指动脉背侧支为蒂逆行指掌背筋膜皮瓣的应用解剖与临床研究

发布时间：2018-08-26 08:48

【摘要】： 手指外伤后软组织缺损常易合并骨关节、肌腱、血管和神经外露,治疗较为棘手,多需采用皮瓣移位或移植修复。目前修复手指创面的皮瓣常见三种类型:近位皮瓣、远位皮瓣和游离皮瓣。常用的传统皮瓣有:局部旋转皮瓣、各种手指推进皮瓣、邻指皮瓣、臂交叉皮瓣、腹部带蒂皮瓣、指动脉岛状皮瓣及游离皮瓣等[1-4]。这些皮瓣存在修复的创面面积有限、固定时间长影响手的功能、皮瓣臃肿外形差、牺牲手指一根主要动脉、需要吻合血管、手术操作复杂及风险比较大等缺点。手指皮肤薄而柔软、血运丰富、感觉灵敏,具有这些特点的皮瓣供区只有手和足。足部各种游离组织瓣可以修复手指相应部位的组织缺损,可以做到“缺什么补什么,缺多少补多少”的完美境界[4],但是需要娴熟的小血管吻合技术,手术操作复杂费时,存在组织瓣坏死的风险,足部供区植皮可能坏死而致肌腱外露,所以临床应用受到一定限制。与手指创面邻近的指背、掌背区域,皮肤柔软松弛、弹性好、质地薄、血运丰富、富有感觉神经、皮瓣旋转幅度大可以覆盖手指中远节较大面积缺损,是修复手指创面的理想皮瓣供区,以指背、掌背作为皮瓣供区切取岛状皮瓣修复手指软组织缺损成为了临床外科医师和解剖学者研究的热点[5-15]。但目前国内外关于以指动脉背侧支为蒂逆行指掌背筋膜皮瓣的应用解剖和临床应用,少见文献报道,尤其缺乏关于以近、中节指动脉背侧支为蒂的掌指背岛状筋膜皮瓣系统而翔实的国人应用解剖资料。本研究采用新鲜手标本动脉灌注乳胶,进行显微解剖学研究,旨在为指动脉背侧支为蒂逆行掌指背筋膜皮瓣提供更加系统、确切的解剖学依据,并应用于临床,验证其临床效果。第一章指动脉背侧支为蒂的逆行指掌背筋膜皮瓣的应用解剖研究目的为指动脉背侧支为蒂的逆行指掌背筋膜皮瓣提供系统翔实的解剖学依据。方法采用14只新鲜成人尸体手标本,经动脉插管灌注红色乳胶,标本冷冻48小时后在手术显微镜下解剖、观测手背和2～5指指背血管的走行、分布、吻合情况及外径。测量数据以SPSS11.0统计软件分析处理。结果掌背浅筋膜层内存在丰富的皮动脉血管网,有四条与相应掌背动脉走行方向一致的较粗大的皮动脉弓。掌背动脉或远端掌深弓穿支在伸肌腱腱联合远侧恒定发出一支粗大的返支皮动脉。掌背动脉终末段和远端掌深弓穿支向每侧掌指关节背侧和指背发出3.82±0.89支(2～7支)皮支,外径0.10～0.72mm。指蹼动脉较为恒定存在,仅1例第4指蹼动脉缺如。手指中、近节每侧各有1～7支间接指动脉背侧皮支,2～8支指动脉背侧皮支。手指近节中段、近节远段、中节近段或中段每侧较为恒定存在一支较粗大的指动脉背侧皮支。掌背动脉终末段和远端掌深弓穿支的指背分支供血手指近节中、近段背侧皮肤,在近节指背与指动脉背侧皮支交通。不同节段指动脉背侧皮支在指背外侧缘交互吻合,在指背外侧缘形成一条营养血管链。结论以指动脉背侧支为蒂的逆行指掌背筋膜皮瓣解剖简单、快捷,旋转弧长,利于修复手指中远节较大面积的软组织缺损。远端蒂掌背皮瓣旋转点可以进一步前移到手指近节中段或远段。第二章指动脉背侧支为蒂的逆行指掌背筋膜皮瓣的临床应用目的探讨指动脉背侧支为蒂的逆行指掌背筋膜皮瓣修复手指中、远节皮肤软组织缺损的可行性。方法15例手指中、远节皮肤软组织缺损,应用以指动脉背侧支为蒂的逆行指掌背筋膜皮瓣修复,皮瓣旋转点位于手指近节中点或近节远段。结果14例皮瓣完全成活,1例皮瓣远端少部分表皮层坏死。远期随访皮瓣血运良好,耐寒,皮瓣薄而质地柔软,外观色泽良好,皮瓣供区无伸肌腱粘连和指蹼挛缩。结论以指动脉背侧支为蒂的逆行指掌背筋膜皮瓣血运可靠、旋转弧长、操作简单、皮瓣更接近创面、对皮瓣供区损伤更小、可以吻合皮神经重建皮瓣感觉,是一种修复手指中、远节软组织缺损的理想方法。
[Abstract]:The soft tissue defect after finger trauma is often complicated by bone and joint, tendon, blood vessel and nerve exposure. The treatment is difficult and needs to be repaired by flap transfer or transplantation. Flaps, adjacent finger flaps, cross-arm flaps, abdominal pedicled flaps, digital artery island flaps and free flaps [1-4]. These flaps have some disadvantages, such as limited wound area, long fixation time affecting hand function, poor appearance of the flaps, sacrificing a major artery of the finger, requiring vascular anastomosis, complicated operation and high risk. All kinds of free tissue flaps of the foot can repair the tissue defect of the corresponding part of the finger, and can achieve the perfect state of "what is missing and how much is missing". But it needs skilled small vessel anastomosis technology and surgical operation. There is a complex and time-consuming risk of tissue flap necrosis, skin grafting in the donor site of the foot may necrosis and lead to tendon exposure, so clinical application is limited. The area defect is an ideal flap donor site for repairing finger wounds. The dorsal digital and dorsal metacarpal island flap has become a hot spot for clinical surgeons and anatomists to repair finger soft tissue defects [5-15]. There are few reports on the clinical application of the dorsal metacarpophalangeal fasciocutaneous flap pedicled with the dorsal branch of the digital artery near the middle segment in China. It provides a more systematic and precise anatomical basis and is applied in clinic to verify its clinical effect.
The first chapter is the applied anatomy of the reverse dorsal metacarpal dorsal fasciocutaneous flap pedicled with the dorsal branch of the artery.
