대한체질인류학회지제 23 권제 3 호 Korean J Phys Anthropol Vol. 23, No. 3 (2010) pp. 125~131 Korean Journal of Physical Anthropology 엄지손가락과첫째손샅의등쪽동맥분포 허미선, 한희돈 1,, 곽현호 2, 허경석 3, 이규석, 김희진 3 관동대학교의과대학해부학교실 1 울산대학교의과대학강릉아산병원정형외과학교실 2 부산대학교치의학전문대학원구강해부학교실 3 연세대학교치과대학구강생물학교실해부및발생생물학연구실 (2010 년 7 월 12 일접수, 2010 년 8 월 16 일수정접수, 2010 년 8 월 30 일게재승인 ) 간추림 : 손등은이식시공여부로흔히사용되어왔으며, 그중에서등쪽손허리동맥피판 (dorsal metacarpal arterial flaps) 은손가락피부와물렁조직의결손부위를덮는데자주사용되지만, 손등동맥의해부학적변이는다양하므로동맥피판을다루는데공여부확보에있어어려움을줄수있다. 이연구의목적은엄지손가락, 집게손가락, 첫째손샅 (first web space) 의등쪽동맥분포를밝히고, 동맥피판술에도움이되는해부학적자료를만들기위함이다. 재료는한국성인시신손 26쪽 ( 오른손 13쪽, 왼손 13쪽, 평균나이 67.7세 ) 을사용하였고, 해부전아래팔중간부위의노동맥에붉은 Latex (Latex 671, Dupont Industry, France) 를주입한후, 해부하였다. 첫째등쪽손허리동맥가지의형태는등쪽자쪽엄지가지와등쪽노쪽집게가지가일어나는형태에따라세가지유형으로분류하였다. 등쪽자쪽엄지가지와등쪽노쪽집게가지가첫째등쪽손허리동맥에서일어나는경우 (10예, 38.5%), 첫째등쪽손허리동맥을형성하지않고노동맥에서등쪽자쪽엄지가지와등쪽노쪽집게가지가각각따로분지되는경우 (5예, 19.2%), 그리고등쪽노쪽집게가지는노동맥에서일어나고, 등쪽자쪽엄지가지는엄지으뜸동맥에서일어나는경우 (11예, 42.3%) 가있었다. 첫째등쪽손허리동맥가지의첫째등쪽뼈사이근에대한위치관계는등쪽자쪽엄지가지가근육에대해달리는위치에따라두가지유형이있었다. 등쪽자쪽엄지가지가첫째등쪽뼈사이근의표면을달리는경우는 17예 (65.4%) 가있었고, 첫째등쪽뼈사이근에덮여달리는경우는 9예 (34.6%) 로관찰되었다. 등쪽노쪽집게가지는모든예에서첫째등쪽뼈사이근의표면으로달렸다. 이상의결과들은엄지손가락과첫째손샅의등쪽동맥분포에대한국소해부학적자료를제공함으로써, 손외상치료와동맥피판술시도움이될것으로기대된다. 찾아보기낱말 : 노동맥, 첫째등쪽손허리동맥, 등쪽자쪽엄지가지, 등쪽노쪽집게가지, 동맥피판술 서 론 엄지와집게손가락의먼쪽은비교적손상이많은부위이나 (Pistre 등 2001, Tan 등 2010), 손가락피부와물렁조직의재건수술은결손부위의크기와국소피판이 * 이논문은 2009년도정부 ( 교육과학기술부 ) 의재원으로한국연구재단의지원을받아수행된기초연구사업임 (No. R13-2003-013-03001-0). 공동제1저자로동등한역할을수행하였음. 교신저자 : 김희진 ( 연세대학교치과대학구강생물학교실해부및발생생물학연구실 ) 전자우편 : hjk776@yuhs.ac 동술 (local flap mobilization) 의제한으로어려운점이많다 (Pelissier 등 1999). 손등은공여부위로흔히사용되어왔으며, 등쪽손허리동맥피판 (dorsal metacarpal arterial flaps) 은손가락피부와물렁조직의손상부위를덮는데자주사용된다 (Gregory 등 2007, Koch 등 2007, Lai-Jin 등 2008, Friedrich 등 2009, Zhang 등 2009). 특히, 첫째등쪽손허리동맥은손의물렁조직손상의재건술에흔히사용되어왔으며, 첫째등쪽손허리동맥을이용한피판술은엄지손가락먼쪽부위의과도한손상을재건하는데가장우선시되는수술로보고되고있다 (Pagliei 등 2003, Chang
