上交大外科学课件12皮肤与软组织外科伤病

皮肤与软组织外科伤病

disordersofskinand

subcutaneoustissue

Chapter1皮肤的解剖

AnatomyofSkin皮肤的组成1、表皮（epidermis)2、真皮（dermis)血管、淋巴管、神经末梢及大、小汗腺、皮脂腺3、皮下组织(subcutaneousfattissue)毛囊、甲等附属器Chapter2TraumaofskinandsofttissueLacerations撕裂伤andFingertip指尖andComplexSoftTissueInjuries1、Sprain扭伤2、contusion挫伤

3、Prickingwound刺伤4、Foreignbody异物5、Incisedwound割裂伤6、Bitesandstings叮咬伤Sprain扭伤、contusion挫伤鈍性暴力软组织闭合性损伤肿胀、疼痛、皮下淤血，甚至关节活动障碍24H内不宜热敷及活血化瘀关节扭伤需固定2周Prickingwound刺伤、Foreignbody异物锐器戳刺皮肤伤口小易造成深部组织损伤易继发化脓性感染和破伤风伤口处理术后应用抗生素及破伤风抗毒素异物：透光、不透光Incisedwound割裂伤锐器割裂大血管破裂致休克神经损伤致运动感觉丧失肌腱损伤致运动障碍伤口处理包括神经肌腱术后应用抗生素及破伤风抗毒素Bitesandstings叮咬伤

兽咬伤animalbites清创：3%过氧化氢、生理盐水原则上不一期缝合伤口术后应用抗生素及破伤风抗毒素、狂犬疫苗毒蛇咬伤snakebites神经毒：延髓及脊神经细胞，0.5~2H呼吸肌麻痹。

金环蛇、银环蛇血液毒:溶组织、溶血及抗凝作用致组织坏死感染。

竹叶青、五步蛇阻断静脉血、淋巴液回流、清创服用蛇药：南通季得胜蛇药、广州何晓生蛇药口服10#T.I.D或外用应用抗生素及破伤风抗毒素、抗蛇毒血清气管切开蜂螫伤beestings：过敏反应及组织损害蜈蚣咬伤centipedebites：同上蝎螫伤scorpionstings：类似毒蛇咬伤局部处理：挑出蜂刺，避免挤压全身处理:补液、肾上腺皮质激素、抗组胺药SurgicalWoundTypesClassificationTypeI(Clean):infectionrisk1to5%TypeII(Clean-contaminated):infectionrisk5to10%TypeIII(Contaminated):infectionrisk10to15%TypeIV(Dirty):infectionrisk30to50%SurgicalWoundTypesClassification(continued)TypeI(Clean)NontraumaticNoinflammationpresent无炎症表现TypeII(Clean-contaminated)Nonsterilebodyregion体内无菌环境entered(gastro-intestinal胃肠道,urogenital生殖道,biliarytract胆道orrespiratorytract呼吸道,oropharynx鼻咽道,etc.)TypeIII:ContaminatedWoundsGrossspillage溢出fromgastro-intestinaltractInfectedgastro-intestinal,urogenital生殖道orbiliarytractenteredFreshtraumaticwound(throughunpreparedskin未消毒的皮肤)TypeIV:DirtyWoundsWoundsassociatedwithperforatedviscus内脏(stomach,bowel,gallbladder)Traumaticwoundswith:Imbeddedforeignbody异物植入Fecalcontamination粪便污染Delayedpresentation>12to24hoursforfaceorscalp>6hourselsewhereonbodyProperSequenceofStepsforRoutineWoundCare&Repair1.Adequatelyexposethewoundarea充分暴露创面2.Removesuperficialcontaminants(gravel,etc.)浅表污染物去除3.Cleansearoundthewound伤口清洗4.Considerlocalhairremoval局部备皮

