HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U I X
NHAN MOT TRirONG HOP CHEN EP KHOANG 0 GANG TAY Bi BO SOT OirgC BAG TON CHi - TAG HiNH B A N G GHEP XlTONG iVIAC Vi P H A O
VA CHUYEN CO CHijrc NANG
Pham Dang Nhat - Ho Man Trucmg Phu Le Thira Trung Hau(*)
TOM TAT
Mgt benh nhan 4 tud'i gay Monteggia phai, chen ep khoang d cang tay do bo bgt bi bd sot, CO bien chu'ng hoai tii" - nhiem triing - mat rdng mo mem va xUdng d cang tay. Benh nhan dUdc dieu trj bao ton chi va tao hinh chu'c nang vdi 12 lan phau thuat dUdc thUc hien trong thdi gian 4 nam, trong dd cd 2 cugc md vi phau - ghep xUdng mac tU do va chuyen cd thon chu'c nang.
Ket qua dieu trj la (1) bao ton dUdc cang va ban tay, (2) phuc hoi dUdc mgt sd chirc nang cd ban ciia ban tay nhUng van cdn mgt sd bien dang va mat mgt so chirc nang ciia cang-ban tay.
ABSTRACT
Missed compartment syndrome of forearm:
Limb salvage and reconstruction using free fibular transfer and functioning free muscle
transplantation - A case report A 4 year old patient with extended defect of bone and soft tissue due to a missed compartment syndrome of forearm after casting.
A series of 12 surgeries including a free fibular transfer and a functioning free gracilis transplantation have been performed during 4 years. Results of treatment are (1) limb salvage, (2) restauration of basic hand functions, but there are still some deformities of the forearm and the hand as well as some functional losts
I. Gldl THIEU
Hdi chiing chen ep khoang (CEK) do bd
* B^nli vien Trung uomg Hui
bdt chat va sai ky thuat van thudng thdy d cac nudc dang phat trien [6]. Neu bi bd sdt, khdng dugc phat hien va xir tri kip thdi thudng de lai nhimg hau qua rat trdm trgng, nhe la co riit Volkmann, nang ban thi phai cat cut chi hay tham chi tir vong [1][15].
Nhftng trudng hgp CEK bi bd sdt cd bien chimg hoai tir, nhiem triing xuang va md mem thudng hiem khi bao tdn dugc.
Mdt sd tac gia tren the gidi da bao cao chuyen cac ca chiic nang de khdi phuc chiic nang chi tren cho liet dam rdi thdn kinh canh tay, mdt sd trudng hgp hdi chimg Volkmann hay mdt ca rdng [3][4][5][8][10][12][13], nhung chua cd bao cao nao sir dung ca ghep xuang mac vi phdu va chuyen ca thon chiic nang de tao hinh va khdi phuc chiic nang ban tay va chi tren sau hoai tir mdt doan xuong va md mem do CEK bi bd sdt.
Bao cao nay gidi thieu mdt benh nhan 4 tudi gay Monteggia phai, CEK d cang tay do bd bdt bi bd sdt, cd bien chiing hoai tir, nhiem triing md mem va xuang d cang tay.
Benh nhdn dugc dieu tri bao tdn chi va tao hinh chiic nang vdi nhieu ldn phdu thuat dugc thuc thien trong thdi gian 4 nam, trong dd cd 2 cugc md vi phdu - ghep xuang mac tu do va chuyen ca thon chiic nang. Muc dich bao cao nay nham thdng bao mdt trudng hgp vdi 1dm sang vdi dieu tri kha dac biet;
dong thdi gidi thieu kha nang dieu tri phuc hdi lai chiic nang van ddng ban tay bdng
Y HOC VIET NAM THANG 10 - 5 0 2/2010
phuang phap cdn it dugc de cap din trong nudc dd la chuyen ca chiic nang vi phau.
