腕部切割伤治疗283例临床分析
摘要
腕部切割伤在手外科损伤中占很大比例，损伤时多为包括肌腱、血管、神经的复合伤，如诊断及处理不当，对手的功能会造成严重损失，甚至残废。预防或及时正确处理，对于减少患者残疾，改善医患关系，减少纠纷十分重要。本研究综述了国内外关于腕部切割伤肌腱、神经和血管损伤的治疗经验和最新进展，并就本院2年来收治的283例病例做以回顾性总结和分析，浅谈对腕部切割伤的治疗体会。
临床资料：急慢诊腕部切割伤患者中有确切病例的283例，深筋膜以浅的47例，单纯肌腱损伤的35例；肌腱合并神经损伤的102例：其中合并正中神经损伤的85例，合并尺神经损伤的16例，合并桡神经浅支损伤的1例，正中神经与尺神经合并损伤的有9例，肌腱合并尺动脉损伤27例，合并桡动脉损伤62例，尺、桡动脉同时损伤12例。
治疗方法：腕部肌腱损伤均争取一期缝合，在局麻下采用Bunnell缝合法，Kessler缝合法，津下缝合法端-端缝合肌腱，在合并神经损伤时对正中神经采用外膜缝合法，对尺神经常常用束束缝合方法，腕部切割伤的血管损伤常见的为尺、桡动脉,离断。术后肌腱损伤需固定3周，3周后功能锻炼，防止肌腱粘连。神经损伤需营养神经，感觉恢复训练，血管损伤需抗凝对症治疗。
治疗结果：腕背部指伸肌腱损伤者，本组8例均为一期缝合肌腱、闭合创面。术后3周开始功能锻炼，效果较好。仅有1例
术后3个月因粘连再次松解。腕掌侧屈肌腱损伤者，本组218例，除2例合并尺神经，正中神经损伤恢复效果不满意，其余功能恢复均达良好，对单纯肌腱治疗满意率100%，单纯合并正中神经损伤满意率100%，单纯合并尺神经损伤96%，合并正中神经，尺神经同时损伤满意率87.5%。
讨论：1、腕前区切割伤的治疗：腕掌侧屈肌腱切割伤时，此处的屈肌腱位于腕管内，其损伤采用Bunnell缝合法、Kessler缝合法端端肌腱。在术中部分指伸肌腱的切开，有组于手术操作，亦能避免缝合的肌腱被伸肌支持带卡压。术后石膏固定3周，3周后功能锻炼。2、神经损伤的修复：对急诊损伤常采用神经外膜缝合法、神经束组膜缝合法，尤其尺神经损伤，要做到束束吻合，争取达到最佳的恢复效果。术后系统的神经康复治疗。正中神经较粗应避免错接或者漏接。3、肌腱粘连的防止与松解：肌腱粘连是导致肌腱修复疗效欠佳的主要原因，防止粘连时手部肌腱外科的一个中心问题，在临床中，无论是屈肌腱还是伸肌腱，修复后多数病例会有不同程度的粘连。要认清粘连的性质及来源，判断是否适应于粘连松解，在术中需完全松解粘连肌腱，松解的范围必须超过粘连的边缘，松解不彻底则术后恢复效果达不到预想的效果，必须认真对待。4、腕部切割伤的血管损伤常见的为尺、桡动脉,离断。采用端端吻合术修复尺、桡动脉，术后抗凝对症治疗。总之，腕部切割伤组织损伤类型复杂，需合理的有效的选择不同的治疗方法使患肢达到最大程度的外形、功能上的恢复。
Wrist laceration play an important role in modern hand surgery, which include tendon, blood vessel, nerve compound injuries, if not properly diagnosed and handled, it can cause losing the function of the hands, even disabled. It’s very important to prevent and correctly treat patients on time, then it can decrease the rate of hand disable, improve the relationship between doctors and patients and reduce the disputation. In this study, we reviewed the clinic experiences of the treatment of wrist laceration and the latest progress, besides, we analyzed 283 patients with wrist laceration in the fist hospital of Jilin university, to discuss some thoughts in the treatment.
