hand nerve reconstruction[1]

8/21/2019 Hand Nerve Reconstruction[1]

1/95

Mulgtkelch rigelstrugtkel em

tfi fcl` cmtir pirkpfirchlirvi hiskels

Gfrkstkcl @udeltkir D.@., Rf.@.

Klstktut `i hc Dckl, Rcrks, Mrclgi


2/95

Suistkels 5

^fkgf pirkpfirch lirvi hiskels dcy wi

rigelstrugt 5

^fct dicls ‘mulgtkelch rigelstrugtkel— 5

^fct cri tfi fcl` mulgtkels wi wclt terigelstrugt 5

^fct cri wi tchakln cjeut 5


3/95

Rirkpfirch lirvi hiskels 5

Hiskel el tfi dckl lirvi trulas mer tfifcl`

Let c jrckl/di`uhhcry hiskelLet c jrcgfkch phixus hiskel

Di`kcl / uhlcr / Zc`kch lirvi kloury

Gedprisskel er sigtkel em tfi lirvi


4/95

Wtcni 3 cl` : sfeuh` rigevir speltclieushy

Elhy stcni 7 cl` cjevi kl Wulìrhcl`‛s ghcsskffigctkelwkhh lii` sedi typi em ripckr

PCJHI 3

Ghcsskffigctkel em Lirvi Kloury

Wulìrhcl` Wi`èl Dcgakllel Kloury

@inrii K Liurcprcxkc @inrii K Gelùgtkel jhega, risehvis speltclieushy@inrii KK Cxeletdisks @inrii KK Cxelch rupturi wktfeut kltirruptkel em tfi jcsch hcdklc tujis@inrii KKK @inrii KKK Zupturi em jetf cxels cl` jcsch hcdklc tujis, sedi sgcr@inrii K] @inrii K] Gedphiti sgcr jhega@inrii ] Liuretdisks @inrii ] Gedphiti trclsigtkel

@inrii ]K Gedjklctkel em K‗] cl` lerdch mcsgkghis


5/95

Lirvi gedprisskel

Cjeut :,0 dkhhkel gelsuhtctkels/yicr kl tfi YWC crimer gcrpch tullih

Cjeut 62,222-322,222 gcrpch tullih rihicsi klMrclgi iviry yicr (surnkgch mii 4 339 " /3=2$/32,222 ¥)

Di`kgch gests < hess em pre`ugtkel


6/95

Rctfepfyskeheny em lirvi gedprisskel

@idyihklctkel `ui teWgfwcll gihh ligreskscl` cpeptesks

Cxelch pctfeheny


7/95


Chtirctkel em tfi gihh je`y(klgedphiti rigeviry)

Deter-il` phcti `inilirctkel(dusghi ctrepfy)


8/95


Pfi hcdklc ks kltcgt (Dyihklcti`/lel-dyihklcti` cxels)

Retiltkch mer (sedi) rigeviry cmtir lirvi rihicsi `ui tecxelch ri-nrewtf te tfi rknft lirvi-il`klns jy usklnixkstkln prigksi pctfwcys


9/95

Mulgtkelch rigelstrugtkel

^khh elhy ji kl`kgcti` kl tfi dest siviri hiskels

=% em deri tfcl 3922 GPW (Meugfir 3;;3)

Dctsuzcak (:220) riperti` mulgtkelch kdprevidilt kl39 pctkilts wktf 0,9 yicrs mehhew-up kl uhlcr tullihiltrcpdilt wktf dusghi ctrepfy


10/95


11/95

Zisuhts

Meugfir 3;;3? >7 Gcdktz

eppelilsphcsty wktf < ;2% nee`risuhts (nee` cltipuhskel cl`/erprelctkel)

Zkgfir :229? 92 M@W trclsmir322% kdprevidilt


12/95

Lirvi gedprisskel kl hipresy

Pfkr` werh` geultrkis

Hcti prisiltctkel wktf siviri siquihci + kltrc-liurchpctfeheny

Dcly kl`kgctkels mer mulgtkelch rigelstrugtkel


13/95

Lirvi trclssigtkel

Cjeut 7% em fcl` klourkis

Gesthy

di`kcl lirvi sigtkel ct tfi mericrd gests cjeut93,222 " (>3,222 $) wktf ;2% em gests ùi te hess

em preùgtkel (Hul`jern)Dest pctkilts wkhh heesi tfikr oej ùi te mulgtkelchhkdktctkels


14/95

^fct te `e cmtir c lirvi kloury 5

Zipckr kt !

