合并骨关节严重损伤的全手脱套伤治疗方式选择  

An outcome comparison for the treatment of totally degloved hand combining with multiple metacarpus and phalange fractures

作　　者：刘育杰[1] 丁小珩[1] 屈志刚[1] 孙乐天[1] 焦鸿生[1] 张宏勋[1] 仲霄鹏[1] 纪翔[1] 郑波[1] 

机构地区：[1]解放军第401医院全军手外科中心,青岛266071

出　　处：《中国骨与关节杂志》2015年第12期941-945,共5页Chinese Journal of Bone and Joint

摘　　要：目的通过病例回顾,探讨合并骨关节严重损伤的全手脱套伤分型及治疗方法。方法 2005年1月至2014年1月,共收治28例全手脱套伤患者,所有患者撕脱的皮肤均无回植条件同时伴有骨关节损伤。对所有患者按照伤情进行分型,并根据分型确定治疗方案。术后通过检测患手静态两点辨别觉（s2PD）,握力,主动活动度（ROM）等指标综合评价疗效。结果 （1）将合并骨关节严重损伤的全手脱套伤根据骨关节损伤严重程度分成4种类型,其中I型为手部骨关节损伤不严重,大部分拇手指骨支架可以重建功能长度;II型为2-5指毁损不能重建功能长度,拇指可以重建功能长度;III型为拇指毁损,2-5指能够重建功能长度;IV型为1-5指均毁损,不能重建功能长度。（2）治疗方式选择：I型12例,5例采用腹部袋状皮瓣修复法,7例采用带足背皮瓣的拇甲瓣或第二趾游离移植修复拇指及第一掌骨背侧皮肤缺损,同时应用腹部皮瓣修复手其它部位皮肤缺损;II型6例,其中3例采用腹部皮瓣修复创面,二期再造手指。3例采用一期拇甲瓣修复拇指皮肤缺损,剩余创面采用腹部皮瓣修复创面,二期再造手指;III型5例,3例采用腹部皮瓣覆盖创面,二期分指及行游离足趾移植再造拇指;2例采用一期带足背皮瓣的第二趾再造拇指,剩余创面用腹部皮瓣覆盖。IV型5例,急诊行腹部皮瓣覆盖创面,二期行游离足趾移植再造拇手指。所有患者均随访12-24个月,平均16个月。急诊再造手功能评定要优于二期再造,但足部损伤要比二期再造严重。结论合并骨关节严重损伤的全手脱套伤患者应根据伤情进行分类,谨慎截指。选择合适治疗策略尽快覆盖创面并再造手指,均能够恢复一定的手捏握功能。Objective To compare the outcome for the treatment of totally degloved hand combining with multiple metacarpus and phalange fractures by different means and to explore its classification and treatment. Methods From January 2005 to January 2014, 28 cases were collected. Degloved skin could not be back implanted in all cases, accompanied by bone and joint injuries. Standardized assessment of outcomes was based on static two-point discrimination （ s2PD ）, grip power of the reconstructed hand, time taken to return to work, and active total range of motion of the operated finger （ ROM ）. Results （ 1 ） Patients were divided into 4 types mainly according to fractures. Type I： not severe injury of hand and joint, main fingers could be reconstructed to a certain length with functions. Type II： fingers 2-5 could not be reconstructed to a certain length with functions, the thumb could be reconstructed. Type III：fingers 2-5 could be reconstructed to a certain length with functions, the thumb could not be reconstructed. Type IV： all 1-5 fingers could not be reconstructed to a certain length with functions. （ 2 ） Options of the treatment： 12 cases were of type I, in which 5 cases were repaired by traditional abdomen pocket flap and 7 cases were repaired by toe transfer with a dorsalis pedis skin flap combined with abdominal S-shaped tile-joint subdermal vascular network flaps. Six cases were of type II, in which 3 cases were repaired by different types of abdominal flaps and toe transfer at stage II. Another 3 cases were repaired by wraparound flaps of toe and abdominal flap at the stage I. Five cases were of type III and IV. All patients were repaired by abdominal flap and the thumb was reconstructed by toe transfer at stage II. All flaps and skin grafts survived. All patients were followed up from 12 to 24 months （ mean： 16 months ）. Compared with toe transfer at stage II, transfer at stage I showed a better recovery. Conclusions Finger amputation should be chosen cautiously and treatment shou

关 键 词：手关节 外科皮瓣 截肢术 手损伤 指损伤 创伤和损伤 显微外科手术 

分 类 号：R658.2[医药卫生—外科学]