本文選題：燒傷 + 瘢痕　； 參考：《鄭州大學(xué)》2016年碩士論文

【摘要】：背景和目的:燒傷一直是個(gè)熱點(diǎn)課題,其全球發(fā)生率約為每年200/10萬(wàn)~400/10萬(wàn)[1]。在國(guó)內(nèi)外均有一個(gè)共識(shí),即燒傷是一個(gè)高發(fā)的常見(jiàn)病種,而且是一個(gè)對(duì)個(gè)人、家庭、社會(huì)造成嚴(yán)重傷害的病種。但是,燒傷創(chuàng)面早期愈合,并不意味著臨床治療的結(jié)束,創(chuàng)傷后創(chuàng)面愈合出現(xiàn)的瘢痕增生、攣縮等一系列問(wèn)題,嚴(yán)重影響了患者的人際社交、工作、自理能力以及造成心理影響。因此,在燒傷治療過(guò)程中,絕不僅限于對(duì)燒傷患者生命的救治及創(chuàng)面的封閉,而是應(yīng)最大限度的恢復(fù)外觀和功能,減少因瘢痕攣縮對(duì)患者各項(xiàng)生理功能造成的影響。如何在創(chuàng)口封閉后治療瘢痕,也是一個(gè)令臨床工作者為難的課題。瘢痕的研究,包括他的發(fā)生機(jī)制與防治問(wèn)題,迄今仍然困擾著我們[8]。它是一個(gè)聯(lián)結(jié)整個(gè)生命科學(xué)領(lǐng)域的重要問(wèn)題,十分復(fù)雜難解。瘢痕不僅影響美觀,其抗強(qiáng)性亦較正常皮膚組織差,在功能上,往往因收縮或牽拉導(dǎo)致功能障礙。數(shù)世紀(jì)以來(lái),瘢痕就一直困擾著我們,難以治愈,且易復(fù)發(fā)。適度的瘢痕形成是一種生理性和自衛(wèi)性表現(xiàn),而過(guò)度增生則屬于病理性改變[15]。特別是處于關(guān)節(jié)部位的瘢痕組織,一旦對(duì)關(guān)節(jié)形成牽拉,制約關(guān)節(jié)的活動(dòng),會(huì)導(dǎo)致病人自理能力或勞作能力的下降甚至消失,因此,在改善燒傷患者死亡率的同時(shí),更要注重?zé)齻缙诳祻?fù)對(duì)患者日后生活及勞作能力的影響。手是人類(lèi)賴(lài)以生存的重要工具,在人類(lèi)的勞作及生活中起著重要的作用。手為暴露部位,在遇到火焰燃燒時(shí),人的防御動(dòng)作是以雙手撲滅火焰或是以雙手遮面,因此致傷機(jī)會(huì)較多。雖然兩只手的體表面積占體表總面積為5%,不會(huì)造成生命危險(xiǎn),但是愈合過(guò)程中卻容易導(dǎo)致畸形。有些患者燒傷瘢痕雖然不深,但繼發(fā)病變卻很?chē)?yán)重。特別是兒童,在生長(zhǎng)的過(guò)程中瘢痕的生長(zhǎng)速度慢于周?chē)５慕M織,更容易導(dǎo)致?tīng)坷?使手功能受損或喪失。近年來(lái),康復(fù)醫(yī)學(xué)有了很大的進(jìn)步,手部燒傷后早期介入康復(fù)治療的觀念在臨床上也取得了共識(shí):單純的手術(shù)治療僅能解決畸形問(wèn)題,而無(wú)法解決后期瘢痕的攣縮。因此治療燒傷后瘢痕的攣縮必須早期介入綜合康復(fù)治療。康復(fù)器具通過(guò)代償或補(bǔ)償?shù)姆椒▉?lái)矯治畸形、彌補(bǔ)功能缺陷和預(yù)防功能進(jìn)一步退化,是患者能最大限度地實(shí)現(xiàn)生活自理,回歸社會(huì)�？祻�(fù)器具是重要的康復(fù)手段。對(duì)于瘢痕攣縮的治療,矯形支具是一個(gè)很好的選擇,它具有穩(wěn)定與支持、固定與矯正、保護(hù)與免負(fù)荷、代償與助動(dòng)的功能�？祻�(fù)治療種類(lèi)繁多,單憑一種治療方法難以取得理想效果,因此我科在多年治療手燒傷經(jīng)驗(yàn)的基礎(chǔ)上,提出了術(shù)后結(jié)合綜合康復(fù)治療的方法,即術(shù)后早期介入,針對(duì)患者個(gè)體差異定制專(zhuān)業(yè)壓力套和矯形器具,并以常規(guī)未使用壓力套和矯形支具的傳統(tǒng)治療方法作為對(duì)照進(jìn)行比較,觀察兩種方案的療效差異�？祻�(fù)評(píng)定需用確實(shí)能反應(yīng)手部功能的評(píng)價(jià)指標(biāo)[25]:手指關(guān)節(jié)總活動(dòng)度(Total Angle of Motion,TAM)、日常生活活動(dòng)能力(Activities of Daily Living,ADL)和Jebsen手功能測(cè)試。本課題旨在探討綜合康復(fù)治療在兒童手部燒傷后畸形矯治術(shù)后的臨床應(yīng)用價(jià)值,力求尋找更加完善的康復(fù)方案,為手部畸形的矯治提供科學(xué)的依據(jù)。方法:2013年5月~2015年5月,按統(tǒng)一標(biāo)準(zhǔn)入選的60例患兒按隨機(jī)數(shù)字表法分為康復(fù)加強(qiáng)組和傳統(tǒng)治療組,各30例。兩組患者均接受常規(guī)自體皮片移植術(shù),且傷口愈合時(shí)間在20~30天。術(shù)后的康復(fù)治療:康復(fù)加強(qiáng)組采用手術(shù)后指導(dǎo)性手部功能鍛煉,在醫(yī)師指導(dǎo)下進(jìn)行主動(dòng)、被動(dòng)手指活動(dòng),聯(lián)合使用壓力療法和矯形支具綜合治療。傳統(tǒng)治療組采用手術(shù)后指導(dǎo)性手部功能鍛煉,在醫(yī)師指導(dǎo)下進(jìn)行主動(dòng)被動(dòng)手指活動(dòng)。分別于康復(fù)治療前和治療后3個(gè)月、6個(gè)月測(cè)量評(píng)定溫哥華瘢痕量表、指標(biāo)手指關(guān)節(jié)總活動(dòng)度(Total Angle of Motion,TAM)、日常生活活動(dòng)能力(Activities of Daily Living,ADL)和Jebsen手功能測(cè)試。結(jié)果:本臨床試驗(yàn)通過(guò)對(duì)于康復(fù)加強(qiáng)組和傳統(tǒng)治療組患者手部瘢痕攣縮治療的對(duì)比發(fā)現(xiàn),康復(fù)加強(qiáng)組在瘢痕情況、關(guān)節(jié)活動(dòng)度測(cè)量方面、手功能和日常生活能力方便,均優(yōu)于常規(guī)治療組:2組患者瘢痕改善分值差異明顯(t=1.452,P=0.045);2組患兒關(guān)節(jié)活動(dòng)度優(yōu)良比差異明顯(t=8.507,P=0.004);2組患兒手功能測(cè)試改善時(shí)間差異明顯(t=2.618,P=0.012)。2組患兒日常生活活動(dòng)能力改善分值差異明顯(t=2.246,P=0.029)。結(jié)論:本實(shí)驗(yàn)通過(guò)對(duì)60例燒傷后手部畸形患者進(jìn)行手術(shù)和康復(fù)治療后,通過(guò)康復(fù)評(píng)定指標(biāo)的研究,得出以下結(jié)論:燒傷后手部瘢痕攣縮患者經(jīng)自體皮片移植后,綜合康復(fù)治療的療效明顯優(yōu)于術(shù)后單純的指導(dǎo)性運(yùn)動(dòng)治療。