II. TRUdNG HOP LAM S A N G
Vao ngay 11-2-2005, benh nhdn nft, 4 tudi, Pham Thi K.O nhap vien Benh vien Trung l/ang Hue vi nhilm triing va hoai tir mo mem cang tay phai.
Benh sir: 10 ngay trudc nhap vien, benh nhi bi gay kin Monteggia phdi, dugc nan - bd bgt d phdng kham tu nhdn rdi cho ve nha.
Sau dd benh nhdn dau du ddi va sung ne tay phai rdt nhieu. Liic thao bdt sau 7 ngay thdy
. > i . ' '•' JK i '•
cd nhieu bgng nudc dich dd bam, hoai tir da mat sau cang tay, sau dd xudt hien nhiem triing d cang tay ngay cang nang nen dugc chuyen den Benh vien Trung Uong Hue.
Tui2-2 den cudi thang 3, 2005: Vdi chan doan CEK do bd bdt den mudn cd bien chirng nhiem triing va hoai tir md mem cang tay phai, benh nhdn dugc cat lge nhieu ldn, sau ldn cat lge cac md hoai tir ddu tien, ca 2 xuang quay va tru deu bi Id. Cac xuong viem ngay cang nang, ddu tren va thdn xuang quay da bi hoai tir nen phai cat bd d ldn md cat lge thir 3 (Hinh 1)
' • ^ # % « t € i i .
* Hinh 1: Sau ldn cat lge thii 3
Sau 6 tudn dieu tri vdi khang sinh dudng tinh mach va cat lge nhieu ldn, tinh trang nhiem triing cap tinh dugc kiem soat, nhung khuyet hdng phdn mem mat sau cang tay rdng. Id xuang tru, liic nay co rut Volkmann bat ddu hinh thanh.
Ngay 31-3-2005, khuyet hdng phdn men cang tay phai dugc che phii bang vat da bung cd cudng (Hinh 2). Hdu phdu vat sdng tdt, dugc cat cudng vat da sau 3 tudn.
Hinh 2: Che phii khuyet hdng phdn mem cang tay bang vat da bung
HOI CHAN THUONG CHJNH HINH VIET NAM • HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
Tu thang 4-2005 din thang 10-2005:
xuong tru tilp tuc viem, da md nao xuong viem 2 lan nhung cudi ciing phai ldy bd doan xuong tru viem hoai tir vao ngay 15-10-2005.
Liic nay ca xuong tru va xuong quay phdi diu mdt doan hon 2/3 chilu dai nen cang tay bi nit ngdn va du dua khdng viing, Tuy nhien ban tay van dugc tudi mau va cd cam giac tdt, ben canh dd toan trang da cai thien rd ret.
Chiing tdi da dat van de cat cut hay bdo tdn chi? Nhung gia dinh tha thiet yeu cdu gift lai cang - ban tay cho chau. Do dd benh nhdn dugc dat nep ben ngoai va cho ve nha mdt thdi gian.
Thang 4-2006: Nhiem trimg tai chd da hoan toan dn dinh. Do 2/3 gan xuong quay
va phdn xa xuong tru da bi ldy bd nen cang tay phai dung dua. Tren film X quang, phdn xa xuong tru cd hinh thanh cai tu mang xuong nhung rdt ylu (Hinh 3). Liic nay benh nhdn dugc quylt dinh md tao hinh xuong va md mem cang tay phdi bang vat tu do da - xuong mac lay tu cang chdn trai vdi cudng la bd mach mac. Vat phuc hgp dugc cat rdi, chuyen ghep bac cdu tu phdn gdn xuong try den phdn xa xuong quay, cd dinh bang Kirschner va chi thep. Ndi vi phdu tan-ben ddng mach mac - ddng mach tru; ndi tan-tan tinh mach mac - tinh mach nen (Hinh 4,5,6).
Hdu phdu tien trien thudn lgi, vat ghep sdng tdt, xuong lien sau 4 thang. Kirschner duoc riit vao thang 11/2006.
