Parkes surgery

After ischemic contracture of the forearm, the performance of muscle contracture varies depending on the extent and extent of ischemia. The lighter fingers have a certain flexion and extension activity, and the severely injured limbs completely lose their function. The degree of injury is different, the treatment methods are different, and the efficacy is also significantly different. In the early stages of contracture, the support can be used to maintain the hand and forearm in the functional position, while functional exercise to prevent or reduce the occurrence of malformations. It usually takes 6 months to 1 year to observe and treat. At this time, the contracture deformity has become stable, and the recovery of affected muscles and nerves can be seen. Develop an advanced treatment plan. Especially in children, a 1-year observation period is appropriate. Severe forearm ischemic contracture, the current treatment is still very difficult, the existing surgical methods are: muscle release, tendon lengthening, tendon transplantation, tendon fixation, bone shortening, bone resection, interosseous resection Surgery, wrist arthroplasty, interphalangeal fixation, scar resection, pedicled nerve graft, vascular, neuromuscular transplantation and free muscle, flap transplantation. Bone shortening only shortens the fracture of the forearm and corrects the deformity, because it does not fundamentally solve the problem of contracture. As the bone shortens, the extensor muscle has a corresponding relaxation, and the flexor contracture has not been resolved, so it is rarely used at present. Pag (1923) proposed a flexor-starting slide surgery to relax the flexor tendons of the wrist and fingers, but the operation is complicated, easy to hurt the nerves and blood vessels, and the curative effect is not good, so it is rarely used. Parkes, Seddon, and Professor Zhang Xianzhi of China advocated the reconstruction of the forearm by muscle or musculocutaneous flap transplantation with muscle extensor muscle, diaphragm, finger flexor tendon transfer and removal of necrotic scar muscle. The function of the limb. Treating diseases: hemangioma Indication Parkes surgery is indicated for severe Volkmann ischemic contracture cases. This type of surgery needs to be performed within 6 months to 1 year after the contraction occurs, in order to restore muscle and nerve function, and the effect is better. Child recovery is much better than that of adults, but surgery should be performed after 1 year. Contraindications Severe forearm ischemic contracture, extension and flexor muscles were involved, and the muscle strength was still below grade III after 1 year of observation. Preoperative preparation 1. The application of dynamic stents, through active and passive stretching, to achieve the purpose of reducing the contracture deformity of each joint and improving the function of the affected limb. 2. Exercise the wrist and hand joints to maintain the maximum movement function of the joints of the fingers. If the joint loses its function, the prognosis is poor. 3. If there is nerve damage, regular massage and electrical stimulation should be performed on the hands and forearms to promote the recovery of nerve function. Surgical procedure 1. Incision: Make a longitudinal incision in the midline of the forearm palm, starting from the elbow and extending distally to the top of the wrist. 2. Free flap: due to less subcutaneous tissue after ischemia, poor elasticity, deep fascia often adheres to muscle tissue, the flap should be carefully released to both sides, and pulled open with a slit retractor to reveal Deep organization. 3. Expose the median nerve of the elbow: the median nerve is located on the inner side of the biceps tendon at the elbow. After exposure, the electric nerve stimulator can be used to stimulate the median nerve so that the contractility of the forearm muscle can be observed at any time, and the resection of the whole process can be accurately guided. Completely necrotic muscle tissue, maximally retaining muscle tissue that still has contractile force for proper functional reconstruction. 4. Exploring the muscles and removing the necrotic area: firstly, the superficial flexor digitorum is explored. If all necrosis or pallor and fibrosis are present, and the median nerve is not contracted or contracted very little, all resection should be given. However, in most cases, the flexor digitorum is lighter in ischemia. Although there is contracture, there is still some contractility and should be preserved. The tendon can be prolonged in the proximal wrist or left for transplantation. If the superficial muscle has been removed, the deep muscle can be observed. If the superficial muscle is preserved, the deep muscles can be revealed between the distal flexor and the flexor digitorum. If the deep flexor and the long flexor hallucis have been necrotic, the whole muscle should be removed from the junction between the tendon and the muscle. At this point, the deep and shallow flexors have been loosened, and the contracted wrist and fingers can be straightened. 