Skip to main content
NCBI home page
Chinese Journal of Reparative and Reconstructive Surgery logoLink to Chinese Journal of Reparative and Reconstructive Surgery
. 2017 Jun;31(7):841–844. [Article in Chinese] doi: 10.7507/1002-1892.201703053

改良拇指桡侧筋膜蒂皮瓣修复拇指软组织缺损

Repair of thumb defects with modified radial dorsal fasciocutaneous flap of thumb

Hongjiu QIN 1, Jiang XIA 1,*, Bin HU 1, Haisheng WANG 1, Lei XU 1, Yinze WANG 1
PMCID: PMC8498155  PMID: 29798530

Abstract

Objective

To investigate the operative method of repairing soft tissue defect of the thumb with modified radial dorsal fasciocutaneous flap and its effectiveness.

Methods

Between June 2015 and December 2016, 15 patients with volar or dorsal defects of the thumb were treated with modified radial dorsal fasciocutaneous flaps which distal pedicles were cut off. Of 15 cases, 11 were male and 4 were female, aged 35-70 years (mean, 46 years). The causes of injury included crush injury in 12 cases and avulsion injury in 3 cases. Because all patients had volar or dorsal defects of the thumb which were accompanied by tendon or bone exposure, they had no condition or desire to replant. There were 12 cases of volar defect of thumb and 3 cases of dorsal defect. The area of defects ranged from 2.0 cm×1.2 cm to 3.0 cm×2.5 cm. The time between injury and operation was 16 hours to 2 days (mean, 30.4 hours). The radial dorsal fascio-cutaneous flaps of 2.3 cm×1.5 cm to 3.3 cm×2.8 cm in size were adopted to repair defects. The donor sites were directly sutured.

Results

All flaps survived, and no severe swelling or tension blister occurred. The donor sites and wounds healed by first intention. All patients were followed up 3-12 months (mean, 6 months). The color and texture of the grafted flaps were similar to those of normal skin, with no bloated appearance. According to total active motion standard at last follow-up, the finger function was excellent in 8 cases and good in 7 cases.

Conclusion

Modified radial dorsal fasciocutaneous flap of the thumb is a reliable flap with easy dissection and less trauma in repair of soft tissue defects of the thumbs, and satisfactory clinical outcome can be obtained.

Keywords: Thumb, fasciocutaneous flap, tissue defect, repair

拇指软组织缺损是十分常见的手外伤，临床上常用转移皮瓣、岛状皮瓣、推进皮瓣、穿支皮瓣及游离皮瓣等方法修复[1]，但均存在各自的优缺点。拇指桡侧筋膜蒂皮瓣修复创面具有创伤小、手术操作简便的优点[2]，但存在皮瓣自身静脉回流障碍问题[3-4]。2015 年 6 月—2016 年 12 月，我们采用筋膜蒂远端切断的改良拇指桡侧筋膜蒂皮瓣修复 15 例拇指掌背侧软组织缺损患者，术后皮瓣成活且无静脉回流障碍，获得满意疗效。报告如下。

1. 临床资料

1.1. 一般资料

本组男 11 例，女 4 例；年龄 35～70 岁，平均 46 岁。左侧 10 例，右侧 5 例。致伤原因：挤压伤 12 例，撕脱伤 3 例。均为拇指掌背侧软组织缺损伴肌腱或骨组织外露，其中 3 例伴远节指骨骨折，2 例伴近节指骨骨折，无再植条件或再植欲望。拇指掌侧缺损 12 例，背侧缺损 3 例；创面缺损范围为 2.0 cm×1.2 cm～3.0 cm×2.5 cm。拇指第 1 掌骨背桡侧软组织及掌指关节处无明显外伤。受伤至手术时间为 16 h～2 d，平均 30.4 h。