usuallydonotneedtoremovehair(canjustslickitdown withbetadineorK-Yjelly聚维酮碘及K-Y胶冻剂消毒) shavingincreaseswoundinfectionrates localshavingcausestemporarycosmeticproblem NEVERshaveaneyebrow眉毛(itmightnotgrowback)不剔除眉毛（由于眉毛不会生长）ProperSequenceofStepsforWoundCare&Repair(cont.)5.Irrigate冲洗thewound(mostimportantstepforreducing bacterialcountsinthewound)6.Reprepwoundedges伤口周围消毒切口消毒区域大于切7.Drapethewound冲洗伤口伤口铺巾8.Locallyanesthetizethewound局部麻醉9.Close(suture)thewound缝合伤口10.Dressandbandagethewound包扎伤口11.Instructthepatientinfollow-upwoundcare指导患者随访指导患者随访Chapter3SuperficialInfection浅表软组织感染HighRiskFactorsObesity肥胖Diabetes糖尿病Poorhygienecondition卫生条件不理想Intravenousdrugs静脉补液疖（Furuncle)单个毛囊及其所属皮脂腺的急性化脓性感染，常扩展至皮下组织Infectioninvolvinganentirehairfollicle&theunderlyingskintissue

Infectioninvolvinganentirehairfollicleandtheunderlyingskintissue

病原体Pathogens葡萄球菌（Staphylococci）grampositivebacteriaproducingbetahemolysinsandenzymessuppurationandcharacteristicthick,yellowpuswithoutfoulsmelling金黄色葡萄球菌（S.aureus）

furuncle&carbuncle表皮葡萄球菌（S.epidermidis）aftersurgerywithforeignmaterial疖——临床表现

Clinicalfindings

ofFuruncleBackoftheneck（颈背部）Face（脸）Buttocks（臀部）Thighs（大腿）Groin（腹股沟）Breast（乳房）Theunderarmarea（腋下）好发部位疖——临床表现

Clinicalfindings

ofFuruncle红（shiny,brightred）肿（raised）触痛（tender）张力增高（intense）跳痛（throbbingpain）黄色或白色的渗出液yelloworwhitecreamydischarge(matured)疖——临床表现

Clinicalfindings

ofFuruncle疖——临床表现

Clinicalfindings

ofFuruncle危险三角区全身症状不明显危险三角区感染－－内眦V、眼V－－化脓性海绵状静脉窦炎Localtreatment——fomentation热敷及鱼石脂软膏Surgicalincisiondrainage——maturation、fluctuation波动感Antibiotics——systemicsymptomAvoidcompression挤压——diffusion扩散疖——治疗原则

TreatmentofFuruncle痈Carbuncle多个相邻毛囊及其所属皮脂腺、汗腺的急性化脓性感染，或由多个疖融合而成Aconfluent融合infectioninvolvingmultiplecontiguous相邻的follicles毛囊inwhichtheinfectionislimitedtothesubcutaneoustissuebythickoverlyingskinanddensesubcutaneousfascia好发于厚韧皮肤部位——颈项、背部对口疮搭背痈——临床表现

ClinicalFindingsofCarbuncle痛（Pain）肿（Swelling）硬块（Indurationofthesurroundingskin）多个小脓头（Multiplesmallabscess）黄色脓液（Yellowthickpus）痈——临床表现

ClinicalFindingsofCarbuncle

发热（Fever）全身乏力（Fatigue）白细胞升高（Leukocytosis）脓毒症（Sepsis）痈——临床表现ClinicalFindingsofCarbuncle

全身症状明显Warm,moistcompresses（热敷）helptopromotedrainage

Surgicalincisiondrainage（外科引流）Large&deepenoughincision唇痈不宜切开引流－化脓性海绵状静脉窦炎Antibiotics（抗菌素）Penicillin（青霉素）Erythromycin（红霉素）Clindamycin（克林霉素）痈——治疗原则

TtreatmentofCarbuncle

Management：Surgicaldrainage疖、痈——预防（Prevention）goodhygiene（良好的卫生习惯）useofantibacterialsoap（抗菌肥皂）avoidingintravenousdruguse（避免静脉用药）wearinglooseclothingthatallowsairtocirculate（宽松透气服装）急性蜂窝织炎