Clinical data: The total injuries 283 cases, among which 47 cases not hurt deep fascia, the pure tendon injuries 35 cases; the tendon merges nerve injuries 102 cases: Among them company with median nerve injuries 85 cases, with ulnar nerve injuries 16 cases, with low branch of radial nerve injuries 1 cases, median nerve and ulnar nerve injuries 9 cases, tendon with unlar artery injuries 27 cases, company with radial artery injuries 62 cases, unlar artery and radial artery injuries at the same time 12 cases.
Methods: For those patients with wrist laceration, we adopt the Bunnell method, the Kessler method, Tsuge method to make end to end anastomisis. If had nerve injuries, we anastomosed epineurium for median nerve injuries, while for unlar nerve injuries, we always adopt bundle to bundle anastomisis. The vesssel injuries of laceration always happened on ulnar and radial arteries. After operation ,tendon injuries
need 3 weeks fixation, after 3 weeks need function exercises, keep tendon from adhesion The nerve injuries need nerve nutrition, feeling get back training, blood vessel injuries need the anticoagulation.
Result: For those with extensor tendon injuries of the back of wrist, all 8 cases all make the first period anastomisis of tendon. 3 weeks after operation begin to function exercises, and the effects were satisfied, only 1 cases because adhesion need second operation. For those with tendon of flexor injuries of the wrist, 218 cases in this group：except 2 cases which company with ulnar nerve, median nerve injuries, all got good effects. For pure tendon treatment, the satisfied rate is 100%, simply company with median nerve injuries, the satisfied rate 100%, simply with ulnar injuries 96%, both median and ulnar nerve injuries, the rate is 87.5%.
Discussion: 1. The treatment of laceration of wrist: when the tendon of flexor of the wrist got injuries, because the tendon of flexor lies in the carpal canal, we use Bunnell method, Kessler method to make end to end anastomisis. In the operation, incise part of tendon of flexor digitorum, it can benifit the operation, it can also avoid tendon was blocked by the extentor retinaculum. Fix up 3 weeks by gypsum, after 3 weeks make function exercise. 2. The repairment of nerve injuries: For those with acute injuries, we always directly suture the epineurium or suture the bundle of the nerve, especially to the ulnar nerve injuries, need to bundle to bundle anastomisis for the best effects. After operation need systemic treatment of nerve. The median nerve is thick, take care not to misconnected or fumble. 3. Provention of tendon conglutination and relaxation: The tendon conglutination is
the main cause of the failure of the tendon operation, how to prevent to adhesion is the central problem of hand surgery. In clinic, for most cases, wether is tendon of flexor or extensor, after operation there were different degree of adhesion. We have to know the nature and the sources of conglutination, decide wether it fit for relaxation. If yes, in the operation we need to completely relax the tendon, the range must exceed the edge of the adhesion, if not completely relax, it can not get good effects, we must teart it seriously. 4. The blood vessel injuries of the wrist laceration always hanppend on the ulnar and radial arteries. We always adopt end to end anastomisis, after opert
