晚期桡神经损伤的伸腕伸指功能重建

晚期桡神经损伤的伸腕伸指功能重建陈德松，崔大勇，顾玉东桡神经损伤．导致伸腕伸指功能障碍，早期经过神经修复术，包括神经松解、缝接、移植等手术，大多可取得满意的效果。晚期神经损伤．或手术后无效者，Ｓｔａｒｓ（１９２２年）采用屈肌腱转移来重建伸腕伸指功能，...     

伸腕、伸指和伸拇功能重建的手术图解

因桡神经不可逆损伤,造成伸腕、伸指、伸拇和拇指桡侧外展功能丧失,可用正中神经和尺神经支配的前臂屈肌移位重建其功能。修复的方式较多,至今在临床上被公认为是标准的、疗效最好的肌腱移位术,是1960年Boyes提出的肌腱移位组合方式:即用旋前圆肌移位修复桡侧腕长短伸肌,尺侧腕屈肌移位修复指总伸肌,掌长肌移位修复拇长伸肌的方式。1 适应证用正中神经、尺神经支配的前臂屈肌移位,修复伸腕、伸指和伸拇功能,主要用于桡神经不可逆     

劈开桡侧腕屈肌重建伸拇、伸指功能的初步探讨

目的 探讨将前臂桡侧腕屈肌劈开转位重建伸拇、伸指功能的可行性及临床效果.方法 沿桡侧腕屈肌中央肌腱向近心端纵行剖开,形成尺侧部分和肱侧部分同时重建伸拇、伸指功能.术后按照桡神经损伤肌腱移位术的疗效评定标准进行功能评定.结果 本组共3例患者,术后切口均Ⅰ期愈合,获随访12～36个月,疗效优者1例,良者2例,术后患者均未行肌腱松解,伸拇、伸指功能恢复良好.结论 按照骨骼肌"亚部化"的原则,将桡侧腕屈肌劈开后转位,并同时重建两个功能的缺失,与传统的复杂重建术式相比,这一技术的多能性和简易性具有更大的优势.     

桡神经损伤后伸腕、伸指、伸拇功能重建21例报告

前臂下 1/ 3段骨折中桡神经的损伤十分常见 ,损伤后早期探查桡神经一期可行神经松解术、神经端侧吻合术或神经移植修复术。手术中神经损伤严重 ,或是上述几种方法效果不显著的 ,可二期行肌腱转移伸腕、伸指、伸拇功能重建修复术[1] 。我院 1999年共行桡神经损伤后伸腕、伸指、伸拇功能重建术 2 1例 ,手术后随访 1～ 2年 ,功能恢复好 ,现报道如下。1　资料与方法1 1　一般资料本组 2 1例 ,男 15例 ,女 6例 ,年龄 18～ 6 7岁 ,平均37 8岁。致伤原因 :交通事故伤 10例 ,摔伤 5例 ,暴力打击伤 4例 ,挤压伤 2例。二次手术时间平均距离第一次手术 …     

拇长伸肌腱自发性断裂桡侧腕短伸肌腱替代术的临床应用

目的 探讨腕部拇长伸肌腱自发性断裂,采用桡侧腕短伸肌腱替代术的临床疗效.方法 1996年2月-2005年7月,对12例拇长伸肌腱自发性断裂的患者采用桡侧腕短伸肌腱移位替代术.其中桡骨远端骨折愈合后肌腱断裂6例,类风湿骨关节炎4例,不明原因2例.术后均不用石膏固定,术后2d开始练习伸手、伸腕、伸拇动作,2～3次/d;术后7d停止练习;术后4～5周可缓慢伸手持物.结果 12例术后随访均在1年以上,12个月后平均伸拇肌力已达4～5级,腕背肌腱滑动时无障碍.术后无肌腱再断裂者,伸腕、伸指时拇指末节过伸2°～5°,平均3°,拇对掌、对指功能正常.根据中华医学会手外科学会手部肌腱修复后功能评定标准评价,优良率达100%.全部患者对术后功能满意.结论 拇长伸肌腱自发性断裂,应用桡侧腕短伸肌腱移位替代术,对供区损伤小,操作方便,肌腱缝合牢固,有利早期功能恢复.     