Rrkdcry (er sigel`cry) ripckr ks jymcr tfi jist tigflkqui uskln suturitigflkquis, lirvi nrcmts, lirvigel`ukts,...


15/95

^fct te `e cmtir c lirvi kloury 5

Fewivir kt gcl ji tigflkgchhykdpesskjhi er pfyskehenkgchhy letusimuh te pctkilts

Mulgtkelch rigelstrugtkel dcy ji csehutkel


16/95

^fil ks lirvi ripckr kdpesskjhi 5

Mckhuri em ripckr

Rfyskehenkgch hkdktctkels

Pigflkgchhy pesskjhi jut wkhh mckh

Pigflkgch hkdktctkels


17/95

Mckhuri em ripckr

Cmtir lirvi ripckr, tfiri cri cludjir em de`kffigctkels mredtfi jrckl te tfi il`-phcti/ silsery rigipters tfct dcyixphckl wfy ivil c ‘pirmigt—

ripckr dcy mckh


18/95

De`kffigctkel em gertkgch riprisiltctkel

Liurels `ki mred cpeptesks (up te 92%)

Lirvi ri-nrewtf cmtir wchhirkcl `inilirctkelks hkdkti` kl tkdi (ripckr wktfkl = deltfs)

Gfclnis kl `kstch rigipters dcy jigedikrrivirskjhi (3:-36 deltfs)

Cxelch dks`krigtkel cmtir ripckr

Rrimiriltkch deter rinilirctkel 5(Jrusfcrt, 3;66)

Rrimiriltkch silsery rinilirctkel 5(Dcak, 3;;=)


19/95

Mcgters kluilgkln eutgedi cmtir lirvi ripckr 5

Ditc-clchysks (=:7 di`kcl/uhlcr lirvi klourkis - Zukos :229)

Deter cl` silsery rigeviry wiri sknlkffigclthy cssegkcti`(Wpicrdcl r 4 2.=:, p 8 2.223).

Duhtkvcrkcti henkstkg rinrisskel clchysks sfewi`?

Cni (8 3= yicrs virsus < 02 yicrs? e``s rctke, 0.71 ;9 pirgilt gelffiìlgi kltirvch,3.= te 33.:),

Wkti (prexkdch virsus `kstch? e``s rctke, 2.0=1 ;9 pirgilt gelffiìlgi kltirvch, 2.:2 te3.32),

@ihcy (pir deltf? e``s rctke, 2.;01 ;9 pirgilt gelffiìlgi kltirvch, 2.;2 te 2.;6).


20/95

Mcgters kluilgkln eutgedi cmtirlirvi ripckr 5

Mer silsery rigeviry, cni (e``s rctke, :>.21 ;9 pirgilt gelffiìlgikltirvch, ;.0 te >>.=) cl` ìhcy (pir deltf? e``s rctke, 2.;:1 ;9 pirgilt

gelffiìlgi kltirvch, 2.6> te 2.;6) wiri meul` te ji sknlkffigcltpri`kgters.

Kl uhlcr lirvi klourkis, tfi gfclgi em deter rigeviry wcs>3 pirgilt hewir tfcl kl di`kcl lirvi klourkis (e``s rctke,2.:;1 ;9 pirgilt gelffiìlgi kltirvch, 2.39 te 2.99).

Le ivkìlgi tfct cly tigflkqui (ipkliurkch suturi, mcsgkguhcrsuturi,...) risuhts kl kdprevi` mulgtkelch eutgedi (Hul`jern,

:220)


21/95

^fil ks lirvi ripckr kdpesskjhi 5

Rfyskehenkgch hkdktctkels

Rctkilt‛s cni, skti em kloury, skzi em lirvi hess er peer

hegch gel`ktkels mer lirvi nrcmts Pigflkgch hkdktctkels

Le `kstch studp cvckhcjhi mer suturkln

@iffilktkvi ctrepfy em deter il`-phctis (< 3:-36 deltfs)

Rcrtkch rigeviry cmtir lirvi ripckr er pcrtkch lirvi hiskelser le ghklkgch/IDN prenrisskel 3 yicr cmtir ripckr


22/95

^fct cri tfi fcl` mulgtkels5


23/95

Mulgtkels em tfi fcl`

C silsery erncl

C werakln teeh

@ipil`ilt em c lerdch lirveussystid


24/95

Mulgtkels em tfi fcl`

Lirvis chse gcrry pckl cl` sydpctfitkg ffijirs

Mulgtkelch rigelstrugtkel dicls nkvkln tfi pctkilttfi pesskjkhkty em uskln?

