Nghiên cứu đặc điểm tổn thương và đánh giá kết quả điều trị vết thương bàn tay tại bệnh viện xanh pôn

1 T VN Bn tay cha ng nhiu mụ cú cu trỳc tinh vi, phc nh gõn, c, xng, khp, dõy chng, mch mỏu, thn kinh, bao hot dch Cỏc cu trỳc ny c che ph bi da v lp mụ di da mng Bn tay cú chc nng rt quan trng vi hot ng sng ca ngi qua cỏc ng tỏc: gp, dui, sp, nga, i chiu, cm nm, ngoi bn tay cũn cú chc nng s mú, nhn bit Vt thng bn tay l mt tn thng thng gp Nguyờn nhõn bn tay l b phn c s dng nhiu nht mi hot ng lao ng v sinh hot hng ngy Hng nm ti M cú trờn mt triu ca cp cu vờt thng bn tay tai nn lao ng Phỏp cú nm trm nghỡn ca cp cu vt thng bn tay Ti bnh viờn Xanh Pụn, vt thng bn tay chim khong 17 % tng s vt thng cỏc loi [7] Hỡnh thỏi vt thng bn tay rt a dng Nhng vt thng bn tay tai nn sinh hot thng sc gn, n gin d x trớ Ngc li vt thng bn tay tai nn lao ng thng nng n, phc Cú th gp tn thng dp nỏt bn tay, ct mt n nhiu ngún tay, mt ton b da bn tay vv dn n cỏc di chng ht sc nng n v chc nng v thm m Bnh nhõn cú th b gim hay mt kh nng lao ng tr nờn tn ph Vỡ bn tay cú chc nng rt quan trng nh ụng cha ta thng núi giu hai mt khú ụi bn tay m vic iu tr vt thng bn tay rt cn c chỳ ý v quan tõm y V nguyờn tc chung ca vic iu tr vt thng bn tay l gii quyt ba : cha lnh vt thng; phc hi chc nng; phc hi thm m Vic xõy dng h thng cp cu vt thng bn tay hiu qu l rt quan trng nhm kp thi cp cu, iu tr, phc hi chc nng cho ngi bnh H thng cp cu vt thng bn tay ti Bnh vin Xanh Pụn cho n gn õy cha hon thin T nm 2006, Khoa Phu thut to hỡnh Bnh vin Xanh Pụn c giao nhim v x trớ vt thng bn tay Nhm trin khai chng trỡnh xõy dng v hon thin h thng cp cu, x lý iu tr vt thng bn tay ti Bnh vin Xanh Pụn, chỳng tụi iu tra mụ hỡnh bnh lý vt thng bn tay v nhng kt qu iu tr ó t c, to c s d liu cho cỏc k hoch tng lai Vỡ vy, ti : "Nghiờn cu c im tn thng v ỏnh giỏ kt qu iu tr vt thng bn tay ti Bnh vin Xanh Pụn" ó c a vo nghiờn cu vi hai mc tiờu : Nhn xột c im thng tn vt thng bn tay ti Bnh vin Xanh Pụn ỏnh giỏ kt qu iu tr vt thng bn tay qua ú rỳt mt s nhn xột v kin ngh Chng TNG QUAN 1.1 Gii phu ng dng bn tay Bn tay cha ng nhiu mụ cú cu trỳc tinh vi, phc nh gõn, c, xng, khp, dõy chng, mch mỏu, thn kinh, bao hot dch Cỏc mụ quan trng ny ch c che ph bi da v mụ di da mng 1.1.1 Cỏc xng bn tay Vi 27 xng v h thng dõy chng bao khp m bo cho mi hot ng tinh vi phc ca bn tay v c chia thnh nhúm [8,11]: - xng c tay - xng bn tay - 14 xng ngún tay hay t ngún tay Hỡnh1.1 Xng bn tay [12] 1.1.2 Vựng gan bn tay 1.1.2.1 Da t chc di da Da gan tay dy, chc, khụng cú lụng, gn nh dớnh lin vi mc gan tay tr vựng mụ cỏi T chc di da cú lp m m dy hn so vi mt mu chu c lc va chm Da gan tay ớt n hi, bỏm cht vo nhng cu trỳc bờn di quỏ trỡnh cm nm, cỏc ngún tay