前臂屈肌腱移位重建伸腕、伸指功能

我科自2004年以来,共收治伸腕、伸指和拇指桡侧外展功能丧失患者6例,通过利用前臂屈肌腱移位重建伸腕、伸指功能[1],均取得满意效果。1资料与方法1.1一般资料本组6例,均为男性患者,年龄21～43岁,平均32岁。伤情:桡神经不可逆性损伤5例,前臂背侧绞扎伤术后伤口感     

自发性伸拇长肌腱断裂的临床诊治

目的探讨自发性伸拇长肌腱断裂的病因、病理特点和治疗效果。方法分析16例自发性伸拇长肌腱断裂的发病原因及诱因,16例病发前分别有桡骨远端骨折史,类风湿关节炎史,反复多次行局部封闭治疗病史,并分别采用端端缝合,食指固有伸肌腱转位修复,掌长肌移植,桡侧伸腕长、短肌及伸拇短肌腱转移修复。结果术后随访3～6个月,1例端端直接缝合,术后2周再断裂,改用拇短伸肌腱移位修复,另1例发生肌腱黏连二次手术松解,其余患指功能恢复良好。结论骨折端磨损或炎症侵蚀是伸拇肌腱自发性断裂的病理基础,修复方法有多种选择,拇短伸肌腱转位重建拇长伸肌腱疗效更为确切。     

桡侧腕长伸肌腱重建先天性第一腕掌关节发育不良

目的介绍一种修复ⅢB型拇指发育不良腕掌关节不稳的方法, 采用桡侧腕长伸肌腱的一半重建第一腕掌关节, 评价该手术修复ⅢB型拇指发育不良的疗效。方法对4例患儿的单侧拇指发育不良进行回顾性临床研究。均为ⅢB型拇指发育不良, 且X线片示第一掌骨长度接近正常。手术采用桡侧腕长伸肌腱的一半重建第一腕掌关节韧带。后期行拇对掌和伸拇功能重建。术后通过测量拇指桡侧外展、掌侧外展、伸拇和改良Kapandji量表评估临床疗效。结果术后随访1.5～3.0年, 平均2.1年。术后拇指桡侧外展和掌侧外展的平均角度分别为78°和41°, 患儿拇指主动桡侧外展和掌侧外展功能获得改善。术后平均拇指伸直度为-5°, 接近正常拇指。4例患儿术后的第一腕掌关节均稳定。Kapandji评分显示术后所有儿童的拇对掌功能均有所改善。结论对于第一掌骨长度接近正常的ⅢB型拇指发育不良患儿, 使用桡侧腕长伸肌腱的一半重建第一腕掌关节韧带结合肌腱移位的分期手术可能是一种有效的治疗策略。     

臂丛神经损伤后期伸腕（指）功能重建

目的探讨臂丛神经损伤后期,不同肌腱移位方法重建伸腕（指）功能的疗效。方法采用Riordan肌腱移位、指浅屈肌腱移位、伸肌腱固定等手术重建不可逆臂丛神经损伤伸腕（指）功能24例,其中全臂丛12例、臂丛上中干9例、臂丛后侧束神经损伤3例,功能重建术距神经损伤或修复后时间为2～12年。结果术后经3～36个月随访,参照肌腱移位术疗效评定标准,优4例,良11例,可5例,差4例,优良率62．5％。结论臂丛神经损伤后期伸腕（指）功能缺失的重建,需根据患肢条件,采用不同肌腱移位方法。可以获得较满意的基本功能。     