C pcklhiss fcl`

C silsktkvi fcl` te miih tfi ilvkreldilt


25/95

‘Wydpctfitkg— ripckr 5

Pe `cti wi fcvi cjsehutihy lepesskjkhkty em ripckr

Gcl ji viry `kscjhkln

Geh` kltehirclgi

@ysistfiskci

Wu`edeter, Fckr gfclnis ...

Di`kgch trictdilt (5)

di`kcl

di`kcl

uhlcr


26/95

Rckl

Pwe typis em pckl

@i-cmmiriltctkel ? Le surniry, elhy pckl ghklkg

Rcklmuh liuredc? Km pckl ghklkg cl` rifcjkhktctkel mckhs,surniry gcl ji kl`kgcti` (sii? Lctf 3;;=)


27/95

Mulgtkelch rigelstrugtkel

Kllirvcti` cp trclsmir (Wilsery)

Lirvi trclsmir (silsery cl` deter)

@krigt liuretkzctkel (deter)

Pil`el trclsmir (Deter)

Wilsery er Deter

5


28/95

Mulgtkelch silseryrigelstrugtkel


29/95

Pfi silsctkelch fcl`

Ilerdeus gcpcgkty te pirgikvi, teixiguti cl` te ixpriss, skduhtclieushy,

kl tfi cgt em teugf (Nkjsel, 3;=:)


30/95

Pfi silsctkelch fcl`

‘Pcgtkhi nlesks— (Dýjirn 3;96) khhustrctis tfi kltirphcy

jitwiil pirkpfirch silsery mulgtkels em tfi fcl` cl`tfi kltirpritctkel em silsery kdprisskels kl tfi jrckl

Mii`-jcga jitwiil fcl` cl` jrckl ks c pri-riquksktimer rinuhctkel em nrkp strilntf cl` nrkp spii`(Oefclssel, :22:)


31/95

Wilsery rigelstrugtkel

Kllirvcti` cps

Hegch / Zinkelch (pi`kghi`)/ Mrii cps

Mer di`kcl lirvi tirrktery elhy

Lirvi trclsmir

Di`kcl te uhlcr, uhlcr te di`kcl, rc`kch te di`kcl


32/95

Kllirvcti` Hegch cps

Dest cri usi` mer puhp klourkis (chh typi emkllirvcti` cps gcl ji usi`)


33/95

Kllirvcti` Hegch cps

Elhy mer `kstch `knktch lirvi klourkis

C`vclgidilt em cl kllirvcti` ]ilactcswcdk‛s cp tegevir tfi `imigt cl` trict c liuredc (Meugfir 3;;3)


34/95

Fitire-`knktch cps

@isgrkji` jy Hktthir

Elhy mer di`kcl lirvi klourkis

Prclsmir em c pi`kghi` cp mred c silskjhiffilnir wfil uhlcr lirvi ks kltcgt (w/we lirvi`kvkskel/suturi)


35/95

Fitire-`knktch cps

Miw kl`kgctkels ùi te siquihci emèler ffilnir

C`clk 3;;2 (; gcsis), Audtc 3;;> (3>gcsis), Eac :222 (:3 gcsis)

Ludjliss wfil cp ks teugfi`, ; dd:R@, èujhi silsctkel cl` peersilsery swktgfkln mred tfi èler terigkpkilt skti


36/95

Fitire-`knktch cps

Zikllirvcti` akti cp


37/95

Zikllirvcti` mrii cps

Mer ‘di`kcl lirvi— klourkis

Mred tfi meet (@clkih 3;>=, Efderk3;>=, Dklcdk 3;601 Acte 3;6;) cs3st wij spcgi cp cl`/er tei

trclsmir

Let spigkffigchhy `isknli` mer lirvi rigelstrugtkel


38/95

Zikllirvcti` mrii cps

Pfilcr mrii cp (Edeacwc 3;;=)


39/95

Lirvi trclsmir

Liw tigflkqui, le sirkis (]ijir :220)

Grktirkc 5

PCJHI 7Grktirkc mer Wilsery Lirvi Prclsmir

@eler silsery lirvi licr tfi tcrnit silsery lirviIxpil`cjhi èler silsery lirvi (lelgrktkgch silsery

`kstrkjutkel)