1.2. 手术方法

1.2.1 皮瓣设计　取拇指大鱼际桡背侧作为皮瓣设计区，以第 1 掌骨头的桡侧缘与拇指甲根桡侧缘的连线为轴心线，术中根据拇指桡神经浅支走行适当调整。皮瓣形状应根据创面的部位、大小及形状进行设计，皮瓣旋转点不超过拇指近节指骨的近 1/3。皮瓣长度较皮肤缺损区长 0.5～1.0 cm，将皮瓣远端设计为泪滴形状。其中 10 例修复区需跨越拇指指间关节，为了减少缝合张力，蒂部可带 0.6～0.8 cm 皮条以减轻蒂部受压，保证皮瓣血供。筋膜蒂所需长度较皮瓣旋转点与受区近端的距离长 0.6～0.8 cm，以减轻蒂部的旋转张力，蒂宽 0.8～1.0 cm。

1.2.2 皮瓣切取及修复　手术均采用臂丛神经阻滞麻醉，创面彻底清创，对合并的远、近节指骨骨折行克氏针固定。测量创面大小，并根据创面缺损形状于皮瓣轴线两侧切取皮瓣。首先切开皮瓣近端，保留桡神经浅支的桡背侧支于皮瓣，神经近端以利多卡因封闭。切开皮瓣两侧，于鱼际肌膜及拇短伸肌腱表面向远端分离。锯齿状切开皮肤层次行明道转移，蒂部切取时应尽量靠近拇指桡背侧动脉处血管链，以掌指关节关节囊表面为层次切取，同时于指间关节平面作倒 L 形切口，切断浅、深筋膜组织，仅保留掌侧软组织与蒂部相连（图 1）。将皮瓣旋转 120～170° 后修复远端创面，蒂部应呈弧形。5-0 线缝合固定，皮瓣携带神经与创面神经断端以 7-0 线吻合。3-0 线缝合皮瓣供区皮下组织，5-0 线缝合皮肤。

图 1.

图 1

Open in a new tab

Diagrammatic sketch of the flap harvesting

皮瓣切取示意图

1.3. 术后处理

术后患肢抬高以利消肿；积极全身支持治疗，常规给予低分子右旋糖酐抗凝，并行抗痉挛、预防感染治疗。术后无需行石膏固定，待术后 1 周皮瓣血运稳定后即加强拇指主被动功能锻炼。术后根据骨折愈合情况，6~8 周取出克氏针。

2. 结果

术后皮瓣均成活，无极度肿胀和张力性水疱发生；供区及创面均Ⅰ期愈合。15 例患者均获随访，随访时间 3～12 个月，平均 6 个月。筋膜蒂皮瓣色泽与周围组织相近，无明显臃肿，外观满意。末次随访时按照总主动活动度法[5]评定手功能，获优 8 例，良 7 例。见图 2。

图 2.

A-38-year-old male patient with tissue defect and distal phalanx fracture of the left thumb caused by crush injury

患者，男，38 岁，挤压伤致左拇指背侧软组织缺损伴远节指骨骨折

a. 术前外观；b. 术中皮瓣切取，倒L形筋膜蒂远端切口；c. 术中吻合指背神经；d. 术后即刻外观；e. 术后 2 个月外观

a. Appearance before operation; b. Harvested flap during operation and reverse L shape of disal pedicle; c. Repair of the dorsal nerve during operation; d. Appearance at immediate after operation; e. Appearance at 2 months after operation

图 2

Open in a new tab

3. 讨论

拇指桡侧筋膜蒂皮瓣作为拇指指体软组织缺损的修复方法已应用颇多，其具有手术简便易行、创伤小、修复后外观满意、功能及感觉恢复良好等优点[6-7]。但在临床应用中，拇指筋膜蒂这种远端蒂皮瓣常易出现术后肿胀、静脉回流欠佳，甚至静脉危象后致皮瓣坏死等问题[8-9]。

