Retrospective analysis of effects of metacarpus and phalanx traction on correction of scar contracture of hand after burn on the palm side
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摘要: 目的 回顾性分析掌骨指骨牵引矫治手掌侧烧伤后瘢痕挛缩的效果。 方法 2010年5月—2014年12月,笔者单位收治手掌侧烧伤后瘢痕挛缩患者32例共39只手。治疗方法:瘢痕保守松解植皮,简称A方法;在挛缩手指中远节指骨与对应掌骨间呈U形留置克氏针牵引2~7周,简称B方法;在第2~5掌骨、挛缩手指远端指骨留置克氏针形成牵引桩、牵引锚的基础上构建牵引架,用橡皮筋将手指向拉长、伸直位牵引2~6个月,简称C方法。对传统需行瘢痕彻底松解植皮者改行A方法,对松解植皮后既往需行髓内克氏针固定者改行B方法,尚不能达到预期目标者加行C方法;对瘢痕松解可能导致血运障碍或肌腱及骨外露者,先行C方法再行A方法,不能达到预期目标者加行C方法;对不愿行植皮术者仅行C方法。治疗期间,观察术区有无感染、克氏针有无滑动及对组织有无切割等;治疗结束后1~2周,观察瘢痕挛缩有无复发倾向;治疗前、治疗结束时、治疗结束后1个月,测量各挛缩手指末端至腕横纹的掌侧皮肤长度;治疗前及治疗结束后1、3、6个月,采用温哥华瘢痕评定量表进行瘢痕情况评分;治疗前、治疗结束后1个月,采用总主动活动度(TAM)法评定关节活动度,采用Jebsen手功能测试法评定手功能并记录完成测试时间。对数据行方差分析、LSD–
t 检验、t 检验。 结果 24例患者27只手采用A+B方案,5例患者7只手仅行C方法,2例患者3只手采用A+B+C方案,1例患者2只手采用C+A+C方案。治疗期间未见术区感染、组织切割等并发症,13例患者14只手U形克氏针轻微滑动;10例患者11只手瘢痕挛缩有复发倾向,经支具治疗未复发。治疗结束时、治疗结束后1个月,手掌侧皮肤长度分别为(131.8±9.8)、(127.6±7.5)mm,显著长于治疗前的(114.5±2.4)mm(t 值分别为10.71、10.39,P 值均小于0.001)。治疗前及治疗结束后1、3、6个月瘢痕情况评分分别为(9.8±2.4)、(9.7±1.7)、(9.3±0.8)、(7.7±0.5)分,仅治疗结束后6个月评分显著低于治疗前(t =3.28,P <0.01)。治疗前与治疗结束后1个月,TAM评定优良比分别为2.6%(1/39)、94.9%(37/39)。治疗前完成手功能测试时间为(13.9±4.1)min,治疗结束后1个月显著缩短为(11.0±2.8)min(t =3.65,P <0.001)。 结论 掌骨指骨牵引单独应用或与瘢痕松解植皮联合矫治手掌侧烧伤后瘢痕挛缩,均可使挛缩组织蠕变延长,利于手功能及外形恢复。Abstract: Objective To analyze the effects of metacarpus and phalanx traction on correction of scar contracture of hand after burn on the palm side retrospectively. Methods A total of 32 patients with 39 affected hands with scar contracture on the palm side after burn were hospitalized from May 2010 to December 2014. Method of treatment: scar contracture was conservatively released followed by skin grafting, which was referred to as method A; Kirschner wire was inserted into the middle or distal phalanx of finger with contracture and the corresponding metacarpus in the shape of U for 2 to 7 weeks' traction, which was referred to as method B; traction frame was built based on the traction pile and anchor formed by Kirschner wire inserted through the second to the fifth metacarpus and distal phalanx of finger with contracture, and then the affected fingers were pulled into a straight position with rubber bands for 2 to 6 months, which was referred to as method C. Method A was used in patients who would be treated with thorough release of scar followed by skin grafting routinely. Method B was used in patients who would be treated with intramedullary Kirschner wire fixation after release of scar contracture and skin transplantation routinely. Method C was further used in patients when methods A and B failed to accomplish the expected result. Method C was used in the first place followed by method A in whom there might be vascular decompensation or exposure of tendon and bone after scar release, and those who failed to meet the expectation were treated with method C in addition. Patients who were unwilling to undergo surgery were treated with method C exclusively. During the course of treatment, the presence or absence of infection and slipping of Kirschner wire or its slitting through soft tissue were observed. The presence or absence of tendency of recurrence of scar contracture within 1 to 2 weeks after treatment was observed. The length of palmar skin measuring from the root of finger with contracture to wrist crease was measured before treatment, at the termination of treatment, and 1 month after the termination of treatment. Scar condition was assessed with the Vancouver Scar Scale (VSS) before treatment and 1, 3, and 6 month (s) after the termination of treatment. Before treatment and 1 month after the termination of treatment, the range of motion was measured with the Total Active Movement (TAM) method; hand function was evaluated by the Jebsen Test of Hand Function (JTHF), and the completion time was recorded. Data were processed with analysis of variance, LSD–t test, andt test. Results Twenty–four patients with 27 affected hands were treated with scheme A+ B; 5 patients with 7 affected hands were treated with method C exclusively; 2 patients with 3 affected hands were treated with scheme A+ B+ C; 1 patient with 2 affected hands were treated with scheme C+ A+ C. During the course of treatment, no complication such as infection or slicing of tissue was observed, but there was a slight shifting of U–shaped Kirschner wire in 14 affected hands of 13 patients. Tendency of recurrence of scar contracture was observed in 11 affected hands of 10 patients, but the scar contracture did not reoccur after treatment with orthosis. The skin length of palmar side was respectively (131.8±9.8) and (127.6±7.5) mm at the termination of treatment and 1 month after, and they were both significantly longer than that before treatment [(114.5±2.4) mm, witht values respectively 10.71 and 10.39,P values below 0.001]. The score of VSS was respectively (9.8±2.4), (9.7±1.7), (9.3±0.8), and (7.7±0.5) points before treatment and 1, 3, and 6 month (s) after the termination of treatment. Only the score at 6 months after the termination of treatment was significantly lower than that before treatment (t =3.28,P <0.01). The ratio of excellent and good results according to method TAM was respectively 2.6% (1/39) and 94.9% (37/39) before treatment and 1 month after the termination of treatment. The time for JTHF measurement was (13.9±4.1) min before treatment, and it was shortened to (11.0±2.8) min 1 month after the termination of treatment (t =3.65,P <0.001). Conclusions Single application of metacarpus and phalanx traction or its combination with skin transplantation after scar release in correcting scar contracture of the palm of hand after burn can lengthen the contracted tissue, and it is beneficial for the restoration of function and appearance of affected hand.-
Key words:
- Burns /
- Cicatrix /
- Hand /
- Traction /
- Metacarpus /
- Finger phalanges
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