tendon. In the present study, this kind
of connection was found in only two cases. It is possible
that the variability of the extent of the plastic plate on the
respective tendon may be based on individual differences
in connective tissue relationships. Usually, the distal border of the paratendinous connective tissue space of the
extensor tendons is formed by a fusion of the supratendinous connective tissue membrane with the capsular tissue
of metacarpophalangeal joints II–IV and with the periosteum on either side of each extensor tendon.
According to generally accepted opinion (Staubesand,
1988; Platzer, 1989; Frick et al., 1992; Schmidt and Lanz,
1992; Rauber/Kopsch, 1998), tendon sheaths are closed
chambers enveloping the respective tendon throughout
the entire course of the tendon sheath. Based on the results of the present study, we have grounds to assert that
this is not a common pattern for the morphology of the
extensor tendon sheaths of the human hand. The tendons
of the M. extensor digitorum and the M. extensor indicis
are entirely surrounded by their common tendon sheath
only in their proximal aspect under the retinaculum extensorum. Distally, the common tendon sheath divides
into separate recesses, one for each tendon, which continue only on the dorsal aspect of the respective tendon.
These recesses are comparable in size to a bursa, and
terminate distally as small clefts surrounded by the paratendinous connective tissue.
These results concerning the morphology of the extensor
tendon sheaths provide a new model of the blood supply of
the tendons in the transitional region of the paratendinous connective tissue and the tendon sheaths. While a
good blood supply to the extensor tendons is observed in
the extrasynovial region, provided by small vessels forming arcades between the loose paratendinous connective
tissue (Bade et al., 1992), this situation was previously
described as changing abruptly after entering the tendon
sheaths (Edwards, 1946; Chaplin, 1973; Taylor and
Townsend, 1979). Our study showed that the blood supply
of the extensor tendons does not change abruptly in the
transitional region of the gliding spaces, rather the part of
extensor tendons lying in this region are partially nourished by the paratenon and by the tendon sheaths at the
same time.
The dorsal gliding space of the extensor tendons in the
region of the metacarpal, described in this study, is one of
the well-defined deep fascial spaces of the hand. Infection
from local penetrating injuries is said to spread from an
adjacent compartment or from hematogenous seeding
(Hausman and Lisser, 1992). The dissemination of infection in preformed fascial spaces is predictable in that
spread occurs through anatomic compartments and
planes. The results of the current study provide an anatomic basis for the clinical observation of the pattern of
spread of suppurative infections such as may occur following human bite wounds of the dorsal aspect of the hand
(Mason and Koch, 1930; Faciszewski and Coleman, 1989).
Faciszewski and Coleman (1989) described the mode of
spread of infection resulting from bite wounds (clenched
fist injury) over the metacarpophalangeal joints, which
involved the whole extensor compartment within 1 week
and necessitated extensive debridement. Infections of the
closed spaces of the hand tend to produce more rapid
tissue necrosis and abscess formation than those of the
superficial areas of the hand (Glass, 1982). Treatment of
established deep space infections requires both operative
drainage and/or wound debridement, and intravenous antibiotics (Hausman and Lisser, 1992). The incision for
operative drainage has to be placed in such a way as to
give direct access to pus. It should create no additional
Fig. 6. Transverse section through the transitional region of the multilamellary paratendinous connective tissue (red color) on the tendon
sheaths of the extensor tendons of the third and fourth fingers (yellow
color) (Technovit 7100姞, toluidin blue, 7 ␮m, ⫻7, line 3 (Fig. 3)). The distal
recess of the synovial tendon sheath of the third finger (III) lies on the
dorsal aspect of the respective tendon, covered by a thin layer of
paratendinous connective tissue, and does not surround their entire
surface. The tendon of the fourth finger (IV) is partially surrounded by the
paratenon (red color) and the synovial tendon sheath (yellow color).
Fig. 7. Transverse section through the extensor tendon of the fourth
finger in the region of the distal termination of the respective synovial
tendon sheath (yellow color) (Technovit 7100姞, toluidine blue, 7 ␮m, ⫻9,
line 2 (Fig. 3)). The distal termination of the tendon sheath is enclosed by
the supratendinous membrane (arrow) and lies on the dorsal aspect of
the paratendinous connective tissue (red color) without contact to the
respective tendon.
Fig. 8. Transverse section through the transitional region of the multilamellary paratendinous connective tissue (red color) on the tendon
sheath of the extensor tendon of the second finger (yellow color) (Technovit 7100姞, toluidine blue, 7 ␮m, ⫻7, line 4 (Fig. 3)). The distal termination of the tendon sheath lies on the dorsal surface of the radial part
of the extensor tendon of the second finger (II) covered by a thin layer of
paratendinous connective tissue (red color). The synovial tendon sheath
of the extensor tendon of the third finger (III) is marked by an arrow.
250
THURMÜLLER ET AL.
damage, it should be as limited as is expedient, and it
should protect the subsequent function of the hand by
ensuring that scars will heal with a minimum of deforming contracture (Linscheid and Dobyns, 1975; Glass,
1982).