Hinh 3: Ldm sang va x quang trudc ghep xuong mac vi phdu
Hinh 4: So dd ghep chuyin xuong mac tu do
Y HOC VIET NAM THANG 10 - SO 2/2010
Hinh 5: Ldy vat da - xuong mac trai
Hinh 6: Ghep chuyen xuong mac tu do vao cang tay phai
Thang 7, 2008: Benh nhdn tai nhap vien vdi cang tay phai ngan hon trai nhung xuong ghep da lien, xuong va md mem d cang tay da dn dinh. Mdt ddng tac gap ngdn cai va cac ngdn tay nhung cdn van ddng dudi chii ddng cac ngdn tay, cam giac ban tay phai tdt. Chup mach mau va doppler cho thdy ddng mach quay la mach chinh cdn lai d cang tay phai (Hinh 7). De khdi phuc mdt phan chuc nang tay phai, phuong an chuyen co vi phdu chirc nang de phuc hdi ddng tac gap cac ngdn tay da dugc quyet dinh.
HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
Hinh 7: Ldm sang, x quang va chup mach trudc md chuyen co chiic nang Ngay 24-7-2008: md tham dd nham xac dinh thdn kinh nhdn de ndi vao thdn kinh van ddng ciia vat co. Da xac dinh dugc thdn kinh gian cdt trudc cdn chiic nang (Hinh 8).
Hinh 8: Tham dd va xac dinh dugc than kinh gian cdt trudc
Ngay 30-7-2008: Tien hanh phau thuat chuyen co chiic nang vi phau. Nguyen co thon phdi dugc phau tich cimg vdi cudng mach va thdn kinh van ddng rdi cat rdi, chuyen den cang tay phai. Cd dinh nguyen iiy co thon vao mdm tren ldi cdu trong; Khau ndi bang ky thudt vi phau ddng mach vat (mu diii trong) vdi ddng mach quay: tan-ben, va tinh mach vat vdi tinh mach nen: tan-tan; Khdu 4 gdn gdp sdu va gdn gdp dai ngdn cai lai vdi nhau rdi khau ndi vao gdn CO thon. Cudi cung la khau ndi than kinh van ddng co thon vdi than kinh gian cdt trudc kieu nhdm bd bang ky thudt vi phdu (Hinh 9, 10).
Y HOC VIET NAM THANG 10 - SO 2/2010
Hinh 9: Ldy vat co thon cung cudng mach va thdn kinh van ddng
.. Hinh 10: Chuyen co thon chiic nang de phuc hdi gdp cac ngdn tay phai
Benh nhdn dugc tap phuc hdi chiic nang va theo ddi dinh ky moi 3 thang. Sau md 3 thang bat ddu cd trieu chimg rung co d co thon chuyen ghep, tiep den siic co ddn ddn khdi phuc. Sau 18 thang, tai kham vao thdng 3-2010, ghi nhdn benh nhdn khdng cdn biln dang Volkmann, cang tay ben phai vthig nhung ngan hon ben trai 8cm, ban tay phai cung nhd hon ban tay trai, co-dudi khuyu 0-85°, cam giac ban tay tdt, van ddng co-dudi ngdn cai va cac ngdn tay chua dugc linh boat nhu binh thudng nhung kha tdt, sue co thon chuyen ghep dat dugc 4 diem (Hinh 11, 12), ban tay phai cd the cdm nam dugc, thuc hien dugc mdt sd ddng tac trong sinh boat ca nhan. Benh nhdn va gia dinh hai ldng vdi ket qua dat dugc.
