Connection between medial dorsal cutaneous nerve and saphenous nerve: case report.

PURPOSE: There are no data on the connection of the saphenous nerve (SN), located on the medial side of the foot, with the terminal branches of the superficial fibular nerve. The aim of this study is to reveal the variation that surgeons should pay attention to for anesthesia applied in foot surgeries. METHODS: In this study, the left foot of a 70-year-old female cadaver fixed with formalin was dissected. The distance to the medial malleolus and the incision line was recorded using digital caliper to determine the reference points in the resulting variation. RESULTS: It was observed that a branch from the SN, which arose from the SN and proceeded anteriorly to the upper part of the medial malleolus and continued towards the dorsum of the foot, hooked with a branch from the medial dorsal cutaneous nerve (MDCN). The branches arising from this hook were distributed on the medial edge of the foot up to the proximal metatarsophalangeal joint I. The distance of this nerve connection to the medial malleolus is 91.14 mm, and the distance to the incision line is 15.76 mm. CONCLUSIONS: It is suggested that the case presented as an unusual SN variation, which may affect the success of local anesthesia in invasive procedures to the medial part of the foot and could be considered in the evaluation of sensory loss after anteromedial surgical approach to the ankle, should be included in the classification of the cutaneous innervation pattern of the foot.

Autopsy findings of an isolated persistent left superior vena cava in an intrauterine dead fetus.

Persistent left superior vena cava (PLSVC) is one of the cardiac system abnormalities with a 0.3-0.5% incidence and caused by inadequate obliteration of the left anterior cardinal vein during embryonic development. Prognosis of PLSVC is generally assumed to be good if it is not accompanied by other cardiac system abnormalities. During the routine ultrasound control of a patient at 25th week of pregnancy at the Obstetrics and Gynecology Department of Mersin University, PLSVC anomaly was detected in an intrauterine fetus. Then, intrauterine death occurred and after removal of the deceased fetus, PLSVC diagnosis was confirmed by autopsy. According to the autopsy findings, right superior vena cava (SVC) and azygos vein were found in normal course. PLSVC opened into the right atrium via enlarged coronary sinus. There was no connection between the two SVCs. On the left side of posterior mediastinum, instead of hemiazygos or accessory hemiazygos veins, a vein symmetrical to azygos was opened into PLSVC, similar to the one on the right. No other cardiac anomaly associated with PLSVC or any other pathology in the other parts of body that could be responsible for death was discovered during autopsy. There was no evidence indicating that PLSVC played any role in intrauterine exitus of the present case. However, as mentioned in the literature, the ectopic beats in the atrium wall of patients with isolated PLSVC and enlarged coronary sinus may lead to pathologies in the conduction system of the heart. Considering the intrauterine death of an isolated PLSVC case associated with cardiac conduction pathologies, we recommend that the common assumption of 'isolated PLSVC is not associated with death' should be reviewed by studies on large series and even intrauterine cases should be closely monitored for cardiac arrhythmia.

Effects of different cadaver preservation methods on muscles and tendons: a morphometric, biomechanical and histological study.

No prior publication studying the biomechanical and histological properties of cadavers fixed with Logan or modified Logan solution (MLS) was found in the literature. It was aimed in this study to compare MLS fixation and other cadaver preservation procedures regarding the use in basic histological studies, anatomy education and surgical trainings. This study was placed on 35 male 17-week-old Wistar Albino rats. MLS fixated tissues were systematically compared with 10% formalin (F10), saturated salt solution (SSS), Thiel and frozen/thawed (FT) tissues. Organoleptic (color, appearance, flexibility, odor, etc.), morphometric (e.g. length, width and cross-sectional area), biomechanical (Young's modulus, stiffness, maximum load, etc.) and histological (tendon and muscle fiber integrity, nuclear prominence, blur in microscopy, etc.) analyses were conducted. Organoleptic properties of Thiel and SSS fixated muscles and tendons were better preserved than F10 and MLS. No significant difference was observed in gross morphometric properties (e.g. length, width and cross sectional area) following any of the cadaver and tissue preservation techniques. MLS and F10 was observed to increase the stiffness, Young's modulus and maximum load parameters of the tendons. Thiel and SSS fixated tendons had similar mechanical properties to fresh and FT tendons. No effect of fixation solutions on tendons is observed in the histological analysis regarding fiber integrity, nuclear prominence, blur in microscopy, shrinkage of tissues. Thiel solution was observed to distort fiber integrity, nuclear prominence and blur the microscopy of muscle tissue. Thiel and SSS fixated muscles and tendons were observed to absorb more stain with Masson's trichrome staining and appear as darker red. No muscle and tendon shrinkage due to fixative solutions was observed with our fixation method. Pondering the organoleptic (color, appearance, consistency, odor, etc.) and biomechanical analyses (stiffness, Young's modulus, etc.), Thiel and SSS fixed cadavers are more suitable for purposes as surgical trainings and development of new surgical procedures. However, the change in the micro-anatomical structure of the muscles, especially with the Masson's trichrome staining, caused by these two solutions should not be overlooked.