临床资料：急慢诊腕部切割伤患者中有确切病例的283例，深筋膜以浅的47例，单纯肌腱损伤的35例；肌腱合并神经损伤的102例：其中合并正中神经损伤的85例，合并尺神经损伤的16例，合并桡神经浅支损伤的1例，正中神经与尺神经合并损伤的有9例，肌腱合并尺动脉损伤27例，合并桡动脉损伤62例，尺、桡动脉同时损伤12例。
治疗方法：腕部肌腱损伤均争取一期缝合，在局麻下采用Bunnell缝合法，Kessler缝合法，津下缝合法端-端缝合肌腱，在合并神经损伤时对正中神经采用外膜缝合法，对尺神经常常用束束缝合方法，腕部切割伤的血管损伤常见的为尺、桡动脉,离断。术后肌腱损伤需固定3周，3周后功能锻炼，防止肌腱粘连。神经损伤需营养神经，感觉恢复训练，血管损伤需抗凝对症治疗。
治疗结果：腕背部指伸肌腱损伤者，本组8例均为一期缝合肌腱、闭合创面。术后3周开始功能锻炼，效果较好。仅有1例
术后3个月因粘连再次松解。腕掌侧屈肌腱损伤者，本组218例，除2例合并尺神经，正中神经损伤恢复效果不满意，其余功能恢复均达良好，对单纯肌腱治疗满意率100%，单纯合并正中神经损伤满意率100%，单纯合并尺神经损伤96%，合并正中神经，尺神经同时损伤满意率87.5%。
讨论：1、腕前区切割伤的治疗：腕掌侧屈肌腱切割伤时，此处的屈肌腱位于腕管内，其损伤采用Bunnell缝合法、Kessler缝合法端端肌腱。在术中部分指伸肌腱的切开，有组于手术操作，亦能避免缝合的肌腱被伸肌支持带卡压。术后石膏固定3周，3周后功能锻炼。2、神经损伤的修复：对急诊损伤常采用神经外膜缝合法、神经束组膜缝合法，尤其尺神经损伤，要做到束束吻合，争取达到最佳的恢复效果。术后系统的神经康复治疗。正中神经较粗应避免错接或者漏接。3、肌腱粘连的防止与松解：肌腱粘连是导致肌腱修复疗效欠佳的主要原因，防止粘连时手部肌腱外科的一个中心问题，在临床中，无论是屈肌腱还是伸肌腱，修复后多数病例会有不同程度的粘连。要认清粘连的性质及来源，判断是否适应于粘连松解，在术中需完全松解粘连肌腱，松解的范围必须超过粘连的边缘，松解不彻底则术后恢复效果达不到预想的效果，必须认真对待。4、腕部切割伤的血管损伤常见的为尺、桡动脉,离断。采用端端吻合术修复尺、桡动脉，术后抗凝对症治疗。总之，腕部切割伤组织损伤类型复杂，需合理的有效的选择不同的治疗方法使患肢达到最大程度的外形、功能上的恢复。
Wrist laceration play an important role in modern hand surgery, which include tendon, blood vessel, nerve compound injuries, if not properly diagnosed and handled, it can cause losing the function of the hands, even disabled. It’s very important to prevent and correctly treat patients on time, then it can decrease the rate of hand disable, improve the relationship between doctors and patients and reduce the disputation. In this study, we reviewed the clinic experiences of the treatment of wrist laceration and the latest progress, besides, we analyzed 283 patients with wrist laceration in the fist hospital of Jilin university, to discuss some thoughts in the treatment.
Clinical data: The total injuries 283 cases, among which 47 cases not hurt deep fascia, the pure tendon injuries 35 cases; the tendon merges nerve injuries 102 cases: Among them company with median nerve injuries 85 cases, with ulnar nerve injuries 16 cases, with low branch of radial nerve injuries 1 cases, median nerve and ulnar nerve injuries 9 cases, tendon with unlar artery injuries 27 cases, company with radial artery injuries 62 cases, unlar artery and radial artery injuries at the same time 12 cases.
Methods: For those patients with wrist laceration, we adopt the Bunnell method, the Kessler method, Tsuge method to make end to end anastomisis. If had nerve injuries, we anastomosed epineurium for median nerve injuries, while for unlar nerve injuries, we always adopt bundle to bundle anastomisis. The vesssel injuries of laceration always happened on ulnar and radial arteries. After operation ,tendon injuries
need 3 weeks fixation, after 3 weeks need function exercises, keep tendon from adhesion The nerve injuries need nerve nutrition, feeling get back training, blood vessel injuries need the anticoagulation.
Result: For those with extensor tendon injuries of the back of wrist, all 8 cases all make the first period anastomisis of tendon. 3 weeks after operation begin to function exercises, and the effects were satisfied, only 1 cases because adhesion need second operation. For those with tendon of flexor injuries of the wrist, 218 cases in this group：except 2 cases which company with ulnar nerve, median nerve injuries, all got good effects. For pure tendon treatment, the satisfied rate is 100%, simply company with median nerve injuries, the satisfied rate 100%, simply with ulnar injuries 96%, both median and ulnar nerve injuries, the rate is 87.5%.