126 허미선, 한희돈, 곽현호, 허경석, 이규석, 김희진 a b c Fig. 1. Variations in the arrangement of the first dorsal metacarpal artery(fdma) and its branches. a: The dorso-ulnar thumb branch (DUTB) and dorso-radial index branch (DRIB) arising from the FDMA. b: Each DUTB and DRIB arising separately from the radial artery (RA). c: The DUTB arising from the princeps pollicis artery (PPA) and the DRIB arising from the RA. 등 2004, Prakash와 Chawla 2004, Cil 등 2008, Muyldermans와 Hierner 2009). Palgliei 등 (2003) 은첫째등쪽손샅부위의동맥피판술을쉽고빠르게사용할수있으며, 신경이분포하지않은피판임에도신경재활후감각회복이되었다고보고하였다. 또한섬피판 (island flap) 은 Dupuytren s contracture 치료시근막절제술로인한피부결손부위를덮는경우에도사용되어지며 (Ozdemir 등 2004), 화상으로인한반흔구축절제술후피부이식에도사용되어진다 (Eski 등 2007). 첫째등쪽손허리동맥은노동맥에서일어난후, 곧등쪽자쪽엄지가지와등쪽노쪽집게가지로나뉘어져엄지손가락의자쪽부분과집게손가락의노쪽부분에각각분포한다 (Woodburne과 Burkel 1994, Standring 2008). 특히엄지손가락의등쪽자쪽부위는다른손가락에비하여동맥의분포가매우풍부하게발달하여있으며 (Brunelli 등 1999), 첫째등쪽손허리동맥은다른손허리동맥에비하여다양한해부학적형태와변이를보인다 (Braga-Silva 등 2002). 그러나이에대한정확한해부학적지식이충분하게알려져있지않아동맥피판술시어려움을줄수있으며, 이동맥가지들을부르는용어가문헌마다다르게기술되어있어해부학적구조및관계를이해하는데혼동을줄수있다 (Bertelli 등 1992, Pistre 등 2001, Agur와 Dalley 2005, Schuenke 등 2006). 따라서이연구의목적은엄지손가락과첫째손샅의등쪽동맥분포의정확한국소해부학적형태와변이를밝히고, 안전하고효율적인동맥피판술을위한임상해부학적자료를마련하는데있다. 재료및방법 재료는한국성인시신손 26쪽 ( 오른손 13쪽, 왼손 13 쪽, 평균나이 67.7세 ) 을사용하였고, 해부를시작하기에앞서최소한의절개로노동맥의중간부위에카테터를삽입하여붉은라텍스 (Latex 671, Dupont Industry, France) 를주입하고 2주동안굳힌후해부하였다. 필요한경우에수술현미경 (OPMI 19-FC, Carl Zeiss Co., Germany) 을 4~25배율로사용하여미세해부를시행하였다. 모든표본에서손등의피부를절개하여조심스럽게젖히면서피부밑조직을노출하였다. 특히, 첫째손샅, 엄지와집게손가락의등쪽부위에서첫째등쪽손허리동맥과그가지들의주행이보이도록미세해부를시행하여주위의결합조직을제거하고깨끗이하였다. 해부후, 첫째등쪽손허리동맥가지가일어나는형태를분류하고, 그빈도를조사하였다 (Fig. 1). 첫째등쪽손허리동맥가지의첫째등쪽뼈사이근에대한위치관계는동맥가지가첫째등쪽뼈사이근의표면으로달리는지또는첫째등쪽뼈사이근에덮여달리는지로구분하였다 (Fig. 2). 등쪽자쪽엄지가지가근육에덮여깊게달리는경우는첫째손허리뼈에붙는첫째등쪽뼈사이근의힘살을잘라젖혀동맥가지가일어나는곳을확인하였다. 결과 첫째등쪽손허리동맥이노동맥에서일어나형성되는
엄지손가락과첫째손샅의등쪽동맥분포 127 경우는 10예 (38.5%) 가있었으며, 첫째등쪽손허리동맥이형성되지않고노동맥에서직접첫째등쪽손허리동맥가지인등쪽자쪽엄지가지와등쪽노쪽집게가지가분지되는경우는 16예 (61.5%) 에서관찰되었다. 첫째등쪽손허리동맥가지의형태는등쪽자쪽엄지가지와등쪽노쪽집게가지가일어나는형태에따라세가지유형으로분류하였다. 등쪽자쪽엄지가지와등쪽노쪽집게가지가첫째등쪽손허리동맥에서일어나는경우 (10예, 38.5%), 첫째등쪽손허리동맥을형성하지않고노동맥에서등쪽 자쪽엄지가지와등쪽노쪽집게가지가각각따로나뉘는경우 (5예, 19.2%), 그리고등쪽노쪽집게가지는노동맥에서일어나고, 등쪽자쪽엄지가지는엄지으뜸동맥에서일어나는경우 (11예, 42.3%) 가있었다 (Fig. 3). 