On this basis, an anatomic approach to the treatment of
infections of the dorsal extensor compartment has much to
recommend it. If the infection involves the whole extensor
compartment, two linear incisions are preferred: one at
the ulnar side of the extensor tendon of the fourth finger
between the fourth and fifth metacarpals, and one at the
radial side of the extensor tendon of the second finger over
the second metacarpal (Burkhalter, 1989; Hausman and
Lisser, 1992). The two-incision approach provides adequate soft-tissue coverage over the tendons, while permitting adequate drainage. Placement of the incisions at the
ulnar and radial borders of the extensor compartment
reduces the risk of tendon adhesions and impairment of
function caused by healing scars. A midline incision directly over the extensor tendons is not recommended. The
potential complications of this approach include extensor
tendon dessication, injury to the junctura tendinum, ischemia due to injury of the loose paratendinous connective
tissue, unsatisfactory wound healing, and formation of
tendon adhesions (Jebson, 1998).
If the infection of the dorsal extensor compartment is
well localized, one longitudinal incision may be sufficient
(Jebson, 1998).
Injuries to the dorsal aspect of the hand with damage to
underlying extensor tendons are associated with loss of
the normally present “gliding mechanism” around these
tendons (Biswas et al., 2001). Extensor tendon defects on
the dorsum of the hand have been reconstructed secondarily by a combination of tendon transfer and tendon
grafting beneath a flap previously placed to cover the
soft-tissue defect (Campbell Reid, 1974). However, this
results in tendon adhesions, and associated limitation of
motion, with extension and flexion deficits in both the
repaired and grafted tendons. Various authors have addressed this problem and emphasized the importance of
reconstitution of the normal milieu for tendon gliding,
with a well-lubricated gliding surface all around the tendons as a precondition for achieving optimum excursion
(Hirase et al., 1991; Hirase and Kojima, 1994; Watanabe
et al., 1996; Biswas et al., 2001).
Hirase et al. (1991) first described a double-layered free
temporal fascia flap as a tendon gliding surface to restore
gliding function after avulsion or degloving injuries of the
dorsum of the hand. By sandwiching the tendons between
the layers of vascularized fascia, gliding surfaces were
recreated, both superficial and deep to the exposed tendons, encouraging preservation of function. This clinical
experience identifies the extensor space as a functional
gliding compartment and emphasizes again the importance of detailed anatomical knowledge of connective tissue spaces on the dorsal side of the human hand as the
basis for a better understanding of clinical disorders and
their treatment.
Evolutionary Considerations
Comparative studies of the extensor assembly of the
human hand and its evolutionary precursors suggest that
progressive tendon fasciculation and individualization has
occurred as a result of increased functional specialization
(Landsmeer, 1987). A simple functional morphological
pattern of the extensor apparatus consisting of a solid
tendon plate over the metacarpal region is described as
prevalent in reptiles, e.g., varanus and iguana. Perhaps
this pattern subserves simple function and a stereotypical
pattern of locomotion (Landsmeer, 1987). In opossum, at
the dawn of mammalian eruption, the hand emerged with
a more complex structure of the extensor assembly, including tendon fasciculation and a first tendency toward
tendon individualization, which contributed to more specialized locomotion and the ability to grasp food (Landsmeer, 1979). Fasciculation and individualization of the
extensor assembly in man and other primates (e.g., chimpanzees) has proceeded to the extent of individual finger
recruitment and individual finger control, contributing to
the adaptation of individual finger position to the shape of
an object.
The dorsal multilamellary paratendinous connective
tissue space of the extensor tendons described in the current study is a gliding space of clearly defined pattern. It
is partitioned into lesser spaces by loose networks of fatty
areolar connective tissue. The findings of the present
study support the concept of evolving separation and individualization of the extensor tendons of the hand.
ACKNOWLEDGMENTS
The authors thank Prof. E.B. Seldin, Massachusetts
General Hospital, Harvard School of Dental Medicine,
Boston, MA, for his support in the English language.
LITERATURE CITED
Anson BJ, Wright RR, Ashley FL, Dykes Y. 1945. The fascia of the
dorsum of the hand. Surg Gynecol Obstet 81:327–331.
Bade H, Koebke J, Gronenberg B. 1992. Gefä␤versorgung der sehnenscheidenfreien Strecke der Extensorensehnen des II. bis V. Fingers
am Handrücken. Handchir Mikrochir Plast Chir 24:233–238.
Bade H, Schubert M, Koebke J. 1994. Dorsale Gleit- und Funktionsräume des metakarpophalangealen Übergangs. Handchir Mikrochir Plast Chir 26:251–257.
Bade H, Schubert M, Koebke J. 1995. Morphology of the dorsal phalangeal connective tissue body. Anat Rec 243:1–9.
Biswas G, Lohani I, Chari PS. 2001. The sandwich temporoparietal
free fascial flap for tendon gliding. Plast Reconstr Surg 108:1639 –
1645.
Burkhalter WE. 1989. Deep space infections. Hand Clin 5:553–559.
Campbell Reid DA. 1974. Hand injuries requiring skin replacement
and restoration of tendon function. Br J Plast Surg 27:5–18.