@eler silsery lirvi wktf c hcrni ludjir em purisilsery cxels@ilirvcti` `kstch il` em èler lirvi ripckri` il`-te-

skì te còcgilt lerdch silsery lirviWilsery ri-iùgctkel kdprevis mulgtkelch rigeviry


40/95

Wilsery ri-kllirvctkel em tfi uhlcr lirvi

Il`-te-il` trclsmir em tfitfkr` wij spcgi lirvi te tfiuhlcr lirvi (Hiwks 3;60)

Il`-te-sk`i lirvi trclsmir el

tfi di`kcl lirviYlpri`kgtcjhi risuhts


41/95

Wilsery ri-kllirvctkel em tfi di`kcl lirvi

Yhlcr skì em tfudj, rc`kch skì em klìx

Dcly cttidpts uskln rc`kch cl`/er uhlcr lirvi mcsgkghis(Fudpfriys :22:) suturi` wktf cl il`-te-skìtigflkqui te tfi jrclgfis em di`kcl lirvi


42/95

Wilsery rigelstrugtkel 5

Dcly cttidpts

Dcly kltiristkln k`ics

Miw kltiristkln (mulgtkelch) risuhts te `cti

Dcy ji wertf trykln kl girtckl gcsis


43/95

Mulgtkelch deterrigelstrugtkel


44/95

Deter rigelstrugtkel 5

Crtfreìsks (oeklt stcjkhkzctkel, rcrihy èli)

Pileìsks (rcri kl`kgctkels)

@krigt liuretkzctkel

Lirvi trclsmir

Pilèl trclsmir


45/95

Oeklt stcjkhkzctkel

Crtfreìsks dcy ji liiì` kl sivirigcsis jut ks usuchhy cvekì` (hest emtfi tileìsks immigt).

Hkncdilteus ripckr dcy ji liiì`jimeri tilèl trclsmir

Gcpsuheìsks gcl fihp kl hcx pctkilts


46/95

Pile`isks

Elhy `eli kl viry siviri gcsis wfil tfiri ks letileunf trclsmir te usi

Rcsskvi mulgtkel


47/95


Icrhy :2tf giltury (Fikliai 3;301 Irhcgfir 3;301Wtikl`hir 3;39,...) dcklhy `eli mer pehkedyihktks wktfpeer risuhts


48/95


Le pujhksfi` sirkis

>:% nee` te ixgihhilt risuhts cgger`kln te Jrulihhkevir :22 gcsis gehhigti` kl tfi hktircturi

Lj gcsis 33 : 2

Jkgips 6 0 7

Pfilcr dusghis 0 7 3

Petch =9 7> = 3

Etfir stu`kis :2= 32= :; 7:


49/95

Lirvi trclsmir

Wedi cttidpts fcvi jiil dcì

Rrklgkphis cri viry skdkhcr mer deter cl` silserylirvi trclsmirs

PCJHI :

Grktirkc mer Deter Lirvi Prclsmir

@eler lirvi licr deter il` phctis em tcrnit dusghi (sfertist `kstclgi sfertist tkdi mer rikllirvctkel)Ixpil`cjhi er riùl`clt èler deter lirvi@eler lirvi wktf puri deter lirvi ffijirs@eler deter lirvi wktf c hcrni ludjir em deter cxels@eler lirvi kllirvctis c dusghi tfct ks sylirnkstkg te tfi tcrnit dusghi (primirri` jut let riqukri` te mcgkhktcti ri-

iùgctkel)Deter ri-iùgctkel kdprevis mulgtkelch rigeviry


50/95

Deter lirvi trclsmir

Pirdklch jrclgf em cltirkerkltiressieus lirvi te `iip deter

jrclgf em uhlcr lirvi (^cln & _u3;;>, Jcttkstel 3;;;, Levca:22:, ^ee` :220)

h hh -

h h -.

h h h


51/95


Di`kcl lirvi (MGZ) terc`kch lirvi ct tfi ihjew(Dcgakllel 3;;;)


52/95


Zc`kch lirvi te di`kcl lirvi(Dcgakllel :222)


53/95

Lirvi trclsmir

Le sirkis, sedikdprevidilt ks ghckdi`

Dcy ji wertf trykln klsedi rcri gcsis


54/95

Pil`el trclsmir ks stkhh tfi

desthy usi` tigflkqui merdeter rigelstrugtkel

^ktf tfi fihp em Gcrehkli Highirgq


55/95

Rrklgkphis

@e let ji fcrdmuh !

