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微型外固定支架在虎口外傷急診治療中的應用及療效

目的探討微型外固定支架在急診治療虎口外傷中的應用及臨床療效。 方法2009年2月－2011年6月，收治虎口外傷患者34例。男21例，女13例；年齡18～65歲，平均31.4歲。致傷原因：機器沖壓傷15例，重物壓砸傷12例，切割傷5例，爆炸傷2例。受傷至入院時間20 min～6 h 30 min。按創傷程度及范圍，26例為簡單損傷，8例為復合性損傷。急診清創后一期微型外固定支架開大虎口或聯合虎口“Z”字成形治療，復合性損傷者二期行皮瓣修復。 結果術后1例發生針道感染，經對癥處理后愈合；其余患者切口均Ⅰ期愈合，復合性損傷患者皮瓣及供區植皮均順利成活。31例獲隨訪，隨訪時間5～14個月，平均7.5個月。末次隨訪時虎口開大角度為65～95°，平均80°。拇指指間關節紋尺側點與示指掌指關節橈側點距離為4.0～5.5 cm，平均4.8 cm；按顧玉東等的評價方法評價，獲優19例，良10例，差2例，優良率達93.5%。 結論在虎口外傷急診治療中，采用微型外固定支架開大虎口，手術操作簡便，損傷小，避免了虎口攣縮的發生。

Modified induced membrane technique and pedicled skin (myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes

ObjectiveTo investigate the effectiveness of modified induced membrane technique and pedicled skin (myocutaneous) flap for chronic tibial osteomyelitis in patients with diabetes. Methods A clinical data of 22 diabetic patients with chronic tibial osteomyelitis between January 2017 and March 2019 was retrospectively analyzed. There were 15 males and 7 females with an average age of 52 years (range, 44-65 years). The course of diabetes was 3-12 years (mean, 6.1 years). The course of chronic osteomyelitis was 4 months to 7 years (mean, 3.3 years). The chronic osteomyelitis was rated as type Ⅲ in 9 cases and as type Ⅳ in 13 cases according to the Cierny-Mader classification criteria. Bacterial culture showed 21 cases of single bacterial infection and 1 case of mixed bacterial infection. Preoperative color Doppler ultrasound and CT angiography confirmed that the anterior and posterior tibial arteries were unobstructed. In the first stage of treatment, the bone and soft tissue defects were filled with antibiotic bone cement after the lesion was thoroughly debrided; the length of bone defect was 4-9 cm (mean, 5.6 cm), and the size of soft tissue defect was 5 cm×2 cm to 10 cm×7 cm. After 7-10 days, the bone cement was removed and a new antibiotic bone cement was filled into the bone defect. Meanwhile, the pedicled skin (myocutaneous) flap was performed to repair the wound. After 7-12 weeks, the inflammatory indexes returned to normal, autogenous iliac bone or combined with artificial bone was used to repair the bone defect in the second stage of treatment. The wound healing, bone defect healing, complications, and the number of successful treatments were recorded. The satisfaction of the skin flap efficacy and the function of the affected limb were evaluated. ResultsLocal necrosis of the skin flap occurred in 3 cases after operation, leading to delayed healing of the wound; the other 19 flaps survived successfully, leading to primary healing of the wound. The skin grafts survived completely and the incisions healed by first intention. All cases were followed up 13-28 months with an average of 20 months. The infection recurred in 2 cases within 12 months after operation, and the bone defects healed after treated by modified induced membrane technique. The bone defect healing rate was 100%; the bone healing time was 6-10 months, with an average of 8.9 months; the infection control rate and successful treatment rate were 90.9% (20/22) and 90.9% (20/22), respectively. At 12 months after operation, according to the satisfaction evaluation standard of skin flap efficacy formulated by ZHANG Hao et al., all were satisfied. According to Johner-Wruhs adjacent joint function method, the limb function recovery was excellent in 13 cases, good in 7 cases, and fair in 2 cases, with an excellent and good rate of 90.9%. ConclusionFor the treatment of chronic tibial osteomyelitis in patients with diabetes without vascular occlusion, the modified induced membrane technique and pedicled skin (myocutaneous) flap can repair bone and soft tissue defects, and control the infection at the same time, the short- and medium-term effectiveness are good.

