本文關(guān)鍵詞：指?jìng)?cè)方皮瓣和微型靜脈皮瓣的解剖及在皮膚缺損型斷指再植的應(yīng)用研究　出處：《第一軍醫(yī)大學(xué)》2007年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 指?jìng)?cè)方島狀皮瓣 微型靜脈皮瓣 皮膚軟組織缺損 斷指 再植修復(fù)

【摘要】： 目的 在手外傷臨床診治中，壓軋傷、旋轉(zhuǎn)撕脫傷、電鋸傷、熱壓傷等各種致傷原因所致的手指離斷或手指血運(yùn)障礙并皮膚軟組織缺損的病例越來越多，這些病例臨床治療均較棘手，，由于再植難度大，加之對(duì)皮膚血管缺損缺乏有效的修復(fù)手段，故過去常采患指縮短再植或直接截指，嚴(yán)重影響手的外觀和功能，對(duì)患者的生活和心理均造成巨大壓力，因此對(duì)于骨與關(guān)節(jié)較完整而皮膚軟組織缺損的斷指病例，根據(jù)損傷、缺損的程度、部位和范圍，通過某種修復(fù)方法使患指保存完整乃十分必要。本研究目的正是在對(duì)指?jìng)?cè)方島狀皮瓣和微型游離靜脈皮瓣應(yīng)用解剖學(xué)研究的基礎(chǔ)上，進(jìn)一步探討指?jìng)?cè)方島狀皮瓣和微型游離靜脈皮瓣在各種類型皮膚軟組織缺損型斷指再植修復(fù)的術(shù)式，并應(yīng)用于臨床，驗(yàn)證指?jìng)?cè)方島狀皮瓣和微型游離靜脈皮瓣設(shè)計(jì)術(shù)式對(duì)皮膚軟組織缺損型斷指病例進(jìn)行再植修復(fù)的可行性和實(shí)用性。 方法 1．應(yīng)用解剖學(xué)研究 1．1．研究總結(jié)現(xiàn)已有手部血管造影及手部應(yīng)用解剖資料，了解手部血管神經(jīng)走行和分布； 1．2．采用5例上肢血管鑄形標(biāo)本，直觀觀察總結(jié)手部血管及前臂皮下淺靜脈走行分布； 1．3．采用10例前臂取皮手術(shù)標(biāo)本，觀察皮下靜脈分布、數(shù)量、直徑， 并行血管通水試驗(yàn)，觀察小靜脈瓣膜作用。 1．4．采用5例福爾馬林固定的成人上肢標(biāo)本和1例新鮮毀損廢棄手部標(biāo)本，逐層解剖，觀察掌淺弓、指總動(dòng)脈神經(jīng)及指固有動(dòng)脈神經(jīng)走向，分別測(cè)量指總動(dòng)脈掌淺弓發(fā)出點(diǎn)(a_1點(diǎn))及指總動(dòng)脈位掌骨頭平面分叉點(diǎn)(a點(diǎn))至示、中、環(huán)、小指末節(jié)基底(c點(diǎn))的距離，再分別測(cè)定3條指總動(dòng)脈掌淺弓發(fā)出點(diǎn)(a_1點(diǎn))及位掌骨頭平面分叉點(diǎn)(a點(diǎn))根據(jù)所測(cè)量a_1-c及a-c長(zhǎng)度來轉(zhuǎn)移所能達(dá)至各指平面位置； 1．5．選取50例活體手部體表測(cè)量標(biāo)本，根據(jù)體表解剖學(xué)標(biāo)志，測(cè)量可設(shè)計(jì)島狀皮瓣最遠(yuǎn)端c點(diǎn)(即示、中、環(huán)、小指末節(jié)基底)至轉(zhuǎn)移軸點(diǎn)(指總動(dòng)脈位掌骨頭平面分叉點(diǎn)a點(diǎn)及指總動(dòng)脈位掌淺弓發(fā)出點(diǎn)a_1點(diǎn))距離，再根據(jù)a_1-c及a-c長(zhǎng)度來測(cè)定從轉(zhuǎn)移軸點(diǎn)能達(dá)至各指的平面位置； 1．6．采用70例國(guó)人新鮮廢棄指體標(biāo)本(示指15例、中環(huán)指各20例、小指15例)，設(shè)計(jì)并切取示指尺側(cè)、中環(huán)指兩側(cè)、小指橈側(cè)近中節(jié)不同部位例數(shù)不等的1.0cm×1.0cm和2.0cm×2.0cm皮瓣，觀察計(jì)數(shù)島狀皮瓣內(nèi)的靜脈數(shù)量及可供吻合之靜脈端口數(shù)目； 2．臨床研究 本組12例13指，其中男9例10指，女3例3指，年齡16～48歲，平均年齡23.6歲。