[Abstract]:Background and purpose: burn has always been a hot topic. It has a global incidence of about 200/10 million ~400/10 000 a year, and there is a consensus at home and abroad that burns are a common disease with high incidence and a serious injury to individuals, families and society. However, the early healing of burn wounds does not mean clinical treatment. End, a series of problems such as scar hyperplasia and contracture of wound healing after trauma, which seriously affect the interpersonal, work, self-care and psychological effects of the patients. Therefore, in the process of burn treatment, it is not limited to the treatment of the lives of the burned patients and the closure of the wounds, but to the maximum restoration of appearance and function. Reducing the effects of scar contracture on the physiological function of the patients. How to treat scar after the wound closure is also a difficult task for the clinical workers. The research on scar, including his mechanism and prevention, still plagued us [8]., which is an important issue in the whole life science field. The scar not only affects the beauty, its resistance to strength is also worse than the normal skin tissue. In function, it often causes dysfunction due to contraction or traction. For centuries, scar has been plaguing us, difficult to cure, and easy to relapse. Moderate scar formation is a physiological and self-defense performance, and hyperproliferation is pathological. Change the [15]. especially in the joints of scar tissue, once the joint formation is drawn, restriction of joint activities will lead to the patient's self-care ability or decrease or even disappearance. Therefore, in improving the mortality of the burn patients, we should pay more attention to the effect of early burn on the patient's daily life and work ability. An important tool for human survival plays an important role in the work and life of human beings. When the hands are exposed to the exposed parts, when the flame is burning, the defensive action of the human is to extinguish the flame by both hands or to cover the face with both hands. Therefore, there are more chances of injury. Although the surface of the body surface of two hands is 5%, it will not cause the danger of life. But it is easy to cause malformation during the healing process. Some patients with burn scar are not deep, but secondary lesions are very serious. Especially in children, the growth rate of scar is slower than normal tissue in the process of growth. It is more likely to lead to traction, and the function of hand is damaged or lost. In recent years, rehabilitation medicine has made great progress and hand burn. The concept of early intervention rehabilitation after injury has also achieved a common understanding in clinical: simple surgical treatment can only solve malformation problems, but can not solve the later scar contracture. Therefore, the treatment of scar contracture after burn must be intervened in a comprehensive rehabilitation therapy. The rehabilitation device can be used to remedy deformity through compensatory or compensatory methods, and make up for the deficiency of function. The function of depression and prevention is further degenerated. It is the patient who can maximize the life and return to the society. The rehabilitation apparatus is an important means of rehabilitation. For the treatment of scar contracture, the orthopedic support is a good choice. It has the function of stability and support, fixation and