AcuteCellulitis，Phlegmon皮下、筋膜下、肌间隙、深部蜂窝组织的化脓性感染溶血性链球菌、金葡菌、厌氧菌发展迅速、不易局限、边界不清acutespreadinginfectionofthedermis&subcutaneoustissuesresultinginpain,erythema,edema,andwarmth病原体Pathogens最常见A型溶血性链球菌（groupAStreptococci）葡萄球菌（Staphylococcusaureus）婴儿（infants）

B型溶血性链球菌（groupBStreptococci）免疫力低下（Immunocompromised）肺炎球菌（Pneumococcus）革兰氏阴性杆菌（gram-negativerods）真菌（fungi）创口（Wounds）嗜水气单胞菌（Aeromonashydrophila）革兰氏阴性杆菌（gram-negativerods）急性蜂窝织炎——病史

HistoryofAcuteCellulitis外伤、手术史（traumaorsurgery）皮肤溃破史（causingabreakintheskin）没有明确皮肤外伤史（nodiscernibledermalinjury）

Cellulitis

typicallydevelopsoveraperiodofseveraldays急性蜂窝织炎——临床表现

ClinicalFindingsofAcuteCellulitis浅表Redness（红）Edema（肿）Tenderness（痛）Warmth（热）深部局部水肿、压痛厌氧菌致捻发音性蜂窝组织炎Irregularmarginsbutnotraisedsecond-degreeburnfirst-degreeburn急性蜂窝织炎——临床表现

ClinicalFindingsofAcuteCellulitisAnulceratedareainthecenterIntenseerythemainapatchydistributionPainfulandwarmtothetouchAscendinglymphangitisSeverecellulitis急性蜂窝织炎——治疗

TreatmentofAcuteCellulitis抗生素（Antibiotics）penicillinase-resistantsyntheticpenicillinfirst-generationcephalosporin一代头孢Clindamycin克林霉素Metronidazole甲硝唑热敷（Warm,moistcompresses）不能控制者需作广泛多处切开引流口底、颌下—－及早气管切开防止喉头水肿捻发音性蜂窝组织炎及早切开引流、切除坏死组织，伤口予3%过氧化氢冲洗丹毒

Erysipelas皮肤和粘膜网状淋巴管的急性炎症（askininfectionInvolvingdermisandlymphatics）Β-溶血性链球菌（beta-hemolyticstreptococci）丹毒

Erysipelaslowerextremitiesin70-80%faceaffectedin5-20%全身反应剧烈（Systemicinfectiousmanifestations）Initialfeverandchills(发热)Muscleandjointpain（肌肉关节酸痛）Nausea（恶心）Headache（头痛）组织坏死、化脓少见容易复发丹毒

——临床表现

Clinicalfindings

ofErysipelas丹毒——临床表现

Clinicalfindings

ofErysipelas痛性红疹Painful,Erythematous,EdematousRash浅表性感染、中间较淡moresuperficialsubcutaneousinfectionthancellulitis丹毒

——临床表现

Clinicalfindings

ofErysipelas边界清楚Sharply-raisedborderwithabruptdemarcationfromhealthyadjacentskin丹毒——临床表现

Clinicalfindings

ofErysipelas丹毒——临床表现

Clinicalfindings

ofErysipelas红肿沿淋巴管扩展，可致橡皮肿Erythemaisirregularwithextensionsthatmayfollowlymphaticchannels丹毒——治疗

Treatment

ofErysipelas抬高患处局部50%硫酸镁湿敷Antibiotics（抗生素）——assoonaspossiblePenicillin（青霉素）Erythromycin（红霉素）Cephalexin

（头孢菌素）Symptomatictreatment（对症处理）Antipyretic（退热剂）Analgesics（镇痛剂）处理足癣Gangrene&Amputation坏疽甚至截肢Bacteremia&Sepsis菌血症及脓毒症Scarletfever猩红热Pneumonia肺炎Abscess脓肿Embolism血栓Meningitis脑膜炎Death死亡Complications：Theinfectionoflymphnodes

