手外科的手术操作解读6037拇指畸形
图.1三岁的孩子与联想的眼睛（眼睛的缺损，缺损心脏缺损、后鼻孔闭锁、生长迟缓和/或发展，泌尿生殖道畸形和外耳畸形、耳聋）综合征。(CourtesyofShrinersHospitalforChildren,Philadelphia.)e图.1A和B，II型拇指发育不全。(CourtesyofShrinersHospitalforChildren,Philadelphia.)e图.2外科技术。A，屈指趾浅表（FDS）收获。B，屈腕尺侧滑车。C，FDS通过滑轮。D，FDS通过皮下隧道。E，FDS通过掌骨头。F，FDS沿尺骨掌指关节。G，尺骨侧副韧带重建。H，钉住和四瓣“Z”-封闭。(CourtesyofShrinersHospitalforChildren,Philadelphia.)e图.3A和B，长期结果。(CourtesyofShrinersHospitalforChildren,Philadelphia,)图.2两岁时患II型左拇指缺陷。A，缺乏鱼际肌肉。B，尺骨侧副韧带功能不全。C，缩小的拇指/食指网络空间。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.3一名2岁的患者射线照片显示拇指掌骨逐渐变细，指示不稳定的腕掌关节。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.4一岁时伴有严重IV型拇指发育不全（浮肿或浮动拇指）。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.54岁患儿双侧尺骨缺损和左拇指发育不全。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.6四瓣“Z”形-扩大缩小的拇指/食指网络空间。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.7无名指弯屈指浅部肌腱在手指根部和前臂内被识别。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.8无名指弯屈指浅浅肌腱入掌侧前臂切口。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.9使用尺侧腕屈肌腱2#;3cm远端的一半用于构建屈指肌腱浅屈肌肌腱滑车。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.10无名指屈指腱浅指肌腱通过尺侧腕屈肌环。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.11屈指趾浅屈肌腱穿过皮下隧道到拇指的桡侧。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.12克氏针在平行于关节面的掌骨头上钻出。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.13指屈肌腱浅层肌腱通过掌骨头到拇指的尺侧。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.14屈指肌腱浅表肌腱被用于重建尺侧副韧带。请注意纵向克氏针线离开拇指尖。(CourtesyofShrinersHospitalforChildren,Philadelphia.)e图.4左拇指发育不全。(CourtesyofShrinersHospitalforChildren,Philadelphia.)e图.5A和B切口。C和D，神经血管隔离。E和F，拇指消融。G-J，骨切除和外展肌重建。(CourtesyofShrinersHospi-talforChildren,Philadelphia.)e图.6复原。(CourtesyofShrinersHospitalforChildren,Philadelphia.)e图.7A到D，结果。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.15四岁，缺乏拇指和尺骨。A，掌皮肤切口允许更多的无毛皮肤沿着食指的手掌放置。B，背部切口设计。C，用于进入拇指掌骨基部的桡骨切口。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.16在这种患有IIIB型拇指发育不全的儿童中，发育拇指的单个血管追踪至食指的桡骨神经血管束以便于识别。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.17尺骨解剖以识别食指/长指网络空间的常见手指血管。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.18使用结扎夹将适当的手指动脉结扎到长指状物上。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.19切开第一环形滑轮以防止食指缩短后的屈肌腱屈曲。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.20该掌骨间韧带也分离。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.21第一掌侧骨间肌部分伸肌的解剖。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.22解剖第一背侧骨间肌。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.23远端掌切直接通过物理。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.24细刃锯用于通过预期拇指平面上的干骺端闪光切割掌骨基部。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.25指甲掌骨从其基部被去除到骨骺。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.26咬骨钳靠蹬周围皮质扩大基底。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.27该手指是固定掌指关节过伸，将剩余的掌骨头弯曲。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.28AntegradeKirschner导线放置。A，通过掌骨骨骺。B，通过近节指骨的基部。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.29克氏针穿过近节指骨并穿出近端指间关节。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.30克氏针用作操纵杆来定位食指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.31一旦食指被定位在足够的外展和内旋中，克氏针就会穿过掌骨基底逆行钻入腕部。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.32肌腱转移恢复拇指的内在功能。A，第一手掌与近侧关节间关节尺骨侧骨带骨间。B，第一骨间背侧至桡侧带。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.33皮肤被插入，任何多余的皮肤被切除。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.34仔细插入皮肤以最大化第一幅空间并优化外观。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.35十岁左右的孩子继左屈指腹肌腱反对转移。A，优秀的反小手指。B，提高获取大型物体的能力。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.36三岁以下食指多样化。A，整体外观。B，运动模式。C，捏一个贴纸。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.37食指过度旋转可能会导致拇指对齐失败。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.38六岁，长拇指归因于在掌跖解剖持续增长。A，拉长拇指的临床外观。B，骨切除和固定术。C，减少皮肤。D，最终外观。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.39A和B，一岁，左手拇指重复（IV型重复）。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.40A和B，临床图片和双侧微妙的I型重叠的加宽甲板的X射线。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.41具有主要径向分量的不对称II型重复。