5. Exploring the median and ulnar nerves: First, the median nerve is placed in the wrist, and then the proximal anatomy is carefully performed, especially in the proximal part of the forearm to protect the nerve branches in the muscles that have a certain contraction force. The fibrotic pronator and the superficial flexor are cut off, and the median nerve under it is released. If the median nerve thickness is normal and the electrical stimulation has a certain function, it should be loosened from the surrounding scar tissue, and the scarred neuroepithelium should be cut longitudinally to perform nerve release and decompression. If the median nerve has become hard and thin, the diameter is normal 1/2 to 1/4, and it is dark red. When there is no function at all, the necrotic section should be removed, and then the nerve re-synthesis or autologous nerve transplantation should be performed. repair. At the same time, the ulnar nerve was probed. Generally ulnar nerve injury is lighter than the median nerve. Such as nerve surface scar hardness, morphology is close to normal, should be retained. 6. Functional reconstruction: After partial muscle and nerve resection of severe ischemic necrosis, different degrees of dysfunction will occur in the hand. At this time, muscles and nerves with certain functions should be utilized according to the retained muscle and nerve function. To repair the most important muscles and nerves of your hand as much as possible to maximize the most important and basic functions of your hands. From the current point of view, the method of muscle function reconstruction can be summarized as: 1 "shallow" (+) + "deep" (-): "shallow" cut from the distal end, "deep" cut from the proximal end, "shallow" transfer to "deep". 2 "Shallow" (+) + "Deep" (+): "Shallow" cut from the far end, "deep" extended, "shallow" strengthened "deep". 3 "shallow" (-) + "deep" (+): "shallow" resection, "deep" extension. 4 "shallow" (-) + "deep" (-): "shallow" resection, "deep" cut from the proximal end, "deep" tendon transfer to "deep", latissimus dorsi flap transfer or free musculocutaneous flap transplantation . Note: [(+) has enough power, (-) has no power. "Shallow" - shallow muscles. Including the ulnar flexor carpal muscle, palmar long muscle, finger shallow flexor; "deep" - deep muscle. Including the flexor hallucis longus and the deep flexor. ] 7. If the operation only removes the contracted deep flexor tendon and the flexor hallucis longus, and the superficial flexor and palmar muscles are still good, the deep flexor tendon can be cut off at the abdomen of the muscle, referring to the superficial flexor tendon and palm. The long muscle is cut at the proximal wrist, and then the proximal end of the superficial flexor tendon is woven with the distal end of the deep flexor tendon, so that the deep finger and the shallow flexor tendon are prolonged, and the proximal end of the palmar tendon and the flexor hallucis longus are far away. End suture to reconstruct the function of the thumb flexor. 8. If the deep, shallow flexor and palmar long muscles and the flexor hallucis longus have residual muscle strength, the finger flexor and palmar muscles can be cut off the proximal wrist, and then the deep flexor and the thumb length The flexor muscles are properly extended, and the severed flexor muscles are sewn to the deep flexor muscles, and the long palm muscles are sutured to the flexor hallucis longus to strengthen the deep flexor and the flexor hallucis longus. 9. If the deep flexor and the flexor hallucis longus have been necrotic, and the wrist flexor and palmar muscle are better, the flexor digitorum can be used to replace the flexor muscle. Muscle effect. The radial flexor tendon and the longissimus tendon are cut off near the wrist, and then the proximal end of the radial flexor tendon is sutured to the distal end of the flexor tendon, and the proximal end of the long tendon is sutured to the distal end of the flexor hallucis longus. 10. If the superficial flexor muscle has been necrotic resection, and the deep flexor and the flexor hallucis longus are still good, then the deep flexor and the flexor hallucis longus can be extended. 11. If the flexor muscles have completely lost function, the long extensor digitorum of the radial side of the wrist can be cut off from the posterior end of the base of the second metacarpal bone, and then pulled out from the proximal end, bypassing the lateral humerus through the subcutaneous tunnel, to the palm The side was sutured at the distal end of the flexor hallucis longus. The ulnar wrist extensor tendon was transferred to the volar side and the distal flexor tendon of 2 to 5 fingers was sutured. If the wrist extensors are used to restore flexion and the stability of the wrist is lost, wrist fusion is required. 12. When the thumb function is lost, the appropriate tendon shift reconstruction can be selected as needed. If there is no proper dynamic tendon, the thumb can be fixed to the palm.