Repair strategies and efficacy analysis of deep electrical burn wounds in children's fingers
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摘要:
目的 探讨儿童手指深度电烧伤创面修复策略并分析其疗效。 方法 该研究为回顾性观察性研究。2008年1月—2024年1月,首都医科大学附属北京儿童医院收治80例符合入选标准的手指深度电烧伤患儿,其中男54例、女26例,年龄11个月~12岁9个月,共170个手指受累。根据清创后创面特点制订修复策略：对伴肌腱和/或骨骼外露的创面,优先选用局部皮瓣或腹部带蒂皮瓣修复,对其中对供区美观要求较高的患者,采用双层人工真皮+中厚皮进行创面修复。对无肌腱或骨骼外露的创面,采用全厚皮修复全层皮肤缺损者,对其中对供区美观要求较高的患者,采用单纯中厚皮进行创面修复；对合并皮下组织严重缺损且位于关节掌侧的创面,采用双层人工真皮+中厚皮、腹部带蒂皮瓣或局部皮瓣修复。对窄条状创面,若满足无张力闭合、切口方向与手指横纹呈斜行或平行且无重要血管、神经损伤风险,无论是否伴肌腱和/或骨骼外露均直接缝合。按照清创后创面是否伴肌腱和/或骨骼外露分类,统计患指采用的修复方式、创面面积、皮瓣或皮片成活率；末次随访时,采用量角器测量患指关节总主动活动度（TAM）评估患指功能并统计优良比,采用温哥华瘢痕量表（VSS）评估患指瘢痕情况,采用自制量表调查患儿主要照护者对疗效的满意度。 结果 创面伴肌腱和/或骨骼外露的59个患指中,行腹部带蒂皮瓣、局部皮瓣、双层人工真皮+中厚皮移植及直接缝合者分别为31、9、10、9个,其中行直接缝合者创面面积0.20（0.20,0.80）cm2最小,行腹部带蒂皮瓣移植者创面面积2.00（2.00,4.00）cm2最大；行腹部带蒂皮瓣、局部皮瓣、双层人工真皮+中厚皮移植者皮瓣或皮片成活率中位数均为90%；行直接缝合者瘢痕VSS评分3.0（2.0,4.0）分最低,行其余术式者瘢痕VSS评分中位数为4.0~5.0分；行直接缝合者关节TAM优良比9/9最高,其次为行腹部带蒂皮瓣移植者的24/31和行双层人工真皮+中厚皮移植者的7/10；患儿主要照护者对疗效的满意度评分中位数,除行局部皮瓣移植者为8.0分以外,其余均为9.0分。创面无肌腱或骨骼外露的111个患指中,行腹部带蒂皮瓣、局部皮瓣、全厚皮、单纯中厚皮、双层人工真皮+中厚皮移植及直接缝合者分别为9、5、69、11、10、7个,其中行直接缝合者创面面积0.25（0.10,0.50）cm2最小,行腹部带蒂皮瓣移植者创面面积2.00（1.50,3.00）cm2最大；行腹部带蒂皮瓣、局部皮瓣、全厚皮、双层人工真皮+中厚皮移植者皮瓣或皮片成活率中位数均为90%,行单纯中厚皮移植者皮片成活率92%（90%,100%）最高；行直接缝合者瘢痕VSS评分3.0（3.0,4.0）分最低,行双层人工真皮+中厚皮移植者瘢痕VSS评分5.0（5.0,7.0）分高；行局部皮瓣移植者关节TAM优良比5/5最高,行单纯中厚皮移植者关节TAM优良比9/11最低；患儿主要照护者对疗效的满意度评分中位数,除行腹部带蒂皮瓣或局部皮瓣移植者为8.0分以外,其余均为9.0分。 结论 对于儿童手指深度电烧伤,需根据具体情况优先采用皮瓣修复伴肌腱和/或骨骼外露创面,采用皮片修复无肌腱或骨骼外露创面,将符合条件的窄条状创面直接缝合可获得最佳功能与瘢痕评分,个体化修复方案能有效兼顾患指功能恢复与照护者对疗效的满意度。 Abstract:Objective To explore the repair strategies for deep electrical burn wounds in children's fingers and analyze their efficacy. Methods This study was a retrospective observational study. From January 2008 to January 2024, 80 children with deep electrical burn wounds in fingers meeting the inclusion criteria were admitted to Beijing Children's Hospital Affiliated to Capital Medical University, including 54 males and 26 females, aged 11 months to 12 years and 9 months with a total of 170 fingers affected. Repair strategies were formulated based on wound characteristics after debridement. For wounds with exposed tendons and/or bones, local flaps or abdominal pedicled flaps were preferentially used. For some of the patients who had higher aesthetic requirements for the donor sites, bilayer artificial dermis (AD)+split-thickness skin graft (STSG) was applied for wound repair. For wounds without exposed tendons or bones, full-thickness skin graft (FTSG) was used to repair those with full-thickness skin defects, while STSG alone was employed for wound repair in patients who had higher aesthetic requirements for the donor sites. Bilayer AD+STSG, abdominal pedicled flaps, or local flaps were used to repair the wounds with severe subcutaneous tissue defects located on the volar side of joints. For narrow strip-shaped wounds, direct suturing was performed regardless of tendon and/or bone exposure if tension-free closure was achievable, the incision direction was oblique or parallel to finger creases, and there was no risk of