Iliocapsularis muscle in human fetuses.

PURPOSE: To determine the incidence of the iliocapsularis muscle in fetal period and its relationship with the hip joint capsule. METHODS: Twenty-one formalin-fixed fetuses (12 female and 9 male) with a mean gestational age of 29 ± 3.89 weeks (range 25-36) were dissected to reveal morphological properties of iliocapsularis muscle. RESULTS: Iliocapsularis muscle was observed in 39 out of 42 sides (92%). Its proximal attachment was detected either below the proximal attachment of rectus femoris muscle in 21 out of 39 sides (54%), or it was forming a common tendon with rectus femoris on the anterior inferior iliac spine in 10 out of 39 sides (26%), or it was forming an arch along the superior-medial-inferior sides of the proximal attachment of rectus femoris muscle in 8 out of 39 sides (20%). Muscle fibers originating from the anteromedial part of hip joint capsule were also constant in all sides. Distal attachment of iliocapsularis muscle was distal to the lesser trochanter in all specimens. Its form was as a broad muscle in 32 out of 39 sides (82%) and as a thin rectangular muscular slip in 7 out of 39 sides (18%). Iliopsoas and iliocapsularis muscles had their particular fascia in 34 out of 39 sides (87%), and in the other 5 sides, there was no fascia which prominently separated the two muscles. Its length was longer in females than males (p = 0.031) and it was wider on the right side (p = 0.029). Linear functions were y = 0.49 + 0.17 × weeks and y = 6.94 + 0.89 × weeks for width and length, respectively. CONCLUSION: Data obtained with the present study about iliocapsularis muscle in fetal period revealed that it is an individual and constant muscle. Its dimension, location, and course over the hip joint capsule support the idea that it tightens the hip capsule and stabilizes the femoral head.

Evaluation of the stapedial tendon growth dynamic in human fetuses.

PURPOSE: The main objective of the study was to investigate the morphometric properties of the stapedial tendon (ST) for pediatric otosurgeons and anatomists. METHODS: The present study was placed on 15 fetuses (8 females, 7 males) aged from 20 to 30 weeks of gestation (at mean, 24.27 ± 3.24 weeks) using the collection of the Anatomy Department of Medicine Faculty, Mersin University. All measurements were obtained with a digital image analysis software. RESULTS: In terms of male/female or right/left comparisons, no statistically significant difference was found in relation with the numerical data of ST. The surface area, length, and width of ST were detected as follows: 0.61 ± 0.15 mm2, 1.27 ± 0.30 mm, and 0.45 ± 0.08 mm, respectively. The absence of ST was observed in two fetuses with and without severe malformations. In another fetus with cleft lip and polydactyly, multiple abnormalities were bilaterally identified in the middle ear: (1) the absence of the incudostapedial joint and (2) the presence of an abnormal tissue attaching to the stapes. The abnormal tissue was determined to be irregular dense connective tissue using light microscope and electron microscope. CONCLUSION: Our findings showed that ST did not proportionally grow according to increasing gestational weeks. In the light of the numerical data, we thought that similar to stapes, ST attains the adult size in the fetal period. As ST anomalies may accompany severe malformations (e.g., cleft lip, polydactyly or syndactyly) that can be easily detected on observation by clinicians, we suggest that the detailed examination of middle ear in newborns should be taken into account for early diagnosis of conductive hearing loss to prevent any management delays.