Discussion: 1. The treatment of laceration of wrist: when the tendon of flexor of the wrist got injuries, because the tendon of flexor lies in the carpal canal, we use Bunnell method, Kessler method to make end to end anastomisis. In the operation, incise part of tendon of flexor digitorum, it can benifit the operation, it can also avoid tendon was blocked by the extentor retinaculum. Fix up 3 weeks by gypsum, after 3 weeks make function exercise. 2. The repairment of nerve injuries: For those with acute injuries, we always directly suture the epineurium or suture the bundle of the nerve, especially to the ulnar nerve injuries, need to bundle to bundle anastomisis for the best effects. After operation need systemic treatment of nerve. The median nerve is thick, take care not to misconnected or fumble. 3. Provention of tendon conglutination and relaxation: The tendon conglutination is
the main cause of the failure of the tendon operation, how to prevent to adhesion is the central problem of hand surgery. In clinic, for most cases, wether is tendon of flexor or extensor, after operation there were different degree of adhesion. We have to know the nature and the sources of conglutination, decide wether it fit for relaxation. If yes, in the operation we need to completely relax the tendon, the range must exceed the edge of the adhesion, if not completely relax, it can not get good effects, we must teart it seriously. 4. The blood vessel injuries of the wrist laceration always hanppend on the ulnar and radial arteries. We always adopt end to end anastomisis, after opert
引文
王根本, 刘里侯, 主编. 医用局部解剖学1996年 (M), p:80. 人民卫生出版社.
Gelberman RH, Rydevik BL, Pess GM, Szabo RM, Lundborg G. Carpal tunnel syndrome. Orthop Clin North Am, 1988; 19: 115-124. 3. Rempel D, Evanoff B, Amadio PC, et al. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Am J Public Health, 1998; 88: 1447-1451.
顾玉东, 王澍寰, 主编. 手部解剖结构的形态与功能手外科学p23-27, 上海科学技术出版社.
刘建平. 腕部切割伤的处理. 广东医学, 2003, 6(24):654.
Kleinert HE, Verdan C. Report of the Committee on tendon injuries. J Hand Surg, 1983, 8(5):794.
汤锦波, 石井清一, 侍德. 不同伤情的屈肌腱愈合. 手外科杂志, 1992, 8(1):31.
韦正超, 蔡道章, 金文涛, 等. 四肢血管损伤的显微外科治疗. 中华显微外科杂志, 2001, 24:215-216.
史少敏, 陆裕朴, 胡蕴玉. 神经束膜缝合与外膜缝合效果比较的实验研究. 中华外科杂志, 1984, 22:40-41.
朱盛修, 主编. 周围神经纤维修复学. 北京科学出版社, 1991, p342.
陈中伟, 主编. 周围神经损伤基础与临床研究. 济南山东科学
技术出版社, 1998 p23.
Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM, 2nd ed. Edinburgh: Churchill.
Uncini A, Di Muzio A, Awad J, Manente G, Tafuro M, Gambi D. Sensitivity of three median-to-ulnar comparative tests in diagnosis of mild carpal tunnel syndrome. Muscle Nerve, 1993; 16: 1366- 1373.
Schmitz N, Kruse J, Tress W. Application of stratum-specific likelihood ratios in mental health screening. Soc Psychiatry Psychiatr Epidemiol, 2000; 35: 375-379.
Fagan TJ. Nomogram for Bayer’s theorem. N Engl J Med 1975; 293: 257.
Katz JN, Stirrat C, Larson MG, Fossel AH, Eaton HM, Liang MH. A self-administered hand symptom diagram in the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol, 1990; 17: 1495-1498.
Stevens JC, Smith BE, Weaver AL, Bosch EP, Deen HG Jr, Wilkens JA. Symptoms of 100 patients with electromy ographically verified carpal tunnel syndrome. Muscle Nerve, 1999; 22: 1448-1456.
Madrazo J, Marin I, Bringas A, Fernandez A. The efficacy of neurophysiological examination in the diagnosis of carpal tunnel
syndrome. Revista de Neurologia, 2000; 30:1005-1008.
刘坚义, 卢德文. 显微外科技术在周围神经损伤修复中的应用. 中华显微外科杂志, 1998, 21:100-101.
潘丞中, 汤锦波, 谢仁国, 等. 五种肌腱缝合方法的生物力学研究. 中华骨科杂志, 1999, 19(6):367.
Kwai Ben I, Elliot D. “Venting”or partal lateral release of the A2 and A4 pulleys after repair of zone 2 flexor tendon injuries. J Hand Surg (Br), 1998, 23(5):649.
汤锦波, 侍德, 顾永强, 等. 肌腱修复时机及腱鞘处理的实验研究. 中华手外科杂志, 1995, 33:532.
