创伤性截肢的适应证与手术原则探讨

截肢是肢体严重损伤时的一个重要治疗方法,在决定截肢与肢体挽救时受到多方面因素的影响,但在相当程度取决于原发损伤的严重性。目前还没有一个明确的截肢适应证标准,需要一个客观的对肢体估价的方法以明确是否行截肢术,损毁肢体严重程度评分MESS（mangled extremity security score）有较大的临床指导意义。截肢虽是一种破坏性手术,也是一种重建与修复手术,同样遵守矫形外科手术的基本原则。当肢体损伤必须截肢时,要认真周密地设计、仔细地组织处理,在满足治疗的前提下,合理保存肢体长度,最大限度地保留患肢功能,获得较为理想的残肢,以使装配的假肢发挥最佳的功能。严格创伤截肢的标准,掌握截肢的手术原则,了解假肢的安装要求,与患者及家属的积极沟通,进行必要的会诊,是截肢手术医生必须要做到的。     

我观故我在？— 从橡胶手错觉对自我身体所有权的探讨

橡胶手错觉是一种能将非自我的肢体感知为自我的肢体的反应。继发现橡胶手错觉现象后,研究者通过操纵自变量以及观测不同的因变量,得到了大量新的研究结果。橡胶手错觉的出现与强度受到时间、空间和手姿势的影响。橡胶手错觉的产生机制为单纯的多感觉整合或多感觉整合与身体表征共同作用的结果。未来研究侧重于被试取样、研究策略以及医学领域中瘫痪患者的认知神经康复和截肢病人的假肢控制方面。     

创伤截肢家庭护理与心理疏导

创伤截肢术后给患者带来不同程度的躯体残疾和缺陷,同时使患者产生巨大的心理压力,做好创伤截肢患者家庭护理与心理疏导非常关键。在慢性康复期,要关注患者的心理应激反应,纠正其认识偏差,减轻“自避”行为,消除“患肢痛”幻觉;在家庭康复护理过程中,要建立和谐的康复环境,训练其自我照顾及运动功能,预防各种并发症的发生。使患者尽快恢复身心健康,重新回归社会。     

儿童创伤截肢

儿童意外伤害在国内外一直是受到普遍重视的问题,我国在这这方面的研究不多。严重肢体创伤的处理无论从专业理论还是在手术技巧上均要求很高,尤其对儿童肢体的毁损性创伤的治疗往往使临床医师常需在截肢与肢体挽救二者之间作出困难的选择。如何确定急诊截肢和保留肢体,国内外目前尚未有一个客观合理权威的标准。本文主要综述儿童截肢的标准和方法,以供参考。     

导言：外固定与肢体重建——符合生态医学的新学科

29岁的内蒙古青年,15年前车祸伤致小腿肌肉广泛坏死,遗留整个小腿皮包骨头,重度马蹄内翻足,用足背负重行走,去过多个大医院检查都建议膝关节下截肢,在秦泗河的矫形骨科用细钢针穿骨安装骨外固定器（Ilizarov环式外固定器）,术后通过缓慢牵伸,足内翻畸形完全矫正,可以用足底全负重弃拐行走,避免了截肢。在秦泗河矫形外科用这项技术治疗的5000多例患者中,已经挽救了30多例濒临截肢的下肢残缺畸形,使许多无望、悲观的患者重新迈上了新生活。     

地震伤截肢纪实与感悟

笔者亲身经历了“5·12”四川汶川8．0级特大地震中救治地震伤员的医疗工作,结合相关的创伤性截肢的一些经验和一些感悟,初步分析了地震伤员的创伤性截肢的特点、原因以及创面处理的一些措施和原则,以期与同道共同探讨类似突发性、群发性伤害事件中更加有效的救治措施。     

导言：创伤性截肢术简介

汶川大地震造成突发性、群体性肢体毁损。在救治工作中,为挽救部分患者的生命,接受伤员的医院对他们施行了截肢术。为配合医治此类伤员的需要,编辑部委托本刊编委秦泗河教授就此组织了一组文章。我们对秦泗河教授和各位撰文的专家表示衷心的感谢!     