s khụng b trt hoc di ng quỏ mc T chc di da vựng gan bn tay cha nhiu th th thn kinh nờn vựng gan bn tay nhn c cm giỏc rt tinh t nht l mt gan cỏc bỳp ngún tay [8,11] Trong phu thut che ph tn khuyt phn mm ti vựng ny cn phi chỳ ý n phc hi li chc nng cm giỏc 1.1.2.2 Mc gan tay Mc gan tay liờn tip vi gõn c gan tay di vựng cng tay trc trờn i xung gan tay tn cựng t chc di da ngang mc khp bn ngún, hai bờn to nờn mc ph mụ cỏi ngoi v mc ph mụ ỳt gia mc gan tay dy lờn gi l cõn gan tay cú tỏc dng bo v cỏc thnh phn gõn, mch mỏu, thn kinh bờn di [8] Hỡnh1.2 Phu tớch nụng mt gan tay [12] 1.1.2.3 Gõn, c vựng gan tay Bao gm hai h thng l h thng gõn c di ngoi vựng (t cng tay) v h thng c ngn ni vựng (ti bn tay) bao gm hng chc c khỏc õy l ng lc cho mi hot ng ca bn tay, ngún tay Cỏc gõn gp di cú chc nng gp c tay, bn - ngún tay Cỏc gõn ny cựng i qua ng c tay vi cỏc mch mỏu v thn kinh nờn d b tn thng nhiu gõn phi hp vi thng tn mch mỏu v thn kinh cú vt thng ti vựng c bn tay vựng gan tay, cỏc gõn gp ngún di nm ụ gia, sau lp mch thn kinh (cung ng mch gan tay nụng v cỏc nhỏnh ngún tay ca dõy thn kinh gia v dõy tr) [8] Hỡnh 1.3 Cỏc ụ gan tay [12] 1.1.3 Vựng mu bn tay 1.1.3.1 Da t chc di da Da mt mu bn ngún tay mng, mm, di ng, n hi tt, cú lụng, cu lờn thnh lp d dng Chớnh nh s chun gión tt ca da ó giỳp cỏc khp gp li d dng T chc di da nghốo nn ớt m hn so vi phớa gan bn tay Tớnh cht chun gión ca vựng mu bn tay cho phộp to cỏc vt cú cung che ph tn khuyt mt gan ngún tay Trong t chc di da mu bn tay l h thng tnh mch an xen dy c [11] Di t chc di da l cỏc gõn dui ngún tay vi c im khỏc bit l bao gõn dui rt mng nhng cú nhiu mch mỏu bao quanh, nh ú ta cú th ghộp da trc tip lờn trờn, rt ớt kh nng gõy dớnh gõn [2] Hỡnh 1.4 Phu tớch nụng mt mu tay [12] 1.1.3.2 Gõn dui Gõn dui di mc chia thnh nhúm: + Nhúm ngoi chy vo ngún cỏi + Nhúm chy vo ngún ỳt + Nhúm gia chy vo cỏc ngún khỏc ng dng: rch gia cỏc nhúm gõn vo m bao khp hay ct on xng [8] 1.1.4 Vựng ngún tay 1.1.4.1 Da t chc di da Da mt gan ngún tay dy, t chc m di da c bit u bỳp ngún tay l cỏc cm m chc c phõn lp thnh tng ụ nh cỏc vỏch x si i t lp da ca u bỳp ngún n tn mng xng, ú viờm nhim thng bin chng gõy viờm gõn xng Trong vỏch x cú mng li dy c cỏc mch mỏu v thn kinh giỳp cho bỳp ngún cú kh nng xỳc giỏc t nh [8] Do c im trờn nờn cỏc tn khuyt phn mm ngún tay ũi hi phi c phu thut che ph bng da dy cú lp m m mng nhm phc hi ti a chc nng ca ngún tay [1,2] Mt mu tay cú da mng n hi, lp m di da mng Hỡnh 1.5 Cu trỳc gii phu ca ngún tay [12] 1.1.4.2 Gõn vựng ngún tay Hai gõn gp ngún nụng v sõu nm bao hot dch chui qua ng gõn trt hp to bi cỏc dõy chng to nờn d dớnh gõn sau khõu ni [1,14,15,17] Gõn dui ngún l gõn dt khụng cú bao hot dch [11] Hỡnh 1.6 Gõn