Objective to provide an anatomical basis for the retrograde dorsal metacarpal fasciocutaneous flap pedicled with the dorsal branch of the artery.
Methods 14 fresh adult cadaveric hand specimens were perfused with red latex through arterial cannula. The specimens were frozen for 48 hours and dissected under the operating microscope. The course, distribution, anastomosis and external diameter of the dorsal blood vessels of the hand and 2-5 fingers were observed.
Results There were abundant vascular networks of cutaneous arteries in the superficial dorsal metacarpal fascia, and there were four thicker cutaneous arterial arches in the direction of the corresponding dorsal metacarpal arteries. The dorsal and dorsal metacarpophalangeal joints had 3.82 (- 0.89) cutaneous branches (2-7) with a diameter of 0.10-0.72 mm. The webbed digital artery was relatively constant in one case, but the fourth webbed artery was absent. In the finger, there were 1-7 dorsal cutaneous branches of the indirect digital artery on each side of the proximal segment, and 2-8 dorsal cutaneous branches of the digital artery on each side of the proximal segment, proximal segment and middle segment of the finger. The dorsal cutaneous branch of the dorsal metacarpal artery and the perforating branch of the distal deep palmar arch supply the dorsal skin of the proximal segment of the finger and communicate with the dorsal cutaneous branch of the digital artery in the proximal segment. Nutrient vascular chain.
Conclusion The reverse dorsal metacarpal fasciocutaneous flap pedicled with the dorsal branch of the digital artery is simple, fast and has a long rotation arc, which is beneficial to repair the large soft tissue defect in the middle and distal segment of the finger.
The second chapter refers to the clinical application of retrograde dorsal metacarpal fasciocutaneous flap pedicled with the dorsal branch of the artery.
Objective To explore the feasibility of repairing skin and soft tissue defect of middle and distal segment of finger with reverse dorsal digital artery fasciocutaneous flap pedicled with dorsal branch of digital artery.
Methods Retrograde dorsal metacarpal fasciocutaneous flap pedicled with dorsal branch of digital artery was used to repair 15 cases of skin and soft tissue defects in the middle and distal segments of fingers.
Results The flap survived completely in 14 cases, and the distal part of the flap was necrotic in 1 case. The long-term follow-up showed that the flap had good blood supply, cold resistance, thin and soft texture, good appearance and color. There was no extensor tendon adhesion and web contracture in the donor area of the flap.
Conclusion The reverse dorsal digital palmar fasciocutaneous flap pedicled with dorsal branch of digital artery has reliable blood supply, long rotation arc, simple operation, closer to the wound surface, less damage to the donor area of the flap, and can anastomose the cutaneous nerve to reconstruct the sensation of the flap. It is an ideal method for repairing the soft tissue defect in the middle and distal segments of the finger.
【学位授予单位】：南华大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R658.2;R322

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