指侧方皮瓣和微型静脉皮瓣的解剖及在皮肤缺损型断指再植的应用研究

发布时间：2018-01-01 19:41

本文关键词：指侧方皮瓣和微型静脉皮瓣的解剖及在皮肤缺损型断指再植的应用研究　出处：《第一军医大学》2007年硕士论文　论文类型：学位论文

【摘要】： 目的在手外伤临床诊治中，压轧伤、旋转撕脱伤、电锯伤、热压伤等各种致伤原因所致的手指离断或手指血运障碍并皮肤软组织缺损的病例越来越多，这些病例临床治疗均较棘手，，由于再植难度大，加之对皮肤血管缺损缺乏有效的修复手段，故过去常采患指缩短再植或直接截指，严重影响手的外观和功能，对患者的生活和心理均造成巨大压力，因此对于骨与关节较完整而皮肤软组织缺损的断指病例，根据损伤、缺损的程度、部位和范围，通过某种修复方法使患指保存完整乃十分必要。本研究目的正是在对指侧方岛状皮瓣和微型游离静脉皮瓣应用解剖学研究的基础上，进一步探讨指侧方岛状皮瓣和微型游离静脉皮瓣在各种类型皮肤软组织缺损型断指再植修复的术式，并应用于临床，验证指侧方岛状皮瓣和微型游离静脉皮瓣设计术式对皮肤软组织缺损型断指病例进行再植修复的可行性和实用性。方法 1．应用解剖学研究 1．1．研究总结现已有手部血管造影及手部应用解剖资料，了解手部血管神经走行和分布； 1．2．采用5例上肢血管铸形标本，直观观察总结手部血管及前臂皮下浅静脉走行分布； 1．3．采用10例前臂取皮手术标本，观察皮下静脉分布、数量、直径，并行血管通水试验，观察小静脉瓣膜作用。 1．4．采用5例福尔马林固定的成人上肢标本和1例新鲜毁损废弃手部标本，逐层解剖，观察掌浅弓、指总动脉神经及指固有动脉神经走向，分别测量指总动脉掌浅弓发出点(a_1点)及指总动脉位掌骨头平面分叉点(a点)至示、中、环、小指末节基底(c点)的距离，再分别测定3条指总动脉掌浅弓发出点(a_1点)及位掌骨头平面分叉点(a点)根据所测量a_1-c及a-c长度来转移所能达至各指平面位置； 1．5．选取50例活体手部体表测量标本，根据体表解剖学标志，测量可设计岛状皮瓣最远端c点(即示、中、环、小指末节基底)至转移轴点(指总动脉位掌骨头平面分叉点a点及指总动脉位掌浅弓发出点a_1点)距离，再根据a_1-c及a-c长度来测定从转移轴点能达至各指的平面位置； 1．6．采用70例国人新鲜废弃指体标本(示指15例、中环指各20例、小指15例)，设计并切取示指尺侧、中环指两侧、小指桡侧近中节不同部位例数不等的1.0cm×1.0cm和2.0cm×2.0cm皮瓣，观察计数岛状皮瓣内的静脉数量及可供吻合之静脉端口数目； 2．临床研究本组12例13指，其中男9例10指，女3例3指，年龄16～48岁，平均年龄23.6岁。完全离断6指，不完全离断7指。离断部位从近节根部至末节基底。致伤原因：压轧伤6例，旋转撕脱伤1例，电锯伤2例，热压伤1例，，电击伤1例，化学烧伤1例。清创前期处理后均有皮肤血管缺损，根据缺损部位不同可将这些皮肤缺损型断指大体分为掌侧、背侧和环状缺损型3种类型，再根据这3种类型将指侧方岛状皮瓣和前臂微型游离静脉皮瓣作不同术式设计进行修复，术后观察皮瓣和断指成活情况，长期随访观察患指感觉和功能恢复情况。结果 1．应用解剖学研究 1．1．清楚掌握手部血管神经，尤其是指掌侧总动脉和指掌侧固有动脉的分布走行；前臂掌侧远部皮下浅静脉皮瓣有如下特点：皮肤薄，静脉网丰富，皮下静脉表浅、细小，直径与手指血管相近，小静脉内瓣膜作用弱。 1．2．福尔马林固定上肢标本和新鲜废弃手部标本解剖测量结果和活体手部体表测量标本所得测量结果均显示：示指尺侧、中指两侧和环指桡侧a-c转移均能达至拇指c点，环指尺侧a_1-c转移可达至拇指近节中部；中指a-c转移均可达至示环小指c点以远；示指尺侧a-c转移可达至中环小指中节远部，a_1-c转移可达至中环小指c点；环指桡侧a-c转移可达至示中指中节远部，a_1-c转移可达至示中指c点；环指尺侧a-c和a_1-c转移均只能达至中指中节远部和示指中节近部；环指两侧a-c和a_1-c转移均能达至小指c点；小指桡侧a-c和a_1-c转移能达至环指近节远端，中指近节近部。 1．3．切取1.0cm×1.0cm指侧方皮瓣可包含指掌侧浅静脉1条以上(或皮瓣远近侧各1个以上可供吻合的端口)，和／或指背侧浅静脉1条以上(或皮瓣远近侧各1个以上可供吻合的端口)；切取2.0cm×2.0cm皮瓣可包含指掌侧浅静脉2条以上(或皮瓣远近侧各2个以上可供吻合的端口)，和／或指背侧浅静脉2条以上(或皮瓣远近侧各2个以上可供吻合的端口)。 2．临床应用研究本组12例13指，均顺利成活，长度无明显缩短，外观良好。后期动脉皮瓣外观、质地良好，静脉皮瓣则有不同程度的收缩，颜色较深，质地稍硬，弹性稍差。按TAM功能评定法：优6指，良5指，差2指，优良率84.6％。结论 1．指侧方岛状皮瓣和前臂微型游离静脉皮瓣可扩大应用于各种类型的皮肤软组织缺损型断指再植修复术。 2．术式设计具有灵活、安全、损伤小及操作容易掌握，适应范围广等优点，是皮肤软组织缺损型断指再植修复较理想术式。
[Abstract]:objective
In the clinical diagnosis and treatment of hand trauma, crush injury, rotation avulsion, electric saw injury cases increasing, heat injury caused by various injury severed fingers or disturbance of blood circulation and skin and soft tissue defects, the clinical treatment was difficult, because of difficulty, in addition to the lack of skin defect of blood vessels repair of effective means, is used to shorten the mining finger replantation or direct cut finger, seriously affect the appearance and function of hand, causing tremendous pressure on the patient's life and psychology, so for bone and joint is complete and skin and soft tissue defect of finger injury according to the case, the extent of the defect, location and scope. Through some repair methods with complete preservation is very necessary. The purpose of this study is on the basis of the lateral island flap and miniature free vein flap applied anatomy study on the further study of the lateral island flap Micro flap and free vein flap in the surgical repair of various types of skin and soft tissue defect of finger replantation, and clinical application to verify the feasibility and practicability of the lateral island flap and miniature free vein flap design for replantation repair of skin and soft tissue defect of finger type case.