gp ngún tay vi dõy chng, bao hot dch vựng ngún tay [12] 1.1.5 Mch mỏu bn tay 1.1.5.1 ng mch Bn tay c cung cp mỏu rt di t ng mch (M) quay v ng mch tr qua hai cung ng mch chớnh l cung ng mch gan tay nụng v cung ng mch gan tay sõu Ngoi vựng mu tay cũn cú cung ng mch mu c tay, tng i mnh hn hai cung mch trờn, cỏc nhỏnh bờn ca ng mch quay v tr to nờn Hai ng mch gan tay nụng v sõu tip ni vi rt cht ch nờn cú tn thng mt cung ng mch thỡ bn tay c cp mỏu [5,8,11] Mi ngún tay c cung cp mỏu chớnh qua M gan ngún tay ni vi bng cỏc vũng ni quanh cỏc khp gian t v khp bn ngún, ú ch cn M hot ng tt l nuụi sng ngún tay [5,8,11] 1.1.5.2 Tnh mch Phn ln cỏc tnh mch (TM) c dn lu theo ng mu tay Tnh mch bn tay c chia thnh nhúm: tnh mch sõu i kốm cung M cựng tờn v tnh mch nụng di da (h thng tnh mch chớnh ca bn tay) TM nụng to nờn mng tnh mch mu tay ri vo TM u phớa ngoi v TM nn phớa [8,11] 1.1.6 Thn kinh bn tay Vn ng v cm giỏc bn ngún tay l ba dõy thn kinh gia, quay, tr chi phi [8,11] 1.1.6.1 Thn kinh quay Nhỏnh nụng TK quay l nhỏnh cm giỏc n thun i t cng tay xung mu bn tay cm giỏc cho na ngoi mu bn tay v mu ba ngún ri na ngoi 1.1.6.2 Thn kinh gia 10 L dõy hn hp ng v cm giỏc - Vn ng cỏc c mụ cỏi tr bú sõu c gp ngn v c khộp ngún cỏi, c giun I v II - Cm giỏc cho hn na gan tay t phớa ngoi (tr phn nh da phớa ngoi dõy quay chi phi), mt gan ngún ri phớa ngoi k t ngún cỏi v c mt mu cỏc t II, III ca cỏc ngún 2,3 1.1.6.3 Thn kinh tr - Vn ng c mụ ỳt, bú sõu c gp ngn ngún cỏi, c ghộp ngún cỏi, c gan tay ngn, cỏc c gian ct, c giun 1,2 - Cm giỏc cho na mt gan v mu tay, mt gan v mu ngún ri phớa k t ngún ỳt Hỡnh 1.7 M v TK bn tay [12] 1.2 Phõn loi vt thng bn tay Lu Danh Huy (2005), "ỏnh giỏ kt qu phu thut thỡ u vt thng gõn gp v 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doigts (rộcentes et anciennes), EMC, Techniques Chirurgicales Orthopedie-Traumatologie, 44-397 63 Le Nen D, Hu W, Guyot X, Lefevre C, Dartoy C, (1999), Plaies de la main, EMC, appareil locomoteur, 14-062-A-10 64 Alain Charles Masquelet, Alain Gilbert, (2003), Atlas de lambeaux de l'appareil locomoteur, Sauramns mộdical, 56-121 65 Merle M, Dautel G, (1997), La main traumatique, Urgent , Mason II, Paris, 67-360 66 P Bellemốre, F Chaise, E Gaisne, T Loubersac, P Poirier, (2003), Fractures des phalanges et des mộtacarpiens, EMC, Techniques Chirurgicales Orthopedie-Traumatologie, 44-368 MC LC T VN .1 TNG QUAN 1.1 Gii phu ng dng bn tay 1.1.1.Cỏc xng bn tay 1.1.2 Vựng gan bn tay 1.1.3 Vựng mu bn tay .6 1.1.4 Vựng ngún tay 1.1.5 Mch mỏu bn tay 1.1.6 Thn kinh bn tay 1.2 Phõn loi vt thng bn tay .10 1.2.1 Phõn loi theo v trớ v mc phc ca thng tn .11 1.2.2 Phõn loi theo yu t t chc ca bn tay b tn thng 15 1.2.3 Mt s hỡnh thỏi