Hinh 11: Xuong mac ghep vi phdu lien va phi dai
HOI CHAN THUONG CHINH HJNH VIET NAM - HOI NGHj KHOA HOC TOAN QUQC LAN T H U IX
Hinh 12: Chuc nang gdp dudi ban tay phai sau chuyen co chuc nang 18 thang
Ml. BAN LUAN
Chen ep khoang bi bd sdt d benh nhdn nay la qua rd rang vdi tinh trang gay kin Monteggia dugc bd bdt nhung khdng dugc theo ddi, sau dd sung ne va dau dft ddi, dugc thao bdt rdt mudn sau 1 tudn, da d mat sau cang tay trong bdt bi hoai tu do bdt ep vao, phdn cdn lai cd nhieu ndt phdng [14]. Cdc Id CO d cang tay phdi vdn da thieu mau do chen ep khoang da trd thanh mdi trudng tdt cho vi trung phat trien khi xam nhap tu chd hoai tir da va cac bgng nudc. Dieu dd gidi thich hien tugng nhiem triing hoai tu rdng md mem d benh nhdn nay. Tinh trang nhiem trung chi dn dinh khi tdt cd md hoai tu dugc lay bd bang cat lge, ma hau qud la khuyet hdng ldn Id xuong quay va tru trong mdi trudng nhiem trimg ddn den viem va hoai tu rdng hai xuong cang tay. Dieu nay phu hgp vdi gidi thich cua Gulgonen [6], Hawkins [7].
Sau nhieu ldn cat lge, thuong tdn nhiem trung kem khuyet hdng md mem va xuong rdng da dat ra vdn de cat cut hay bdo tdn chi.
Tuy nhien ban tay ciia benh nhdn van dugc tudi mau va cd cam giac tdt, ben canh dd toan trang da cai thien, va gia dinh tha thilt yeu cdu gift lai cang - ban tay cho chau, dd la nhirng ly do de chung tdi quylt dinh bao ton
chi va tiep tuc thuc hien cac phdu thudt tao hinh tiep theo.
Do ca phdn xa xuong tru va phdn gdn xuong quay phai deu mdt doan hon 2/3 chilu dai nen cang tay phai du dua khdng vung ddng thdi md mem d cang tay kha cang va nhieu md seo, nen chiing tdi da chgn giai phap ddng thdi tao hinh xuong va md mem cang tay phai bang vat tu do da - xuong mac.
Muc tieu tao hinh d ddy la tao mdt true xuong vftng chac vdi phdn da che phii thoai mai d cang tay, lam sao de cd the gap-duoi dugc khdp khiiy va cd tay, ddng thdi phai chap nhdn hy sinh ddng tac sap - ngira. Doan xuong mac ghep vi phdu dugc bac cdu tir phdn gdn xuong tru den phan xa xuong quay, cd dinh bang Kirschner & chi thep. U'u diem cua ghep xuong mac vi phau d ddy la cho phep bac cau qua mdt khuyet xuong dai, lien xuong tien trien nhu lien xuong trong cac gay xuong thdng thudng va manh ghep xuong tham gia chii ddng vao tiln trinh lien xuong ddng thdi cho phep manh ghep tang the tich lam tang tinh vftng cho viing dugc tao hinh [2].
Chuyin co chuc nang la phdu thudt chuyen nguyen mdt co tu do din mdt vi tri khac trong co the, ndi vao cac gdn vung nhdn dl tao mdt don vi co van ddng, thuc hien
Y HOC VIET NAM THANG 10 - SO 2/2010
chiic nang thay thi cho mdt co hay nhdm co tai cho da mat chuc nang. Co ghep chuyen nay dugc tudi mau thdng qua cudng ddng - tinh mach ciia co dugc ndi vdi ddng - tinh mach vimg nhdn bdng ky thudt vi phdu, thdn kinh van ddng cua co cung dugc ndi bang ky thudt vi phdu vdi mdt thdn kinh van ddng d vimg nhdn de dilu khiln sir co nit co [16].
