60例儿童手部瘢痕挛缩综合康复治疗的疗效观察

发布时间：2018-05-20 11:36

本文选题：烧伤 + 瘢痕　；参考：《郑州大学》2016年硕士论文

【摘要】：背景和目的:烧伤一直是个热点课题,其全球发生率约为每年200/10万~400/10万[1]。在国内外均有一个共识,即烧伤是一个高发的常见病种,而且是一个对个人、家庭、社会造成严重伤害的病种。但是,烧伤创面早期愈合,并不意味着临床治疗的结束,创伤后创面愈合出现的瘢痕增生、挛缩等一系列问题,严重影响了患者的人际社交、工作、自理能力以及造成心理影响。因此,在烧伤治疗过程中,绝不仅限于对烧伤患者生命的救治及创面的封闭,而是应最大限度的恢复外观和功能,减少因瘢痕挛缩对患者各项生理功能造成的影响。如何在创口封闭后治疗瘢痕,也是一个令临床工作者为难的课题。瘢痕的研究,包括他的发生机制与防治问题,迄今仍然困扰着我们[8]。它是一个联结整个生命科学领域的重要问题,十分复杂难解。瘢痕不仅影响美观,其抗强性亦较正常皮肤组织差,在功能上,往往因收缩或牵拉导致功能障碍。数世纪以来,瘢痕就一直困扰着我们,难以治愈,且易复发。适度的瘢痕形成是一种生理性和自卫性表现,而过度增生则属于病理性改变[15]。特别是处于关节部位的瘢痕组织,一旦对关节形成牵拉,制约关节的活动,会导致病人自理能力或劳作能力的下降甚至消失,因此,在改善烧伤患者死亡率的同时,更要注重烧伤早期康复对患者日后生活及劳作能力的影响。手是人类赖以生存的重要工具,在人类的劳作及生活中起着重要的作用。手为暴露部位,在遇到火焰燃烧时,人的防御动作是以双手扑灭火焰或是以双手遮面,因此致伤机会较多。虽然两只手的体表面积占体表总面积为5%,不会造成生命危险,但是愈合过程中却容易导致畸形。有些患者烧伤瘢痕虽然不深,但继发病变却很严重。特别是儿童,在生长的过程中瘢痕的生长速度慢于周围正常的组织,更容易导致牵拉,使手功能受损或丧失。近年来,康复医学有了很大的进步,手部烧伤后早期介入康复治疗的观念在临床上也取得了共识:单纯的手术治疗仅能解决畸形问题,而无法解决后期瘢痕的挛缩。因此治疗烧伤后瘢痕的挛缩必须早期介入综合康复治疗。康复器具通过代偿或补偿的方法来矫治畸形、弥补功能缺陷和预防功能进一步退化,是患者能最大限度地实现生活自理,回归社会。康复器具是重要的康复手段。对于瘢痕挛缩的治疗,矫形支具是一个很好的选择,它具有稳定与支持、固定与矫正、保护与免负荷、代偿与助动的功能。康复治疗种类繁多,单凭一种治疗方法难以取得理想效果,因此我科在多年治疗手烧伤经验的基础上,提出了术后结合综合康复治疗的方法,即术后早期介入,针对患者个体差异定制专业压力套和矫形器具,并以常规未使用压力套和矫形支具的传统治疗方法作为对照进行比较,观察两种方案的疗效差异。康复评定需用确实能反应手部功能的评价指标[25]:手指关节总活动度(Total Angle of Motion,TAM)、日常生活活动能力(Activities of Daily Living,ADL)和Jebsen手功能测试。本课题旨在探讨综合康复治疗在儿童手部烧伤后畸形矫治术后的临床应用价值,力求寻找更加完善的康复方案,为手部畸形的矫治提供科学的依据。方法:2013年5月~2015年5月,按统一标准入选的60例患儿按随机数字表法分为康复加强组和传统治疗组,各30例。两组患者均接受常规自体皮片移植术,且伤口愈合时间在20~30天。术后的康复治疗:康复加强组采用手术后指导性手部功能锻炼,在医师指导下进行主动、被动手指活动,联合使用压力疗法和矫形支具综合治疗。传统治疗组采用手术后指导性手部功能锻炼,在医师指导下进行主动被动手指活动。分别于康复治疗前和治疗后3个月、6个月测量评定温哥华瘢痕量表、指标手指关节总活动度(Total Angle of Motion,TAM)、日常生活活动能力(Activities of Daily Living,ADL)和Jebsen手功能测试。结果:本临床试验通过对于康复加强组和传统治疗组患者手部瘢痕挛缩治疗的对比发现,康复加强组在瘢痕情况、关节活动度测量方面、手功能和日常生活能力方便,均优于常规治疗组:2组患者瘢痕改善分值差异明显(t=1.452,P=0.045);2组患儿关节活动度优良比差异明显(t=8.507,P=0.004);2组患儿手功能测试改善时间差异明显(t=2.618,P=0.012)。2组患儿日常生活活动能力改善分值差异明显(t=2.246,P=0.029)。结论:本实验通过对60例烧伤后手部畸形患者进行手术和康复治疗后,通过康复评定指标的研究,得出以下结论:烧伤后手部瘢痕挛缩患者经自体皮片移植后,综合康复治疗的疗效明显优于术后单纯的指导性运动治疗。
[Abstract]:Background and purpose: burn has always been a hot topic. It has a global incidence of about 200/10 million ~400/10 000 a year, and there is a consensus at home and abroad that burns are a common disease with high incidence and a serious injury to individuals, families and society. However, the early healing of burn wounds does not mean clinical treatment. End, a series of problems such as scar hyperplasia and contracture of wound healing after trauma, which seriously affect the interpersonal, work, self-care and psychological effects of the patients. Therefore, in the process of burn treatment, it is not limited to the treatment of the lives of the burned patients and the closure of the wounds, but to the maximum restoration of appearance and function. Reducing the effects of scar contracture on the physiological function of the patients. How to treat scar after the wound closure is also a difficult task for the clinical workers. The research on scar, including his mechanism and prevention, still plagued us [8]., which is an important issue in the whole life science field. The scar not only affects the beauty, its resistance to strength is also worse than the normal skin tissue. In function, it often causes dysfunction due to contraction or traction. For centuries, scar has been plaguing us, difficult to cure, and easy to relapse. Moderate scar formation is a physiological and self-defense performance, and hyperproliferation is pathological. Change the [15]. especially in the joints of scar tissue, once the joint formation is drawn, restriction of joint activities will lead to the patient's self-care ability or decrease or even disappearance. Therefore, in improving the mortality of the burn patients, we should pay more attention to the effect of early burn on the patient's daily life and work ability. An important tool for human survival plays an important role in the work and life of human beings. When the hands are exposed to the exposed parts, when the flame is burning, the defensive action of the human is to extinguish the flame by both hands or to cover the face with both hands. Therefore, there are more chances of injury. Although the surface of the body surface of two hands is 5%, it will not cause the danger of life. But it is easy to cause malformation during the healing process. Some patients with burn scar are not deep, but secondary lesions are very serious. Especially in