利用尺桡侧腕屈肌移位重建伸指、伸拇功能

目的：分析前臂背侧高位肌肉损伤一期手术修复后伸指、伸拇功能障碍原因,提高对前臂背侧高位肌肉损伤恢复机理的认识,保证手部伸指、伸拇正常功能。方法对2010-2012年收治的50例前臂背侧近端开放性外伤患者（术中探查排除桡神经深支损伤）进行回顾性分析。46例肌肉损伤患者同时出现伸指、伸拇功能障碍,占92%;2例肌肉损伤患者出现伸指功能障碍,占4%;2例肌肉损伤患者出现伸拇功能障碍,占4%。而后均行功能重建恢复伸指、伸拇功能,术后上肢石膏托外固定,术后6周左右行功能锻炼。结果50例患者功能重建伤口均愈合良好,随访各指背伸功能良好,伸屈腕功能无影响或影响不大。结论前臂背侧高位开放性外伤致肌肉损伤,一期术后肌肉伸缩功能障碍导致伸指、伸拇功能障碍,二期采用收缩功能较好的尺侧腕屈肌移位修复2~5指的伸指功能,桡侧腕屈肌移位修复伸拇功能,可收到良好的效果。     

桡神经损伤25例手术效果分析

目的观察桡神经损伤后行神经松解、缝合和移植术的手术效果。方法根据损伤类型，对25例桡神经损伤患者采用神经内外松解术、直接缝合、神经移植术。结果术后随访1～10年，12例桡神经松解术，11例伸腕、伸拇、伸指肌力M3～M4，虎口区刺痛觉S3～S4；10例神经直接缝合者，8例伸腕、伸拇、伸指肌力为M3～M4，虎口区刺痛觉S3～S4；3例神经移植术中，2例伸腕、伸拇、伸指肌力为M3～M4，虎口区刺痛觉S3～S4。结论桡神经损伤早期，根据损伤类型进行合适的手术，均能取得满意疗效。     

桡神经损伤的治疗效果

目的 观察桡神经损伤后行神经松解，缝合和移植术的疗效。方法 46例桡神经损伤根据损伤类型。采用神经内，外松解术，直接缝合，神经移植治疗。结果 术后随访1年至10年，21例桡神经松解术中，17例的伸腕，伸拇，伸指肌力为M3-M5，虎口区感觉为S4。19例神经直接缝合者14例。伸腕、伸拇，伸指肌力为M3-M5；16例虎口区感觉为S4。6例神经移植者5例伸腕、伸拇，伸指肌力为M3-M5。虎口区感觉达S4。结论 桡神经损伤早期根据其损伤类型进行合适的手术方法均能取得满意的疗效。     

Radial nerve excursion and strain at the elbow and wrist associated with upper-extremity motion

PURPOSE: This study evaluated the excursion necessary to accommodate common motions of daily living and associated strain on the radial nerve. The radial nerve was evaluated at the wrist and proximal to the elbow before it bifurcated. METHODS: Five fresh-frozen transthoracic cadaver specimens (10 arms) were dissected; the radial nerve was exposed at the elbow and wrist only enough to be marked with a microsuture. Excursion was measured using a laser mounted on a caliper fixed to the bone and aligned in the direction of nerve motion. Strain was measured with a device applied to the nerve at the elbow. Nerve excursion associated with motion of the shoulder, elbow, wrist, and fingers (measured by a goniometer) was assessed at the wrist and elbow. RESULTS: An average of 4.3 mm of radial nerve excursion was required at the wrist to accommodate wrist motion from 15 degrees of radial deviation to 30 degrees of ulnar deviation and 8.8 mm was needed for elbow motion from 10 degrees to 90 degrees . The radial nerve at the elbow experienced a 28% strain associated with the same motion of flexion and extension at the elbow. When all the motions of the wrist, fingers, elbow, and shoulder were combined 9.4 mm of radial nerve excursion was required at the wrist and 14.2 mm at the elbow. CONCLUSIONS: Any factor that limits excursion at these sites could result in repetitive traction of the nerve and possibly could play a role in the pathophysiology of a mechanical neuropathy, which in the case of the radial nerve most often manifests as pain.     