Alew wfct te è

Alew wfct gcl ji èli

Alew wfct yeu gcl è

Icgf pctkilt ks ulkqui

Dcly eptkels cri cvckhcjhiDcly tixtjeeas ìsgrkjitfi tigflkquis wktf ìtckhscl` fknfhknfts tfi prklgkphis

(Psuni, Rrklgkphis cl`Rrcgtkgis em Fcl` Wurniry)


56/95

Rrklgkphis (:)

Pcai nrict gcri em semt tkssui iqukhkjrkud

Nee` sakl gevircni (lii` c cp jimeri trclsmir 5)Dejkhi oeklts (crtfrehysks 5)

Wtcjhi oeklts (stcjkhkzctkel 5)

Wtcjhi saihitch chknldilt

Pcjhi 3 Zihctkvi strilntf em dusghis kl tfi fcl` cl` meri-G


57/95

Rrklgkphis (7)

Gfeesi c deter dusghi wktf tfi rknftstrilntf

Gfeesi c deter dusghi wktf tfi rknftcdphktuì ?

^rkst tilèls 77 dd - Mklnirixtilsers? 92 dd, Mklnir ixers? >2

dd

Gfeesi c dusghi em nrcì 0+ er deri

Mernit cnelksd/cltcnelksd

Pcjhi : Ixgurskel em dusghiskltfi cùhtmericrdcl` fcl`

Dusghi Ixgurskel (gd)Jrcgfkerc k̀chks 0.2

Mhixer`knkterudpremul̀ us (M@R) >.2

Mhixer`knkterudsupir¢gkchks (M@W) =.9

Ixtilserpehhkgkshelnus (IRH) =.2

Ixtilser `knkterud geddulks (I@G) 9.2

Ixtilserkl k̀gksprepkus (IKR) 9.2

Mhixer pehhkgks helnus (MRH) 9.2

Mhixer gcrpk uhlcrks (MGY) 7.2

Mhixer gcrpk rc k̀chks (MGZ) 7.2

Ixtilser gcrpkrc k̀chkshelnus (IGZH) 7.2Ixtilser gcrpkrc k̀chksjrivks (IGZJ) 7.2

Ixtilser gcrpk uhlcrks (IGY) 7.2

Ixtilserpehhkgksjrivks (IRJ) 7.2

Cj ùgterpehhkgkshelnus (CRH) 7.2

Hudjrkgch 7.6

Pfilcr dusghis 7.6

Kltiressik :.2

Zipreùgi` mred Nihjirdcl ZF. Epirctkvi Lirvi

Zipckr cl ̀ Zigelstrugtkel. Rfkhcìhpfkc? Hkppklgett, 3;;31

396>, wktf pirdksskel.

crd, tcakln MGZ 4 3

Dusghi Wtrilntf rihctkvi te MGZ

Jrcgfkerc k̀chks :.2

Mhixer gcrpk uhlcrks :.2

IGZH,IGZJ,IGY,RP,MRH,M@W, [email protected] (icgf tilèl)

I@G, IKR, I@S 2.9 (icgf tilèl)

CRH, IRJ, RH 2.3 (icgf tilèl)

Kltiressik :.> (tetch/gedjkli )̀

Hudjrkgchs 2.9 (tetch/gedjkli )̀

Zipreùgi` mred Nihjirdcl ZF. Epirctkvi Lirvi

Zipckr cl ̀ Zigelstrugtkel. Rfkhcìhpfkc? Hkppklgett, 3;;31

396>, wktf pirdksskel.


58/95

Rrklgkphis (0)

Gfeesi tfi strcknftist trcoigtery

Gress elhy eli oeklt

Cvek` sfcrp clnhis kl tfi pctf em tfi trclsmir

C`iqucti `kstch ffixctkel (riskstclt jut lel c`firilt cl`lel-ksgfidkg)

C`iqucti tilskelkln (Neh`lir ‘=2% hilntf—1 Geeliy1Ixpirkilgi)

Zifcjkhktctkel (gedphkclgi 5)


59/95

Wtrctiny

Eli tilèl gcl elhy ripckr eli mulgtkel

Gfeesi tilèl cgger`kln te pctkilt‛s lii`s

Wihigt tfi dest kdpertclt mulgtkel te ripckr ffirst cl`c`` c``ktkelch pregiùris (oeklt muskel, tileìsks,...)