(glands)usuallyassociatedwiththesiteoftheunderlyinginfection,tumor,inflammationcommonresultofacellulitis蜂窝织炎orotherbacteriainfectionLymphadenitis淋巴结炎：Characteristicswollen,tender,hardnodes肿、压痛、硬结smoothorirregulartotouch表面光滑或不规则orsoftand“rubbery”(fluctuant)ifanabscesshasformed质软、韧，脓肿形成时呈波动感theskinoveranodemaybereddenedandhot皮肤红、皮温高Lymphadenitis：Signs&SymptomsInfectionoflymphvessels/channelsCommonlyresultsfromcellulitis蜂窝织炎orabscess

intheskinorsofttissuesAprogressinginfectionraisingspreadofbacteriatothebloodstreamlife-threateninginfections

Be

confusedwitha

clotinavein(thrombophlebitis)易于血栓性静脉炎混淆Lymphangitis管状淋巴管炎LYMPHANGITISredstreaks浅层淋巴管炎可出现红线frominfectedareatothearmpit腋窝orgroin腹股沟throbbingpain搏动性疼痛alongtheaffectedarealymphnodes

feverandchills

malaise,lossofappetite,headache,muscleachesPhysicalexaminationBiopsy(LN)Bloodculture血培养Lymphadenitisandlymphangitismayspreadwithinhours,spreadingtothebloodstreammaybefatal致命的.Diagnosis：TreatmentshouldbeginpromptlySpecificantibiotics抗生素Surgicaldrainage外科引流Hotmoistcompresses湿热敷Primarydiseasemanagement扁桃体炎、龋齿、手足感染Management：手部急性化脓性感染

HandInfection甲(nail)（角质形成细胞构成）

甲板（外露部）甲床（甲板下）甲甲根（深入近端皮肤、甲根之下甲床甲母质）甲周（甲板周围皮肤甲皱襞）甲半月（新月状淡色区）

1、掌面表皮厚--哑铃状感染2、掌面皮下组织致密--腱鞘炎、骨髓炎3、背面疏松、淋巴引流掌向背—掌不肿、背肿4、组织致密—张力高、疼痛剧烈5、腱鞘、滑囊、间隙互通—感染易蔓延手部感染的特点CharacteristicsofHandInfection手部感染的背景

BackgroundofHandInfection及时、准确地诊断手部感染的来源和位置并非容易Difficulttomakeacorrectdiagnosisforseriousinfectionofnature&position手部的间隙错综复杂Multiplecompartmentsandplanesinhand手部感染是沿着筋膜发展InfectionsaredictatedbyfascialboundariesinhandHandInfection甲沟炎（Paronychia）脓性指头炎（Felon）手掌侧化脓性腱鞘炎（Tenosynovitis）掌深间隙感染（Deepfascialspaceinfections）RecenttraumatolateralnailfoldNailbiting（手指咬伤）Manicuring（修剪手指甲）Dishwashing（洗碗工作）Fingersucking（吮吸手指）

甲沟炎(Paronychia)甲沟炎

Paronychia侧甲褶感染（Infectionofthelateralnailfold）急性蜂窝织炎（Cellulitis）甲床积脓（Eponychia）甲沟炎——临床表现

ClinicalFindingsofParonychiaalonglateraledgeofnailfold

Edema（肿）Erythema（红）Pain（痛）脓肿形成（frankabscessformation）甲沟炎——临床表现

ClinicalFindingsofParonychiaIfnofrankabscess无脓肿形成

frequenthotsoaks&antibiotics

（抗生素+热液浸泡）Ifpusispresent脓肿形成

incisionanddrainage

（切开引流）Ifpushastrackedbeneaththenail甲下有脓

removeanadjacentlongitudinalsection

（部分拔甲）

Ifeponychiaisresulted甲床积脓

removetheentirenailplate

（拔甲术）甲沟炎——治疗原则

TreatmentofParonychia甲沟炎——并发症

ComplicationsofParonychia

Eponychia(甲床积脓)Osteomyelitis（骨髓炎）Felon（指头炎）Chronicinfection（慢性感染）指头炎

Felon末节手指掌面皮下化脓性感染（掌侧）Theinfectionofdistalpalmarphalanx密闭腔（aclosedcompartment）Topreventtheproximalspreadofinfection（防止感染扩散）Toincreasepressurewithintheclosedcompartment（增加密闭腔压力）Toimpairvenousoutflow&leadtoalocalcompartmentsyndrome（室间隔综合征）

osteomyelitis（骨髓炎）指头炎——病理

PathologyofFelon

近期有指垫外伤或甲沟炎史Recenttraumatofingerpadorparonychia典型的手指波动性跳痛TypicallyThrobbingPain手指垫红肿、张力增高Swelling,Pressure,Erythema指头炎——临床表现