첫째등쪽손허리동맥은모든예에서긴엄지폄근힘줄의바로안쪽을지나가는노동맥에서일어났다. 첫째등쪽손허리동맥은노동맥에서일어나자마자곧등쪽자쪽엄지가지와등쪽노쪽집게가지로나뉘어졌다. 따라서등쪽자쪽엄지가지와등쪽노쪽집게가지가첫째등쪽손허리 a b Fig. 2. The courses of the first dorsal metacarpal artery (FDMA) and its branches in relation with the first dorsal interosseous muscle (FDI). a: The FDMA and its branches ran overlying the FDI. b: The dorso-radial index branch (DRIB) ran on the FDI and the dorso-ulnar thumb branch (DUTB) had a deep course within the substance of the FDI. RA, radial artery. a b c Fig. 3. The first web space showing the branches of the first dorsal metacarpal artery (FDMA). a: The dorso-ulnar thumb branch (DUTB) and dorso-radial index branch (DRIB) originated from the FDMA. b: The DUTB and DRIB arose separately from the radial artery (RA). c: The DUTB originated from the princeps pollicis artery (PPA) and the DRIB arose from the RA.
128 허미선, 한희돈, 곽현호, 허경석, 이규석, 김희진 a b Fig. 4. Locational relationship of the princeps pollicis artery (PPA) with the first dorsal interosseous muscle (FDI). a: The PPA running beneath the transverse head of the adductor pollicis muscle. The FDI and the oblique head of the adductor pollicis were excised and reflected. b: The PPA running on the surface of the FDI. DRIB, dorso-radial index branch; DUTB, dorso-ulnar thumb branch. a b Fig. 5. The dorso-radial thumb branch (arrowheads) arising from the radial artery (RA). a: The dorso-radial thumb branch, which is the direct branch originating from the RA, ran on the dorso-radial aspect of the thumb in the anatomical snuffbox. b: The tendons of the extensor pollicis longus (EPL) and extensor pollicis brevis (EPB) were excised to reveal the dorso-radial thumb branch arsing from the RA. 동맥에서일어나는경우와노동맥에서각각일어나는경우에서두동맥가지의경로에는큰차이가없었다. 그러나등쪽자쪽엄지가지가엄지으뜸동맥에서일어나 는경우는 42.3% 로높은빈도를보였으며, 이경우의대부분은등쪽자쪽엄지가지가첫째등쪽뼈사이근에덮여첫째손샅등쪽먼쪽부위로나와분포하였다. 그리
