断肢断腕断掌再植后手内在肌挛缩51例分析

探讨断肢断腕断掌再植术后手内在肌挛缩的发病机理,结合临床经验提出分类、预防和治疗方法。方法:对51例断肢(腕、掌)再植,分别采用术中切开骨间肌肌筋膜、掌腱膜及腕横韧带;术后严重肿胀时早期切开骨筋膜室;缺血时间超过10小时者,除上述措施外尚须切断或部分切除拇收肌和骨间肌肌腹。结果:采用上述预防措施后,手内在肌挛缩的发生率明显降低。结论:本症重在预防,如能及时、果断地采取措施,效果良好。一旦发生中、重度手内在肌挛缩应尽早手术。     

上肢再植要严防手内在肌挛缩发生积极开展康复治疗发展第三医学

上肢再植术后发生手内在肌挛缩的主要原因是断肢温缺血时间过长,加上再植术中静脉回流建立不全,淋巴回流中断;肢体再灌注后因细胞水肿、肌肉变性肿胀、组织渗透压增高,在有限的掌内筋膜间区中因内容物增加而致压力增高的恶性循环所致。最后导致手内在肌中心坏死,肌肉弹性丧失,渐渐被瘢痕组织代替,形成手内在肌挛缩。成都军区昆明总医院师继红报道的断肢再植术后获随访63例中,发生手内在肌挛缩者竟达41例占65％,其中缺血时间长达16小时者发生率很高。上海长海医院张少成报道的108例上肢再植术,术后发生不同程度手内在肌挛缩者达32例占     

断肢断腕再植术后手内在肌挛缩原因探讨

应中华手外科杂志编缉委员会之约,让我写“断肢断腕再植术后手内在肌挛缩的原因探讨”专论。现就断肢、断腕再植术后发生手内在肌挛缩的原因作一初步探讨,意见不很成熟,望同道们指正。 一、断肢温缺血时间过长 断肢再植温缺血时间限为肢体离断后6～8小时内,最迟要在10小时内重建血液循环。因为在常温条件下,肢体离断后,三磷酸腺苷、琥珀酸脱氢酶、酸性磷酸酶及糖原等急骤下降,乳酸迅速增高,组织出现分解。肢体离体4小时后肌糖原残余少量,组织尚未出现严重分解。从病理形态学观     

断掌腕再植术后手内在肌挛缩的原因及防治措施

目的 探讨断掌、腕再植术后手内在肌挛缩的原因，结合临床经验提出治疗方法和预防措施。方法 １９８５年～１９９７年进行断掌、腕再植４８例４９只手，发生程度不等的拇收肌挛缩９例和手内在肌挛缩６例，其中２例拇内收肌轻度挛缩采用保守治疗，７例拇内收肌中度以上挛缩和６例手内在肌挛缩均采用手术治疗。对１５例肌挛缩的发生机制、治疗结果、预防措施进行讨论。结果 拇内收肌挛缩术后功能恢复良好４例，中５例，手内在肌阳性     

断腕再植术后尺神经功能恢复的临床研究

目的 探讨断腕再植术后尺神经功能恢复情况,分析手内在肌恢复不良的原因.方法 分析48例腕部完全离断再植术后的手内在肌功能恢复状况.结果 本组术后手内在肌功能根据中华医学会手外科学会断指再植功能评定试用标准,优3例,良8例,一般28例,差9例,优良率22.9%.结论 尽快恢复离断手的血液循环,尽可能多的吻合深浅静脉,常规...     

