拇指背侧筋膜皮瓣修复虎口中重度挛缩的中远期功能评估

目的:对虎口中重度挛缩患者行拇指背侧筋膜皮瓣修复,并观察术后患侧中远期的功能恢复情况。方法:选取1995-08/2004-12广东省中医院珠海医院骨科收治的13例重度虎口挛缩患者,均采用带拇指背侧筋膜皮瓣转移修复,术前常规检查确定是否有手术禁忌证。手术于臂丛麻醉下进行,切取拇指背侧筋膜皮瓣(带拇背桡侧或尺侧动脉及神经),皮瓣切取范围远端至拇指甲根部近侧0.5cm,两侧至指侧中线,以第一掌骨基底部至第一掌骨中点之间为蒂部。供区创面予以植皮,皮瓣转移后首先修复虎口底部,如掌侧或两侧遗留少许创面,可以游离皮片进行移植修复。对掌功能位行克氏针固定三四周,拔针早期中药熏洗,术后半年内虎口必须予以支具保护,以保证修复后效果。按照手指总活动度系统评价法(优:正常;良:手指总活动度为健侧的75%以上;尚可:手指总活动度为健侧的50%～75%;差:手指总活动度为健侧的50%以下;极差:手指总活动度比术前恶化)以及患侧外形、感觉、拇指使用情况等对关节功能进行综合评估。结果:实验纳入13例患者均完成2年随访,中途无脱落者。①术后不同随访时间患侧关节功能恢复情况:13例患者术后6个月皮瓣成活良好,虎口开大与健侧基本相同,关节外形满意,关节稳定,术后2年屈曲畸形消失,伸指活动可,拇指外展对掌功能良好,第1掌指关节活动正常,主观满意率为84.6%(11/13)。②术后6个月手指总活动度评估结果:13例患者中,优10例,良2例,可1例,优良率92.3%。③术后6个月患侧外形、感觉及拇指使用情况:全部患者重建虎口外形正常,皮肤质地及色泽接近正常,未见明显的色素沉着,冬季皮肤无明显异常;13例患者痛觉全部恢复,触觉迟钝者占6.2%,只有17.4%的患者两点辨别感觉恢复到正常范围内,实体综合感觉能力优良率92.1%,平均分13分;全部患者在工作和生活中均能自然地使用患指,使用时虎口无触痛或感觉异常等现象。结论:虎口中重度挛缩患者行拇指背侧筋膜皮瓣修复,重建虎口外形美观,感觉良好,拇指外展及对掌功能恢复满意,损伤小,皮瓣切取范围完全可以达到虎口开大后所需皮瓣修复的宽度,手术操作简便易行,其中远期疗效满意。     

虎口挛缩的修复

目的：探讨治疗虎口挛缩的理想方法。方法：自1997年5月至2002年5月对26例虎口孪缩患者，根据其挛缩严重程度分别采用“Z”字成形加植皮、局部皮瓣、逆行岛状瓣及游离皮瓣等不同手术方法修复。结果：经4个月至2年随访，采用“Z”字成形加植皮术的患者虎口开大达健侧的70％～80％；采用拇示指背皮瓣的患者虎口开大达健侧的80％～85％；采用其他皮瓣转移修复者术后虎口开达健侧的85％以上。本组所有植皮和皮瓣全部成活，拇指伸展、外展及对掌活动好，外观满意。结论：针对不同程度虎口挛缩采用不同修复方式是治疗虎口挛缩的有效方法。     

示指背侧皮瓣修复虎口瘢痕挛缩畸形及康复治疗

拇指的功能占全手功能的50%以上,多数虎口瘢痕挛缩畸形严重影响拇指的功能活动。探讨示指背侧皮瓣局部转移修复虎口瘢痕挛缩畸形及康复治疗的临床效果。虎口松解后采用示指背侧皮瓣局部转移比游离皮片移植能更好地保持虎口的宽度,有利于拇指的功能活动,而且外形好。并且配带支架的时间明显短于利用游离皮片移植修复者。因示指背侧皮瓣局部转移不必解剖暴露血管蒂,确保皮瓣内包括有知名动、静脉,所以手术操作简便、安全。而且皮瓣厚薄适中、耐磨,特别适合虎口的修复。因皮瓣内有桡神经分出的感觉支,所以术后具有良好的感觉。     

示指背侧皮瓣修复虎口瘢痕挛缩畸形及康复治疗

拇指的功能占全手功能的50％以上，多数虎口瘢痕挛缩畸形严重影响拇指的功能活动。探讨示指背侧皮瓣局部转移修复虎口瘢痕挛缩畸形及康复治疗的临床效果。虎口松解后采用示指背侧皮瓣局部转移比游离皮片移植能更好地保持虎口的宽度，有利于拇指的功能活动，而且外形好。并且配带支架的时间明显短于利用游离皮片移植修复者。因示指背侧皮瓣局部转移不必解剖暴露血管蒂，确保皮瓣内包括有知名动、静脉，所以手术操作简便、安全。而且皮瓣厚薄适中、耐磨，特别适合虎口的修复。因皮瓣内有桡神经分出的感觉支，所以术后具有良好的感觉。     