thng tn c bit vựng bn tay 19 1.3 X trớ vt thng bn tay 20 1.3.1 Nguyờn tc iu tr vt thng bn tay 20 1.3.2 Ct lc vt thng .20 1.3.3 Kết hợp xơng 22 1.3.4 X trớ vt thng khp .22 1.3.5 Ni gõn 22 1.3.6 X trớ tn thng mch mỏu .23 1.3.7 Tn thng thn kinh 24 1.3.8 Cỏc phng phỏp che ph khuyt da bn tay 25 1.4 Tp luyn phc hi chc nng sau m .33 I TNG V PHNG PHP NGHIấN CU .34 2.1 i tng nghiờn cu 34 2.2 Phng phỏp nghiờn cu .34 2.3 Cỏc tiờu nghiờn cu 35 2.3.1 c im chung ca i tng nghiờn cu 35 2.3.2 Tiờu nghiờn cu vt thng 35 2.3.4 Din bin quỏ trỡnh iu tr .36 2.3.5 Kt qu iu tr 36 2.4 ỏnh giỏ kt qu 36 2.4.1 Lin vt thng 36 2.4.2 Thm m .37 2.4.3 Kt qu iu tr tng hp 38 2.5 Phng phỏp x lý s liu 38 KT QU NGHIấN CU .40 3.1 c im chung ca i tng nghiờn cu .40 3.1.1 Phõn b theo gii tớnh 40 3.1.2 Phõn b theo nhúm tui 40 3.1.3 Phõn b theo ngh nghip 41 3.1.4 Phõn b theo nguyờn nhõn gõy vt thng bn tay 41 3.2 c im lõm sng .42 3.2.1 Thi gian t b tai nn n phu thut 42 3.2.3 Phân loại chung VTBT 43 3.2.3 Tay b tn thng 43 3.2.4 Phõn b theo b mt tay b tn thng .44 3.2.5 Cỏc trng hp VTBT cú vt thng gõn 44 3.2.4 Cỏc trng hp VTBT cú tn thng xng .45 3.2.5 Cỏc trng hp vt thng bn tay cú khuyt phn mm phi to hỡnh che ph 46 3.2.6 Phõn vựng tn thng t ri bn - ngún tay 47 3.3 Cỏc phng phỏp iu tr 47 3.3.1 Tng hp cỏc phng phỏp iu tr 47 3.3.2 Cỏc phng phỏp che ph khuyt phn mm 48 3.5 Bin chng sau m 50 3.4 Kt qu 50 3.4.1 Lin vt thng 50 3.4.2 Kt qu thm m 50 3.4.3 Kt qu iu tr tng hp 51 3.4.4 Kt qu iu tr tng hp v loi VTBT 51 MT S NH LM SNG .52 BN LUN 61 4.1 c im nhúm nghiờn cu .61 4.1.1 Phõn b gii tớnh 61 4.1.2 Phõn b nhúm tui 61 4.1.3 Ngh nghip 62 4.1.4 Nguyờn nhõn gõy vt thng bn tay 62 4.2 c im lõm sng .63 4.2.1 Thi gian t b tai nn n phu thut 63 4.2.2 Phân loại chung VTBT 64 4.2.3 Tay b tn thng 64 4.2.4 Mt bn tay b tn thng 65 4.2.5 Cỏc trng hp VTBT cú tn thng gõn 65 4.2.6 Cỏc trng hp VTBT cú tn thng xng .66 4.2.7 Các trờng hợp vết thơng bàn tay có khuyết phần mềm phải tạo hình che phủ 67 4.2.8 Phõn vựng tn thng t ri bn - ngún tay 67 4.3.2 Tn thng gõn 68 4.3.3 Tn thng xng bn ngún tay 69 4.3.4 Vt thng cú tn khuyt phn mm 70 4.3.5 Tn thng t ri chi th vựng bn tay 73 4.4 Bin chng sau m 74 4.5 Kt qu 75 4.5.1 Lin vt thng 75 4.5.2 Kt qu thm m 75 4.5.3 Kt qu iu tr tng hp 75 KT LUN 77 KIN NGH 78 Tài liệu tham khảo 79 DANH MC CC BNG Bng 3.1 Phõn b theo ngh nghip (n = 151) .41 Bng 3.2 Thi gian t b tai nn n phu thut (n = 151) 42 Bng 3.3 Phõn b theo b mt bn tay b tn thng (n =153) 44 Bng 3.4 Phõn vựng vt thng gõn dui (n = 93) 45 Bng 3.5 Phõn vựng vt thng gõn gp (n = 49) .45 Bng 3.6 Tỡnh trng nn tn khuyt phn mm VTBT (n = 61) .47 Bng 3.7 Phõn vựng tn thng t ri bn - ngún tay (n = 40) .47 Bng 3.8 Tng hp cỏc phng phỏp iu tr .48 Bng 