major vascular or nerve injury. The wounds were classified according to whether they were accompanied by tendon and/or bone exposure after debridement, the repair methods, wound area, and survival rate of flaps or skin grafts of the affected fingers were recorded. At the final follow-up, the total active motion (TAM) of affected finger joints was measured with a goniometer to assess function of affected fingers and the excellent and good ratio was calculated, the Vancouver scar scale (VSS) was used to evaluate scar conditions of affected fingers, and a self-designed scale was employed to survey the satisfaction of primary caregivers of the child with treatment outcomes. Results Among the 59 affected fingers with wounds accompanied by tendon and/or bone exposure, 31, 9, 10, and 9 of them were treated respectively with abdominal pedicled flaps, local flaps, bilayer AD+STSG, and direct suturing, with the fingers that underwent direct suturing had the smallest wound area of 0.20 (0.20, 0.80) cm2, and the fingers that were transplanted with abdominal pedicled flaps had the largest wound area of 2.00 (2.00, 4.00) cm2. The median survival rate of flaps or skin grafts for the fingers transplanted with abdominal pedicled flaps, local flaps, and bilayer AD+STSG was 90%. The scar VSS score was the lowest 3.0 (2.0, 4.0) for fingers that underwent direct suturing, while the median scar VSS score was 4.0 to 5.0 for fingers that underwent other surgical procedures. The excellent and good ratio of joint TAM was the highest at 9/9 for fingers that underwent direct suturing, followed by 24/31 for fingers that underwent abdominal pedicled flap transplantation and 7/10 for fingers that underwent bilayer AD+STSG transplantation. The median satisfaction score of the primary caregivers of the child with the treatment outcomes was 9.0 points, except for those who underwent local flap transplantation, which was 8 points. Among the 111 affected fingers without tendon or bone exposure, 9, 5, 69, 11, 10, and 7 of them were treated respectively with abdominal pedicled flaps, local flaps, FTSG, STSG alone, bilayer AD+STSG transplantation, and direct suturing, with the fingers that underwent direct suturing had the smallest wound area of 0.25 (0.10, 0.50) cm2, and the fingers that were transplanted with abdominal pedicled flaps had the largest wound area of 2.00 (1.50, 3.00) cm2. The median survival rate of flaps or skin grafts for the fingers transplanted with abdominal pedicled flaps, local flaps, FTSG, and bilayer AD+STSG was 90%. The highest survival rate of skin grafts was 92% (90%, 100%) for fingers that underwent STSG alone transplantation. The scar VSS score was the lowest 3.0 (3.0, 4.0) for fingers that underwent direct suturing, while the scar VSS score was 5.0 (5.0, 7.0) for fingers that underwent bilayer AD+STSG transplantation, which was high. The excellent and good ratio of joint TAM was the highest at 5/5 for fingers that underwent local flap transplantation, while the excellent and good ratio of joint TAM was the lowest at 9/11 