特重度腕部高压电烧伤治疗的改进

目的减少特重度腕部电烧伤截肢率。方法将1980年1月至1998年3月的180例216个上肢腕部高压电烧伤分为两个时期进行比较分析,病例按其伤情分为Ⅰ、Ⅱ、Ⅲ、Ⅳ四型,由于认识上的提高和全身治疗及创面修复方法上的改进,如早期综合用药预防血管栓塞,积极的血管重建和使用大网膜和皮瓣早期修复创面等。将两组各型腕部电烧伤治疗措施和最终的截肢率进行比较。结果 1980～1989年及1989～1998年两个时期轻、中度腕部电烧伤(Ⅰ、Ⅱ型)截肢率保持为零,特重度腕部电烧伤截肢率由前一时期的80%降至后一时期的38.9%。结论重建腕部血管通道、手术修复创面及综合治疗是减少特重度腕部电烧伤截肢率的有效方法。     

特重度腕部高压电烧伤治疗的改进

目的减少特重度腕部电烧伤截肢率。方法将１９８０年１月至１９９８年３月的１８０例２１６个上肢腕部高压电烧伤分为两个时期进行比较分析,病例按其伤情分为Ⅰ、Ⅱ、Ⅲ、Ⅳ四型,由于认识上的提高和全身治疗及创面修复方法上的改进,如早期综合用药预防血管栓塞,积极的血管重建和使用大网膜和皮瓣早期修复创面等。将两组各型腕部电烧伤治疗措施和最终的截肢率进行比较。结果１９８０～１９８９年及１９８９～１９９８年两个时期轻、中度腕部电烧伤（Ⅰ、Ⅱ型）截肢率保持为零,特重度腕部电烧伤截肢率由前一时期的８０％降至后一时期的３８９％。结论重建腕部血管通道、手术修复创面及综合治疗是减少特重度腕部电烧伤截肢率的有效方法。     

腕部电烧伤的修复

目的 探讨腕部电烧伤的修复方法及不同皮瓣的具体应用。方法 对1990年7月至2002年7月治疗腕部电烧伤的不同修复方法进行总结。结果 采用腹部轴型皮瓣和不带主要血管的前臂皮瓣修复Ⅰ、Ⅱ型腕部电烧伤，截肢率1．92％；腹部H型双蒂皮瓣修复Ⅲ型腕部电烧伤，截肢率54．66％；Ⅳ型，放弃皮瓣治疗，全截肢。结论 胸脐皮瓣、髂腹股沟皮瓣是修复腕部Ⅰ、Ⅱ型电烧伤较好的方法；不带主要血管的前臂皮瓣修复腕部电烧伤有一定的适应证，尤其适用于小儿和老人；腹部H型双蒂皮瓣适宜于修复Ⅲ型腕部电烧伤，重建腕部血管是减少Ⅲ型腕部电烧伤截肢率的有效方法。保留伤肢长度对Ⅳ型电烧伤功能有一定意义。     

应用带蒂与游离皮瓣修复腕部电烧伤创面的比较

腕部组织结构精细,皮下软组织薄,且有十余根重要的血管、神经及肌腱贴近皮肤通过腕部。腕部电烧伤后易造成手部缺血坏死,截肢率高达20%～60%。由于肌腱、神经等烧伤,既使创面愈合也常遗留手部严重伤残,功能重建十分困难,疗效也不够满意。少数轻度腕部电烧伤创面可用局部皮瓣修复,但大多数创面修复所需组织量大,必须用远隔皮瓣移植。我们将近8年来临床治疗的57例68个腕部高压电烧伤创面,分为以带蒂腹部皮瓣和吻合血管游离皮瓣修复两组,比较其创面愈合情况、手术总次数及治疗过程中的严重并发症,报道如下。     

手腕部重度电烧伤创面的修复与功能重建

目的：总结降低手腕部严重高压电烧伤后肢体截肢率,并恢复手部分功能。方法：1987年－1999年收治手腕部重度高压电烧伤44例55个肢体,早期充分减张,有血运障碍及时行血管重建手术,及时扩创,应用胸,腹部或腹股沟部皮瓣形成单蒂,双蒂或联全皮瓣修复创面,同时行抗栓,抗凝及抗炎治疗,创面修复后,进行手部感觉和运动功能重建,采用自体或异体肌腱移植修复肌腱缺损以及肌腱移位恢复手部功能,自体神经或胎儿神经睡复神经缺损。结果：III型截肢率为43．8％,自体肌腱移植按TAM标准均达良级;异体肌腱移植达可级,腓肠神经移植7例,胎儿神经移植1例,手指感觉恢复好,手内在肌功能部分恢复,结论：重建腕部血管通路,皮瓣修复创面,及时重建运动和感觉功能是减少手腕部重度电烧伤截肢率和恢复手部分功能的有效方法。     

应用带蒂与游离皮瓣修复腕部电烧伤创面的比较

应用带蒂与游离皮瓣修复腕部电烧伤创面的比较沈祖尧，王乃佐，马春旭，宓惠茹，桑慧华，沈余明，周先锋腕部组织结构精细，皮下软组织簿，且有十余根重要的血管、神经及肌腱贴近皮肤通过腕部。腕部电烧伤后易造成手部缺血坏死，截肢率高达２０％～６０％［１］。由于肌腱...     

