侧胸和背部组织在上肢毁损性损伤功能挽救中的应用

Restorating function of severely impaired upper extremity using the side chest and back tissue

目的探讨侧胸和背部组织在上肢毁损性损伤功能挽救中的应用。方法2000年7月至2003年9月,采用一期保肢或寄养再植治疗6例机器致上肢碾挫损伤患者,缺损面积为8cm×8cm～19cm×17cm,均伴有上肢多发骨折。一期保肢病例固定骨折,修复血管、神经后,侧胸浅筋膜层包埋上臂创面,4周后行上臂取出、腋窝成形、背阔肌皮瓣转位修复创面并屈肘功能重建术;寄养再植病例二期取出上臂、再植,并行背阔肌皮瓣转位屈肘功能重建术。将背阔肌卷起缝合成长管状,重建起止点。在肘关节屈曲90°～100°位,重建屈肘功能并覆盖皮肤。术后肩关节外展90°、肘关节屈曲100°位石膏或支具固定,4周后去除固定行功能锻炼。结果6例再植肢体均顺利成活。随访6个月～2年,平均8.6个月。术后肩关节外展50°～90°、内收20°～40°、前屈50°～70°、后伸20°～30°。肘关节屈曲100°～140°、伸直-20°～0°。重建术后3个月,屈肘肌肌力达4～5级。结论充分利用侧胸和背部组织特点进行分期、分层手术,解决创面覆盖和功能重建互相干扰的矛盾,是挽救严重毁损性损伤上肢,最大程度地恢复其外形和功能的有效方法。

Objective To study the results of restorating function of severely impaired upper extremity using the side chest and back tissue. Methods Six cases from July 2000 to September 2003 with severely impaired upper extremity were treated by the immediate or fosterage replantation, the defected area of skin in 8 cm×8 cm-19 cm×17 cm and the muhifracture of the upper extremity. With the immediate replantation, the raw surface of the upper arms were embedded with superfacial fascia from side chest for four weeks following fracture fixation, blood vessel and nervus plerosis, then, upper arms was taken out to reform armpit and the latissimus dorsi flap was used to repair the wound and reconstruct flexion function at the same time. With the fosterage replantation, the upper arm was taken out to replant and the latissimus dorsi flap was used to repair the wound and reconstruct flexion function. The latissimus dorsi was sutured into the long tubiform in operation, the elbow joint was flexed at 90°-100°. After the operation, shoulder joint was abduced by 90° and elbow joint was flexed by 100% In postoperative 4 weeks, the fixation was removed and the functional training was performed. Results All the 6 replanted limbs successfully survived for 6 months to 2 years follow-up and the range of motion of shoulder joints was 50°-90° of abduction, 20°-40° of adduction, 50°-70° of anteflexion and 20°-30° of posterior extension. The range of motion of elbow joint was 100° -140° of flexion and -20° -0° extension. Conclusion Using side chest and back tissue to repair severely impaired upper extremity by stages and layers was an ideal method to resolve the contradiction between wound cover-up and function reconstruction to restore the function and appearance.