扁形筋膜血管神经蒂第二掌指背岛状皮瓣修复拇指或虎口缺损

目的：探讨应用扁形筋膜血管神经蒂第二掌指背岛状皮瓣治疗拇指或虎口的适宜方法。方法：采用该皮瓣修复伤性拇指缺损10例，拇指中毒感染坏死2例。虎口外伤性缺损2例。电击伤坏死1例。外伤后后瘢痕挛缩1例。结果 皮瓣全部成活。而且都有感觉。结论：扁形筋膜血管神经蒂第二掌指背岛状皮瓣修复拇指或虎口缺损，简单易行。能克服解剖上变异，增加血运，比单纯的血管神经蒂更加安全可靠。     

邻指皮瓣修复手指皮肤缺损21例报告

目的：观察邻指皮瓣修复手指皮肤缺损的效果。方法：21例手指皮肤缺损患者中5例行吻合尺侧指固有神经背侧支的邻近皮瓣修复，16例采用单纯邻指皮瓣修复。结果：21例手指皮肤缺损患者皮瓣全部成活，外观满意。5例行吻合尺侧指固有神经背侧支的邻指皮瓣修复者术后感觉恢复较好。结论：邻指皮瓣是修复手指掌侧和指腹皮肤缺损的一种较好方法，手术操作简单，成活率高，值得临床推广应用。     

示指背侧岛状皮瓣修复拇指皮肤缺损

目的探讨示指背侧岛状皮瓣的临床应用。方法采用示指背侧岛状皮瓣修复拇指掌侧缺损患者5例。拇指掌侧软组织缺损面积⒉5 cm×⒈5 cm-⒈5 cm×⒈0 cm,皮肤切取面积相当,术中皮瓣下常规置橡皮引流条,术后抬高患肢以利于静脉回流,并避免血管蒂受压。供区直接缝合和中厚皮植皮封闭。结果术后5例皮瓣全部成活。术后随访12-18个月,皮瓣感觉恢复良好,皮瓣饱满,无感染。结论示指背侧岛状皮瓣修复拇指掌侧缺损,解剖位置表浅,皮瓣血管蒂恒定,操作简单,血管可靠,不损伤主要血管,旋转灵活,是修复拇指缺损的较理想的方法。     

拇指尺背侧动脉逆行皮瓣修复拇指远节软组织缺损

目的探讨以拇指尺背侧动脉为蒂逆行皮瓣修复软组织缺损的手术方法和适应证。方法选择本科2006年12月至2009年11月,应用以拇指尺背侧动脉为蒂的逆行岛状皮瓣,修复拇指远节软组织缺损伴指骨外露24例,该皮瓣的设计以拇指尺背侧动脉体表投影线为轴心线,距甲沟2.3cm处纵轴线向背侧动脉穿支为旋转点,皮瓣面积为1.0cm×2.5cm～3.0cm×2.5cm。结果术后24例皮瓣完全成活,均获1～6个月随访,指间关节活动度良好;拇指外形满意,指腹两点辨别觉为6～10mm。结论拇指尺背侧动脉为蒂的皮瓣修复是手外科修复拇指缺损创面较为理想的方法,手术操作简单、安全可靠,术后治疗、护理较为容易,外形与功能恢复满意。     

不同逆行岛状皮瓣修复方案在拇指创伤中的疗效比较

[目的] 探讨大鱼际逆行岛状皮瓣和拇指逆行桡背侧皮瓣修复拇指创面患者的临床疗效.[方法] 选取2013年2月至2016年6月在本院接受治疗的拇指损伤患者88例,按照患者拇指手术修复部位分成大鱼际组、拇指桡背组.比较两组患者手术时间、术中出血量、术后视觉痛觉评分(VAS)、主观满意度、患者术后恢复时间、术后关节活动度、感觉、复工时间及拇指血液流量.[结果] 大鱼际组手术时间、术中出血量、术后VAS评分均明显少于拇指桡背组,其差异有统计学意义(P<0.05);大鱼际组指背部位满意度评分明显高于拇指桡背组,而拇指桡背组指腹、指尖部位满意度评分明显高于大鱼际组,其差异均有统计学意义(P<0.05);拇指桡背组术后活动度、感觉测量分数均明显高于大鱼际组,而大鱼际组术后恢复时间、复工时间短于拇指桡背组,术后血液流量大于拇指桡背组,其差异均有统计学意义(P<0.05).[结论] 拇指逆行桡背侧皮瓣修复术适合修复带有感觉功能的指腹部分;而大鱼际逆行岛状皮瓣修复术适合修复不带有感觉功能的指背部分.     