Ⅲ型腕部高压电烧伤患者治疗转归调查

目的总结Ⅲ型腕部高压电烧伤患者的治疗方法及转归,分析不同策略创面修复的临床疗效。方法采用回顾性病例对照研究,收集首都医科大学附属北京积水潭医院烧伤科2008年1月~2020年9月收治的Ⅲ型腕部高压电烧伤住院患者的病历资料,共有28例患者35个腕部入组。以2013年12月31日为界,前一阶段(常规治疗组,简称常规组)9例11个腕部,接受常规治疗;后一阶段(显微技术治疗组,简称显微组)19例24个腕部,接受显微外科治疗。回顾性分析性别、年龄、烧伤总面积、单侧/双侧、伤后至首次皮瓣移植时间、患肢血管重建、皮瓣选择、游离皮瓣面积、皮瓣转移术后感染率、手术次数、创面修复时间、治疗结局、总截肢率等临床指标。结果28例患者均为男性,平均年龄(39.43±12.40)岁。所有患者均接受静脉桥接或通血皮瓣手术进行血运重建。伤后至首次皮瓣/肌皮瓣移植时间为4(3,6)d。常规组共行带蒂轴型皮瓣修复8例,游离皮瓣3例;显微组共行带蒂轴型皮瓣修复6例,游离皮瓣/肌皮瓣18例;两组比较有显著性差异(P=0.011)。常规组接受手术3(2,3)次,显微组接受手术1(1,2.75)次,两组比较有显著性差异(P=0.020)。皮瓣修复术后皮瓣下方继发感染7例,常规组4例,显微组3例,两组比较无显著性差异(P=0.625)。总截肢率22.86%(8/35),常规组27.27%(3/11),显微组20.83%(5/24),两组比较无显著性差异(P=0.462)。腕部创面愈合时间(入院至腕部创面愈合拆线)22(18~38)d,常规组38(25,40)d,显微组20.5(17.25,27)d,有显著性差异(P=0.010)。结论Ⅲ型腕部电烧伤的治疗需在尽早重建血运、彻底清创的同时,优先选择以游离皮瓣/肌皮瓣对腕部创面进行修复,可缩短创面愈合时间,减少手术次数。     

毁损性电烧伤患者的功能重建与康复策略探讨

电烧伤是一种立体性的毁损伤, 要高度重视毁损性电烧伤患者的功能重建与康复。毁损性电烧伤的创面修复、保肢不是治疗的终点, 使患者功能康复、走向社会才是治疗的目标。该文从毁损性电烧伤的早期创面修复和晚期功能重建与康复、保肢与截肢、供区损伤最小化、心理康复及多学科合作方面进行了系统论述。只有高度重视功能重建与康复, 让这方面的理念深入人心, 才能实现毁损性电烧伤的完美修复与康复。     

早期应用上腹部腹直肌双肌皮瓣修复腕部电烧伤创面

目的观察上腹部腹直肌双肌皮瓣在腕部电烧伤中的早期应用效果。方法6例腕部背侧仅残留少量正常皮肤的环状深度电烧伤患者，伤后立即使用蒂在上、下两侧的上腹部腹直肌双肌皮瓣覆盖创面，并观察创面修复及外观、功能恢复情况。结果6例患者的创面均Ⅰ期愈合，功能恢复良好，外观较为理想。结论早期使用上腹部腹直肌双肌皮瓣覆盖腕部深度电烧伤创面，可有效地促使其修复，同时对手腕部的功能起到较好的保护作用。     

早期应用上腹部腹直肌双肌皮辦修复腕部电烧伤创面

目的观察上腹部腹直肌双肌皮辦在腕部电烧伤中的早期应用效果。方法 6例腕部背侧仅残留少量正常皮肤的环状深度电烧伤患者,伤后立即使用蒂在上、下两侧的上腹部腹直肌双肌皮辦覆盖创面,并观察创面修复及外观、功能恢复情况。结果 6例患者的创面均Ⅰ期愈合,功能恢复良好,外观较为理想。结论早期使用上腹部腹直肌双肌皮辦覆盖腕部深度电烧伤创面,可有效地促使其修复,同时对手腕部的功能起到较好的保护作用。     