ClinicalfindingsofFelon

手指垫红肿、疼痛、张力增高Painful,Tense,Erythematousfingerpad脓肿形成Abscess指间关节受累Thedistalinterphalangealjoint其他手指创伤依据Evidenceofpenetratingtrauma指头炎——临床表现

ClinicalfindingsofFelon

手术指征（indication）手指搏动性跳痛（TypicallyThrobbingPain）脓肿形成（Frankabscess）指垫张力增高（tensefingerpad）指头炎——治疗

TreatmentofFelon

切口（incision）以波动感最明显处为中心作纵行切口近端不超越指节横纹；远端不超越甲沟1/2引流（drainage）用血管钳作钝性分离

填塞（packing）指头炎——治疗

TreatmentofFelon

指头炎——治疗

TreatmentofFelon

ImproperIncisionScarring疤痕sensoryloss感觉减退unnecessarypain疼痛instabilityofthefingerpad指垫不稳定spreadofinfectionintotheadjacenttendonsheath感染向邻近腱鞘扩散FelonThetenosynovialcoveringsofthesecond,third,andfourthdigitsdonotcommunicatewitheithertheradialorulnarbursae尺桡侧滑液囊inmostindividualsInfectionwithinatendonsheath腱鞘usuallyistheresultofdirectinoculationofbacteriafrompenetratingtrauma.由穿透性外伤细菌的直接接种导致。InfectiousTenosynovitis腱鞘炎Recentpenetratingtraumatohand手部刺伤Gonococcal淋球菌infection,particularlydisseminatedinfection感染扩散Pain,especiallywithpassiveextensionoffinger主动伸指疼痛Edemaofentirefinger水肿Variablehistoryoffever发热InfectiousTenosynovitisTenderness压痛alongthecourseoftheflexortendon屈肌腱Symmetricedema均匀水肿

ofinvolvedfingerPainonpassiveextension(themostimportantsign)Flexedrestingpostureoffinger手指强迫姿势All4signspossiblynotpresentearlyinthecourseofinfectionMayhaveassociatedlymphangitis,lymphadenopathy,andfeverInfectiousTenosynovitisTendondestruction肌腱破坏Functionaldisability功能障碍Extensionofinfectiontodeepfascialspace手掌深部间隙感染Complications：Deepfascialspaceinfections手掌深部间隙感染

midpalmarspace掌中间隙thenarspace鱼际间隙dorsalsubaponeuroticspace背侧腱膜下间隙subfascialwebspace皮下网状间隙Recentpenetratingtraumatohandoruntreatedtenosynovitis腱鞘炎Palmarblister掌水疱(mayresultinsubfascialwebspaceabscess)PainandedemaofhandPainwithmovementoffingersVariablehistoryoffeverDeepfascialspaceinfectionsPain,swelling,lossofpalmarconcavity手掌凹面消失PainwithmovementofthethirdandfourthdigitsDorsalswelling背部肿胀secondarytothetracking追踪ofinfectiondorsallyalongthelymphaticsMidpalmarspaceinfectionsMarkedswellingofthethumb-indexwebspaceFlexedandabductedrestingpostureofthethumb拇指屈位强制姿势Painwithpassiveadduction主动内收疼痛Thenar鱼际spaceinfectionsFunctionaldisability功能障碍Tendondestruction肌腱破坏Sepsis脓毒血症Handloss截肢Complications：painreliefantibiotictherapyelevatingandimmobilizingthehand患手抬高固定consultinganexperiencedhandsurgeon专业手外科医师处理incisionanddrainage切开引流Management：Dependingontheextentionoftissuedestruction组织破坏程度bonyinvolvement累及骨preexistingvascularinsufficiencysystemiccomplications(bacteremia,sepsis)Prognosis：窦道与瘘管瘘管：Fistulacannulas