断腿舞者舞出精彩人生

[人民网] 廖智,一名普通舞蹈老师,在5·12汶川大地震中失去了双腿和女儿.然而,她没有被灾难打垮,截肢手术仅过了一个月,她忍受痛苦重新开始练舞.2008年7月她重返舞台,用残缺的肢体演绎了献给灾区人民的《鼓舞》.受灾后得到的帮助,让她决心成为志愿者帮助他人,她一次次参加义演、为灾区募捐、从事临终关怀、为病人做心理咨询、为孤寡老人募捐筹建养老院……4·20芦山地震后,廖智也奔赴抢险救灾一线,为灾区民众搭帐篷、发物资,被赞为"最美志愿者".     

我的导师是病人

从事矫形外科(骨科)30余年,主持实施各种肢体残疾、骨科疑难杂症的外科手术治疗2万多例,在矫形外科领域创造了多个国际和全国第一,形成了具有中国特色、疗效奇特、医疗费低廉的下肢残缺修复与功能重建技术体系,我的系列创新、专业发展,身心与文化成长经历证明了一个道理——患者是我的导师。     

学会健“心”

随着现代医学和生物工程技术的飞速发展,下一个世纪的残疾人将不是那些肢体残缺者,癌症和爱滋病等也将不再成为绝症。然而,一种无形的杀手正在向人类社会逼近,它,就是“心理病”。     

Preliminary evidence for a fronto‐parietal dysfunction in able‐bodied participants with a desire for limb amputation

Background. Reports of able‐bodied participants with the persisting desire for limb amputation raise legal and ethical questions that are partly due to insufficient empirical knowledge about the condition. Here, we searched for potential neurological mechanisms in participants with desire for limb amputation in order to help develop adequate nosological classifications, diagnosis, and treatment. Methods. Semi‐structured interviews were carried out with 20 participants who self‐identified themselves as able‐bodied individuals desiring amputation of a limb. Results. The results suggest that amputation desire is not unspecific, but in most cases specific for a circumscribed part of the body. Most frequently affected was the leg, mostly on the left, non‐dominant side. Left‐sidedness and limb specificity was associated with elementary and complex somatosensory disturbances of the affected limb akin to those reported by neurological patients. The most frequent neurological co‐morbidity was migraine headache. Conclusions. These results document the existence of an unusual condition in able‐bodied participants characterized by a person's desire for the amputation of one or more particular limbs. Left‐sidedness, limb specificity and somatosensory disturbances of the affected limb are suggestive of abnormal brain mechanisms in right fronto‐parietal cortex. Based on this association we suggest that desire for limb amputation may be conceptualized as asomatognosia due to disturbed integration of multi‐sensory information of the affected body parts into a coherent cerebral representation of the own body. This suggestion has to be regarded with caution as we did not perform any neurological examination.     

骨外固定——微创肢体重建的利器

骨外固定以其独特的环形、铰链和螺杆等的简单构型,用于复杂创伤及创伤后遗症,复杂的肢体畸形的治疗,可以获得其他方法不可比拟的效果,堪称肢体重建的一把利器.本文从以胫腓骨中段的短斜型闭合骨折为例,详细阐述了外固定器治疗骨折的优势.以复杂的足踝畸形病例为例,阐释了以Ilizarov技术为代表的骨外固定用于肢体畸形矫正并创造神奇效果的秘密.骨外固定顺应了肢体损伤、肢体畸形发生发展的客观规律,由外而内,提供一个适宜的重建方向,符合生物学要求,可以实现骨与软组织的自然修复与重建.     

