Wound repair and functional reconstruction of high-voltage electrical burns in wrists
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摘要: 目的 探讨腕部高压电烧伤创面修复与功能重建的方法与效果。 方法 2009年1月—2016年6月,笔者单位收治腕部高压电烧伤患者71例,共有118个腕部创面,其中Ⅰ型21个、Ⅱ型69个、Ⅲ型9个、Ⅳ型19个。根据腕部损伤情况采用不同手术方法。20个腕部其以远坏死,均行前臂截肢术。其余98个腕部创面在切开减张的基础上及早清创,清创后创面面积10 cm×7 cm~30 cm×18 cm。及早用血运丰富的组织瓣移植修复腕部创面,包括采用带蒂髂腹股沟皮瓣修复32个创面、带蒂脐旁皮瓣修复11个创面、带蒂股前外侧岛状皮瓣修复3个创面、腹部联合轴型皮瓣修复9个创面、游离皮瓣/肌皮瓣修复37个创面、旋股外侧动脉降支血流桥接皮瓣修复6个创面,组织瓣面积12 cm×8 cm~34 cm×20 cm;20个腕部创面行血管桥接重建尺、桡动脉。供瓣区中41处直接拉拢缝合,14处取同侧大腿薄中厚皮覆盖,43处取对侧大腿薄中厚皮覆盖。53个腕部创面行肌腱、神经修复术,其中20个行单纯肌腱、神经松解术;33个腕部创面行自体或异体肌腱移植重建指深屈肌腱和/或拇长屈肌腱,其中21个另采用腓肠神经移植修复正中神经。在末次术后6~24个月,对53个行肌腱修复的腕部创面,采用手指总主动活动度(TAM)评价法评定肌腱功能;对21个行正中神经修复的腕部创面,采用综合评定方法评定正中神经功能。 结果 (1)本组20个腕部其以远坏死,行截肢术后切口愈合良好。(2)98个组织瓣移植术后90个血运良好;8个远端坏死,其中6个去除远端坏死组织后植皮,2个清创后直接缝合。7个皮瓣出现皮瓣下感染,其中3个经换药愈合,4个经再扩创治疗愈合。20个重建桡、尺动脉腕部创面,手部供血得以恢复,未截肢。本组所有行组织瓣修复患者随访1~3年,切口、皮瓣均愈合较佳。(3)本组53个行肌腱、神经修复的腕部,其对应患肢各指TAM优良率为51%。(4)本组20个行单纯肌腱、神经松解术的腕部随访1~2年,正中神经支配的肌肉肌力恢复至Ⅴ级1个、Ⅳ级3个、Ⅲ级2个,尺神经所支配的肌肉肌力恢复至Ⅳ级3个、余无恢复;感觉功能检查结果:S0级4个、S1级2个、S2级3个、S3级8个、S4级3个。本组21个行正中神经修复的腕部随访1~2年,正中神经所支配的肌肉功能无任何恢复;感觉功能检查结果:S0级3个、S1级5个、S2级8个、S3级5个。 结论 根据腕部电烧伤病情,序贯性采用早期切开减张、早期清创、血管桥接、血运丰富的组织瓣移植、肌腱神经修复是修复腕部电烧伤创面、避免截肢、重建手功能的较佳方法。Abstract: Objective To explore the methods and effects of wound repair and functional reconstruction of high-voltage electrical burns in wrists. Methods From January 2009 to June 2016, 71 patients with high-voltage electrical burns in wrists were hospitalized, with 118 wrist wounds including 21 of type Ⅰ, 69 of type Ⅱ, 9 of type Ⅲ, and 19 of type Ⅳ. According to the wrist injuries, different surgical operations were performed. Forearm amputation was conducted in 20 wrists with necrosis in the distal end. On the basis of fasciotomy for decompression, early debridement was performed on the other 98 wrist wounds. After debridement, wounds with area ranging from 10 cm×7 cm to 30 cm×18 cm were repaired with tissue flaps with abundant blood supply. Thirty-two wounds were repaired with pedicled groin flaps, 11 wounds with pedicled paraumbilical flaps, 3 wounds with pedicled anterolateral thigh island flaps, 9 wounds with combined abdominal axial pattern flaps, 37 wounds with free skin flaps or myocutaneous flaps, and 6 wounds with flow-through descending branch of lateral femoral circumflex artery flaps, with tissue flap area ranging from 12 cm×8 cm to 34 cm×20 cm. Ulnar artery or radial artery vascular reconstruction was performed in 20 wrist wounds. Forty-one donor sites were sutured directly, while 14 were closed by thin split-thickness skin grafts from same-side thighs, and 43 were closed by thin split-thickness skin grafts from opposite-side thighs. Fifty-three wrist wounds were performed with tendon and nerve repair surgery, of which 20 were performed with simple tendon and nerve release surgery. Flexor digitorum profundus tendons and (or) flexor pollicis longus tendons were reconstructed with autologous or allogeneic tendon transplantation in 33 wrist wounds, and the median nerve was repaired with sural nerve graft in 21 wrist wounds. In 6 to 24 months after the last operation, tendon function of 53 wrist wounds which had tendon repair was evaluated with finger total active motion (TAM) method, while median nerve function of 21 wrist wounds which had median nerve repair was evaluated with integrate estimation method. Results (1) After forearm amputation, the incisions of 20 wrists with necrosis in the distal end were healed. (2) Among the 98 tissue flaps, 90 had good blood flow, while 8 had distal necrosis, of which 6 were healed after necrotic tissue removal and skin grafting, and two were sutured directly after debridement. Infection occurred under 7 flaps, of which 3 were healed by dressing change, and 4 were healed after second debridement. Twenty wrist wounds which had radial artery or ulnar artery repair had good blood supply of hand and amputation was avoided. During follow-up of 1 to 3 years, the incisions and flaps of patients who had tissue flap repair surgery healed well. (3) The excellent and good rate of TAM in each finger of the corresponding affected limbs of 53 wrist wounds which had tendon and nerve repair surgery was 51%. (4) Twenty wrists which had simple tendon and nerve release surgery were followed up for 1 to 2 years. The strength of muscle dominated by the median nerve was restored to grade Ⅴ in 1 wrist, grade Ⅳ in 3 wrists, and grade Ⅲ in 2 wrists. The strength of muscle dominated by the ulnar nerve was restored to grade Ⅳ in 3 wrists, with no recovery in other wrists. Sensory function examination showed grade S0 in 4 wrists, grade S1 in 2 wrists, grade S2 in 3 wrists, grade S3 in 8 wrists, and grade S4 in 3 wrists. Twenty-one wrists which had median nerve repair were followed up for 1 to 2 years. There was no recovery in muscle strength dominated by the median nerve. Sensory function examination showed grade S0 in 3 wrists, grade S1 in 5 wrists, grade S2 in 8 wrists, and grade S3 in 5 wrists. Conclusions It is a good method to sequentially conduct early fasciotomy for decompression, early debridement, vascular reconstruction, transplant of tissue flap with abundant blood supply, tendon and nerve repair in repairing electrical burn wounds of wrists, avoiding amputation, and reconstructing hand function according to the condition of electrical burns of wrists.
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Key words:
- Burns, electric /
- Wrist /
- Surgical flaps /
- Tendons /
- Nerves
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