엄지손가락과첫째손샅의등쪽동맥분포 129 고등쪽자쪽엄지가지의길이가상대적으로짧은경우에는엄지으뜸동맥과집게노쪽동맥의가지들이등쪽자쪽엄지가지가짧아닿지못하는부위에추가적으로분포하여혈액공급을하는경향을보였다. 첫째등쪽손허리동맥가지의첫째등쪽뼈사이근에대한위치관계는등쪽노쪽집게가지가근육에대해달리는위치에따라두가지유형이있었다. 등쪽자쪽엄지가지가첫째등쪽뼈사이근의표면을달리는경우는 17예 (65.4%) 가있었고, 첫째등쪽뼈사이근에덮여달리는경우는 9예 (34.6%) 로관찰되었다 (Fig. 4a). 등쪽노쪽집게가지는모든예에서첫째등쪽뼈사이근의표면으로달렸다. 노동맥의가지중하나인엄지으뜸동맥이첫째등쪽뼈사이근표면을달리는경우가 2예 (7.7%) 에서관찰되었다 (Fig. 4b). 이경우에서는등쪽자쪽엄지가지가첫째등쪽손허리동맥또는노동맥에서일어나지않고엄지으뜸동맥에서일어나분포하였다. 노동맥에서직접나온작은가지가짧은엄지폄근힘줄바로노쪽으로달리는경우가모든예에서관찰되었다 (Fig. 5). 노동맥이짧은엄지폄근힘줄을지나가는부위또는해부학코담배갑부위에서이동맥가지가일어나짧은엄지폄근힘줄과평행하게달렸다. 일부경우에서는엄지두덩가쪽부분까지분포하는경우도관찰되었다. 고찰 대부분의해부학교과서에서는첫째등쪽손허리동맥이노동맥에서일어나고, 여기에서등쪽자쪽엄지가지와등쪽노쪽집게가지가나뉘어지는것으로기술되어있다. 그러나이연구에서는첫째등쪽손허리동맥의빈도가 38.5% 로낮게나타났다. Braga-silva 등 (2002) 은첫째등쪽손허리동맥이 33.3% 의빈도로관찰되었다고보고하였으며, 이는이연구의결과와비슷한빈도를보였다. 첫째등쪽손허리동맥과그가지들은모든예에서긴엄지폄근힘줄의바로안쪽부분에서일어났다. 긴엄지폄근힘줄은해부학코담배갑의경계를이루는힘줄로피부의표지점 (landmark) 이된다. 따라서해부학코담배갑의바닥을가로지르는노동맥의맥박을찾아노동맥이긴엄지폄근힘줄을지나는위치를파악하면, 이힘줄바로안쪽에서첫째등쪽손허리동맥과그가지들의분지위치를피부표면에서쉽게예측할수있을것으로생각된다. 등쪽노쪽집게가지는모든예에서첫째등쪽뼈사이근 의표면으로달렸으므로, 일정한위치와경로를보였다. 등쪽자쪽엄지가지가근육에덮여있거나길이가짧은경우에는, 가까운위치에있는등쪽노쪽집게가지를이용하여피판술을할수있을것으로생각된다. Cormack 과 Lamberty (1994) 가분류한유형중에는등쪽노쪽집게가지와등쪽자쪽엄지가지가모두첫째등쪽뼈사이근에덮여달리는경우가있었는데, 이연구에서는두가지모두근육에덮여달리는경우는없었고등쪽자쪽엄지가지만첫째등쪽뼈사이근에덮여달리는경우가관찰이되었다. 등쪽자쪽엄지가지가첫째등쪽뼈사이근에덮여달리는경우는첫째등쪽손허리동맥또는노동맥에서이동맥가지가일어나지않고대신등쪽자쪽엄지가지와가까이있는엄지으뜸동맥에서등쪽자쪽엄지가지가일어나분포하는것으로보인다. 첫째등쪽뼈사이근표면을달리는엄지으뜸동맥의경로는 Bergman 등 (1988) 과 Sachs (1987) 의연구에서기술한노동맥등쪽가지의경로와일치하였는데, 노동맥등쪽가지는피부밑조직층에서긴엄지폄근힘줄과첫째손허리사이공간의표면을지나손바닥깊은면으로들어간다고기술되어있었다. 사람에서약 1% 의빈도로나타나는노동맥등쪽가지는진화단계가낮은포유류에서관찰되는얕은노동맥과같은구조로보이며, 이는계통학적인의미를지닐수있다 (Sachs 1987). 노동맥등쪽가지의빈도가매우드물게나타나긴하지만, 이동맥이피부밑조직층을지나가므로재건술및외과적수술시주의해야할것으로생각된다. 짧은엄지폄근힘줄바로노쪽으로달리는노동맥의가지는일부문헌에서등쪽노동맥 (dorsal radial artery) 또는첫째등쪽손허리동맥으로불리고있으며 (Pistre 등 2001, Moschella와 Cordova 2006), 이연구에서는등쪽노쪽엄지가지로이름을붙였다. 등쪽노쪽엄지가지역시해부학코담배갑의경계중하나인짧은엄지폄근힘줄근처에서일어나이힘줄과평행하게달리는경향을보였으므로동맥피판술시동맥가지의위치를피부표면에서예측하기쉬울것으로생각된다. 또한이동맥가지는비교적일정한위치와경로를보였으므로동맥피판술시쉽고빠르게동맥에접근할수있을것으로보인다. Moschella와 Cordova (2006) 는등쪽노쪽엄지가지를이용한피판술이엄지손가락먼쪽손상부위의재건뿐만아니라심미적인측면에서도좋은결과를얻었다고보고하였다. 이상의결과들은엄지손가락과첫째손샅의등쪽동맥분포에대한국소해부학적자료를제공함으로써, 손외상치료와동맥피판술시도움이될것으로생각된다.