朱家恺. 周围神经缺损的显微外科治疗. 中华显微外科杂志, 1999, 22:5-8.
Stetson DS, Albers JW, Silverstein BA, Wolfe RA. Effects of age, sex and anthropometric factors on nerve conduction measures. Muscle Nerve, 1992; 15: 1095-1104.
黄德征, 唐传其, 陈梅, 等. 显微外科手术修复周围神经损伤65例. 中华显微外科杂志, 1995, 18:187-189.
Gelberman RH, Rydevik BL, Pess GM, Szabo RM, Lundborg G. Carpal tunnel syndrome. Orthop Clin North Am, 1988; 19: 115-124. 3. Rempel D, Evanoff B, Amadio PC, et al. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Am J Public Health, 1998; 88: 1447-1451.
顾玉东, 王澍寰, 主编. 手部解剖结构的形态与功能手外科学p23-27, 上海科学技术出版社.
刘建平. 腕部切割伤的处理. 广东医学, 2003, 6(24):654.
Kleinert HE, Verdan C. Report of the Committee on tendon injuries. J Hand Surg, 1983, 8(5):794.
汤锦波, 石井清一, 侍德. 不同伤情的屈肌腱愈合. 手外科杂志, 1992, 8(1):31.
韦正超, 蔡道章, 金文涛, 等. 四肢血管损伤的显微外科治疗. 中华显微外科杂志, 2001, 24:215-216.
史少敏, 陆裕朴, 胡蕴玉. 神经束膜缝合与外膜缝合效果比较的实验研究. 中华外科杂志, 1984, 22:40-41.
朱盛修, 主编. 周围神经纤维修复学. 北京科学出版社, 1991, p342.
陈中伟, 主编. 周围神经损伤基础与临床研究. 济南山东科学
技术出版社, 1998 p23.
Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM, 2nd ed. Edinburgh: Churchill.
Uncini A, Di Muzio A, Awad J, Manente G, Tafuro M, Gambi D. Sensitivity of three median-to-ulnar comparative tests in diagnosis of mild carpal tunnel syndrome. Muscle Nerve, 1993; 16: 1366- 1373.
Schmitz N, Kruse J, Tress W. Application of stratum-specific likelihood ratios in mental health screening. Soc Psychiatry Psychiatr Epidemiol, 2000; 35: 375-379.
Fagan TJ. Nomogram for Bayer’s theorem. N Engl J Med 1975; 293: 257.
Katz JN, Stirrat C, Larson MG, Fossel AH, Eaton HM, Liang MH. A self-administered hand symptom diagram in the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol, 1990; 17: 1495-1498.
Stevens JC, Smith BE, Weaver AL, Bosch EP, Deen HG Jr, Wilkens JA. Symptoms of 100 patients with electromy ographically verified carpal tunnel syndrome. Muscle Nerve, 1999; 22: 1448-1456.
Madrazo J, Marin I, Bringas A, Fernandez A. The efficacy of neurophysiological examination in the diagnosis of carpal tunnel
syndrome. Revista de Neurologia, 2000; 30:1005-1008.
刘坚义, 卢德文. 显微外科技术在周围神经损伤修复中的应用. 中华显微外科杂志, 1998, 21:100-101.
潘丞中, 汤锦波, 谢仁国, 等. 五种肌腱缝合方法的生物力学研究. 中华骨科杂志, 1999, 19(6):367.
Kwai Ben I, Elliot D. “Venting”or partal lateral release of the A2 and A4 pulleys after repair of zone 2 flexor tendon injuries. J Hand Surg (Br), 1998, 23(5):649.
汤锦波, 侍德, 顾永强, 等. 肌腱修复时机及腱鞘处理的实验研究. 中华手外科杂志, 1995, 33:532.
朱家恺. 周围神经缺损的显微外科治疗. 中华显微外科杂志, 1999, 22:5-8.
Stetson DS, Albers JW, Silverstein BA, Wolfe RA. Effects of age, sex and anthropometric factors on nerve conduction measures. Muscle Nerve, 1992; 15: 1095-1104.
黄德征, 唐传其, 陈梅, 等. 显微外科手术修复周围神经损伤65例. 中华显微外科杂志, 1995, 18:187-189.