完全離斷6指，不完全離斷7指。離斷部位從近節(jié)根部至末節(jié)基底。致傷原因：壓軋傷6例，旋轉(zhuǎn)撕脫傷1例，電鋸傷2例，熱壓傷1例，，電擊傷1例，化學(xué)燒傷1例。清創(chuàng)前期處理后均有皮膚血管缺損，根據(jù)缺損部位不同可將這些皮膚缺損型斷指大體分為掌側(cè)、背側(cè)和環(huán)狀缺損型3種類型，再根據(jù)這3種類型將指?jìng)?cè)方島狀皮瓣和前臂微型游離靜脈皮瓣作不同術(shù)式設(shè)計(jì)進(jìn)行修復(fù)，術(shù)后觀察皮瓣和斷指成活情況，長(zhǎng)期隨訪觀察患指感覺和功能恢復(fù)情況。 結(jié)果 1．應(yīng)用解剖學(xué)研究 1．1．清楚掌握手部血管神經(jīng)，尤其是指掌側(cè)總動(dòng)脈和指掌側(cè)固有動(dòng)脈的分布走行；前臂掌側(cè)遠(yuǎn)部皮下淺靜脈皮瓣有如下特點(diǎn)：皮膚薄，靜脈網(wǎng)豐富，皮下靜脈表淺、細(xì)小，直徑與手指血管相近，小靜脈內(nèi)瓣膜作用弱。 1．2．福爾馬林固定上肢標(biāo)本和新鮮廢棄手部標(biāo)本解剖測(cè)量結(jié)果和活體手部體表測(cè)量標(biāo)本所得測(cè)量結(jié)果均顯示：示指尺側(cè)、中指兩側(cè)和環(huán)指橈側(cè)a-c轉(zhuǎn)移均能達(dá)至拇指c點(diǎn)，環(huán)指尺側(cè)a_1-c轉(zhuǎn)移可達(dá)至拇指近節(jié)中部；中指a-c轉(zhuǎn)移均可達(dá)至示環(huán)小指c點(diǎn)以遠(yuǎn)；示指尺側(cè)a-c轉(zhuǎn)移可達(dá)至中環(huán)小指中節(jié)遠(yuǎn)部，a_1-c轉(zhuǎn)移可達(dá)至中環(huán)小指c點(diǎn)；環(huán)指橈側(cè)a-c轉(zhuǎn)移可達(dá)至示中指中節(jié)遠(yuǎn)部，a_1-c轉(zhuǎn)移可達(dá)至示中指c點(diǎn)；環(huán)指尺側(cè)a-c和a_1-c轉(zhuǎn)移均只能達(dá)至中指中節(jié)遠(yuǎn)部和示指中節(jié)近部；環(huán)指兩側(cè)a-c和a_1-c轉(zhuǎn)移均能達(dá)至小指c點(diǎn)；小指橈側(cè)a-c和a_1-c轉(zhuǎn)移能達(dá)至環(huán)指近節(jié)遠(yuǎn)端，中指近節(jié)近部。 1．3．切取1.0cm×1.0cm指?jìng)?cè)方皮瓣可包含指掌側(cè)淺靜脈1條以上(或皮瓣遠(yuǎn)近側(cè)各1個(gè)以上可供吻合的端口)，和／或指背側(cè)淺靜脈1條以上(或皮瓣遠(yuǎn)近側(cè)各1個(gè)以上可供吻合的端口)；切取2.0cm×2.0cm皮瓣可包含指掌側(cè)淺靜脈2條以上(或皮瓣遠(yuǎn)近側(cè)各2個(gè)以上可供吻合的端口)，和／或指背側(cè)淺靜脈2條以上(或皮瓣遠(yuǎn)近側(cè)各2個(gè)以上可供吻合的端口)。 2．臨床應(yīng)用研究 本組12例13指，均順利成活，長(zhǎng)度無明顯縮短，外觀良好。后期動(dòng)脈皮瓣外觀、質(zhì)地良好，靜脈皮瓣則有不同程度的收縮，顏色較深，質(zhì)地稍硬，彈性稍差。按TAM功能評(píng)定法：優(yōu)6指，良5指，差2指，優(yōu)良率84.6％。 結(jié)論 1．指?jìng)?cè)方島狀皮瓣和前臂微型游離靜脈皮瓣可擴(kuò)大應(yīng)用于各種類型的皮膚軟組織缺損型斷指再植修復(fù)術(shù)。 2．術(shù)式設(shè)計(jì)具有靈活、安全、損傷小及操作容易掌握，適應(yīng)范圍廣等優(yōu)點(diǎn)，是皮膚軟組織缺損型斷指再植修復(fù)較理想術(shù)式。
[Abstract]:objective