Method
1. applied anatomy study
1.1. studies have summarized hand angiography and hand applied anatomical data to understand the walking and distribution of the vascular and nerve in the hand.
The blood vessels of the hand and the superficial subcutaneous vein of the forearm were observed in 5 cases by 1.2..
1.3. specimens of 10 cases of forearm skin removal were used to observe the distribution, quantity and diameter of subcutaneous veins.
Parallel vascular water test was used to observe the effect of small venous valve.
1.4. using formalin fixed adult cadaver specimens of 5 cases and 1 cases of fresh damaged abandoned hand were dissected, observed the superficial palmar arch, the artery nerve and nerve to the finger artery, were measured in the artery superficial palmar arch a point (point a_1) and finger artery at the bifurcation point metacarpal head plane (a) to show, ring finger paratelum base (point C) distance, then determination of 3 refers to the superficial palmar arch arteries from point (a_1 point) and palmar head bifurcation point (point a) according to a_1-c and a-c length measurement to transfer to the plane position;
1.5. selected 50 cases of living hand surface were measured, according to the surface anatomical landmarks, measurement of island flap design the most distal point (i.e., C, ring finger paratelum base) to transfer axis point (finger artery at metacarpus head bifurcation point a and finger artery at a superficial palmar arch point a_1) distance, according to a_1-c and a-c to determine the length of plane position from the transfer axis point to each finger;
1.6. with 70 cases of the fresh specimens of abandoned finger (index finger in 15 cases, 20 cases in each ring finger, little finger in 15 cases), design and cut the ulnar side of index finger, ring finger on both sides of the little finger radial proximal section in different parts of the number of cases ranging from 1.0cm * 1.0cm and 2.0cm * 2.0cm flap, intravenous counting in the island flaps and vein anastomosed port number;
2. clinical study
This group of 12 cases 13, 9 cases were male 10, female 3 cases 3 fingers, aged 16 to 48 years old, the average age of 23.6 years. The complete transection of the 6 finger, complete transection of the 7 fingers. From the broken parts from the proximal root to the distal base. The causes of injury: 6 cases of crush injury. Rotation avulsion in 1 cases, 2 cases of electric saw injury, hot crush injury in 1 cases, and electrical injury in 1 cases, 1 cases of chemical burn debridement. After early treatment of skin vascular defects, according to different defect location the skin defect of finger can be divided into dorsal and volar, annular defect of 3 types then, according to the 3 types of the lateral island flap and forearm minisize free vein flap for different operation design of repair, postoperative flap and finger, long-term follow-up with feeling and functional recovery.