130 허미선, 한희돈, 곽현호, 허경석, 이규석, 김희진 참고문헌 Agur AMR, Dalley AF : Grant s atlas of anatomy, 11th ed., Lippincott Willams & Wilkins, Philadelphia, p 557, 2005. Bergman RA, Thompson SA, Afifi AK, Saadeh FA : Compendium of human anatomic variation, Urban & Schwarzenberg, Baltimore, p 388, 1988. Bertelli JA, Pagliei A, Lassau JP : Role of the first dorsal metacarpal artery in the construction of pedicled bone grafts. Surg Radiol Anat 14: 275-277, 1992. Braga-Silva J, Kuyven CR, Fallopa F, Albertoni W : An anatomical study of the dorsal cutaneous branches of the digital arteries. J Hand Surg Br 27: 577-579, 2002. Brunelli F, Vigasio A, Valenti P, Brunelli GR : Arterial anatomy and clinical application of the dorsoulnar flap of the thumb. J Hand Surg Am 24: 803-811, 1999. Chang SC, Chen SL, Chen TM, Chuang CJ, Cheng TY, Wang HJ : Sensate first dorsal metacarpal artery flap for resurfacing extensive pulp defects of the thumb. Ann Plast Surg 53: 449-454, 2004. Cil Y, Eski M, Isik S : First dorsal metacarpal artery adipofascial flap for thenar burn contracture releasing. Burns 34: 127-130, 2008. Cormack GC, Lamberty BGH : The arterial anatomy of skin flaps, 2nd ed., Churchill Livingstone, Edinburgh, pp 205-207, 1994. Eski M, Nisanci M, Sengezer M : Correction of thumb deformities after burn: versatility of first dorsal metacarpal artery flap. Burns 33: 65-71, 2007. Friedrich JB, Katolik LI, Vedder NB : Soft tissue reconstruction of the hand. J Hand Surg Am 34: 1148-1155, 2009. Gregory H, Heitmann C, Germann G : The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps. J Plast Reconstr Aesthet Surg 60: 731-739, 2007. Koch H, Bruckmann L, Hubmer M, Scharnagl E : Extended reverse dorsal metacarpal artery flap: clinical experience and donor site morbidity. J Plast Reconstr Aesthet Surg 60: 349-355, 2007. Lai-Jin L, Xu G, Jian-Li C, Xi-Guang S : A modified approach of the reverse dorsal metacarpal island flap: anatomical basis and application in 24 cases. Ann Plast Surg 61: 392-395, 2008. Moschella F, Cordova A : Reverse homodigital dorsal radial flap of the thumb. Plast Reconstr Surg 117: 920-926, 2006. Muyldermans T, Hierner R : First dorsal metacarpal artery flap for thumb reconstruction: a retrospective clinical study. Strategies Trauma Limb Reconstr 4: 27-33, 2009. Ozdemir O, Coskunol E, Ozalp T : An alternative approach in the treatment of Dupuytren s contracture skin defects: first dorsal metacarpal artery island flap. Tech Hand Up Extrem Surg 8: 16-20, 2004. Pagliei A, Rocchi L, Tulli A : The dorsal flap of the first web. J Hand Surg Br 28: 121-124, 2003. Pelissier P, Casoli V, Bakhach J, Martin D, Baudet J : Reverse dorsal digital and metacarpal flaps: a review of 27 cases. Plast Reconstr Surg 103: 159-165, 1999. Pistre V, Pelissier P, Martin D, Baudet J : Vascular blood supply of the dorsal side of the thumb, first web and index finger: anatomical study. J Hand Surg Br 26: 98-104, 2001. Prakash V, Chawla S : First dorsal metacarpal artery adipofascial flap for a dorsal defect of the thumb. Plast Reconstr Surg 114: 1353-1355, 2004. Sachs M : The arteria radialis superficialis. An unusual variation of the arteria radialis of man and its phylogenetic significance. Acta Anat (Basel) 128: 110-123, 1987. Schuenke M, Schulte