拇指桡背侧动脉是由桡动脉于鼻烟窝处发出，随后较为恒定地延续至拇指桡侧指间关节，并恒定于近节指骨近 1/3 处与拇指桡掌侧动脉背侧穿支相交通，此穿支的存在构成了拇指桡侧筋膜蒂皮瓣的解剖基础[10-11]。拇指桡背侧动脉在沿途中不断发出分支至周围组织，在第 1 掌背桡侧皮瓣供区处，因与拇指桡掌侧动脉的分支吻合，从而存在着丰富的血管网。更为重要的是，桡神经浅支拇指桡侧支血管网接受桡背侧动脉发出的营养支，从而使血管网有了轴向性[12-13]。因而，此皮瓣利用丰富及具有轴向的血管网形成了可靠的动脉血供。传统拇指桡侧筋膜蒂皮瓣便是利用拇指的近节穿支供血，通过轴向血管链的存在营养皮瓣。从穿支皮瓣的角度考虑，伴行静脉引流的范围通常与其动脉供应范围一致，因而常规的皮瓣切取面积应能够同时保证动脉的供血及静脉的回流[14-15]。拇指桡侧筋膜蒂皮瓣由穿支动脉供血，恒定的穿支伴行静脉应当可以满足皮瓣的引流。但如果皮瓣切取面积过大，跨越了动脉的分水岭区，那么相应的静脉便难以达到有效回流。根据静脉回流“由远至近、由浅入深”的基本规律，常规的拇指桡侧筋膜蒂皮瓣保留了筋膜蒂远端，但由于静脉瓣的存在，静脉逆流受限，这样在原有皮瓣依靠穿支静脉回流的基础上，又额外增加了远端蒂部静脉倒灌的负担[16]。因为皮瓣的血运本质上是由近节指骨穿支动脉供应，筋膜蒂远端非但未增加明显的动脉供血，反而额外增加了静脉的回流负担[17-18]，这便导致了临床上常见的术后静脉回流困扰。

本组应用改良的筋膜蒂远端切断的拇指桡侧筋膜蒂皮瓣修复拇指软组织缺损，取得了较好疗效。与传统筋膜蒂皮瓣切取方法相比，该方法具有以下优点：① 手术操作简便，于近侧指间关节处作倒 L 形切口，切断浅、深筋膜组织，从而彻底阻断筋膜蒂远端的浅、深静脉回流，较以往的蒂部浅静脉结扎更安全可靠，直接有效；② 术后皮瓣静脉回流得到明显改善，从而减少了皮瓣切口放血等有创操作；③ 皮瓣术后愈合加快，可提早指导患者进行功能锻炼。但该术式仍局限于拇指创面面积，若皮瓣过大超出穿支伴行静脉的引流范围，那么回流不足的静脉便会导致皮瓣肿胀、淤血甚至坏死。此时，只有将皮瓣内的静脉与受区近端静脉吻合增加回流，才能改善皮瓣的血运障碍。

手术注意事项：① 皮瓣蒂部宽 0.8～1.0 cm 即可，过宽的蒂部不仅不能增加动脉血供，反而在转移时增加了隧道内的容积引起不必要的卡压，从而引起皮瓣的动静脉危象；② 拇指的指间关节处由于骨性解剖因素的存在，基本无法容纳蒂部，因而跨越指间关节的创面修复可携带蒂部皮条以防止卡压；③ 由于静脉壁薄而缺乏弹性，因而筋膜蒂所需要的长度较皮瓣旋转点与受区近端的距离要稍长，从而减轻旋转张力，防止静脉扭转所致的回流欠佳。