Precision grip with congenital hypoplasty or hypofunction of the thumb

We tested the grip in four patients with congenital defects of the hand and either a hypoplastic thumb or a thumb with impaired inervation. Small objects were taken by a scissors grip between the fingers. In a hand with radial duction in the manus vara congenita, during strengthening of the wrist, the grip from the ulnar side between the fourth and fifth fingers was changed to the radial side between the second and third fingers. Large objects were gripped by all the three-phalanx fingers into the palm in a horizontal position. In case 4 with hypoplasia of the thumb grade IIIC by the classification of Blauth and Buck-Gramcko, we describe a transposition of the index finger to the site of the thumb and the hypoplastic thumb to the site of the index finger. It is obvious that the precision grip is affected by the thumb length and strengthening of the ulnar side of the wrist. We assume that the scissors grip is the earliest precision grip in the evolution of the primate hand.     

Verzögerte Radialisparese nach Monteggia-Fraktur – Ein Fallbericht

Concomittant lesions of neural structures represent a rare type of complications in Monteggia's fractures. In acute fractures spontaneous neurological remission usually occurs after reduction of the dislocated radial head. In the presented case a 33-year old man experienced a trady palsy of the posterior interosseus nerve 27 years after a Monteggia's fracture with the radial head left dislocated. Following a minimal trauma in badminton a neurological deficiency probably caused by distraction occurred and resulted in impairment of wrist extension and extension of the fingers. Initiated conservative treatment including intensive physiotherapy and electrotherapy for 4 months was unsuccessful. Consecutively the radial nerve was surgically exposed and released from an entrapping and thickened arcade of Frohse. The radial head was left dislocated. Full neurological recovery was obtained 9 months after surgery.     

全长膈神经移位恢复伸腕指功能的实验研究

目的比较全长膈神经移位至上臂段桡神经前臂支不同部分恢复伸腕、指功能的效果。方法取SD大鼠30只,随机分为3组,每组10只。内侧组:开胸切取全长膈神经移位至背阔肌止点下缘处桡神经前臂支内侧部分。外侧组:开胸切取全长膈神经移位至背阔肌止点下缘处桡神经前臂支外侧部分。直接组:将桡神经前臂支于背阔肌止点下缘处切断再原位缝合,此组作为对照组。于术后4个月行大体观察、电生理和肌湿重检测。结果内侧组和外侧组大鼠均于术后19至23 d出现与呼吸同步的伸腕、指动作。电生理和肌湿重检测显示,内侧组腕伸肌(尺侧腕伸肌)恢复优于外侧组,差异有统计学意义(P<0.05),伸指肌恢复两组相似,差异无统计学意义(P>0.05)。结论经胸切取全长膈神经移位至上臂段桡神经内侧部分能更全面的恢复伸腕、指功能。     

Tenodesis extension splinting for radial nerve palsy

Injuries to the radial nerve or posterior interosseous nerve can lead to significant functional limitation. Inability to extend the wrist and/or digits prevents the hand from being positioned properly for functional tasks. Therapy after radial nerve injury is geared toward maintaining passive extension of the wrist and digits. Sensory reeducation can also be performed but often not necessary since the distribution of the nerve distally is on the dorsoradial surface of the hand. Since nerve regeneration is often a lengthy process and the extent of recovery is variable, splinting the involved extremity is used to prevent contractures and maximize function. This article introduces a new splint that allows patients to extend the fingers and thumb via a tenodesis effect at the wrist. In early trials, it has produced excellent results for enhancing functional use of the injured extremity while nerve regeneration occurs or until tendon transfers have been performed.     