In the clinical diagnosis and treatment of hand trauma, crush injury, rotation avulsion, electric saw injury cases increasing, heat injury caused by various injury severed fingers or disturbance of blood circulation and skin and soft tissue defects, the clinical treatment was difficult, because of difficulty, in addition to the lack of skin defect of blood vessels repair of effective means, is used to shorten the mining finger replantation or direct cut finger, seriously affect the appearance and function of hand, causing tremendous pressure on the patient's life and psychology, so for bone and joint is complete and skin and soft tissue defect of finger injury according to the case, the extent of the defect, location and scope. Through some repair methods with complete preservation is very necessary. The purpose of this study is on the basis of the lateral island flap and miniature free vein flap applied anatomy study on the further study of the lateral island flap Micro flap and free vein flap in the surgical repair of various types of skin and soft tissue defect of finger replantation, and clinical application to verify the feasibility and practicability of the lateral island flap and miniature free vein flap design for replantation repair of skin and soft tissue defect of finger type case.
Method
1. applied anatomy study
1.1. studies have summarized hand angiography and hand applied anatomical data to understand the walking and distribution of the vascular and nerve in the hand.
The blood vessels of the hand and the superficial subcutaneous vein of the forearm were observed in 5 cases by 1.2..
1.3. specimens of 10 cases of forearm skin removal were used to observe the distribution, quantity and diameter of subcutaneous veins.
Parallel vascular water test was used to observe the effect of small venous valve.
