HandInjuryDepartmentofOrthopedicSurgeryZhouXiang,M.D.03/04/201410手外傷Learningoutcomes熟悉手外傷的診斷方法、周圍神經(jīng)損傷的病因和診斷。掌握手開放性損傷的治療原則。03/04/201410手外傷Contents一、手外傷

1.創(chuàng)口情況檢查、診斷2.手部開放性損傷、骨折的處理原則3.肌腱與神經(jīng)損傷的診斷與處理原則二、斷肢（指）再植

1．?dāng)嘀ㄖ福┑姆诸惣邦A(yù)后

2．?dāng)嘀ㄖ福┑募本葍?nèi)容及注意事項3．常溫下一般再植時限10手外傷Anatomy10手外傷HandInjuryMostlyopeninjuryMayaffectpersonality03/04/201410手外傷SkinInjury03/04/201410手外傷TendonInjuryFlexortendonExtensortendon03/04/201410手外傷03/04/201410手外傷VesselInjuryNeurovascularbundlesContaindigitalartery,vein,andnerveTwobundles:oneradialandtheotherulnarRadialandUlnararteriesjoinin2archesSuperficialPalmarArch:superficialtoflexortendonLocatedatbaseoffirstwebspaceDeepPalmarArch(deeptoflexortendons)Proximaltosuperficialarchby1cm03/04/201410手外傷NerveInjuryUlnarNerveMotorAllowsforpowergripInnervatesallhandintrinsicmusclesexcept:DoesnotinnervatetworadiallumbricalsDoesnotinnervatethenarmusclesSensationUlnar1.5fingers(palmar)CoursePasseswithulnararteryviaGuyon'sCanalinwristTestfunctionFingerabductionagainstresistancePalpatebellyoffirstdorsalinterosseusmuscle03/04/201410手外傷NerveInjuryMedianNerveMotorAllowsforfinecontrolofpincergraspInnervatesthenarmusclesandtworadiallumbricalsSensationRadial3.5fingers,andtheirdorsaltipsCutaneousinnervationImageCoursePassesviacarpaltunnelthroughvolarwristTestfunctionOppositionofthumbtoeachfingerObservethenarmusclesforcontractions03/04/201410手外傷03/04/201410手外傷NerveInjuryRadialNerveMotorInnervatesextrinsicwristandfingerextensorsDoesnotinnervateanyintrinsicmusclesSensationDorsallyfor3.5fingersCutaneousinnervationimageTestfunctionWristandhandextensionagainstresistance03/04/201410手外傷03/04/201410手外傷ExaminationanddiagnosisExaminationofthewoundSizeandlocationDepthofthewoundBloodcirculationBloodvesselinjuryNerveinjuryTendoninjuryBoneandjointinjuryX-ray03/04/201410手外傷FirstaidStopbleedingReducecontaminationTemporaryfixationTransportationtoahospital03/04/201410手外傷DebridementIn6-8hoursWashingRemovalofdeadtissue03/04/201410手外傷RepairBoneandjointVesselTendonandligamentNerveSkin03/04/201410手外傷手部骨與關(guān)節(jié)損傷處理GeneralPrinciplesofHandFractureManagement

Avoidover-immobilizationCorrectangularmalalignmentandrotationSplintinpositionofmoderateflexionAvoidsplintingfingersinextension(espMCP)AxesofallflexedfingersshouldpointatScaphoid

Evaluateperi-articularfracturesforavulsedtendonFragmentsareoftenattachedtoatendonorligament03/04/201410手外傷手部骨與關(guān)節(jié)損傷處理ConsiderOpenReductionandInternalFixation(ORIF)

AdvantagesAvoidexcessivemanipulationAvoidsprolongedsplintingIndicationsUnstabledisplacedintra-articularfracturesif>25-30%ofjointsurfaceinvolved03/04/201410手外傷03/04/201410手外傷Prognosis03/04/201410手外傷Replantation10手外傷Whatisreplantation?

Replantationreferstothesurgicalreattachmentofafinger,hand,orarmthathasbeencompletelycutfromaperson’sbody.10手外傷Thegoalofreplantationsurgerytogivethepatientbackasmuchuseoftheinjuredareaaspossible.Insomecases,replantationisnotpossiblebecausethepartistoodamaged.Ifthelostpartcannotbereattached,apatientmayhavetouseaprosthesis(adevicethatsubstitutesforamissingpartofthebody).Insomecases,aprosthesismaygiveapersonwithouthandsorarmstheabilitytofunction.03/04/201410手外傷FirstAidStopbleedingReducecontaminationProtectLimb/fingerTransportationtoahospital03/04/201410手外傷IndicationsofreplantationReplantationisusuallyrecommendedwhenthereplantedpartwillworkatleastaswellasaprosthesis.Generally,amissinghandwouldnotbereplantedknowingthatitwouldnotwork,bepainful,orgetinthewayofeverydaylife.Beforesurgerythedoctor,ifpossible,willexplaintheprocedureandhowmuchuseislikelytoreturnfollowingreplantation.Thepatientorfamilymembermustdecidewhetherthatamountofusejustifiesthelonganddifficultoperation,timeinthehospital,andmonthsoryearsofrehabilitation.03/04/201410手外傷TreatmentafterreplatationThepatienthasthemostimportantroleintherecoveryprocess.Smokingcausespoorcirculationandmaycauselossofbloodflowtothereplantedpart.Allowingthereplantedparttohangbelowheartlevelmayalsocausepoorcirculation.Youngerpatientshaveabetterchanceoftheirnervesgrowingback,theymayregainmorefeeling,andmayregainmoremovementinthereplantedpart.03/04/201410手外傷PrognosisGenerally,thefurtherdownthearmtheinjuryoccurs,thebetterthereturnofusetothepatient.Patientswhohavenotinjuredthejointwillgetmoremovementbackthanthosewhohave.Acleanlycutpartusuallyworksbetterafterreplantationthanonethathasbeencrushedorpulledoff.Recoveryofusedependsonregrowthoftwotypesofnerves:sensorynervesthatletyoufeel,andmotornervesthattellyourmusclestomove.Nervesgrowaboutaninchpermonth.Thereplantedpartneverregains100%ofitsoriginaluse.Mostdoctorsconsider60%to80%anexcellentresult.Coldweathercanbeuncomfortableandafrequentcomplaintevenforthosewithexcellentrecovery.03/04/201410手外傷RehabilitationCompletehealingoftheinjuryandsurgicalwoundsisonlythebeginningofalongprocessofrehabilitation.Therapyandtemporarybracingareimportanttotherecoveryprocess.Fromthebeginning,bracesareusedtoprotectthenewlyrepairedtendonsandallowthepatienttomovethereplantedpart.Therapywithlimitedmotionhelpskeepjointsfromgettingstiff,musclesmoving,andscartissuetoaminimum.Evenafteryouhaverecoveredfully,youmayfindthatyoucannotdoeverythingyouwishtodo.Tailor-madedevicesmayhelpmanypatientsdospecialactivitiesorhobbies.Manyreplantpatientsareabletoreturntothejobstheyheldbeforetheinjury.Whenthisisnotpossible,patientscanseekassistanceinselectinganewtypeofwork.

03/04/201410手外傷03/04/201410手外傷SecondarysurgerymaybeneededSomeofthemostcommonproceduresare:Tenolysis-freestendonsfromscartissue.Capsulotomy-releasesstiff,lockedjoints.Tendonormuscletransfer-movestendonsormusclestoanotherspotsothattheycanworkinanareathatneedsthetendonormusclemore.Nervegrafting-