Mgt sd CO khac nhau dugc cac tac gia dung de chuyen co chuc nang nhu co nguc ldn, co lung rdng, co bung chan..., tuy nhien co thon la CO thudng dugc ua chudng nhdt de tao hinh chiic nang cho chi tren. De cd the chuyen co chiic nang thanh cdng, benh nhdn phai cd (1) Thdn kinh van ddng d vimg nhdn khdng bi thuong tdn, dieu nay cd the xac dinh bang kham lam sang, kich thich dien, thdm chi la md tham dd va sinh thiet than kinh;(2) Cd sdn ddng va tinh mach d vung nhdn, (3) Du da che phii co chuyen; (4) Cac khdp tuong iing cdn mem va gdn tuong iing trugt dugc; (5) Cd cam giac d ban tay; (6) Con chuc nang cdc co ddi khang; va (7) benh nhan cd quyet tdm.
Liic lam phdu thudt chuyen co chuc nang, cdn chii y cac chi tiet ky thudt sau [11]:
• Dat vi tri cua co thon d cang tay lam sao de khoang each tir chd khdu ndi thdn kinh den cho than kinh di vao co la ngan nhdt, khoang 2 -3 cm. Thdn kinh van ddng co thon cd 60% md md va md lien ket do dd nen khdu ndi thdn kinh kieu bd hay nhdm bd.
• Khdu cac gdn gdp sdu lai vdi nhau de cac ngdn d tu the gdp tu nhien tang dan tir ngdn 1 din ngdn 5 rdi khdu ben vao gdn co thon. Chii y cdn tranh khuynh hudng khau gan gdp ngdn cai qua cang lam ngdn cai se gdp vao trudc can trd ddng tac gdp cac ngdn tay.
• Dilu chinh do cdng co thon thich hgp bdng each: (1) Liic chua cat rdi co thon, d tu
thi dang dui va dudi gdi, khdu cac mui chi ddnh ddu each quang 5cm tren be mat co. (2) 6 cang tay, sau khi khdu nguyen iiy co thon vao mdm tren ldi cdu ngoai, keo cang co thon xudng dudi cho den khi khoang each gifta cac ndt chi danh ddu la 5cm, vdi cd tay va cac ngdn tay d tu the dudi thang, danh ddu vi tri tuong img d co thon & cdc gdn gdp sdu;
(3) Khau gdn d vi tri da ddnh ddu trong liic cd tay va cdc ngdn tay gdp de tranh cang
Day la mdt tru:dng hgp ddc biet, dugc dieu tri kien tri trong 4 nam vdi 12 cugc md.
IV. KET LUAN
Bao cao nay trinh bay mdt trudng hgp CEK bi bd sdt, dugc dieu tri trong thdi gian 4 ndm vdi 12 cugc phau thudt, trong dd cd 2 cugc md vi phdu - ghep xuong mac tu do va chuyen co thon chuc nang da mang lai ket qud la: (1) Bdo tdn dugc cang va ban tay, (2) Phuc hdi dugc mdt sd chuc ndng co bdn ciia ban tay mac du van cdn mdt sd bien dang va mdt mdt sd chuc ndng khac. Dieu nay ndi len kha nang cd the tao hinh va phuc hdi mdt sd chuc ndng co bdn cho cac tdn thuang phiic tap d chi tren bdng ky thudt vi phdu khi cd mdt chiln thuat dilu tri hgp ly, tuy nhien khdng phai mgi trudng hgp deu cd the bao tdn dugc chi va khdi phuc dugc hoan todn ve mat gidi phdu va chiic nang. Trong trudng hgp nay, tu ddu neu hdi chiing CEK dugc chdn doan va xu tri kip thdi thi chac chan ket qua diu tri se tdt hon va da khdng phdi thuc hien mdt chuoi dieu tri phuc tap, ldu dai va tdn kem.
TAI LIEU T H A M KHAO
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HOI CHAN THUONG CHJNH HINH VIET NAM - HOI NGHj KHOA HOC TOAN QUOC LAN T H U IX
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Functioning Free Muscle Transfers. Hand Clin 23 (2007): 57-72