Treatment methods of upper limbs with destructive electric burns and its clinical efficacy
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摘要:
目的 探讨上肢毁损性电烧伤的救治方法及其临床疗效。 方法 采用回顾性观察性研究方法。2014年7月—2020年12月，武汉大学同仁医院暨武汉市第三医院收治20例符合入选标准的上肢毁损性电烧伤男性患者，其年龄为21~57岁，其中7例患者行急诊手术，共对20个患肢行保肢治疗。对5个患肢坏死骨行切除处理，将1例患者左侧患肢远端残余手及腕部交叉异位再植至右前臂残端，对2个尺桡骨远端坏死患肢行截骨后短缩再植。彻底清创后，拟用组织瓣修复的创面面积为12 cm×7 cm~58 cm×13 cm。根据创面大小和分布，采用带蒂背阔肌肌皮瓣联合吻合血管的游离腹股沟皮瓣移植修复2个患肢创面；游离移植背阔肌肌皮瓣、股前外侧皮瓣、脐旁穿支皮瓣修复其余17个患肢创面，其中创面较大的10个患肢联合移植腹股沟皮瓣或另一侧脐旁穿支皮瓣。移植组织瓣总面积为20 cm×8 cm~52 cm×20 cm。组织瓣移植术中，根据患肢血管缺损长度，分别用组织瓣血管蒂远端、患侧无损伤静脉、腹壁浅静脉、大隐静脉等桥接14个患肢远端动脉，并对其中3个远端回流不畅患肢行大隐静脉移植再通肢体远端静脉。对供瓣区创面行直接缝合或刃厚头皮移植修复。创面基本愈合后开始循序渐进的功能康复训练，组织瓣移植术后3个月开始进行功能重建和瘢痕整复手术。记录术后组织瓣/皮片成活及创面愈合情况、保肢情况和随访情况，末次随访时评估保肢成功患肢的功能并使用臂、肩、手残障（DASH）评分表进行评分。 结果 术后，患肢移植的组织瓣及供瓣区创面移植的皮片均成活，供受区创面愈合良好。2个患肢于组织瓣移植术后10 d内出现远端坏死，行前臂中上段截肢；其余18个患肢保肢（含短缩再植与交叉异位再植）成功。随访6~48个月，5个保肢成功患肢于组织瓣移植术后3~18个月出现残余肌腱和骨组织无菌性溶解排出，经手术清创联合负压封闭引流治疗后逐渐愈合。末次随访时，2个截肢后患肢残端愈合良好；18个保肢成功患肢均存活良好，其中8个患肢手指屈伸功能及拇指对掌功能恢复良好且可独立完成日常活动，9个患肢恢复部分活动功能且可在对侧上肢协助或辅具辅助下完成穿衣、进食等日常活动，1个患肢无功能。末次随访时，18个保肢成功患肢功能的DASH评分表评分为30.0~100分。 结论 及时手术清创，妥善处理损伤骨组织，有效的血管桥接重建患肢远端动脉，并采用血运丰富的组织瓣修复创面，配合早期康复和功能整复治疗，有利于挽救毁损性电烧伤上肢并改善患肢功能。 Abstract:Objective To investigate the treatment methods of upper limbs with destructive electric burns and its clinical efficacy. Methods A retrospective observational study was conducted. From July 2014 to December 2020, 20 male patients with destructive electric burns in upper limbs who met the inclusion criteria were admitted to Tongren Hospital of Wuhan University ＆ Wuhan Third Hospital, aged from 21 to 57 years, of whom 7 patients underwent emergency surgery, and a total of 20 affected limbs were treated with limb salvage. The necrotic bone was resected in 5 affected limbs, the residual hand and wrist at the distal end of left affected limb was replanted to the residual end of the right forearm in one patient in a cross heterotopic way, and short reduction and replantation after osteotomy were performed for two affected limbs with distal ulnar and radial necrosis. After thorough debridement, the area of wound proposed to be repaired by tissue flap was from 12 cm×7 cm to 58 cm×13 cm. According to the size and distribution of wound, the wounds of 2 affected limbs were repaired by transplantation of pedicled latissimus dorsi myocutaneous flap and free groin flap with vascular anastomosis. The wounds of the remaining 17 affected limbs were repaired with the transplantation of free latissimus dorsi myocutaneous flap, anterolateral thigh flaps, and paraumbilical perforator flap, with 10 affected limbs with larger wounds being jointly transplanted with the groin flap or the paraumbilical perforator flap on the other side. The total grafted tissue flap area was 20 cm×8 cm to 52 cm×20 cm. During tissue flap transplantation, according to the length of blood vessel defect in the affected limb, the distal artery of the affected limb was bridged with the distal part of flap vascular pedicle, undamaged vein on the affected side, superficial vein of abdominal wall, and great saphenous vein, etc., in 14 affected limbs, and the great saphenous vein was grafted in 3 of them with impeded distal return for recanalization of distal limb veins. The wound in the donor area