1.4. using formalin fixed adult cadaver specimens of 5 cases and 1 cases of fresh damaged abandoned hand were dissected, observed the superficial palmar arch, the artery nerve and nerve to the finger artery, were measured in the artery superficial palmar arch a point (point a_1) and finger artery at the bifurcation point metacarpal head plane (a) to show, ring finger paratelum base (point C) distance, then determination of 3 refers to the superficial palmar arch arteries from point (a_1 point) and palmar head bifurcation point (point a) according to a_1-c and a-c length measurement to transfer to the plane position;
1.5. selected 50 cases of living hand surface were measured, according to the surface anatomical landmarks, measurement of island flap design the most distal point (i.e., C, ring finger paratelum base) to transfer axis point (finger artery at metacarpus head bifurcation point a and finger artery at a superficial palmar arch point a_1) distance, according to a_1-c and a-c to determine the length of plane position from the transfer axis point to each finger;
1.6. with 70 cases of the fresh specimens of abandoned finger (index finger in 15 cases, 20 cases in each ring finger, little finger in 15 cases), design and cut the ulnar side of index finger, ring finger on both sides of the little finger radial proximal section in different parts of the number of cases ranging from 1.0cm * 1.0cm and 2.0cm * 2.0cm flap, intravenous counting in the island flaps and vein anastomosed port number;
2. clinical study
This group of 12 cases 13, 9 cases were male 10, female 3 cases 3 fingers, aged 16 to 48 years old, the average age of 23.6 years. The complete transection of the 6 finger, complete transection of the 7 fingers. From the broken parts from the proximal root to the distal base. The causes of injury: 6 cases of crush injury. Rotation avulsion in 1 cases, 2 cases of electric saw injury, hot crush injury in 1 cases, and electrical injury in 1 cases, 1 cases of chemical burn debridement. After early treatment of skin vascular defects, according to different defect location the skin defect of finger can be divided into dorsal and volar, annular defect of 3 types then, according to the 3 types of the lateral island flap and forearm minisize free vein flap for different operation design of repair, postoperative flap and finger, long-term follow-up with feeling and functional recovery.
Result
1. applied anatomy study
1.1. clearly grasp the hand of blood vessels and nerves, especially the distribution of common palmar digital arteries and proper palmar digital artery; far side of subcutaneous superficial vein flap has the following characteristics: the skin is thin, the forearm palm vein network rich, superficial subcutaneous vein, small diameter and small finger vein similar vein valve inside the weak effect.
1.2. formalin fixed upper limb specimens and fresh abandoned hand anatomical specimens and in vivo measurement results of hand surface were measured and the measurement results showed that the index finger ulnar, middle finger and ring finger on both sides of the radial side of the a-c transfer can reach the C point, a_1-c moved up to the ulnar thumb proximal ring finger in the middle; refers to the transfer of up to a-c are shown in the ring and little fingers point beyond C; a-c is the little finger ulnar finger transfer to central section in the distal part, a_1-c transfer to central C point finger can reach up to a-c; radial transfer of index finger in the distal portion of the ring finger section, up to a_1-c transfer of index finger ring finger point C; the ulnar a-c and a_1-c transfer are only up to the festival far part and the index finger in the section near; both a-c and a_1-c transfer can reach C point of little finger ring finger; finger radialis transfer a-c and a_1-c can reach to the ring finger proximal distal and proximal phalanx of middle finger in the Department.
1.3. cut 1.0cm * 1.0cm laterodigital flap contains over 1 palmar superficial vein (or flap near and far side of 1 above for anastomose), and / or dorsal superficial vein (more than 1 or more than 1 of the near and far side flap anastomosed port); cut 2.0cm * 2.0cm flap can contain over 2 palmar superficial vein (or flap near and far side of 2 above for anastomose), and / or dorsal superficial vein (more than 2 or more than 2 of the near and far side flap anastomosed port).
2. clinical application research
The group of 12 patients 13 fingers survived, the length was not shortened, the appearance is good. The late arterial flap appearance, good texture, vein flaps have different degrees of shrinkage, darker color, hard texture, elasticity is poor. According to TAM functional evaluation standard: 6 excellent, 5 good, 2 poor refers to the excellent rate of 84.6%.
conclusion
The 1. finger lateral island flap and the forearm free vein flap can be applied to various types of skin soft tissue defect replantation repair.
2., the design of operation is flexible, safe, less damage, easy to operate and wide range of adaptation. It is an ideal surgical method for skin and soft tissue defect replantation of severed fingers.

【學(xué)位授予單位】：第一軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2007
【分類號(hào)】：R322;R658.1

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本文編號(hào)：1365940