Result
1. applied anatomy study
1.1. clearly grasp the hand of blood vessels and nerves, especially the distribution of common palmar digital arteries and proper palmar digital artery; far side of subcutaneous superficial vein flap has the following characteristics: the skin is thin, the forearm palm vein network rich, superficial subcutaneous vein, small diameter and small finger vein similar vein valve inside the weak effect.
1.2. formalin fixed upper limb specimens and fresh abandoned hand anatomical specimens and in vivo measurement results of hand surface were measured and the measurement results showed that the index finger ulnar, middle finger and ring finger on both sides of the radial side of the a-c transfer can reach the C point, a_1-c moved up to the ulnar thumb proximal ring finger in the middle; refers to the transfer of up to a-c are shown in the ring and little fingers point beyond C; a-c is the little finger ulnar finger transfer to central section in the distal part, a_1-c transfer to central C point finger can reach up to a-c; radial transfer of index finger in the distal portion of the ring finger section, up to a_1-c transfer of index finger ring finger point C; the ulnar a-c and a_1-c transfer are only up to the festival far part and the index finger in the section near; both a-c and a_1-c transfer can reach C point of little finger ring finger; finger radialis transfer a-c and a_1-c can reach to the ring finger proximal distal and proximal phalanx of middle finger in the Department.
1.3. cut 1.0cm * 1.0cm laterodigital flap contains over 1 palmar superficial vein (or flap near and far side of 1 above for anastomose), and / or dorsal superficial vein (more than 1 or more than 1 of the near and far side flap anastomosed port); cut 2.0cm * 2.0cm flap can contain over 2 palmar superficial vein (or flap near and far side of 2 above for anastomose), and / or dorsal superficial vein (more than 2 or more than 2 of the near and far side flap anastomosed port).
2. clinical application research
The group of 12 patients 13 fingers survived, the length was not shortened, the appearance is good. The late arterial flap appearance, good texture, vein flaps have different degrees of shrinkage, darker color, hard texture, elasticity is poor. According to TAM functional evaluation standard: 6 excellent, 5 good, 2 poor refers to the excellent rate of 84.6%.
conclusion
The 1. finger lateral island flap and the forearm free vein flap can be applied to various types of skin soft tissue defect replantation repair.
2., the design of operation is flexible, safe, less damage, easy to operate and wide range of adaptation. It is an ideal surgical method for skin and soft tissue defect replantation of severed fingers.

【学位授予单位】：第一军医大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R322;R658.1

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