“化整为零”理念在拇指两叶皮瓣修复拇指末节脱套伤中的应用

Application of idea of breaking up the whole into parts in repair of degloving injuries on the distal seg- ment of thumb with bilobed skin flap of the same finger

目的探讨“化整为零”理念在拇指两叶皮瓣修复拇指末节脱套伤中的临床应用及疗效。方法自2008年3月至2011年10月，对34例拇指末节脱套伤的患者，应用“化整为零”的理念将末节缺损面分成上、下2个面（20例）及左、右（尺、桡侧）2个面（14例）的小缺损，行拇指动脉近节背支皮瓣修复上面缺损，拇指第一掌背尺侧皮神经营养血管皮瓣或桡侧筋膜皮瓣修复下面缺损，兼顾修复指侧方；行拇指动脉近节背支皮瓣修复左或右面，拇指桡背侧筋膜皮瓣修复右面、尺背侧皮神经营养血管皮瓣修复左面。结果34例双叶皮瓣全部成活，除少部分发生水疱的患者痂下愈合外，余大部分患者的伤口均I期愈合。随访8～20个月（平均12．4个月），皮瓣质地柔软，耐磨，弹性好，外形佳，各关节运动尚可。按TAM系统评价：优29指，良4指，可1指，优良率97．05％。上叶皮瓣恢复保护性感觉，下叶及左右叶皮瓣两点分辨觉为4．5～7．0mm，平均5．5mm，感觉测定按BMRC评级标准为S2＋～S4级，平均S3＋级。结论该方法操作简单，转移灵活，皮瓣组合合理，疗程短，效果满意；一次性修复缺损，可最大限度地降低供区损伤，为修复拇指末节脱套伤提供了全新的修复理念，值得推广应用。

Objective To discuss the clinical application of breaking up the whole into parts in repair of degloving injuries on the distal segment of thumb with bilobed skin flap of the same finger and its results. Methods From March 2008 to October 2011, degloving injuries on the distal segment were divided into upper-lower （20 cases） and right-left defects （14 cases）. The upper and lower defects were repaired by the flap with near dorsal branches of thumb artery and the flap with the first dorsoulnar nerve nutrient vessel of thumb or radialis fascio-cutaneous flap which could also repair the lateral finger defect, respectively; the right or left defects was repaired by the flap with near dorsal branches of thumb artery, the right and left defects was repaired by the radial-dorsal fascio-cutaneous flap of thumb and the dorsoulnar nerve nutrient vessel, respectively. Results Bilobed skin flap on 34 patients survived successfully and all incisions healed primarily except for a few cases with healing under scar because of bubbles, after 8 to 20 months （ mean 12.4 months） following up. All cases were satisfied with the good shape, well contour and acceptable joint movement. According to the total active movement （TAM） evaluation system introduced by the American Society for Surgery of the Hand in 1975, the results of this series were excellent in 29 cases, good in 4 cases and fair in 1 case, the good rate was 97.05%. Conclusion This method is simple with less injury and easy to operate, it is an good method to repair degloving injuries on the distal segment of thumb. Breaking up the whole into parts is new repairing idea, it is worthy of clinical use.