腕部及前臂远端离断再植术后的远期疗效

对６３例腕部及前臂远端离断（完全性３５例，不完全性２８例）再植术后进行了２～２５年（平均８．５年）的随访。结果不全离断再植术后的手关节活动度（ｔｏｔａｌａｃｔｉｖｅｍｏｔｉｏｎ，ＴＡＭ）优良率为６８％，完全离断为３２％。切割伤（３３例）、挤压伤（２０例）及碾挫撕脱伤（１０例）的ＴＡＭ优良率分别为７０％、６０％和２０％；指尖两点辨别觉分别为５．１±０．５ｍｍ、５．７±０．４ｍｍ和７．３±１．４ｍｍ。离断肢体缺血时间７～１０小时、１１～１５小时和１６～２２小时，则再植手的两点辨别觉分别５．１±０．７ｍｍ，６．１±０．５ｍｍ及６．９±１．５ｍｍ，再植后手内在肌挛缩发生率为６５％，手内在肌功能明显减弱或缺失者占９２％。作者强调，尽快恢复离断肢体血循环，清创后离断肢体灌注，完善修复血管（动脉∶静脉＝２∶４）、神经和肌腱，必要的骨短缩术及手筋膜间隔切开术，术后早期功能锻炼和后期的修复重建手术，均是提高再植手功能的重要措施。     

断臂,断腕再植术后手内在肌挛缩的防治

前臂及腕部断肢再植术后常常发生手内在肌挛缩,对手部的功能恢复带来了严重障碍。如何防治手内在肌挛缩,是目前解决前臂及腕部断肢再植后恢复手部功能的关键难题。现就近年来,国内外在这方面的研究进展并结合我们的临床经验进行综合讨论。 一、再植方面 1.手术适应证的选择:断肢再植的目的不仅仅是为了有一个成活的肢体,更重要的是要恢复其相应的功能,对上肢尤为重要。因此,上肢断肢再植术有较为严格的手术适应证。术前应对离断肢体的伤情、再植后可能恢复的功能等作一综合评价,以决定是否适合实施再植术。对那些组织严     

分期手术治疗中晚期前臂缺血性肌挛缩

目的探讨应用分期手术治疗中、晚期前臂缺血性肌挛缩的疗效。方法对32例中、晚期前臂缺血性肌挛缩的患者,进行分期手术治疗。一期行血管、神经松解,前臂屈肌群起点滑移、肌腱延长或变性肌肉切除术。二期行伸肌腱转位或肌肉移植术(带蒂或游离)。三期行肌腱粘连松解或手内在肌功能重建术。结果32例分期手术患者,术后获得10～24个月的随访。手功能评定:优(S3M4)22例,良 (S3M3)6例,可(S2M2例,差(S1M0)2例,腕背伸>30°,握力达健手70％以上者22例;腕背伸20°,握力达健手55％以上者6例,优良率为87．5％。结论分期手术结合系统康复锻炼,是治疗中、晚期前臂缺血性肌挛缩的有效治疗方法。     

手外伤后挛缩的处理

外伤引起的手挛缩和功能障碍,临床经常遇到,是一个必须处理的问题.一、手外伤后挛缩的预防应该牢记:早期预防方法简单,效果好;挛缩一旦形成,处理就困难得多.预防挛缩的基本点是:尽可能维持患手于内在肌伸展位(Intrinsic-plus position),即掌指关节屈曲、指间关节伸直、拇指外展位.理由是急性手外伤后,手背皮下疏松结缔组织和筋膜间隙水肿,手背皮肤和伸指肌腱紧张,使患手表现有掌指关节过伸、拇内收和继发性指间关节屈曲,即内在肌回缩位(Intrinsic—minus position)的趋势,若不及时处理,将在这个位置僵直.但是,不要忽略偶有因骨间肌缺血性坏死,表现为内在肌伸展位挛缩,这种情况若仍固     

断肢（指）再植术后的手功能康复

目的 探讨断肢（指）再植术后手功能分期康复的治疗方法.方法 对我院2400例断肢（指）再植成活患者进行随访及统计,术后970例在院接受正规康复治疗,1100例定期来院接受复诊及康复指导,330例在家不正规训练.结果 接受正规康复治疗的病例手功能恢复明显优于其他对照组.结论 断肢（指）再植术后,康复治疗早期介入,运用正确的物理和运动疗法等,手功能康复效果满意.     

