目录

HE Ren-liang, LI Feng-chun, CHENG Peng
Affilitions: Department of Skin Burns, Traumas and Ulcers, Huangpu People's Hospital of Zhongshan City, Zhongshan 528429, Guangdong Province, China

【Abstract】　Objective　To observe the effect of MEBO in repairing skin soft tissue defect of distal fingers. Methods　A total of 174 fingers in 105 cases with distal finger skin soft tissue injury were treated with MEBO after simple wound debridement. Results　All the 174 fingers of 105 cases were repaired with a favorable rate of 87.93%, and no case required skin grafting or flap repair. Conclusion　MEBO has favorable effect on the skin soft tissue injury of distal fingers, especially on the defect of the V area.
【Key words】　MEBO; Distal finger; Skin soft tissue injury; Treatment

Of the emergency traumas, hand injuries account for a percentage of 15.0% to 28.6%[1,2], while of the emergency bone traumas, hand injuries account for 40%[3]. Moreover, soft tissue injuries of the fingertips occur more frequently, accompanied by soft tissue defect and bone exposure. Traditionally, the degloving injury of fingertips is treated by residual wound repairing or pedicled skin tube repairing, but the post-operative restoration of the outline and function is unfavorable[4]. From March 2005 to March 2010, we used MEBO to treat 174 fingers of 105 patients with fingertip soft tissue injuries and the clinical efficacy was very good. Unnecessary finger amputation was avoided and the lengths and functions of the fingers were remained. We report the cases as follows.
1.  Clinical data
1.1. General data
We treated 174 fingers from 105 patients, including 72 males and 33 females of 4 to 61 years old. We found single finger injury in 127 cases, double fingers injuries in 19 cases and three fingers injuries in 3 cases (Injuries caused by extrusion of the whole hand). There were injuries with 31 thumbs, 64 index fingers, 52 middle fingers and a total of 27 ring fingers and little fingers. The injuries were mainly caused by cutting, punching and extrusion, chainsaw, stone pounding, etc.
1.2. Classification and grading criteria
In accordance to the classification criteria of distal finger defect by XIANG Li-yuan et al[5],  there are five zones and three grades based on the wound surface and injury types, i.e. Zone I: from the distal 1/3 area of the middle phalanx to the proximal  margin of distal finger joint capsule; Zone II: distal finger joint surface (interior joint capsule); Zone III: from distal side of distal finger joint capsule to free margin of posterior nail fold; Zone IV: form free margin of posterior nail fold to 1/2 nail; Zone V: from the 1/2 nail to the distal end. Grade A: The severed surface is neat without finger contusion; Grade B: The severed surface is not neat with defect and obvious finger contusion, but the blood vessel defect can be covered by shortening phalanx; Grade C: The finger is injured severely by contusion or avulsion, and the soft tissue defect needs tissue grafting or shifting repair.
2.  Methods
2.1. Wound debridement, hemostasis and fixation: Perform debridement under sterile condition, use of hydrogen peroxide and other strong stimulant disinfectant should be avoided. The contaminations should be removed carefully from the wound while retaining and protecting viable skin soft tissue. Try to avoid shortening the exposed phalanx and causing new active bleeding while doing debridement. Use Kirschner wire to do intramedullary fixation of the bone fracture, in order to reduce the damage to the blood transportation of the exposed phalanx. Repair the severed tendon and simply suture the viable soft tissue, avoiding skin grafting on the skin and soft tissue defect. If there was active bleeding after wound debridement, loosen the suture in the premise of effective hemostasis in order to guarantee the local blood transportation. Once the bleeding was stopped, remove the stitches as soon as possible.
2.2. Smear MEBO on the wound in the thickness of 1mm, and dress the wound for hemostasis with MEBO oil gauze (every tube of MEBO can be used to prepare 3 pieces of sterile oil gauze). Uncover the dressing after 24h to expose the wound and continue using MEBO once every 4 h~6 h, or keep bandaging method with MEBO dressing changed twice a day. Generally, retrograde and severely contused soft tissues got dark into necrosis in 2 d~7 d, when timely remove necrotic tissues to create a favorable condition for wound regeneration. With the time going, newly growing granulation tissues could be observed on the surface and peripheral area of the exposed bone as well as in the medullary cavity of extremities, covering the exposed phalanx and tendon. With the white epithelial tissue growing around the wound, the wound healed gradually. The longest duration of treatment was up to 3 months.
2.3. Systemic treatment: Administer routinely tetanus antitoxin 1500 IU by intramuscular injection after the reception of negative result of skin test; a dose of 3000 IU was applied for wounds severely contaminated or injured for more than 8h. Then apply penicillin or clindamycin antibiotics by i.m. or i.v. based on the bacteria epidemic report provided by the infectious department of the attending hospital as well as the history of antibiotic use of patients. For fresh wound, apply the above antibiotics in full dose once before debridement, and then continue using for 5 d～7 d and terminate.  Then selectively use antibiotics according to the wound condition and bacteria test. For wounds severely contaminated or injured for more than 8 h, continue using antibiotics until no flare or cellulitis of the wound occurred[6].
2.4. Efficacy assessment criteria
Excellent: Wound healed without scar, the injured finger retained the length without ankylosis, the nail and finger print was intact, finger tip was in rich of nerves, whose function restored fast after treatment with two point discrimination between 2 mm~4 mm; Good: Wound healed  without obvious scar, the injured finger was shortened but beyond the wound level with part nail and finger print restored; Acceptable: The wound healed on the original injury site with obvious scar, the injured finger was shortened with part nail and finger print restored; Poor: The wound could not heal and required skin grafting or skin flap transfer repairing.
3.  Results
All the patients healed with an average healing duration of 5 w, the longest being three months; no case needed skin grafting or skin flap transfer repairing. See table 1~2 below.