for fingers that underwent STSG alone transplantation. The median satisfaction score of the primary caregivers of the child with the treatment outcomes was 9.0 points, except for those who underwent abdominal pedicled flap or local flap transplantation, which was 8.0 points. Conclusions For children's fingers with deep electrical burns, different methods can be used for wound repair according to specific circumstances with skin flaps as the preferred for repairing the wounds with exposed tendons and/or bones, skin grafts for repairing the wounds without tendon or bone exposure, and direct suturing for narrow strip-shaped wounds that meet the conditions to obtain the best functional and scar scores. Individualized repair plans can effectively balance the recovery of finger function and the satisfaction of caregivers with the therapeutic outcome. -
Key words:
- Child /
- Fingers /
- Burns, electric /
- Surgical flaps /
- Treatment outcome /
- Skin grafting /
- Wound repair
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参考文献
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图 1 采用全厚皮修复例1患儿无肌腱或骨骼外露的右手拇指Ⅲ度电烧伤创面的效果。1A.术前创面可见黄褐色焦痂；1B.行全厚皮移植后即刻；1C.术后12个月随访时,虎口可见轻微条索瘢痕
图 2 采用腹部带蒂皮瓣修复例2患儿右手伴肌腱和骨骼外露拇指、示指及严重损伤中指Ⅲ度电烧伤创面的效果。2A.术前,右手拇指及示指掌侧及桡侧可见苍白色焦痂,中指掌侧远端可见黄褐色及苍白色焦痂；2B.清创后,术中侧面观,可见右手拇指及示指骨骼与肌腱外露,中指无肌腱或骨骼外露但皮下软组织缺损严重；2C.清创后,术中正面观,环指及小指可见散在的深Ⅱ度创面；2D.腹部带蒂皮瓣修复手指创面后即刻；2E、2F.分别为皮瓣移植术后3周断蒂后掌面观、背面观,拇指远端少量皮缘坏死；2G、2H.分别为末次术后12个月随访时背面观、掌面观,瘢痕轻度增生,虎口处皮瓣略臃肿
Table 1. 不同修复方式治疗儿童伴肌腱和/或骨骼外露的59个手指深度电烧伤创面的效果比较
修复方式 患指数（个） 创面面积[cm2,M（Q1,Q3）] 手术次数[次,M（Q1,Q3）] 皮瓣或皮片成活率[%,M（Q1,Q3）] 瘢痕VSS评分[分,M（Q1,Q3）] 关节总主动活动度优良比 满意度评分[分,M（Q1,Q3）] 腹部带蒂皮瓣移植 31 2.00（2.00,4.00） 2（2,2） 90（70,90） 5.0（4.0,5.0） 24/31 9.0（8.0,9.0） 局部皮瓣移植 9 1.00（0.50,2.00） 2（1,2） 90（65,90） 4.0（4.0,5.0） 5/9 8.0（7.5,9.0） 双层人工真皮+中厚皮移植 10 1.60（1.00,2.00） 2（2,2） 90（87,91） 5.0（4.0,5.0） 7/10 9.0（7.8,9.0） 直接缝合 9 0.20（0.20,0.80） 1（1,1） — 3.0（2.0,4.0） 9/9 9.0（9.0,9.0） 注：局部皮瓣包括大鱼际带蒂皮瓣、小鱼际带蒂皮瓣和局部推进皮瓣,行双层人工真皮+中厚皮移植创面皮片成活率指中厚皮成活率；分别于腹部带蒂皮瓣、大鱼际带蒂皮瓣、小鱼际带蒂皮瓣断蒂当天术前,局部推进皮瓣移植术后7 d,全厚皮移植术后14 d,中厚皮移植术后3 d计算皮瓣或皮片成活率；手术次数为清创后至创面完全愈合期间数据；“—”表示无此项；VSS为温哥华瘢痕量表；满意度为患儿主要照护者对疗效的满意度；表中最后3项指标为末次随访时统计 
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Table 2. 不同修复方式治疗儿童无肌腱或骨骼外露的111个手指深度电烧伤创面的效果比较
修复方式 患指数（个） 创面面积[cm2,M（Q1,Q3）] 手术次数[次,M（Q1,Q3）] 皮瓣或皮片成活率[%,M（Q1,Q3）] 瘢痕VSS评分[分,M（Q1,Q3）] 关节总主动活动度优良比 满意度评分[分,M（Q1,Q3）] 腹部带蒂皮瓣移植 9 2.00（1.50,3.00） 2（2,2） 90（85,100） 5.0（4.5,5.0） 8/9 8.0（8.0,9.0） 局部皮瓣移植 5 1.00（0.50,1.50） 2（1,2） 90（40,90） 5.0（4.0,5.0） 5/5 8.0（8.0,9.0） 全厚皮移植 69 1.00（0.50,2.00） 1（1,1） 90（80,95） 4.0（4.0,5.0） 60/69 9.0（9.0,9.0） 单纯中厚皮移植 11 1.00（0.90,1.90） 1（1,2） 92（90,100） 4.5（3.0,5.0） 9/11 9.0（8.0,9.0） 双层人工真皮+中厚皮移植 10 1.00（0.60,3.00） 2（2,2） 90（90,100） 5.0（5.0,7.0） 9/10 9.0（8.0,9.0） 直接缝合 7 0.25（0.10,0.50） 1（1,1） — 3.0（3.0,4.0） 6/7 9.0（9.0,9.0） 注：局部皮瓣包括大鱼际带蒂皮瓣、小鱼际带蒂皮瓣和局部推进皮瓣,行双层人工真皮+中厚皮移植创面皮片成活率指中厚皮成活率；分别于腹部带蒂皮瓣、大鱼际带蒂皮瓣、小鱼际带蒂皮瓣断蒂当天术前,局部推进皮瓣移植术后7 d,全厚皮移植术后14 d,中厚皮移植术后3 d计算皮瓣或皮片成活率；手术次数为清创后至创面完全愈合期间数据；“—”表示无此项；VSS为温哥华瘢痕量表；满意度为患儿主要照护者对疗效的满意度；表中最后3项指标为末次随访时统计
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