EFFECTIVENESS OF DORSAL METACARPAL ISLAND FLAP FOR TREATING SCAR CONTRACTURE OF FINGER WEB

Objective To investigate the effectiveness of dorsal metacarpal island flap for treating scar contracture of the finger web. Methods Between June 2009 and December 2010, 10 patients with scar contracture of the finger web were treated. There were 6 males and 4 females with an average age of 30 years (range, 14-57 years). Scar contracture was caused byinjury in 8 cases, by burn in 1 case, and by operation in 1 case. The locations were the 1st web space in 1 case, the 2nd web space in 3 cases, the 3rd web space in 5 cases, and the 4th web space in 1 case. The disease duration was 3 to 9 months with an average of 5 months. The maximum abduction was 10-20°. After web space scar release, the dorsal metacarpal island flap (3.5 cm × 1.2 cm-4.0 cm × 2.0 cm in size) was used to reconstruct web space (2.0 cm × 1.0 cm-3.0 cm × 1.8 cm in size). The donor site was directly sutured or repaired with local flaps. Results At 2 days after operation, necrosis occurred in 1 flap, which healed by extractive treatment. The other flaps survived and wound healed by first intention; all the flaps at donor sites survived and incision healed by first intention. Ten patients were followed up 6 to 15 months (mean, 9 months). The reconstructed web space had good appearance, the maximum abduction was 80 ° in 1 case of the 1st web space scars contracture, and the maximum abduction was 35-45° (mean, 40°) in the other 9 cases. In 8 scar patients causing by injury, no scar contracture recurred during follow-up. Conclusion It can achieve good results in appearance and function to use dorsal metacarpal island flap for treating scar contracture of the finger web.

第一掌骨橈背側穿支皮瓣修復拇指背島狀皮瓣供區

目的 總結第1掌骨橈背側穿支皮瓣修復拇指背島狀皮瓣供區的療效。 方法 2010年1月－2012年7月，收治21例拇指軟組織缺損患者。男13例，女8例；年齡17～56歲，平均32.3歲。指端缺損7例，指腹缺損10例，甲床缺損4例。創面范圍1.5 cm × 1.5 cm～2.0 cm × 1.8 cm。受傷至入院時間20 min～14 h，平均4.6 h。采用大小為1.8 cm × 1.8 cm～2.3 cm × 2.0 cm的近節指背島狀皮瓣修復創面后，利用大小為1.3 cm × 1.1 cm～2.0 cm × 1.5 cm的第1掌骨橈背側穿支皮瓣修復供區，穿支皮瓣供區直接縫合。 結果術后拇指背島狀皮瓣和第1掌骨橈背側穿支皮瓣均順利成活，創面Ⅰ期愈合。19例獲隨訪，隨訪時間5～17個月，平均10.4個月。皮瓣血運、彈性好，手指無疼痛。末次隨訪時，供區皮瓣兩點辨別覺為8～12 mm，平均9.6 mm。拇指對掌、對指功能正常。根據中華醫學會手外科學會斷指再植功能評定試用標準，獲優16例，良3例，優良率100%。 結論采用第1掌骨橈背側穿支皮瓣修復拇指背島狀皮瓣供區，避免植皮后掌指關節背側瘢痕攣縮，最大限度保留掌指關節功能，穿支皮瓣供區可直接縫合，是一種有效術式。

逆行前踝上島狀皮瓣修復足背部軟組織缺損

指動脈串聯逆行島狀皮瓣修復老年指端脫套傷

目的總結指動脈串聯逆行島狀皮瓣修復老年指端脫套傷的療效。 方法2011年6月－2012年8月，收治7例老年指端脫套傷。男5例，女2例；年齡56～68歲，平均62歲。致傷原因：沖壓傷4例，機器絞傷3例。損傷指別：示指3例，中指3例，環指1例。合并末節指骨骨折2例，伸肌腱止點撕脫1例，相鄰指損傷1例。傷后至手術時間為3～5 d，平均3.6 d。術中在患指切取近節指根部及掌遠端2塊皮瓣瓦合修復指端皮膚軟組織缺損；近節指根部側方皮瓣切取范圍為1.4 cm × 1.2 cm～2.0 cm × 1.8 cm，掌遠端皮瓣為1.1 cm × 1.0 cm～1.8 cm × 1.5 cm。掌遠端供區直接縫合，指根部供區游離植皮修復。 結果1例掌遠端皮瓣術后12 h發生靜脈危象，經間斷拆線后緩解；其余皮瓣及供區植皮均順利成活，創面Ⅰ期愈合。術后7例均獲隨訪，隨訪時間6～20個月，平均12個月。皮瓣外形、質地均良好。末次隨訪時，近節指根部側方皮瓣兩點辨別覺為7～10 mm，掌遠端皮瓣為8～12 mm；手指功能參照中華醫學會手外科學會上肢部分功能評定試用標準：獲優6例，良1例。 結論指動脈串聯逆行島狀皮瓣是利用遠側指間關節指固有動脈交通支的解剖特點，將相鄰的2塊皮瓣瓦合修復老年患者指端脫套傷，手術操作簡便，療效滿意。

指背動脈筋膜瓣結合皮膚原位回植治療拇指末節指腹撕脫傷

目的探討以指背動脈筋膜瓣結合皮膚原位回植治療拇指末節指腹撕脫傷的療效。 方法2014年3月－2015年1月，收治9例（9指）因機器擠壓導致的拇指末節指腹撕脫傷患者。男6例，女3例；年齡13～58歲，平均33歲。均為拇指指間關節平面以遠指掌側皮膚軟組織撕脫缺損，伴骨、肌腱外露，無再植條件。創面范圍為1.4 cm×1.2 cm～1.6 cm×1.4 cm。受傷至手術時間3～10 h，平均6 h。以拇指指背動脈筋膜瓣覆蓋外露肌腱、指骨，將撕脫皮膚修薄成全厚皮片回植覆蓋筋膜瓣。 結果術后回植皮片順利成活，創面Ⅰ期愈合。患者均獲隨訪，隨訪時間6～12個月，平均8個月。筋膜蒂部無臃腫，回植皮片質地柔軟、外觀滿意、顏色與周圍皮膚接近、皮紋恢復。術后6個月按照總主動活動度法評定手功能，獲優7指，良2指。 結論采用指背動脈筋膜瓣結合皮膚原位回植治療拇指末節指腹皮膚撕脫傷不損傷指動脈和指神經，可獲得較好療效。