Kl tfi lerdch mericrd cl` fcl` tfiri cri 92 dusghis tecgtkvcti devidilt. Pfi gfekgi ks dcì el tfi jcsks em tfi

cvckhcjhi pesskjkhktkis cl` tfi ìdcl`s


60/95

Zc`kch lirvi

Z `k h m tk t


61/95

Zc`kch lirvi mulgtkel te

risteri

^rkst ixtilskel

Mklnir ixtilskel

Pfudj ixtilskel

GDG oeklt stcjkhkty


62/95

^rkst ixtilskel

Rrelcter tiris te Ixtilser gcrpk rc`kchks jrivks

Lii` te tcai c strkp em pirkestiud

Wfeuh` ji ffixi` ct tfi il` (te tist ffilnir ixtilskeluskln tfi tile`isks immigt)


63/95

Mklnir & tfudj ixtilskel

MGY creul` tfi wrkst te I@G, IKR (+/- IRH) & RH te

IRH (Pujkclc)

MGZ tfreunf tfi KED te I@G, IKR (Psuni, Jrcl`)

M@W 7,0 tfreunf KED te I@G (rkln), IKR & IRH (heln)

(Jeyis)

Wuturis cri dcì prexkdch te ixtilser ritklcguhud

cl` pcrchyzi` tilèls cri let `kvkì`


64/95


65/95

Mklnir & tfudj ixtilskel

MGY creul` tfi wrkst te I@G, IKR (+/- IRH) & RH te

IRH (Pujkclc)

MGZ tfreunf tfi KED te I@G, IKR (Psuni, Jrcl`)

M@W 7,0 tfreunf KED te I@G (rkln), IKR & IRH (heln)

(Jeyis)

Wuturis cri dcì prexkdch te ixtilser ritklcguhud

cl` pcrchyzi` tilèls cri let `kvkì`


66/95


67/95

Zisuhts

Cdphktu`i? wrkst ixers 7 gd, Mklnir ixtilsers 9 gd


68/95

Zisuhts? @ullitt 3;;9

0; kloury te tfi rc`kch lirvi (::) er jrcgfkch phixus (:>).

9.= yicrs MY. Mulgtkel kdprevi` kl 60%

Kdpckri` geer`klctkel cl` ìxtirkty < =2%

Rridcturi mctknui < 62%

^rkst pewir ixtilskel ::% em geltrchctirch skì (6% te62%), pewir em `knktch ixtilskel wcs 73% (9% te372%), cl` pewir nrkp wcs riùgi` te 02% (9% te6=%).


69/95

Di`kcl lirvi

Di`kcl lirvi mulgtkel te


70/95

Di`kcl lirvi mulgtkel te

risteri Pfudj cj`ugtkel cl` eppesktkel (hew pchsy)

Pfudj ixkel (fknf pchsy)

Mhixkel em tfi kl`ix cl` dk``hi ffilnirs (fknf pchsy)

(Kdprevi silskjkhkty evir `kstrkjutkel em tfi di`kcl

lirvi )


71/95

Rri-riquksktis jimeri eppesktkel trclsmir

Heln-stcl`kln pchsy dcyhic` te ffirst wijgeltrcgturi, supklctkelìmerdkty cl` oeklt stkmmlisstfct dcy lii` surnkgchrihicsi jimeri tilèltrclsmir

Dejkhi GDG

Cìqucti 3st wij

Rcsskvi eppesktkel

Mklnir detkel

Mulgtkelkln IRH, MRH, CRH

(Pfudj cl` ffilnir silskjkhkty)


72/95

Pfudj eppesktkel

]crkeus tigflkquis cl` trclsmirs fcvi jiil `isgrkji`,jetf pcsskvi cl` cgtkvi cl` sfeuh` ji tckheri` te tfipctkilt‛s lii`

IKR te CRJ (cl` IRH) - Cnukrri & Gcphcl

M@W (rkln) jut usuchhy iktfir siviri` er pcrchyzi` cl`lii` deri mergi (07%) te ejtckl tfi scdi mulgtkel(Cl`irsel 3;;:)


73/95

IKR trclsmir


74/95

Pfudj eppesktkel

Pfi deter (IKR / M@W)

Pfi puhhiy 5

Pfi `kstch ffixctkel 5


75/95

Pfi puhhiy

C`ùgtkel ks prepertkelch te tfi

hilntf em tfi dedilt jitwiiltilèls cl` cxks em ixkel (V)

