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拇指软组织缺损的修复

目的 探讨不同类型拇指软组织缺损的修复方法。方法 2003年1月～2005年1月，对23例外伤性拇指软组织缺损患者采用单纯或联合食指背侧岛状皮瓣、拇指桡侧指动脉逆行岛状皮瓣、指动脉侧方岛状皮瓣、趾腹皮瓣及足母甲皮瓣移植术治疗。 结果 术后皮瓣全部成活，均获随访6～24个月。皮瓣血运、外观、质地均良好，拇指活动、对掌功能及皮肤感觉均恢复良好。 结论 不同皮瓣对于拇指软组织缺损修复有其适应证。手术时皮瓣选取适宜、设计合理，可以最小的创伤获得最佳的拇指修复效果。

MICROSURGICAL TREATMENT OF ARTERIAL OCCLUSION IN LOWER EXTREMITY

Objective To investigate the procedure and clinical effect of revascularization for arterial occlusion in lower extremity. Methods From July 1998 to March 2005, 29 cases of arterial occlusion were treated by microsurgery. Of 29 cases, there 22 males and 7 females, aging 22-86 years, including 9 cases of thromboangiitis obliterans(TAO), 17 cases of arterial sclerosis obstruction(ASO) and 3 cases of diabetic foot(DF). The location was the left in 17 cases, the right in 11 cases and both sides in 1 case. All cases were inspected by color-Doppler ultrasonic scanning before operation. The cases of ASO and DF were checked with MRA. The results of examinations showed that the locations of arteriostenosis and obstruction were: in 9 cases of TAO, the distal superficial femoral artery in 3 cases, popliteal artery in 5 cases, bilateral dorsal metatarsal artery in 1 case; in 17 cases of ASO, common iliac artery in 2 cases, external iliac artery in 4 cases, femoral artery in 10 cases and popliteal artery in 1 case; and were all superficial femoral artery in 3 cases of DF. DSA examination confirmed that there was appropriate outflow in 15 cases. Basing on the location and extent of the arterial occlusion, 11 cases were treated by the primary deep vein arterializing, 16 cases by arterial bypass distribution and 2 cases of extensive common iliac arterial occlusion were amputated in the level of 1/3 distal thigh. Results The postoperative duration of follow-up for all cases was 3 months to 7 years. In 9 cases of TAO, 2 healed by first intention after deterioration, 4 healed after changing dressing and 3 had fresh soft tissue growth after debrided superficial secondary necrosis. In 17 cases of ASO, 13 healed by first intention, 2 healed after changing dressing and 2 were amputated. In 3 cases of DF, 2 healed after changed dressing and debrided, 1 was aggravated with the second toe necrosis. Conclusion Performing primary deep veinarteriolization and arterial bypassdistribution is effective for treatment of arterial occlusion of lower extremity. The arterial reconstructive patency rate can be improved by microsurgical treatment. 

小腿严重开放性损伤的修复重建

含肋间神经前皮支皮瓣修复手部皮肤缺损

经宿主携带的指甲重建

CLINICAL RESEARCH OF ULNAR STYLOID FRACTURE COMPLICATED WITH WRIST DORSAL BRANCH OF ULNAR NERVE INJURY

Objective To analyze the therapy and effectiveness of ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury. Methods Between October 2005 and October 2012, 16 cases of ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury were treated. There were 14 males and 2 females with an average age of 42 years (range, 22-58 years). Fracture was caused by traffic accident in 8 cases, by mechanical crush in 5 cases, and by falling in 3 cases. According to the anatomical features of the ulnar styloid and imaging findings, ulnar styloid fractures were classified as type I (ulnar styloid tip fracture) in 1 case and type II (ulnar styloid base fracture) in 15 cases. The skin sensation of ulnar wrist was S0 in 5 cases, S1 in 1 case, S2 in 7 cases, and S3 in 3 cases according to the criteria of the British Medical Research Council in 1954 for the sensory functions of the ulnar wrist. The time from injury to operation was 6-72 hours (mean, 18 hours). Fracture was treated by operative fixation, and nerve was repaired by epineurium neurolysis in 13 cases of nerve contusion and by sural nerve graft in 3 cases of complete nerve rupture. Results All incisions healed by first intention. Sixteen patients were followed up for an average time of 14 months (range, 6-24 months). The X-ray films showed that all of them achieved bone union at 4-10 weeks after operation (mean, 6 weeks). No patient had complications such as ulnar wrist chronic pain and an inability to rotate. According to Green-O’Brien wrist scoring system, the results were excellent in 13 cases and good in 3 cases; according to the criteria of the British Medical Research Council in 1954 for the sensory functions of the ulnar wrist, the results were excellent in all cases, including 11 cases of S4 and 5 cases of S3+. Two-point discrimination of the ulnar wrist was 5-9 mm (mean, 6.6 mm). Conclusion For patients with ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury, internal fixation and nerve repair should be performed. It can prevent ulnar wrist pain and promote sensory recovery.