注：1. 因为结果中均无疗效等级“差”，本表中省略；
2. 全组总体愈合优秀率为63.8%，优良合并率达87.9%；
3. 愈合优良率与手指末节损伤程度有关，Ⅰ、Ⅱ、Ⅲ区损伤的优秀愈合率均低于50%，而Ⅳ、Ⅴ区的愈合优良率达100%。
Note: 1. For no “poor” was available in results, the table didn't list it.
2. The total excellent rate of the whole group was 63.8%, and the combined rate 87.9%.
3. The combined rate was related to the degrees of distal finger injuries, the excellent healing rate of injury in Zone I, II, III was all below 50% while the combined rate of Zone IV, V was 100%.

4.  Discussion
4.1. The irreversible loss of local blood supply of the injured area is the only and definite indication to early stage amputation[7]. Phalangette injury is common in clinic. Due to the hand and forearm are lack of subcutaneous soft tissue, it’s likely to have blood vessel, nerve and tendon injury, open articulation or bone exposure occurring after injury. Stage II surgery is always required by the conventional repairing method, and the current popular methods include various sub-dermal vasoganglion skin flap repairing surgeries[8] aimed at protecting finger outline and functions and adjacent finger or palm pedicled skin flap repairing surgery[8], as well as finger stump debridement and sutura surgery not focusing on protecting finger outline and functions by thorough debridement of necrotic tissues and contused tissues, removing phalanx debris of the stump and burnishing the surface, and then directly perform sutura to close the wound. The former one requires not only equipments, but the mastery of technique and experience on micro-surgery of the surgeon, as well as the condition of the donor site and the grafted site. Some even hold that the fresh wound with good basal blood supply is the only indication of sub-dermal vasoganglion skin flap repairing surgery[9]. The latter one is likely to cause the stump shortened and consequently lead to deformity, outline disfigurement and dysfunction of the finger though it requires less on the surgery procedure, surgeon and the equipment. When adjacent finger or palm pedicled skin flap repairing surgery is applied, the surgical area may be expanded with longer surgical duration and higher expense; moreover, such surgery cannot be applied to wound with severe complex injuries. It’s noted by WEI Jia-guo et al[10] that the phalangette soft tissue contusion injury always damages the blood transportation of the soft tissue, causing ischemia and necrosis, and the blood supply of the phalangette endosteum and periosteum hasn’t been damaged completely at early stage. Early application of MEBT/MEBO should be performed to maximumly protect the blood transportation and prevent necrosis of the phalangette, which benefits bone granulation tissue growth and promotes wound healing. It’s important to preserve the length of the injured finger, and do not hurry to shorten phalangette and harm the hand function simply because of the ischemia and defect of the soft tissue.
4.2. MEBO can eliminate necrotic tissue and promote granulation tissue growth as well as reepithelialization. We obtained favorable clinical results in treating phalangette ischemia and necrosis with MEBO[11]. In addition, we found that application of MEBO immediately after debridement of phalangette injury wound with soft tissue defect and suspected soft tissue ischemia and necrosis may reduce the necrosis area, avoid dryness and necrosis of the exposed phalanx and tendon, as well as accelerate wound healing time. Based on the study result that MEBO could sustain the survival and proliferation of gastric and intestinal tissue explant of embryonic white mouse in vitro[12～13], it is safe to infer that early application of MEBO could survive the ischemic agonal tissue cells, reduce necrotic area and shorten wound healing time.
4.3. MEBO is effective on infection control by inducing the heteromorphosis of E. coli, bacillus proteus, staphylococcus aureus and pseudomonas aeruginosa with depigmentation of pseudomonas aeruginosa and debilitation of productive ability of plasma coagulase of staphylococcus aureus, consequently decreasing the speed of bacteria metabolism and synthesis, interfering their growth and multiplication as well as toxicity action[14]. Excessive debridement, local blood transportation damage and strong disinfectants could impair the regenerative functions of tissue cells, and consequently may increase the local infection rate as well as decrease the wound healing quality. Thus, we suggest that strongly irritative disinfectant or excessive debridement should be avoided in order to protect the blood transportation. During MEBO application, follow the principle of application, i.e. “three no” and “three timely” principle. MEBO is effective on skin soft tissue defect of Zone V of phalangette, and for injuries and defect on the joint and cross-joint site, MEBO could repair the injured wound, but not the joint defect. Therefore, it is recommended phalangette defect at the proximate end of the joint be treated by surgery if it has surgical indication.
4.4. In the past studies, we divided the regenerative repairing process of phalangette defect into four stages: stage of wound necrosis, stage of necrotic tissue liquefaction, stage of granulation proliferation and stage of wound skin regeneration[6]. However, such classification in the repairing process of phalangette soft tissue defect of Zone V is not as distinguishable as in that of Zone I~Zone IV. Sometimes, such classification may overlap with each other.

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Received Jan. 31, 2011