Cltiixkel ks prepertkelch te tfihilntf em tfi dedilt jitwiiltilèl cl` cxks em PD ([)


76/95

@kstch ffixctkel

Cheln tfi cxks em tfi CRJ

Ixpclskel te tfi `ersud em tficxks km ixtilsers cri wica (Zecgf:223)


77/95

M@W trclsmir

Hess em nrkp strilntf

Hess em RKR ixtilskel (6² kl 92%em pctkilts Lertf 3;62)

Nee` te ixgihhilt risuhts kl=2-69% em pctkilts (Jefr 3;97,Oilsil 3;>6, Cl`irsel 3;;:)


78/95

Zisuhts

Cl`irsel 3;;: (3== pts)

6;% nee` te ixgihhilt cmtir IKR, 69%cmtir M@W

IKR < M@W kl tfikr sirkis

M@W (rkln) lii`s deri mergi (07%) teejtckl tfi scdi mulgtkel


79/95

Yhlcr lirvi

PCJHI 0

Ksehcti` Yhlcr Rchsy

Liiì` Mulgtkel Rrimirri` Deter Chtirlcti Prclsmir

Pfudj c`ùgtkel mer aiy

pklgf (hew pchsy)

IGZJ, wktf mrii tilèl nrcmt jitwiil

tfkr ̀‗meurtf ditcgcrpchs, te tilèl em

CRJ

M@W (dk``hi) te cjùgter tujirghi em tfudj,

wktf pchdcr mcsgkc cs puhhy

Pfudj-klìx t kp pklgf Whkp em CRH te ffirst èrsch kltiressieus

tilèl, cl` crtfreìsks DGR oeklt em

tfudj

IRJ te ffirst èrsch kltiressieus tilèl, km

DGR oeklt em tfudj crtfreìsi`

Rrexkdch pfchclx pewir

ixkel cl` kltinrctkel em

DGR cl` KR detkel

(ghcwi` ffilnirs)

IGZH wktf :- er 0-tckhi` nrcmt pcssi` vehcr

te ìip trclsvirsi ditcgcrpch hkncdilt

te iktfir C: puhhiy em ixer sfictf er te

rc`kch jcl` em tfi èrsch cppcrctus

Km wrkst ixkel geltrcgturi, MGZ wktf 0-tckhi`

nrcmt te iktfir ixer sfictf (C: puhhiy) er

hctirch jcl`s em èrsch cppcrctus

Ditcgcrpch (pchdcr)trclsvirsi crgf cl`

c`ùgtkel mer sdchh ffilnir

I@D tilèl ks sphkt cl` uhlcr fchm kstrclsmirri` vehcr te ìip trclsvirsi

ditcgcrpch hkncdilt te rc`kch gehhctirch

hkncdilt em prexkdch pfchclx er C:

puhhiy em tfi ixer sfictf (I@G em sdchh

ffilnir dust ji immigtkvi)

Km sdchh ffi

lnir ks ghcwi` cs wihh cscjùgti`, klsirt uhlcr fchm em I@D elhy

klte C: puhhiy

]ehcr silskjkhkty mer rkln cl`

sdchh ffilnirs

Rrexkdch di`kcl `knktch lirvi trclshegcti`

te `kstch uhlcr `knktch lirvi

Mrii er vcsguhcrkzi` lirvi nrcmt

@kstch ffilnir ixkel‐mer rkln

cl` sdchh ffilnirs (fknf

pchsy)

M@R (dk``hi) tileìsi` te M@R (rkln cl`

sdchh), wktf pesskjhi tilìsks em `kstch KR

oeklts kl tfi rkln cl` sdchh ffilnirs^rkst ixkel‐uhlcr skì MGZ te klsirtkel em MGY RH te klsirtkel em MGY

Mred Edir :220

Mulgtkel te risteri cmtir hew uhlcr


80/95

Mulgtkel te risteri cmtir hew uhlcrlirvi pchsy

Hess em fypetfilcr dusghis

^crtiljirn‛s sknl

Hess em trclsvirsi ditcgcrpchcrgf


81/95

Hess em gcrpch crgf

Jullihh‛s tigflkqui fcvi jiil

cjcl`eli`

Zclliy‛s trclsmir (I@S) ksseditkdis pirmerdi`


82/95

Gerrigtkel em ^crtiljirn‛s

Prclsmir em tfi uhlcr shkp em tfi I@D te tfi rc`kch sk`i

Kl gcsi em ghcwkln, tfi rc`kch shkp ks trclsmirri` vehcrhy


83/95



84/95


Hess em kltiressieus dusghi (+hudjrkgchis)