Hand Replantation with Proximal Row Carpectomy

The purpose of this study is to present our operative technique and postoperative results of the hand replantation with proximal row carpectomy in cases of complete amputation at the level of wrist joint. From May 2003 to April 2005, five patients suffered from complete amputation of the hand due to industrial trauma. Amputation level was radiocarpal joint in three cases and midcarpal joint in two cases. Three cases represented guillotine type and two cases with local crush type injuries. All were men and the mean age was 26.6 years. The mean follow-up period was 26.8 months. At the time of replantation, the wrist joint was stabilized with transarticular fixation using three to four Kirschner's wires after performing proximal row carpectomy. Postoperatively, functional results such as muscle strength, range of motion of the wrist and fingers, and sensory recovery were assessed according to Chen's criteria. Joint width and arthritic changes of the radio-capitate joint were evaluated with radiologic tools. According to Chen's criteria, the overall results in five cases were classified as grade II. Intrinsic muscle power of hands was found to be grade 4. The mean grip and pinch powers were 41% and 45%, respectively, compared to contralateral hand. The mean arc of flexion-extension of wrist was 53 degrees . Total mean active motion of fingers was 215 degrees. Static two-point discrimination of fingertip ranged from 8 to 13 mm. On the follow-up, computerized tomography showed well-preserved radio-capitate joint space without any arthritic changes. While performing hand replantation after amputation at the radiocarpal or midcarpal level, proximal row carpectomy is a useful procedure to preserve joint motion of the wrist in selected cases.     

Hand replantation after 54 hours of cold ischemia: a case report.

A number of case reports and series have reported successful replantation after prolonged periods of ischemia. However, the acceptable range of normothermic and hypothermic ischemic storage remains controversial. There is little question that the tolerance of composite tissue for ischemia is dependent on the quantity of contained skeletal muscle. We report a successful hand replantation after 54 hours of cold ischemia. We believe that this case documents the longest anoxic period yet reported for successful hand replantation. We further believe that the functional results obtained confirm the value of hand replantation even after such a prolonged ischemic interval.     

前臂中段离断伤再植保留手功能及加强肌力的方法

目的探讨前臂中段离断伤再植保留手功能及加强肌力的方法。方法断肢再植时将离断肢体以远失神经支配的肌肉组织切除,切取髂胫束条桥接远端肌腱和近端肌肉组织,并桥接肱二头肌加强屈腕屈指,桥接肱三头肌加强伸腕伸指功能,同时完好地接神经,以恢复手的感觉和手内在肌肌力。结果共治疗4例,术后随访19个月～28个月,平均24个月。平均肌力屈腕屈指M4;伸腕伸指M4。腕平均活动度屈腕60°,伸腕48°,桡偏20°,尺偏40°,手指总活动度（TAM）2例属优,2例属良,TAM＞80%。手部感觉恢复至S     

毁损性手外伤的早期修复与功能重建

目的 寻找手部大范围多元组织毁损后组织修复及功能重建的最佳方法。方法 １９９０年１月～１９９９年６月,采用急症（３３例）、亚急症（伤手三天内,２６例）吻合血管的组织移植或复合组织移植的方法一期修复毁损组织并重建手部功能。对手部桡侧的再造采用皮瓣与足践组合时于皮瓣局部打孔的方法将再造拇指引出,解决虎口瘢痕挛缩;百游离第二足趾的同时游离仲、伸趾短肌或短展肌或短肌组合移植重建再造拇指对掌功能,对常区无可     

Ischemic contractures of muscle and nerve lesions (author's transl)]

Reporting 14 own cases symptomatology and treatment of the common ischemic syndromes of the extremities (Volkmann's contracture, thumb adduction contracture respectively contracture of the intrinsic hand muscles and anterior tibial syndrome) including the regularly concomitant nerve lesions are discussed. Edema and compression beyond the primary ischemia are essential factors in pathogenesis of nerve and muscle lesions. The electromyographic examination is helpful in diagnosis, prognosis and treatment of the severe sequelae of nerve and muscle. Since late diagnosis yields poor therapeutical results, early recognition of ischemic states and prophylaxis are most important.     