Anatomic and histological analyses of chiasma plantare and long flexor tendons of the foot on human fetuses.

PURPOSE: The aim of present study was to reveal slip transfers related to flexor hallucis longus (FHL) and flexor digitorum longus (FDL) by dissection and to investigate detailed structure of chiasma plantare composed of FHL-FDL tendons and quadratus plantae (QP), with precise composition of the long flexor tendons of lesser toes by histological sections in human fetuses. METHOD: Slip transfers related to FHL and FDL tendons were identified and the related morphometric measurements were taken with dissection in 28 formalin-fixed fetuses (25-40 weeks). Composition and restoration of chiasma plantare and long flexor tendons of lesser toes were traced histological by analyzing movements of the tissues on the sequential coronal sections in five fetuses in the third trimester. The numbers of layers constituting chiasma plantare and the muscles that formed layers were specified. Each of two to five flexor tendons arising from the chiasma plantare was analyzed regarding its formation and contribution of FHL slip. RESULTS: Slip transfers were found as FHL slip in 86% and cross-connections in 14%. The ratios of the slip width to that of FHL and FDL tendons were found higher than in adult literature. Variance in the involvement of slip to FDL and QP, formation and layering of chiasma plantare and formation of long flexor tendons from chiasma plantare were revealed and great similarities were found with data from dissection of adult in literature. CONCLUSION: Slip transfers between FHL and FDL tendons, and layering properties of chiasma plantare were largely finalized during intrauterine period, while structural changes in slip seem to continue in the later stages of life, possibly by the effects of growth and usage of the extremity. In addition to individual variations, investigating the contribution of FHL slip, FDL and QP to long flexor tendons by different methods in literature is also suggested to be responsible for some diversities of our histological study.

Multiple muscular abnormalities in a fetal cadaver with CHARGE syndrome.

The CHARGE syndrome characterized by coloboma, heart defects, atresia of the choanae, retarded growth, genitourinary hypoplasia, and ear anomalies is one of the rare syndromes. Although certain clinical issues (scapular winging, sloping shoulder, Sprengel's deformity, kyphosis and scoliosis) which could be related to abnormalities in musculoskeletal structures of the neck and shoulder have been identified in CHARGE syndrome, data on details of muscle anomalies seem to be quite limited in the literature. In this case report, bilateral multiple muscular abnormalities (agenesis of the trapezius, presence of the rhombo-atloid muscle, and presence of the bipartite rhomboid minor with superficial and deep parts) was presented in a fetus cadaver with atypical CHARGE syndrome to attract the attention of clinicians for definitive diagnoses and surgical reconstruction of the shoulders deformity such as scapular winging and Sprengel's deformity. By considering the previous studies, we propose that the absence of the trapezius, as well as the other muscle abnormalities around the neck and shoulder, should be revised as being a component of CHARGE syndrome.

Fetal anatomy of the facial nerve trunk and its relationship with posterior auricular artery.

PURPOSE: The aims of the study are to define anatomy of the facial nerve (FN) and its main trunks as well as their relationship with the posterior auricular artery in fetal period to evaluate the data for regional surgery in newborns and young infants. METHODS: Formalin-fixed 34 fetuses from anatomy laboratory collection with a mean gestational age of 26.4 ± 4.6 (20-36) weeks were dissected. Parameters regarding the presence of major or minor trunks, width, length, branching pattern of FN were evaluated according to side, gender and trimester. The positional relationship of posterior auricular artery with the FN trunk was inspected. RESULTS: On all sides only the major trunk of the FN was detected. For length and width parameters, there was no statistically significant difference for side and gender except for trimester. Linear functions were found as 0.329 + 0.025 × weeks for width and 5.264 + 0.185 × weeks for length. There are statistically significant linear relationships between width and length of the FN trunk and week parameters as r = 0.507, p < 0.001 and r = 0.484, p < 0.001, respectively. Posterior auricular artery crossed FN trunk laterally in 42 of 53 sides, medially in 9 sides while it was puncturing it proximally in 2 sides. In all cases, it was in close contact to the FN trunk. FN trunk showed bifurcation in 82% and trifurcation in 18%. CONCLUSION: Dimensions of FN trunk, growth ratio and linear functions can be beneficial in understanding the fetal growth of FN trunk and its usage for grafts. Data about the relationship of the posterior auricular artery with FN trunk may be crucial in avoiding iatrogenic injuries during surgery in early ages.