Electrical injury of wrist: classification and treatment - clinical analysis of 90 cases

Between January 1980 and December 1989, a prospective study was carried out on 114 upper limbs in 90 patients, which were electrically burned with the wrist as the current entrance site. Based upon extensive clinical investigations of arterial injury and its adverse effect on hand circulation, a grading system is suggested for electrically injured wrists based on the severity of injury. The total amputation rate was 39.4 per cent in this group, which was composed of miscellaneous cases with various injuries. However, in subgroups of Type I to Type IV, the amputation rates were 0, 0, 80 and 100 per cent, respectively. A new method to repair the circumferential wound of an electrically burned wrist as well as to bypass the blood flow to the obstructed hand, using a pedicled greater omentum transfer and vascular anastomosis between gastroepiploic artery and the palmar artery, was successfully used in a Type III case.     

Combined rectus abdominis muscle/paraumbilical flap and lower abdominal flap for the treatment of type III circumferential electrical burns of the wrist

Background

Type III circumferential electrical burns of the wrist are one of the most severe electrical injuries, involving rather extensive necrosis, progressive blood circulatory embarrassment and a high amputation rate. This injury poses a challenge for vascular reconstruction and wound coverage. The purpose of this study was to evaluate the effectiveness of the combined rectus abdominis muscle/paraumbilical flap and lower abdominal flap for the treatment of type III circumferential electrical burns of the wrist.

Methods

Six men (age, 19–32 years; average, 21 years) with type III circumferential electrical burns of the wrist were included. After thorough debridement, the volar wound was repaired with a partial rectus abdominis muscle/paraumbilical flap and the dorsal wound was repaired with a lower abdominal flap.

Results

Flap survival was complete in all six patients. During a follow-up of 6–12 months, the flaps showed good texture and shape. No abdominal hernia occurred in any patients. The scar on the abdominal wall was acceptable.

Conclusion

The combined rectus abdominis muscle/paraumbilical flap and lower abdominal flap has large wound coverage potential and offers a new, easy, safe option for the treatment of type III circumferential electrical burns of wrist.     

Early vascular grafting to prevent upper extremity necrosis after electrical burns. Commentary on indications for surgery

Early vascular grafting is the only effective form of treatment for electrical burns of the wrist which are severe enough to impair blood flow to the hand. Failure to appreciate the significance of early changes in blood flow and to take prompt appropriate action may result in the irreversible loss of blood supply and subsequent amputation. This report analyses the problems encountered in six patients where the early signs of impaired blood flow were not appreciated and amputations were subsequently required.     

高压电烧伤合并肢体血管损伤治疗10年回顾性分析

背景与目的 高压电烧伤虽然发生率很低，但是潜在的肌肉、神经和血管受损比火焰灼伤更加隐匿，危及肢体的缺血和迟发破裂出血会导致肢体功能丧失、致残甚至致死。高压电烧伤后的肢体血管损伤尚无明确的发生率，也没有诊疗指南的推荐，各个中心的治疗方案也不尽相同。北京积水潭医院作为全国烧伤抢救中心，每年要收治大量的烧伤患者，其中高压电烧伤合并血管损伤的患者屡见不鲜。本文总结了近10年来北京积水潭医院收治的高压电烧伤合并血管损伤的患者诊治方案，试图从中分析出此类患者与创伤性动脉损伤患者的差异，归纳出此类患者的诊疗特点，为今后的临床工作提供有力的证据支持。方法 回顾本中心2010年1月—2020年1月收治的由于高压电烧伤导致肢体血管损伤的患者94例，患者的血管修复方式包括直接局部修补、自体血管重建和人工血管重建。分析术后血管血栓形成、迟发破裂出血、感染、截肢等术后并发症的发生比例，对比数据间的差异。结果 94例患者中，男83例，女11例；平均年龄（30.4±20.1）岁。7例来院时肢体毁损严重，行截肢术。87例完成血管修复，29例行局部修补术，53例采用自体血管重建，5例采用人工血管材料重建，技术成功率100%。局部修补患者术后2周内血栓形成3例，假性动脉瘤2例，均再次手术行自体血管重建。自体血管重建患者中，术后2周内血栓形成7例，切开取栓后血运改善，发生迟发破裂出血4例，切开止血再次重建1例，腔内介入置入覆膜支架3例，术后感染或软组织严重坏死截肢3例。人工血管材料重建患者中，术后2周内血栓形成1例，切开取栓后恢复血运，发生迟发破裂大出血1例，腔内介入置入覆膜支架。75例患者获随访3~6个月，血管通畅率89.3%（67/75）。结论 高压电烧伤后的血管损伤远超肉眼可见的损伤范围，不同于一般创伤导致的相关损伤；血管重建前应充分评估损伤血管及周围组织条件，在充分清创的前提下自体血管和人工血管均可成为良好的重建材料；高压电烧伤导致的血管损伤会随时间推移而进展，应该警惕血栓形成和迟发破裂出血，一旦发生迟发破裂需再次切开止血重建或腔内介入治疗，这样才能保全患肢。     