E, Schumacher U : General anatomy and musculoskeletal system (THIEME atlas of anatomy), Thieme, New York, p 348, 2006. Standring S : Gray s anatomy, 40ed., Churchill livingstone, Edinburgh, p 890, 2008. Tan O : Reverse dorsolateral proximal phalangeal island flap: a new versatile technique for coverage of finger defects. J Plast Reconstr Aesthet Surg 63: 146-152, 2010. Woodburne RT, Burkel WE : Essentials of human anatomy, 9th ed., Oxford University Press, Oxford, p 157, 1994. Zhang X, He Y, Shao X, Li Y, Wen S, Zhu H : Second dorsal metacarpal artery flap from the dorsum of the middle finger for coverage of volar thumb defect. J Hand Surg Am 34: 1467-1473, 2009.
엄지손가락과첫째손샅의등쪽동맥분포 131 Anatomy of the Blood Supply of Dorsal Side of Thumb and First Web Mi-Sun Hur, Hee Don Han 1, Hyun-Ho Kwak 2, Kyung-Seok Hu 3, Kyu-Seok Lee, Hee-Jin Kim 3 Department of Anatomy, Kwandong University College of Medicine 1 Department of Orthopedic Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine 2 Department of Oral Anatomy, Medical Research Institute, Pusan National University School of Dentistry 3 Division in Anatomy and Developmental Biology, Department of Oral Biology, Oral Science Research Center, Human Identification Research Center, Brain Korea 21 Project, Yonsei University College of Dentistry Abstract : Distal thumb injuries are a common and difficult problem for hand surgeons. Coverage of soft tissue on the fingers may be difficult due to the size of the defect or the limitation of local flap mobilization. However, the variable anatomy of the dorsal hand vascular system sometimes prevents successful flap harvest. The purpose of this study was to clarify the vascular anatomy of the dorsal side of the thumb and the first web for the flaps. Twenty six hands (13 right and 13 left hands) from Korean embalmed cadavers were dissected. A catheter was inserted into the radial artery in the forearm, and the red colored latex (Latex 671, Dupont Industry, France) was injected until the dorsum of the hand was colored. The arrangement of the first dorsal metacarpal artery (FDMA) and its branches were vary and classified into three categories according to their branching patterns; Both dorso-ulnar thumb branch (DUTB) and dorso-radial index branch (DRIB) arose from the FDMA (10 cases, 38.5%). Each DUTB and DRIB arose separately from the radial artery (5 cases, 19.2%). The DUTB and the DRIB originated from the princeps pollicis artery and the radial artery, respectively (11 cases, 42.3%). The typical course of the FDMA and its branches ran overlying the first dorsal interosseous muscle in 17 cases of the 26 specimens (65.4%). However, in nine cases (34.6%) the DRIB ran on the first dorsal interosseous muscle and the DUTB had a deep course within the substance of the first dorsal interosseous muscle. The FDMA flap represents a good option to cover defects for the thumb. These anatomical findings in the present study could provide useful knowledge of flaps for dorsal aspect of the thumb and the first web. Keywords : Radial artery, First dorsal metacarpal artery, Dorso-ulnar thumb branch, Dorso-radial index branch, Arterial flap Correspondence to : Hee-Jin Kim (Department of Anatomy, Yonsei University College of Dentistry) E-mail : hjk776@yuhs.ac