was repaired by direct suture or grafting with split-thickness scalp. After the wound was basically healed, the functional rehabilitation training was started gradually, and the functional reconstruction and scar rectification surgery were started 3 months after tissue flap transplantation. The survival of tissue flaps/skin grafts, wound healing, limb salvage, and follow-up status after surgery were recorded. At the last follow-up, the function of the successfully salvaged limb was evaluated and scored by the disabilities of the arm, shoulder and hand (DASH) scoring scale. Results After surgery, the grafted tissue flap in the affected limb and the skin grafts transplanted on the wound at flap donor site survived, and wounds at the recipient and donor sites healed well. Two affected limbs had distal necrosis within 10 days after tissue flap transplantation, and the middle and upper forearms were amputated. The remaining 18 affected limbs were successfully salvaged (including shortened replantation and cross heterotopic replantation). During 6-48 months of follow-up, 5 affected limbs that were successfully salvaged developed aseptic dissolution of residual tendon and bone tissue 3 to 18 months after tissue flap transplantation, which gradually healed after surgical debridement combined with vacuum sealing drainage treatment. At the last follow-up, the stump of two affected limbs healed well after amputation; 18 affected limbs that were successfully salvaged all survived well, of which 8 affected limbs had good recovery of finger flexion and extension function and thumb opponensplasty and could complete daily activities independently, 9 affected limbs regained partial mobility and could complete daily activities such as dressing and eating with the assistance of the opposite upper limb or auxiliary devices, and one affected limb had no function. At the last follow-up, the functional scores of DASH scoring scale of the 18 affected limbs that were successfully salvaged ranged from 30.0 to 100. Conclusions Timely surgical debridement, proper treatment of the injured bone tissue, effective vascular bridging for reconstruction of the distal artery of the affected limb, and the use of blood-rich tissue flap to repair the wound, combined with early rehabilitation and functional restoration treatment, are beneficial to salvage the upper limb with destructive electric burns and improve the function of the affected limb. -
Key words:
- Burns, electric /
- Surgical flaps /
- Microsurgery /
- Amputation /
- Arteriovenous anastomosis /
- Hand function /
- Limb salvage
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参考文献
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1 将例1高压电烧伤患者左手及腕部交叉异位再植至右前臂截肢残端重建右上肢。1A.伤后9 h，左上肢除手和腕部外均为环形Ⅳ度创面；1B.左肩关节离断后，剥离切取左手及腕部以供移植；1C.将左手及腕部交叉异位再植于右前臂截肢后残端；1D.伤后2个月行钢板植入固定再植处尺桡骨两端；1E.伤后3个月再植手腕部愈合后情况；1F、1G.分别为伤后11个月行同侧背阔肌肌皮瓣带蒂移植重建屈肘功能+修复上肢内侧瘢痕切除后创面术中、术后即刻；1H、1I、1J.分别为再植术后随访24个月右上肢可进行玩手机、抓小球、完成辅具下进食操作
2 大隐静脉桥接联合背阔肌肌皮瓣带蒂移植+吻合血管的腹股沟皮瓣游离移植修复例2患者右上肢高压电烧伤创面。2A.伤后12 d，右上肢屈侧组织大范围坏死，上肢主干动脉栓塞裸露；2B.切取大隐静脉准备桥接上肢动静脉，大隐静脉含1条长属支（红色箭头所示）；2C.右上肢清创完毕，组织瓣切取完毕；2D.用大隐静脉桥接受区动脉及再通远端静脉（纸质箭头指示吻合口位置）后即刻；2E.背阔肌肌皮瓣带蒂移植+吻合血管的腹股沟皮瓣游离移植修复右上肢创面后即刻；2F.组织瓣修复术后随访15个月，右上肢外观良好
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