Study of clinical pattern of limb loss in electrical burn injuries

Introduction: Electrical burn injuries are devastating and cause not only loss of life but also severe disabilities in the form of limb loss. Increase in urbanization, industrialization and overcrowding has led to an increase in electric injuries. Material and methods: The study was prospective in nature evaluating electric burns and studied the pattern of limb loss for a duration of 18 months from October 2016 to March 2018. Parameters recorded were demographic data, clinical data regarding the electrical injuries, complications, and outcomes. Results: Male patients made up 85.3% of cases. Mean TBSA was 24.76 ± 19.18%. Mean age was 27.59 ± 13.73 years. Pediatric patients made up 17%. High voltage burns constituted 68.2 %. Electric contact burn was the most common type making up 49.5% of cases. The most common cause was occupational (38.9%). A fasciotomy was required in 22% of cases with an amputation rate of 38% (209 out of 550). There were 190 major amputations and 106 minor amputations. Overall, the right upper limb amputations were twice as common as the left. The ratio of upper limb: lower limb amputation was 4:1. Fifty patients (23.9%) required revision amputation. The age group 11 to 30 years made up 55.5% of amputations. There was no statistical difference in amputation rates between males (31.31%) and females (41.97%). In patients with TBSA less than 25% amputation rate was 47.77% as compared to patients with more than 25% TBSA, 19.47% (p<0.001). Most amputations occurred due to electric contact burns (74.16%). In the high voltage group, 46.1% underwent amputation vs low voltage group -20.6% (p<0.001). Overall mortality rate was 12.7%. Three hundred patients (55%) had low level of awareness regarding consequences of electric injury. Thirty one percent had medium level of awareness and only 14 % had high level of awareness. There was a significant correlation between education level and awareness in adult patients (p<0.001). Seventy percent of persons with occupational injuries used only footwear and no other protective equipment. Conclusion: Increasing public awareness, safety measures at workplaces are measures that will help reducing electrical burns which reduce limb and life loss.     

Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

Classification of the pattern of intrauterine amputations of the upper limb in constriction ring syndrome

Twenty patients with congenital upper limb amputations caused by constriction rings were reviewed to classify the pattern of these amputations. In the 20 patients studied, 31 upper limbs had congenital amputations. The pattern of amputation was classified into three types. Proximal upper limb amputation was considered type I and was only seen in one limb. The most common pattern of amputation was digital amputation associated with "coning" or "superimposition" of the digits (type II) and was seen in 20 hands. Type II amputations were subclassified according to the involvement of all, ulnar, radial, or central digits by the constriction ring. In type III amputations (N = 10 limbs), there was no associated coning or superimposition of the digits. This type of amputation was subclassified into type IIIA (multiple-digit amputations within the same hand) and type III B (single-digit amputation). Associated anomalies are reviewed and the pathogenesis of constriction rings is discussed.     

Arthrodesis of the spastic wrist.

The clinical and radiographic results of 9 patients (11 wrists) who had wrist arthrodeses for severe spastic flexion contracture were evaluated. The spasticity was due to cerebral palsy, traumatic head injury, and cerebrovascular accident. All wrist deformities were aesthetically unappealing and the patients or their caretakers had difficulty with hygiene or function. The subjective evaluation included overall satisfaction, hand hygiene, wrist deformity, functional improvement, and willingness to have surgery again given the same preoperative circumstances. A standardized hand function questionnaire was used to determine functional improvement following surgery. The objective evaluation included clinical evidence of fusion, skin condition, wrist position, and radiographic assessment. The average age of the patients was 22 years at the time of surgery and the average follow-up period was 32 months. All patients were satisfied with the results of the surgery and hygiene improved in all cases. None had palmar skin maceration or breakdown. All patients or their caretakers rated the overall appearance or wrist and hand deformity as improved and all but one patient would agree to have the surgery over again given the same preoperative circumstances. According to a 17-task hand function questionnaire, 8 of 9 patients (10 wrists) reported improved function after surgery. Face washing, propelling a wheelchair, and picking up both large and small objects were among the most frequently improved functions. Radiographic fusion was present in all cases. The average position of wrist fusion was 15 degrees flexion and the average amount of wrist correction was 85 degrees. Improved appearance, hygiene, and a certain degree of upper extremity function, regardless of cognitive abilities, can be expected following arthrodesis for severe spastic wrist deformity.