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[临床医学影像]:骨筋膜室综合征
2017年11月21日 临床影像, 临床话题 暂无评论

IMAGES IN CLINICAL MEDICINE

Compartment Syndrome

Aileen F. Egan, M.B., B.A.O., M.Ch., and Kevin C. Cahill, M.D.

N Engl J Med 2017; 377:1877 November 9, 2017

DOI: 10.1056/NEJMicm1701729

A 26-year-old man presented to the emergency department with a painful, swollen left hand (Panel A). He had been lying on the ground for more than 13 hours after using illicit drugs. The physical examination revealed edema in the left hand and forearm. Active and passive motion of the hand was limited by pain. Sensation was diminished in distributions of the median, ulnar, and radial nerves. Capillary refilling was delayed; the ulnar pulse was palpable, but the radial pulse was undetectable. Laboratory analyses revealed a creatine kinase level of 21,500 U per liter (normal range, 38 to 309). Emergency surgical decompression under tourniquet control showed a demarcation between perfused muscle fibers and ischemic, pale, noncontractile muscle (Panel B, arrow). Perfusion was restored after decompression and release of the tourniquet (Panel C). The compartment syndrome occurs after crush trauma injury or prolonged immobilization, as in this patient. Prompt surgical decompression is critical to reperfuse ischemic muscles and nerves in the compartment. However, even delayed decompression, as in this case, may have the potential to restore perfusion, although full recovery of nerves and muscles may be limited. A second operation that was performed 48 hours after the first procedure showed viable muscle tissue, and the wound was covered with a split-thickness skin graft. The patient did not participate in recommended hand therapy, and hand stiffness and paresthesia persisted. He was subsequently lost to follow-up.

一名26岁男性患者因左手疼痛肿胀到急诊就诊(图A)。吸毒后患者在地上躺了13个小时以上。体格检查发现左手及前臂水肿。因疼痛左手的主动及被动运动受限。正中神经、尺神经及挠神经分布区域感觉减退。毛细血管再充盈事件延长;尺动脉脉搏可扪及,但挠动脉脉搏无法扪及。实验室检查显示肌酸激酶21500 U/L(正常范围38-309)。在止血带加压下进行了急诊外科减压术,术中发现灌注良好的肌纤维及缺血、苍白、无收缩性的肌肉之间界限明显(图B,箭头)。减压并解除止血带加压后灌注恢复(图C)。挤压伤或长时间制动后可发生骨筋膜室综合征,正如此例患者。立即进行手术减压对于筋膜室中缺血的肌肉和神经恢复灌注非常重要。然而,即使减压手术延迟进行,正如此例,也仍然可能恢复灌注,尽管神经和肌肉的完全恢复可能受到影响。第一次手术48小时后进行了第二次手术,术中发现肌肉组织活力恢复,遂采用中厚皮片覆盖伤口。患者未参加医生推荐的手部治疗,手部的僵硬和感觉异常持续存在。随后患者失访。

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