correction, protection and no load, compensatory and auxiliary functions. On the basis of many years' experience in treating hand burn, we put forward a method of combining comprehensive rehabilitation after operation, namely, early postoperative intervention, customizing professional pressure sets and orthopedics according to individual differences of patients, with the tradition of conventional unused pressure sets and orthopedics. The treatment methods were compared as controls to observe the difference in the efficacy of the two schemes. The evaluation of the rehabilitation of the hand was [25]: the total activity of the finger joint (Total Angle of Motion, TAM), the ability of daily living (Activities of Daily Living, ADL) and the test of the Jebsen function. The purpose of this study was to discuss the comprehensive health. The clinical application value of complex treatment after orthopedics after hand burn in children is to seek a more perfect rehabilitation program and provide scientific basis for the correction of hand deformity. Method: in May ~2015 May 2013, 60 children selected according to the unified standard were divided into the rehabilitation strengthening group and the traditional treatment group according to the random digital table method, each 30 cases two. The patients in the group received conventional autologous skin graft, and the healing time of the wound was 20~30 days. The rehabilitation treatment after operation: the rehabilitation and strengthening group adopted the guiding hand exercise after the operation. Under the guidance of the doctor, the active, passive finger movement, combined use of pressure therapy and orthopedic support were combined. The traditional treatment group was guided by postoperative guidance. Sexual hand exercise was conducted under the guidance of doctors. The Vancouver scar scale was assessed before and 3 months after rehabilitation and 6 months after treatment. The total activity of the finger joint (Total Angle of Motion, TAM), the activity of daily living (Activities of Daily Living, ADL) and Jebsen hand test. Results: by comparing the treatment of hand scar contracture in the rehabilitation group and the traditional treatment group, it was found that the rehabilitation group was better than the conventional treatment group in the scar condition, the measurement of joint activity, the hand function and the daily life ability, and the difference of scar improvement score in the 2 groups was obviously different (t=1.452, P=0.045); The good ratio of joint activity was obvious (t=8.507, P=0.004), and the difference of the time of improvement of hand function test in the 2 groups was obvious (t=2.618, P=0.012), the difference of the daily living ability of the children was significantly different (t=2.246, P=0.029). Conclusion: after the operation and rehabilitation treatment of the hand deformity patients after the burn, the experiment was carried out through rehabilitation. The following conclusions are drawn: after transplantation of autologous skin graft in patients with scar contracture after burn, the curative effect of comprehensive rehabilitation is better than that of simple guided exercise after the operation.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類(lèi)號(hào)】：R644

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