帶部分甲床的指動脈順行皮瓣側方推進修復拇指指端斜形缺損

目的總結帶部分甲床的指動脈順行皮瓣側方推進修復拇指指端斜形缺損的療效。 方法2013年6月-2014年9月，收治7例拇指指端斜形缺損患者。男5例，女2例；年齡25～68歲，平均47歲。致傷原因：鉸鏈傷3例，壓榨傷4例。軟組織缺損范圍1.5 cm×1.2 cm～1.6 cm×1.4 cm；創面近端甲床部分缺損，缺損范圍4 mm×3 mm～5 mm×4 mm。以斜面遠端指動脈順行皮瓣側方推進修復創面，同時皮瓣遠端帶入部分甲床修復缺損甲床。供區直接縫合。 結果術后皮瓣全部成活，創面Ⅰ期愈合；供區切口Ⅰ期愈合。7例均獲隨訪，隨訪時間8～22個月，平均13個月。拇指外形良好，指端圓滑、患指無疼痛和瘢痕攣縮；皮瓣質地柔軟，有指紋，術后4個月靜止兩點辨別覺達4～6 mm，平均5 mm；指甲光滑，無甲棘。術后8個月按中華醫學會手外科學會上肢部分功能評定試用標準評價手功能，獲優6例，良1例。 結論采用帶部分甲床的指動脈順行皮瓣側方推進修復拇指指端斜形缺損可獲得滿意療效。

游離尺動脈近中段穿支蒂M形皮瓣修復手指末節脫套傷

目的探討游離尺動脈近中段穿支蒂M形皮瓣修復手指末節脫套傷的療效。 方法2012年3月－2013年3月，收治9例手指末節脫套傷患者。男7例，女2例；年齡18～68歲，平均38歲。致傷原因：沖壓傷5例，機器絞軋傷4例。損傷指別：示指4例，中指3例，環指2例。合并末節指骨骨折1例，伸肌腱止點斷裂1例。傷后至手術時間為3～8 h，平均4.6 h。采用大小為6.5 cm×1.8 cm～6.8 cm×2.2 cm的前臂尺側游離尺動脈近中段穿支蒂M形皮瓣修復缺損，供區創面直接縫合。 結果術后1例背側皮瓣發生張力性水皰，對癥處理后成活；其余皮瓣均順利成活，創面Ⅰ期愈合。術后9例均獲隨訪，隨訪時間6～17個月，平均12個月。除1例發生張力性水皰者皮瓣色素沉著較明顯外，其余皮瓣外形、質地均良好；末次隨訪時皮瓣兩點辨別覺為7～12 mm，平均9 mm；參照中華醫學會手外科學會上肢部分功能評定試用標準評價手指功能：獲優8例，良1例。 結論尺動脈近中段穿支解剖較為恒定，利用穿支蒂M形皮瓣修復手指末節脫套傷，不犧牲主干血管，手術操作簡便，療效滿意。

鉤型克氏針內固定技術治療Mallet 骨折

目的 總結應用鉤型克氏針內固定技術治療 Mallet 骨折的臨床療效。 方法 2007 年 8 月－ 2009 年1 月，收治 13 例 Mallet 骨折患者。其中男 9 例，女 4 例；年齡 18 ～ 56 歲，平均 30 歲。示指 6 例，中指 2 例，環指 1 例，小指 4 例。開放性損傷 2 例，閉合性損傷 11 例。采用 Wehbe 和 Schneider 分型，Ⅰ B 型 10 例，Ⅱ B 型 3 例。受傷至入院時間 40 min ～ 15 d，平均 5 d。術中采用單枚 1.0 mm 克氏針尾部制成鉤型，關節背側切開骨折復位，克氏針從指骨背側進針貫穿指骨至指掌側，鉤部固定骨折，掌側支具板固定克氏針，術后行限制性遠指間關節早期屈伸鍛煉。 結果 患者術后切口均Ⅰ期愈合。12 例獲隨訪，隨訪時間 5 ～ 18 個月，平均 11 個月。骨折于術后 5 ～ 8 周達骨性愈合，平均 6 周。手指外觀及功能恢復良好，無并發癥發生。末次隨訪時療效評估采用 Crawford 標準，獲優 8 例，良 3 例，可 1 例，優良率91.7%。 結論 應用鉤型克氏針內固定技術治療 Mallet 骨折能有效降低術后關節疼痛及關節活動受限，是治療 Mallet骨折的有效方法之一。