桡动脉掌浅支腕横纹皮瓣在手指创面修复中的应用

目的:总结桡动脉掌浅支腕横纹皮瓣在手指创面修复中的应用方法及疗效。方法:2012年11月~2013年5月,收治9例手指创面患者,其中男5例,女4例;年龄13~68岁,平均42.5岁。致伤原因:机器挤压伤4例,压砸伤4例,热压伤1例。致伤部位:均为手指,其中拇指1例,示指4例,中指3例,环指1例,小指2例,指掌侧创面5例,指背侧创面4例,创面范围1.5cm×3cm~3.0cm×7cm,单纯皮肤软组织缺损1例,其余均伴指骨骨折、肌腱损伤、血管神经等损伤,急诊一期手术5例,延迟手术4例;然后采用大小为2.0cm×3.5cm~3.5cm×7.5cm的桡动脉掌浅支腕横纹皮瓣游离移植修复缺损;供区直接缝合。结果:术后皮瓣完全成活,创面Ⅰ期愈合;供区切口Ⅰ期愈合。术后患者均获随访,随访时间6~12个月,平均8.5月。皮瓣不臃肿,颜色及质地与周围正常皮肤相似,手指外形满意。手指恢复部分浅感觉,术后6月,按中华医学会手外科学会上肢部分功能评定试用标准中拇、手指再造功能评定试用标准评定,获优7例,良1例,中1例,差0例,优良率88.89%。结论:桡动脉掌浅支腕横纹游离皮瓣具有术后功能、外观良好的优点,是修复手指创面的理想方法之一。     

不可逆桡神经损伤的手功能重建

目的评估不可逆桡神经损伤后肌腱移位重建伸腕、伸拇及伸指功能的效果。方法1987年1月～2005年2月，用Riordan肌腱移位术治疗不可逆桡神经损伤25例。其中桡神经主干损伤19例，桡神经深支损伤6例；均伴伸拇及伸指功能障碍，肌力0～1级，前臂肌萎缩。肌腱移位术距神经损伤或修复时间为4个月～8年。结果术后23例经3～60个月随访，根据陈德松等制定的桡神经损伤后肌腱移位术疗效判定标准，优10例，良9例，手功能恢复基本满意；可2例，差2例，其中1例为移位肌腱张力不足，3例为移位肌腱粘连所致。结论Riordan肌腱移位术可作为不可逆桡神经损伤功能重建的首选方法。     

Palliative tendon transfer for reanimation of the wrist and finger extension lag. Report of 14 transfers for radial nerve palsies and ten transfers for brachial plexus lesions

This retrospective study is based on 23 males and one female, of an average age of 36.2 years that presented to us between 1982 and 2000 with an average follow up of 61 months, with fully established paralysis of wrist and fingers extension. Fourteen patients had isolated radial nerve palsy, while ten patients had brachial plexus lesions. 1) The tendon transfer for radial nerve palsy was: PT to ECRB, FCU to ED + EPL and PL to APL + EPB; 2) for brachial plexus injury, the tendon transfer was: PT (n = 4) or FDS III or IV (n = 5) to ECRB, FCU (n = 8) or FDS IV (n = 1) to ED + EPL, PL to APL + EPB and wrist arthrodesis with transfer of FDS IV to ED + EPL and PL to APL + EPB. The results were evaluated according to the degree of wrist movement, MP extension of long fingers, opening of first commissure, thumb opposition, grip power and the subjective evaluation of results. Concerning the radial nerve palsy: results are excellent in nine cases and good in one case. An active extension of the wrist of 38 degrees was obtained as well as MP extension of 0 degree with the wrist straightened. Thumb oppositioned was conserved (Kapandji = 8.2), opening of the first commissure 40 degrees and grip power was 20 kg. Concerning the brachial plexus lesions: results are excellent in five cases and good in the other five. An active wrist extension of 32 degrees was obtained, as well as MP extension deficit of 16 degrees with wrist straightened. Opposition was concerned (Kapandji = 7.2), opening of first commissure of 38 degrees and grip power of 13 kg. The functional results are satisfactory, but the analytic study shows some effect of tenodesis of MP extension.