综上述，采用筋膜蒂远端切断的改良桡侧筋膜蒂皮瓣修复拇指软组织缺损具有损伤小、手术操作简便的优点，并可有效减少术后静脉危象的发生，是一种有效治疗方法。

References

  • 1.Lemmon JA, Janis JE, Rohrich RJ Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg. 2008;122(3):105e–117e. doi: 10.1097/PRS.0b013e3181823be0. [DOI] [PubMed] [Google Scholar]
  • 2.Hrabowski M, Kloeters O, Germann G Reverse homodigital dorsoradial flap for thumb soft tissue reconstruction: surgical technique. J Hand Surg (Am) 2010;35(4):659–662. doi: 10.1016/j.jhsa.2010.01.013. [DOI] [PubMed] [Google Scholar]
  • 3.毛莉颖, 黄东, 江奕恒, 等 手部不同远端蒂皮瓣静脉回流障碍的原因分析. 中国临床解剖学杂志. 2013;31(4):484–486. [Google Scholar]
  • 4.张世民, 袁锋, 俞光荣, 等 远端蒂拇指背尺侧皮瓣修复指端缺损及静脉回流. 中国临床解剖学杂志. 2005;23(2):206–208. [Google Scholar]
  • 5.潘达德, 顾玉东, 侍德, 等 中华医学会手外科学会上肢部分功能评定试用标准. 中华手外科杂志. 2000;16(3):130–135. [Google Scholar]
  • 6.Bao QY, Xiao CW, Peng F, et al Restoration of thumb sensibility with innervated reverse homodigital dorsoradial flap. J Reconstr Microsurg. 2014;30(1):15–20. doi: 10.1055/s-0033-1345430. [DOI] [PubMed] [Google Scholar]
  • 7.Sun YC, Gong YP, Chen QZ A reverse dorsoradial pedicled flap from the thumb for a soft tissue defect in the finger. J Hand Surg (Eur Vol) 2015;40(9):1000–1001. doi: 10.1177/1753193415595192. [DOI] [PubMed] [Google Scholar]
  • 8.Lazzeri D, Huemer GM, Nicoli F, et al Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: asystematic review. Arch Plast Surg. 2013;40(1):44–50. doi: 10.5999/aps.2013.40.1.44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.代杰志, 柴益民 远端蒂隐神经营养血管皮瓣研究进展. 国际骨科学杂志. 2013;34(1):53–54. [Google Scholar]
  • 10.Checcucci G, Galeano M, Zucchini M, et al Reverse flow first dorsal metacarpal artery flap for covering the defect of distal thumb. Microsurgery. 2014;34(4):283–286. doi: 10.1002/micr.22198. [DOI] [PubMed] [Google Scholar]
  • 11.Ramírez AR, Gonzalez SM Arteries of the thumb:, description of anatomical variations and review of the literature. Plast Reconstr Surg. 2012;129(3):468e–476e. doi: 10.1097/PRS.0b013e3182402d43. [DOI] [PubMed] [Google Scholar]
  • 12.Moschella F, Cordova A Reverse homodigital dorsal radial flap of the thumb. Plast Reconstr Surg. 2006;117(3):920–926. doi: 10.1097/01.prs.0000200665.73624.6d. [DOI] [PubMed] [Google Scholar]
  • 13.Sun YC, Chen QZ, Chen J, et al Reverse Dorsoradial Flaps for Thumb Coverage Show Increased Sensory Recovery with Smaller Flap Sizes. J Reconstr Microsurg. 2015;31(6):426–433. doi: 10.1055/s-0035-1548743. [DOI] [PubMed] [Google Scholar]
  • 14.梁成, 谢昀, 郑和平, 等 穿支蒂足背外侧皮神经浅静脉营养血管皮瓣的解剖基础. 中国临床解剖学杂志. 2014;32(4):377–380. [Google Scholar]
  • 15.张发惠, 谢其扬, 郑和平, 等 腓肠神经-小隐静脉营养血管远端蒂皮瓣动脉穿支的应用解剖. 中国修复重建外科杂志. 2005;19(7):501–504. [Google Scholar]
  • 16.张世民, 刘大雄, 张连生, 等 远端蒂皮瓣的血液循环特征及临床意义. 中国临床解剖学杂志. 1998;16(2):103–106. [Google Scholar]
  • 17.Akita S, Mitsukawa N, Rikihisa N, et al Reconstruction of the great toe using a pedicled medial plantar flap with anterograde venous drainage. Microsurgery. 2014;34(5):398–403. doi: 10.1002/micr.22234. [DOI] [PubMed] [Google Scholar]
  • 18.查选平, 周赤龙, 金钟鸣, 等 经皮缝扎阻断小隐静脉回流降低远端蒂腓肠神经营养血管皮瓣静脉瘀血的临床研究. 中华损伤与修复杂志(电子版) 2009;4(3):16–19. [Google Scholar]

Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

RESOURCES