Chaplin DM. 1973. The vascular anatomy within normal tendons,
divided tendons, free tendon grafts and pedicle tendon grafts in
rabbits. J Bone Joint Surg 55 B:369 –389.
Dykyj D, Jules KT. 1991. The clinical anatomy of tendons. J Am
Podiatr Med Assoc 81:358 –365.
Edwards DA. 1946. The blood supply and lymphatic drainage of
tendon. J Anat 80:147–153.
Faciszewski T, Coleman DA. 1989. Human bite wounds. Hand Clin
4:561–569.
Feneis H. 1935. Die Anordnung und die Bedeutung des Bindegewebes
für die Mechanik der Skelettmuskulatur. Morph Jb 91:161–201.
Flynn JE. 1942. Clinical and anatomical investigations of deep fascial
space infections of the hand. Am J Surg 55:467– 475.
Frick H, Leonhardt H, Starck D. 1992. Allgemeine Anatomie, Spezielle Anatomie I. Stuttgart, New York: Thieme Verlag. p 247–250.
Garlock JH. 1924. Infections of the hand. Surg Gynecol Obstet 39:
165–191.
Glass KD. 1982. Factors related to the resolution of treated hand
infections. J Hand Surg 7A:388 –394.
Grodinsky M, Holyoke EA. 1941. The fasciae and fascial spaces of the
palm. Anat Rec 79:435– 451.
Hausman MR, Lisser SP. 1992. Hand infections. Orthop Clin North
Am 23:171–185.
GLIDING SPACES OF THE DORSAL SIDE OF THE HAND
Hirase Y, Kojima T, Bang H-H. 1991. Double-layered free temporal
fascia flap as a two-layered tendon-gliding surface. Plast Reconstr
Surg 88:707–712.
Hirase Y, Kojima T. 1994. Use of the double-layered free temporal
fascia flap for upper extremity coverage. J Hand Surg 19A:864–870.
Jebson PJ. 1998. Deep subfascial space infections. Hand Clin 14:557–
566.
Kanaval AB. 1939. Infections of the hand. Philadelphia: Lea & Febiger. p 23–50.
Landsmeer JMF. 1976. Atlas of anatomy of the hand. Edinburgh:
Churchill Livingstone. p 285–314.
Landsmeer JMF. 1979. The extensor assembly in two species of opossum, philander opossum and didelphis marsupialis. J Morphol 161:
373–346.
Landsmeer JMF. 1987. The hand and hominisation. Acta Morphol
Neerl-Scand 25:83–93.
Lang J. 1960. Über das Gleitgewebe der Sehnen, Muskeln, Faszien
und Gefä␤e. Z Anat Entwickl-Gesch 122:197–231.
Linscheid RL, Dobyns JH. 1975. Common and uncommon infections of
the hand. Orthop Clin North Am 6:1063–1104.
Mason ML, Koch SL. 1930. Human bite infections of the hand. Surg
Gynecol Obstet 5:591– 625.
Platzer W. 1989. Pernkopf Anatomie. Vol. 3, pt II. München-WienBaltimore: Urban & Schwarzenberg. p 159.
Rauber/Kopsch. 1998. Anatomie des Menschen, Lehrbuch und Atlas
Bd. 1 Bewegungsapparat. 2nd ed. Stuttgart, New York: Thieme
Verlag. p 158.
251
Rieger H, Brug E. 1992. Das Panaritium. München: Marseille. p 21–
37.
Schlüter O. 1961. Praktische Erfahrungen bei der Verwendung von
polymerisierbaren Vinylverbindungen zur Gewinnung von
Ausgu␤präparaten. Der Präparator 7:177–184.
Schmidt H-M, Lanz U. 1992. Chirurgische Anatomie der Hand.
Stuttgart: Hippokrates. p 224 –230.
Schubert M, Notermans H-P, Bade H, Koebke J. 1994. Darstellung
von Gleit- und Funktionsräumen am Finger der menschlichen
Hand. Der Präparator 40:75–79.
Schubert M, Bade H, Notermans H-P, Knifka J, Koebke J. 1996.
Functional gliding spaces of the dorsal side of the human finger.
Surg Radiol Anat 18:17–22.
Staubesand J. 1988. Sobotta: Atlas der Anatomie des Menschen. Vol.
19, pt I. München-Wien-Baltimore: Urban & Schwarzenberg. p
258.
Taylor GI, Townsend P. 1979. Composite free flap and tendon
transfer: an anatomical study and a clinical technique. Br J Plast
Surg 32:170 –183.
von Hagens G. 1985/1986. Heidelberger plastinations folder. Anatomisches Institut 1, Universität Heidelberg.
von Hagens G, Tiedemann K, Kriz W. 1987. The current potential of
plastination. Anat Embryol 175:411– 421.
Watanabe T, Iwasawa M, Kushima H, Kikuchi N. 1996. Free temporal fascial flap for coverage and estensor tendon reconstruction. Ann
Plast Surg 37:469 – 472.
Документ
Категория
Без категории
Просмотров
5
Размер файла
3 040 Кб
Теги
gliding, space, side, dorsal, hands, function, human
1/--страниц
Пожаловаться на содержимое документа