骨巨细胞瘤外科治疗几个问题的思考

骨巨细胞瘤是临床上常见的骨肿瘤,其治疗方式由以前的截肢术发展到保肢术,一直到现在的多种局部切除与功能重建方式,透过其治疗理念的更新,以及手术技术的转变,不难看出临床医生应重视循证医学实践,不断更新观念,坚持个体化治疗,明确切除范围、切除方式与重建方法及肢体功能之间的关系,不断改善患者的生活质量。     

Feeling the burn: When it looks like it hurts,and belongs to me,it really does hurt more

We examined changes in pain sensitivity in the rubber hand illusion (RHI). Experiment 1 investigated changes in pain tolerance immediately after a “healthy” and “wounded” RHI when immersing the hand in a cold pressor ice bath. There was 19% increased pain tolerance and increased perception detection threshold after the healthy RHI, but 11% reduction after the wounded RHI. Experiment 2 examined pain experience during the wounded RHI with capsaicin-induced hyperalgesia. Pain intensity and unpleasantness was higher on the illusion arm during the synchronous RHI, compared with asynchronous trials. There was no change in pain experience on the control arm, and both arms had similar pain sensitivity after the experiment. Our results highlight the impact of embodying a substitute limb on pain, with increased tolerance and reduced tactile sensitivity when the fake limb is healthy and apparently pain-free, but increased pain sensitivity when the self-attributed limb appears to be wounded.     

Attention Demands in Balance Recovery following Lower Limb Amputation

The attention demands in balance control after damage to the peripheral sensorimotor system were studied in 12 persons with a recent lower limb amputation. The interference of an arithmetic task with two postural tasks of different complexity (quiet standing and active weight shifting) was examined several times during their rehabilitation while the subjects stood on a force platform. Control data were obtained from healthy subjects. For both postural tasks, persons with amputation performed worse than controls. Quiet standing, a relatively simple task, revealed clear dual-task interference only in the amputation group. Evidence was found for a reduction in dual-task interference as rehabilitation progressed. In contrast, voluntary (feedback-controlled) weight shifting, a more complex task, revealed an equal amount of dual-task interference in persons with amputation and in controls, without changes in interference over the period of rehabilitation. The results indicate that attentional mechanisms may be involved in postural control, depending on both the novelty and complexity of the task. Moreover, a reduction in attention demands of quiet standing may reflect a central adaptation of the postural organization to the peripheral sensorimotor impairments caused by lower limb amputation.     

Attention demands in balance recovery following lower limb amputation

The attention demands in balance control after damage to the peripheral sensorimotor system were studied in 12 persons with a recent lower limb amputation. The interference of an arithmetic task with two postural tasks of different complexity (quiet standing and active weight shifting) was examined several times during their rehabilitation while the subjects stood on a force platform. Control data were obtained from healthy subjects. For both postural tasks, persons with amputation performed worse than controls. Quiet standing, a relatively simple task, revealed clear dual-task interference only in the amputation group. Evidence was found for a reduction in dual-task interference as rehabilitation progressed. In contrast, voluntary (feedback-controlled) weight shifting, a more complex task, revealed an equal amount of dual-task interference in persons with amputation and in controls, without changes in interference over the period of rehabilitation. The results indicate that attentional mechanisms may be involved in postural control, depending on both the novelty and complexity of the task. Moreover a reduction in attention demands of quiet standing may reflect a central adaptation of the postural organization to the peripheral sensorimotor impairments caused by lower limb amputation.     

Body Integrity Identity Disorder: From A Psychological to A Neurological Syndrome

Body Integrity Identity Disorder (BIID) is a condition in which individuals experience an intense desire for amputation of an healthy limb. Recently, McGeoch and colleagues provided the first direct evidence that this syndrome may be neurological rather than psychological in its origin. However, before including BIID in body ownership disorders, several concerns should be clarified, exploring other components of body representation and not only somatosensory perception.     

Working through. A process of restitution.

A number of authors, including Freud, have written about the process of working through but have left unsettled what is actually involved. I have attempted to outline the step-by-step process of working through, starting with recollection and repetition and ending with restitution and resolution. I have introduced the term restitution in order to give more importance to an already existing step in the working-throught process; it should not be looked upon as an artificial device. Restitution allows the patient to find appropriate gratification in present reality, and this helps him to relinquish the past. Rather than allowing the patient to "wallow in the muck of guilt," as Eveoleen Rexford suggests society "wallows" in its inability to help its children, restitution gives appropriate direction for change. It is a natural step in the successful resolution of treatment.