两个开口窦道：Sinustract

一个开口，病理性盲管慢性溃疡

Chroniculcer肿瘤性溃疡血运障碍性溃疡结核性溃疡褥疮Chapter4浅表软组织肿块

softtissuetumornevus痣皮肤良性色素斑块皮内痣：无活跃痣细胞，常有毛发交界痣：有活跃痣细胞，一般无毛发混合痣：同时存在ClinicalFindingsThelesionsareoftenflat扁平atbirth,browntoblackincolor.Theyoftengrowproportionallytothebodysizeasthechildmatures.Astheymature,theyoftendevelopthickness厚,andbecomeselevated隆起.Prominentterminalhairsoftenform,especiallyafterpuberty.Withmaturity,thenevuscanhavevariationincolor,andthesurfacemightbetexturedwithgrowths.TreatmentSurgicalexcision手术切除isthestandardofcare.Theuseofhairremovallaserforthetreatmentislikelysafeandeffectiveforsmallcongenitalnevus.对于浅表较小的色素痣也可使用激光ifmalignancydevelopedfromadeepcomponentofthenevusthatisnotreachedbythelaser.Lipoma脂肪瘤Alipomaisabenigntumorcomposedoffattytissue.Thesearethemostcommonformofsofttissuetumor.最常见体表良性肿瘤Lipomasaresofttothetouch质软,usuallymoveable活动度佳,andaregenerallypainless.Manylipomasaresmall(underonecentimeterdiameter)butcanenlargetosizesgreaterthansixcentimeters.Somesourcessaythatmalignanttransformationcanoccur.TreatmentUsually,treatmentofalipomaisnotnecessary,unlessthetumorbecomespainfulorrestrictsmovement.一般脂肪瘤不必积极治疗，除非其出现疼痛及限制正常活动。Theyareusuallyremovedforcosmeticreasons,iftheygrowverylarge,orforhistopathologytocheckthattheyarenotamoredangeroustypeoftumorsuchasaliposarcoma.通常为了外表美观、进行性增大或为了鉴别脂肪肉瘤而手术切除。sebaceouscyst皮脂腺囊肿Asebaceouscyst(aformoftrichilemmalcyst)isaclosedsacorcystbelowthesurfaceoftheskinthathasaliningthatresemblestheuppermostpart(infundibulum)ofahairfollicleandfillswithafattywhite,semi-solidmaterialcalledsebum.皮脂腺囊肿（毛囊囊肿的一种形式）是表皮下封闭的囊袋。开口于毛囊顶端，内含有脂白色的半固体的皮脂。Sebumisproducedbysebaceousglandsoftheepidermis.皮脂由表皮的皮脂腺分泌。TreatmentSebaceouscystsgenerallydonotrequiremedicaltreatment.However,iftheycontinuetogrow,theymaybecomeunsightly不美观,painful,infected,oralloftheabove.Surgicalexcisionofasebaceouscystisasimpleproceduretocompletelyremovethesacanditscontents.Aninfectedcystmayrequireoralantibioticsorothertreatmentbeforeand/orafterexcision.SurgicalexcisionofasebaceouscystGanglionCysts腱鞘囊肿Ganglions腱鞘囊肿areformedbyanoutpouching隆起ofthesynovialmembrane滑膜fromajoint关节ortendonsheath腱鞘andcontainthickjelly-likemucinousmaterial稠厚的冻胶样黏液样物质similarincompositiontosynovialfluid滑囊液.PyogenicGranulomaPyogenicgranuloma炎性肉芽肿isamisnomer别称foranexuberantoutburstofhighlyvasculargranulationtissue高度增生的血管肉芽组织atthesiteofpreviousrelativelytrivialtrauma轻微损伤.Theselesionsareveryfriable质脆,bleedeasily,andmaygrowrapidly.Theyrespondtoeithercurettage刮除术orsimpleexcision.Theyoccurmostcommonlyonthefingertips