3.9 Cỏc phng phỏp che ph khuyt phn mm (n = 56) .49 Bng 3.10 Bin chng sau m (n = 17) 50 Bng 3.11 Liờn quan gia kt qu iu tr tng hp vi loi VTBT 52 Bng 4.1 Kt qu ng ch ng ngún tay tn thng n c gõn dui hay góy xng v tn thng phi hp ti v trớ t gn ngún tay theo Bỹchler 76 DANH MC CC BIU Biểu đồ 3.1 Phân bố theo giới tính (n = 151) 40 Biu 3.2 Phõn b theo nhúm tui (n = 151) 40 Biu 3.3 Phõn b theo nguyờn nhõn gõy vt thng bn tay (n = 151).41 Biu 3.4 Phõn loi chung VTBT (n = 151) 43 Biu 3.5 Phõn b tay b tn thng (n = 151) 43 Biu 3.6 Phõn b vt thng gõn gp v dui (n = 142) .44 Biu 3.7 Phõn b VTBT cú tn thng xng (n = 134) 46 Biu 3.8 V trớ khuyt phn mm VTBT (n = 61) .46 Biu 3.9 Kt qu lin vt thng (n = 151) 50 Biu 3.10 Kt qu thm m (n = 50) 51 Biu 3.11 Kt qu iu tr tng hp (n = 50) 51 DANH MC CC HèNH Hỡnh1.1 Xng bn tay [12] Hỡnh1.2 Phu tớch nụng mt gan tay [12] Hỡnh 1.3 Cỏc ụ gan tay [12] Hỡnh 1.4 Phu tớch nụng mt mu tay [12] Hỡnh 1.5 Cu trỳc gii phu ca ngún tay [12] .8 Hỡnh 1.6 Gõn gp ngún tay vi dõy chng, bao hot dch vựng ngún tay [12] Hỡnh 1.7 M v TK bn tay [12] 10 Hỡnh1.8 Cỏc vựng t ri bỳp ngún [65] 13 Hỡnh 1.9 Phõn vựng tn thng t ri bn ngún tay theo Biemer [22] 14 Hỡnh 1.10 Phõn vựng gõn gp [65] .17 Hỡnh 1.11 Phõn vựng gõn dui [65] 19 Hỡnh 1.12 Nguyờn tc rch da trớch theo [63] .21 Hỡnh 1.13 Mt s k thut khõu ni gõn [1,3,14,15,24,61,62] 23 A: Bunnell; B: Kessler kinh in; C, D: Kessler ci tin .23 Hỡnh 1.14 Vt Atasoy [65] .26 Hỡnh 1.15 Vt Kutler [65] 26 Hỡnh 1.16 Vt Venkataswami [65] 27 Hỡnh 1.17 Vt o da bỳp ngún cung M ngún tay [65] 27 Hỡnh 1.18 Vt diu bay [65] 28 Hỡnh 1.19 Vt mụ cỏi [65] .28 Hỡnh 1.20 Vt cung M ngún tay [65] .29 Hỡnh 1.21 Cỏc vt liờn ct bn, mu k ngún [65] .30 Hỡnh 1.22 Vt cung [64] 31 Hỡnh 1.23 Vt qu trỏm [64] 31 Hỡnh 1.24 Vt quay cung mch ngc dũng [64] .32 Hỡnh 1.25 Vt tr cung mch ngc dũng [64] .32 Hỡnh 1.26 Vt liờn ct sau cung mch ngc dũng [64] 32 DANH MC CC NH nh minh 3.1: Cao Th H, 17 tui 53 nh minh 3.2: Lờ ỡnh H, 31 tui 54 nh minh 3.3: BN Bựi Quang H, 20 tui 56 nh minh 3.4: Nguyn Ngc N, 28 tui .57 nh minh 3.5: Trn Thanh S, 21 tui 58 nh minh 3.6: Trn Tin L, 49 tui .60 ... xng bn tay Vi 27 xng v h thng dõy chng bao khp m bo cho mi hot ng tinh vi phc ca bn tay v c chia thnh nhúm [8,11]: - xng c tay - xng bn tay - 14 xng ngún tay hay t ngún tay Hỡnh1.1 Xng bn tay [12]... trờn ng c tay: - Thn kinh gia v tru - ng mch quay v tr - Gõn gp c tay: gp c tay quay, gan tay di, gp c tay tr 15 - Gõn gp ngún tay: gp di ngún cỏi, gõn gp nụng, gõn gp sõu cỏc ngún ng c tay: -... ngún tay) +Khuyt ton b mt gan ngún tay( khuyt gan t) +Khuyt ton b mt mu ngún tay( khuyt mu t) + Khuyt phn mm ton b ngún tay( khuyt chu vi ngún tay) + Khuyt phn mm mt ngún tay hay nhiu ngún tay