尺神经手背支损伤的一期修复

目的 总结尺神经手背支急性锐器伤的治疗方法及疗效。 方法 2007 年10 月－ 2009 年3 月，对36 例尺神经手背支急性损伤采用显微外科技术一期修复。男29 例，女7 例；年龄20 ～ 59 岁，平均28 岁。玻璃切伤6 例，刀伤11 例，电锯伤19 例。损伤部位：尺神经手背支起始处至发出横支处13 例，尺神经手背支中间支与尺侧支联合损伤18 例，尺侧支损伤5 例。单纯尺神经手背支损伤22 例，合并尺骨茎突骨折1 例，第4 掌骨骨折2 例，第5 掌骨骨折3 例，环指伸肌腱断裂1 例，小指伸肌腱断裂7 例。 结果 术后伤口均Ⅰ期愈合，无感染等并发症发生。36 例均获随访，随访时间6 ～ 24 个月，平均16 个月。根据中华医学会手外科分会上肢部分功能评定试用标准中尺神经功能评定试用标准：获优33 例，良2 例，中1 例，优良率97.2%。 结论 尺神经手背支急性锐器伤采用显微外科技术一期修复，腕背及手背尺侧重要感觉功能恢复良好，效果满意。

DORSALIS PEDIS FLAP SERIES-PARALLEL BIG TOE NAIL COMPOSITE TISSUE FLAP TO REPAIR HAND SKIN OF DEGLOVING INJURY WITH THUMB DEFECT

ObjectiveTo investigate the effectiveness of dorsalis pedis flap series-parallel big toe nail composite tissue flap in the repairment of hand skin of degloving injury with tumb defect. MethodsBetween March 2009 and June 2013, 8 cases of hand degloving injury with thumb defect caused by machine twisting were treated. There were 7 males and 1 female with the mean age of 36 years (range, 26-48 years). Injury located at the left hand in 3 cases and at the right hand in 5 cases. The time from injury to hospitalization was 1.5-4.0 hours (mean, 2.5 hours). The defect area was 8 cm×6 cm to 15 cm×11 cm. The thumb defect was rated as degree I in 5 cases and as degree II in 3 cases. The contralateral dorsal skin flap (9 cm×7 cm to 10 cm×8 cm) combined with ipsilateral big toe nail composite tissue flap (2.5 cm×1.8 cm to 3.0 cm×2.0 cm) was used, including 3 parallel anastomosis flaps and 5 series anastomosis flaps. The donor site of the dorsal flap was repaired with thick skin grafts, the stumps wound was covered with tongue flap at the shank side of big toe. ResultsVascular crisis occurred in 1 big toe nail composite tissue flap, margin necrosis occurred in 2 dorsalis pedis flap;the other flaps survived, and primary healing of wound was obtained. The grafted skin at dorsal donor site all survived, skin of hallux toe stump had no necrosis. Eight cases were followed up 4-20 months (mean, 15.5 months). All flaps had soft texture and satisfactory appearance;the cutaneous sensory recovery time was 4-7 months (mean, 5 months). At 4 months after operation, the two-point discrimination of the thumb pulp was 8-10 mm (mean, 9 mm), and the two-point discrimination of dorsal skin flap was 7-9 mm (mean, 8.5 mm). According to Society of Hand Surgery standard for the evaluation of upper part of the function, the results were excellent in 4 cases, good in 3 cases, and fair in 1 case. The donor foot had normal function. ConclusionDorsalis pedis flap series-parallel big toe nail composite tissue flap is an ideal way to repair hand skin defect, and reconstructs the thumb, which has many advantages, including simple surgical procedure, no limitation to recipient site, soft texture, satisfactory appearance and function of reconstructing thumb, and small donor foot loss.