应用带感觉神经的皮瓣修复拇指指腹缺损的临床体会

目的：探讨采用带感觉神经的三种皮辩修复拇指指腹缺损的手术方法。分析吻合神经后重建皮瓣感觉的临床效果。方法：18例外伤所致拇指指腹缺损患者分别采用三种皮辩。修复在手术显微镜下行皮瓣所带神经与供区的神经吻合。其中8例为偏挠侧皮肤缺损，行第一掌骨背逆行筋膜皮瓣修复。4例为指腹偏足侧皮肤缺损。行示指背侧岛状皮瓣修复，6例为全指腹、指端皮肤缺损，行拇指桡侧指动脉为蒂的大鱼际桡侧皮瓣。结果：本组18例皮辩术后全部成活，其中2块皮瓣出现青紫，张力性水疱，1块皮瓣出现苍白、皮温低，及时行间断拆除缝线等对症处置。最终成活，随访3个月～1年。皮瓣血运、质地、弹性良好，外形较满意；随访3个月以上患者，这种吻合神经的感觉皮瓣随着浅痛觉、浅触觉、冷热觉、实物觉等逐步恢复，随访1年时皮辩二点辩别觉达到8～12mm，临床上在到时皮瓣自身的保护和拇指功能恢复，随着随访时间延长，皮瓣的感觉恢复程度和范围增加。结论：选择合适的带感觉神经皮瓣是修复拇指皮肤缺损的良好方法。可重建拇指指膻的感觉，恢复外形、手术相对简单，成功率高，疗程短，效果好。     

Gamekeeper's thumb

Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint can result in significant pain and instability. Patients with this injury have severe difficulties with pinching and grasping objects. Avulsions of this collateral ligament from the proximal phalanx and midsubstance tears provide the usual mechanisms of injury. Complete ruptures usually require surgical treatment. Cast immobilization is usually satisfactory for partial tears.     

A modified thumb spica splint for thumb injuries in the ED

There are a significant number of hand and upper extremity injuries treated in US emergency departments (EDs) each year. Many of these involve the thumb and wrist. These injuries encompass the range from fractures, strains, and sprains to more specific injuries such as gamekeeper thumb and de Quervain tenosynovitis. These injuries often require diagnosis, splinting, and referral to a hand or orthopedic surgeon. The splint described in this article is presently being used for patients with de Quervain tenosynovitis, but it may have more widespread application in emergency medicine. It is a safe and simple splint that is underused in EDs for splinting thumb injuries.     

Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures

Pain is common in the thumbs of physiotherapists. The purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain. One hundred and twenty-nine physiotherapists who attended the Musculoskeletal Physiotherapy Association Conference (2003) participated. After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed. There was an association (p<0.05) between work-related thumb pain and alignment of the thumb during performance of PA pressures: participants who were able to maintain their MP and IP joints in extension were less likely to report pain. These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.     

In-vivo function of the thumb muscles

OBJECTIVE: The purpose of this study is to quantify the electrical activity of the thumb muscles responsible for the production of force in different directions of thumb movement. DESIGN: The isometric forces and electromyographic activity generated by seven thumb muscles were measured on five normal healthy test subjects. BACKGROUND: The thumb is very important for proper hand function. Presently available electromyographic studies of the thumb muscles provide only limited information. Most thumb muscles have more than one function. Additional studies are required to carefully examine and confirm the in-vivo relationship between the thumb muscle electromyogram and mechanical output. METHODS: The direction and magnitude of the force vector generated at the interphalangeal joint and the relative electrical activity were obtained for eight directions of thumb action. The regions of function were defined for the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, adductor pollicis, flexor pollicis longus, extensor pollicis longus, and the abductor pollicis longus. Data was collected during voluntary isometric contraction, both before and after blocking the median nerve at the wrist. RESULTS: The highest force production was obtained during flexion. The region of maximal muscle electrical activity varied for each muscle studied. The areas of maximal in-vivo muscle activity agreed with the moment arm data reported in the literature. The median nerve block eliminated the ability to produce force in abduction. CONCLUSIONS: This study has demonstrated that by combining electromyographic measurement and biomechanical analysis it is possible to confirm the relationship between in-vivo thumb muscle function and muscle mechanics in a novel manner. The findings of this study indicate the importance of the local anatomy in controlling the direction of force production.     

改良第2足趾再造手拇指术后功能状况及外观形态学特征

目的探讨用足拇趾腓侧瓣镶嵌的改良第2足趾再造手拇指的术后功能及外观形态。方法利用趾蹼处的血管吻合形成的交通支,分清趾蹼处血管吻合,切取以趾底动脉为蒂的足拇趾腓侧皮瓣,将其嵌入第2足趾的中节与近节的跖侧狭细处,消除其狭细的外观。结果13例14指全部成功,镶嵌的皮瓣全部成活,再造指的外形逼真。其关节屈曲60°～80°,对掌功能基本恢复。术后1～3个月恢复了痛温触觉及2点分辨觉。术后6个月测量再造拇指与正常拇指的中间周径差异为0.3cm,差异无显著性意义(t=0.02,P>0.05,α=0.05)。结论切取拇趾腓侧瓣镶嵌的改良第2足趾再造拇(手)指的手术方法较传统第2足趾再造拇(手)指的手术方法难度增加不大,再造指功能恢复良好。