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.42A和B，剩余手指的角度畸形可以通过在平滑的共同关节表面上移动手指并修复紧贴的副韧带来矫正。图.43经典的Bilhaut-Cloquet手术，其中两个远端指骨的外侧部分在切除过多的中央软组织和骨组织后在中线连接。图.44修改后的Bilhaut-Cloquet程序应用于WasselII型重复。图.岁的X射线照片与WasselIV复制。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.46A和B，背侧和掌侧皮瓣切口用于WasselIV型重建。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.47来自被去除组件的软组织瓣被保留以增强保留的拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.48用缺损的拇指与侧副韧带抬起骨膜骨袖并最终转移到重建的拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.49完全切除术后桡骨拇指切除术。(Cour-tesyofShrinersHospitalforChildren,Philadelphia.)图.50掌上手术刀切除桡骨小面。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.51桡侧副韧带和骨膜套拇短展肌重建拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.52A和B，关闭后，重建IV型拇指的背侧和掌侧视图。(CourtesyofShrinersHospitalforChildren,Philadelphia,)图.53一岁的WasselIV型重复。A，临床表现与尺骨组成占主导地位。B，皮肤设计。C，皮瓣升高。D，骨膜套急剧升高。E，骨掌骨套骨近端抬高。F，关节检查。G，桡骨头掌侧关节突切除术。H，径向部分丢弃。I，顺行穿针导线放置。图.53,续#;J，关节复位和克氏针固定。K，骨膜套附尺骨组成。L，皮肤闭合。M，射线照射术后1年。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.54A和B，一岁，左拇指重复（III型重复），90度掌指关节活动。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.55III型重复X线片，计划截骨以保护基底韧带和副韧带。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.56去除径向分量并保留骨性基底。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.57A和B，一岁，左侧拇指重复（类型VII重复）和显性尺骨拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.58射线照片显示三角尺骨部分（VII型重复）和小多角骨近端指骨。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.59桡骨拇指与骨膜骨袖切除以保留副韧带。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.60逆行克氏针导丝放置以维持掌指关节对齐，并将骨骨膜袖（绿色缝合）修复至近节指骨。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.61持续角度需要指骨截骨术进行定位。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.62扩展机制集中在重建拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.63拇指重建后的最终外观。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.64拔针后显示了良好的对齐和指骨截骨片愈合。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.65两岁的复杂的拇指。尺骨拇指有更好的远端组件，但没有掌骨基部。桡侧拇指有更好的基础，但没有远端运动。A，射线照片。B，手术暴露于顶部成形术并将神经血管束隔离至尺骨拇指。(CourtesyofFranciscoSoldado,MD.)图.66克氏针固定后置顶置入。(CourtesyofFranciscoSoldado,MD.)图.67八岁以下的Bilhaut-Cloquet手术伴有指甲畸形和指间关节僵硬。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.68四岁以下重建WasselIV重复掌指关节。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.69射线照片显示放大的掌骨头与持续的桡切面，切除拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.70使用骨刀切断和切除额外的小平面。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.71关节内骨切除术后最终出现。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.72三十岁女性患有Holt-Oram综合征和双侧三指拇指。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.73图.72中描绘的母亲的一岁小孩。儿童有发育不良的指甲拇指和Holt-Oram综合征。(CourtesyofShri-nersHospitalforChildren,Philadelphia.)图.74母亲和儿子（见图.75）与双侧类似外观的三指大拇指。A，母亲的拇指稍长，角度适中。B，X光片显示小多角中间指骨。图.75孩子有相似的外观和角度。A，稍长的拇指，先端有尺骨角。B，X线片显示更多的三角中间指骨。图.76一个完全发育的指骨位于手指的平面上，被认为是一个五指的手。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.77食指多元化和去除拇指肿瘤的指甲。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.78扳机拇指与指间关节固定屈曲畸形。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.79Notta结节触及A1滑轮的近端。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.80在松开皮带轮前，对桡神经进行识别和保护。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.81第一个环形滑轮释放后，拇长屈肌被隔离。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.82两岁的小孩，右手长且有环形板机指。A，长而僵硬的手指在屈曲时卡住。B，滑轮隔离。C，释放第一个环形滑轮。D，在A3皮带轮下方隔离屈肌腱膜浅部（FDS）。E，分离FDS。F，FDS插入在中间指骨的基部分离。G，释放FDS的尺骨。H，A2滑轮近端FDS的尺骨滑动回缩。I，保留的桡侧滑移的FDS的尺侧滑动的近端分离。J，正式切除FDS的尺骨。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.83类型I紧握拇指缺少拇短伸肌。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.84一岁大的孩子拇指更紧张，拇长伸肌和短伸肌不足。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.85一个III型紧握拇指在有关节息肉的小孩。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.86双侧未治疗的拇指和最小功能障碍的青少年。(CourtesyofShrinersHospitalforChildren,Philadelphia.)图.87紧握拇指伴掌指关节屈曲挛缩。(CourtesyofShrinersHospitalforChildren,Philadelphia.)参考：Green’sOperativeHandSurgery-SeventhEdition
上期：手外科的手术操作解读:60-36手和手指畸形「图解」
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