全手皮肤脱套伤的分型和治疗

目的总结全手皮肤脱套伤的伤情特点,探讨全手皮肤脱套伤的分型标准及治疗方法。方法 1999年12月-2010年5月,收治41例全手皮肤脱套伤。男28例,女13例;年龄18～58岁,平均35岁。致伤原因:碾压伤28例,挤压伤13例。受伤至手术时间1～10 h,平均3 h。根据自定全手皮肤脱套伤分型标准:Ⅰ型11例,Ⅱ型5例,Ⅲ型4例,Ⅳ型8例,Ⅴ型13例。Ⅰ型采用吻合血管回植术;Ⅱ型采用带足背皮瓣的甲瓣、第2趾甲瓣再造术;Ⅲ型采用双足带足背皮瓣的第2趾甲瓣再造术;Ⅳ型采用吻合血管回植术;Ⅴ型采用带足背皮瓣的甲瓣再造(8例)或腹部皮瓣修复术(5例)。足背皮瓣切取范围为9 cm×6 cm～17 cm×11 cm,足背供区游离植皮修复。结果术后Ⅰ型6例发生部分手指坏死,Ⅳ型6例发生部分手指及手掌皮肤坏死;其余患者皮瓣、再造指及回植皮肤均成活。足背供区及腹部供区均顺利愈合。40例患者获随访,随访时间6个月～7年,平均14个月。采用吻合血管回植治疗者,手部皮肤颜色、质地接近正常,功能恢复佳,感觉恢复至S2～S4;采用甲瓣及趾甲瓣再造手指者,手功能基本恢复,再造指感觉恢复至S2～S3;采用腹部皮瓣者,手功能恢复欠佳,手部感觉恢复至S1～S2。结论采用自定标准对全手皮肤脱套伤程度进行分型,并指导临床治疗方案的选择,可获得较好临床疗效。

Classification and treatment of whole hand degloving injury

Objective To summarize the injury characteristics of the whole hand degloving injury and to explore its classification and treatment.Methods Between December 1999 and May 2010,41 cases of the whole hand degloving injury were admitted for treatment.There were 28 males and 13 females with an average age of 35 years(range,18-58 years).The causes of injury included mangled injury in 28 cases and crush injury in 13 cases.The interval between injury and surgery was 1-10 hours(mean,3 hours).According to self-made classification standard for whole hand degloving injury,11 cases were rated as type I,5 cases as type II,4 cases as type III,8 cases as type IV,and 13 cases as type V.Type I injury was treated by replantation surgery with vascular anastomosis,type II by reconstruction with thumb flap and the second toe containing dorsal skin flap,type III by reconstruction with the second toe containing dorsal skin flap of both feet,type IV by replantation surgery with vascular anastomosis,and type V by reconstruction with thumb flap containing dorsal skin flap(8 cases) or repairing with abdominal flap(5 cases).The size of the dorsal flap was between 9 cm × 6 cm and 17 cm × 11 cm and the dorsal donor site was covered with free skin grafting.Results After surgery,partial necrosis occurred at fingers in 6 patients with type I injury,and at fingers and palm skin in 6 patients with type IV injury;the flaps,the reconstructed fingers,and replanted skin all survived in the others.The grafted skin at donor sites successfully healed.Forty cases were followed up from 6 months to 7 years(mean,14 months).The skin color and texture were close to normal hand in the cases undergoing replantation,who had the best function restoration with S2-S4 sensory recovery;the hand function was basically restored with S2-S3 sensory recovery in the cases undergoing finger reconstruction with thumb and toe flaps;and the restoration of the hand function was not satisfactory with S1-S2 sensory recovery in the cases undergoing abdominal flaps.Conclusion Whole hand degloving injury can be classified into different types according to injury degree and this will help choose the clinical treatment plan.The appropriate treatment based on these types can obtain better clinical effectiveness.