Quantitative assessment of the growth dynamics of the teres major in human fetuses.

PURPOSE: The main objective of the study was to examine the use of teres major (TM) as a flap in the pediatric surgeries from an anatomical perspective by: (1) revealing the growth dynamics of the developing TM; (2) assessing the possible interconnecting structures between TM and latissimus dorsi (LD); (3) exposing the innervation patterns of TM in human fetuses. METHODS: Study was conducted on 50 fetuses (26 females and 24 males), on a mean gestational age of 22.86 ± 3.21 (range 18-30) weeks. All the measurements were collected with a digital caliper and a digital image analysis software. Additionally, structural relations between TM and LD were examined in detail and further classified. RESULTS: No significant difference of side and sex was detected on TM measurements (p > 0.05). Linear functions for the surface area, width, length of the superior and inferior margins of TM were detected as follows: y = - 257.142 + 18.334 × age (weeks), y = - 5.497 + 0.545 × age (weeks), y = - 1.621 + 1.068 × age (weeks), and y = - 2.147 + 1.284 × age (weeks), respectively. As classified in five types, a number of 33 muscular or tendinous connections between TM and LD were detected. Musculo-tendinous slips from TM to triceps brachii (TB) were evident in four sides. Innervation of TM was observed to be providing by the lower subscapular nerve in all the cases. CONCLUSION: First, linear functions, representing the developing fetal morphometry obtained by our study can be adapted for estimating the morphometric of this muscle in early childhood. Besides, acknowledging the diverse appointments of TM with the surrounding muscles such as LD and TB may facilitate the prevention of neurovascular structures and the application of surgical procedures during tendon transfers. In brief, our findings are highly potent to bring the attention of pediatric surgeons.

Quantitative and Neurovascular Anatomy of the Growing Gracilis Muscle in the Human Fetuses.

This study is intended to obtain the algebraic growth dynamics of the gracilis in fetuses and determine the variations of neurovascular pedicle(s) of the gracilis, to aid infant surgeries. Forty fetuses (19 males and 21 females) were included in the study. Gestational mean age of the fetuses was 22.40 ±â€Š2.67 (range, 18-28) weeks. Numerical values were obtained using a digital caliper and a digital image analysis software. Linear functions for the surface area, width, anterior, and posterior margin lengths of the gracilis were calculated, respectively, as: y = -289.307 + 20.501 × age (weeks), y = -7.113 + 0.622 × age (weeks), y = -24.421 + 3.434 × age (weeks), and y = -24.397 + 3.314 × age (weeks). In addition, length and width of the gracilis tendon were calculated as y = -6.676 + 0.934 × age (weeks) and y = -0.732 + 0.074 × age (weeks), respectively. Parameters of the gracilis had no statistically significant difference regarding side and sex (P > 0.05). In all the specimens, the gracilis was innervated by the anterior branch of the obturator nerve. Blood supply of the gracilis was identified to be derived from 1 single artery in 38 sides of total 80 (47.5%), from 2 arteries in 36 (45%) and from 3 arteries in 6 (7.5%). In 74 sides (92.5%), the nerve was superficial to the main artery, whereas in 6 sides (7.5%), it was deeper. The data of the present study could be beneficial for surgeons in infant surgeries to treat conditions such as obstetrical brachial plexus paralysis, facial palsy, or anal incontinence. Linear functions can be utilized to better evaluate the growth course of the gracilis in fetuses and to predict the dimensions thereof. Additionally, comprehending the structure and recognizing the variations of the gracilis nerves and arteries can help to protect the neurovascular pedicle(s) of the gracilis during the operations.