children, the growth rate of scar is slower than normal tissue in the process of growth. It is more likely to lead to traction, and the function of hand is damaged or lost. In recent years, rehabilitation medicine has made great progress and hand burn. The concept of early intervention rehabilitation after injury has also achieved a common understanding in clinical: simple surgical treatment can only solve malformation problems, but can not solve the later scar contracture. Therefore, the treatment of scar contracture after burn must be intervened in a comprehensive rehabilitation therapy. The rehabilitation device can be used to remedy deformity through compensatory or compensatory methods, and make up for the deficiency of function. The function of depression and prevention is further degenerated. It is the patient who can maximize the life and return to the society. The rehabilitation apparatus is an important means of rehabilitation. For the treatment of scar contracture, the orthopedic support is a good choice. It has the function of stability and support, fixation and correction, protection and no load, compensatory and auxiliary functions. On the basis of many years' experience in treating hand burn, we put forward a method of combining comprehensive rehabilitation after operation, namely, early postoperative intervention, customizing professional pressure sets and orthopedics according to individual differences of patients, with the tradition of conventional unused pressure sets and orthopedics. The treatment methods were compared as controls to observe the difference in the efficacy of the two schemes. The evaluation of the rehabilitation of the hand was [25]: the total activity of the finger joint (Total Angle of Motion, TAM), the ability of daily living (Activities of Daily Living, ADL) and the test of the Jebsen function. The purpose of this study was to discuss the comprehensive health. The clinical application value of complex treatment after orthopedics after hand burn in children is to seek a more perfect rehabilitation program and provide scientific basis for the correction of hand deformity. Method: in May ~2015 May 2013, 60 children selected according to the unified standard were divided into the rehabilitation strengthening group and the traditional treatment group according to the random digital table method, each 30 cases two. The patients in the group received conventional autologous skin graft, and the healing time of the wound was 20~30 days. The rehabilitation treatment after operation: the rehabilitation and strengthening group adopted the guiding hand exercise after the operation. Under the guidance of the doctor, the active, passive finger movement, combined use of pressure therapy and orthopedic support were combined. The traditional treatment group was guided by postoperative guidance. Sexual hand exercise was conducted under the guidance of doctors. The Vancouver scar scale was assessed before and 3 months after rehabilitation and 6 months after treatment. The total activity of the finger joint (Total Angle of Motion, TAM), the activity of daily living (Activities of Daily Living, ADL) and Jebsen hand test. Results: by comparing the treatment of hand scar contracture in the rehabilitation group and the traditional treatment group, it was found that the rehabilitation group was better than the conventional treatment group in the scar condition, the measurement of joint activity, the hand function and the daily life ability, and the difference of scar improvement score in the 2 groups was obviously different (t=1.452, P=0.045); The good ratio of joint activity was obvious (t=8.507, P=0.004), and the difference of the time of improvement of hand function test in the 2 groups was obvious (t=2.618, P=0.012), the difference of the daily living ability of the children was significantly different (t=2.246, P=0.029). Conclusion: after the operation and rehabilitation treatment of the hand deformity patients after the burn, the experiment was carried out through rehabilitation. The following conclusions are drawn: after transplantation of autologous skin graft in patients with scar contracture after burn, the curative effect of comprehensive rehabilitation is better than that of simple guided exercise after the operation.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R644

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