An experimental study of the effect of fluorocarbon perfusion for amputated limb preservation. The effect of inhibition for replantation toxemia and muscle tissue destruction

In replantation surgery, it is widely accepted that replantation toxemia or muscle destruction in replanted limbs might occur after a long time of ischemia. Their possibilities are particularly high after replantation of the amputated limbs which contain more muscle tissue than tendon and bones. The present study was performed to investigate the efficacy of fluorocarbon (FC: artificial blood) perfusion to the amputated limbs in preventing these problems after replantation. The hind limbs of dogs were completely amputated at mid-thigh. Amputated limbs were divided into two groups. One was stored in ice water and the other at room temperature for six hours. Each group was furthermore divided into four subgroups. The amputated limbs were perfused with oxygenated FC or Hartmann's solution before replantation and remaining limbs were not perfused. All of them were replanted under an operating microscope. The results were as follows: Perfusion with FC had an inhibiting effect on the anaerobic metabolism in an amputated limb and also decreased the rate of death due to replantation toxemia. Perfusion with FC was effective for inhibiting leakage of creatine phosphokinase from the replanted limb and preventing muscle destruction. Both these effects were detected biochemically and histologically. The reactive hyperemia of the replanted limb usually occurred after replantation. This rate, however, was significantly decreased after replantation of the amputated limb perfusion with FC. These effects described above were more remarkable when the amputated limb was perfused continuously rather than intermittently. It is therefore reasonable to conclude that for prevention of systemic ill effect after replantation and for preservation of function of the amputated limb, continuous perfusion with FC in ice water is more effective than ice water cooling alone.     

Réimplantation de la main: résultats fonctionnels à long terme (à propos de huit observations)

Study aimThe aim of this study was to report the long term functional results after replantation of the hand in eight patients.Materials and methodsBetween 1977 and 1995, hand replantation was performed in eight cases (six males and two females). Mean age at the time of injury was 31 years (24–47 years). The dominant hand was amputated in half of the cases. In two cases, the soft tissue lesions were severe; in the six other cases, the wound was clean-cut. The level of amputation was transmetacarpal (n = 2), carpal (n = 2), wrist (n = 2), distal part of the forearm (n = 2).ResultsThe mean convalescence time was 16 months (from 6 months to 2 years). The degree of disability ranged from 40 to 65%. Patient follow-up lasted 2 to 20 years (mean: 11 years). The return of discriminative sensitivity of the digits was noted in six cases. The active motion of the fingers was satisfactory in all cases, but intrinsic muscle function was weak or absent. Pinch and grasp strength was reduced from 10 to 60% (when compared to the non-damaged hand). One patient resumed his prior occupation, and another resumed his occupation part-time. The six other patients found new occupations.ConclusionAll the patients achieved a useful function of their replanted hand in their daily, spare-time and professional activities.     

前臂及腕部离断伤再植13例分析

目的 探讨前臂及腕部离断伤再植成功及提高术后手功能恢复优良率的要素.方法 对13例前臂及腕部离断伤患者进行再植,予彻底清创、精确修复血管及神经;术后早期进行功能康训练.结果 13例患者再植手全部成活,经6个月～3年的随访,手功能均有不程度恢复.根据陈中伟上肢功能评定标准:Ⅰ级2例,Ⅱ级8例,Ⅲ级3例.结论 彻底的清创、精确的血管及神经修复、术后早期的功能康复训练是前臂及腕部离断伤再植的成功以及手功能良好恢复的重要因素.