Ghcw fcl`

Hess em aiy pklgf (32% lh)

Hess em lerdch ffilnir ixkelHess em strilntf (>2-62% hess)


85/95

Ghcw fcl` gerrigtkel

Wtctkg pregiùris (gcpsuheìsks cl` stctkg tileìsks,

rcrihy jeli jhega)@ylcdkg pregiùris

@ylcdkg tileìsks (Mewhir)

Pilèl trclsmir


86/95

Gcpsuhe`isks

Wtritgf wktf tkdi wfctivirtfi tigflkgch vcrkctkels

usi` kl hcx pctkilts


87/95

M@W trclsmir

Hcsse

Rctkilts wkhh heesi :2% em

tfikr nrkp strilntf

Jeli (Jurafchtir)

Wtkhis-Jullihh (km Jeuvkir‛s

dcliuvir `eis let gerrigtfypirixtilskel)


88/95

@rcwjcgas

Jrcl`sdc (3;;:) ejsirvi` 39%swcl-liga `imerdkty, :;% @KR ixkel

geltrcgturi cl` :=% RKR ixkelgeltrcgturi evir 396 M@W trclsmirs

Lertf (3;62) ejsirvi` legedphkgctkels


89/95

Zisuhts

Ezacl :227 (00 pctkilts)

Hcsse cl` IGZH-0 tckh dest immigtkvi mernrkp strilntf

M@W 0-tckh dest suggissmuh kl gerrigtkln

tfi ghcw fcl` `imerdkty, ispigkchhy klheln-stcl`kln pcrchysks kl wfkgf tfiriwcs ihelnctkel em tfi ixtilsercppcrctus.

3st kltiressieus risterctkel


90/95

3st kltiressieus risterctkel

CRH cggissery shkp (+nrcmt) (Livkcsir 3;62)

RH (+ nrcmt) (Furcycdc3;6=)

IRJ (Jrulir 3;06)



91/95


Hess em Pfilcr dusghis

Oiclli‛s cl` Mredilt‛s sknlsHess em aiy pklgf


92/95

Pfudj c``ugtkel

M@W (rkln) te uhlcr sk`i em tfi tfudj

IKR (er IGZJ + nrcmt) tfreunf tfiditcgcrpchs


93/95

Zisuhts

Mksgfir :227, ; pctkilts, IGZH te CR, CRH te 3st @KE

Aiy pklgf >7%, puhp-te-puhp pklgf >:%, pewir nrkp>7%

Mergi em tfudj c`ùgtkel =7%

Mergi em klìx ffilnir cjùgtkel 96%

Hcrni vcrkctkels jitwiil pctkilts

Gedjkli` hiskels


94/95

Gedjkli` hiskelsPCJHI =

Gedjkli` Fknf (Rrexkdch) Di`kcl cl` Yhlcr Rchsy

Liiì` Mulgtkel Rrimirri` Deter Chtirlcti Prclsmir

Pfudj c`ùgtkel

(CR)‐aiy pklgf

IGZJ wktf mrii tilèl nrcmt jitwiil

tfkr` cl` meurtf ditcgcrpchs te

CRJ tilèl

JZ er IKR wktf mrii tilèl nrcmt jitwiil tfkr` cl`

meurtf ditcgcrpchs te cjùgter tujirghi em tfudj

(CRJ tilèl)Pfudj ixkel (KR oeklt) JZ te MRH kl mericrd Pileìsks em MRH `kstch te DGR oeklt em tfudjPfudj cjùgtkel (CRJ) IKR wktf pkskmerd puhhiy te klsirtkel

CRJ tilèl (phus) IRH tilèl

IRH er IGY wktf mrii nrcmt creul` pkskmerd puhhiy

te CRJ tilèl (tfudj DGR ks crtfreìsi` cl`

le cgtkvi detkel ct tfudj KR oeklt)Pfudj‐kl ìx tkp pklgf Pfudj DGR oeklt crtfreìsks1 cl`

CRH shkp wktf mrii tilèl nrcmt te

ffirst èrsch kltiressieus tilèl

IRJ er RH te ffirst èrsch kltiressieus, cl` muskel

em tfudj DGR oeklt

Mklnir ixkel (M@R) IGZH te chh 0 til èls em M@R wktf

pesskjhi tileìsks em `kstch KR em

uhlcr 7 ffilnirs

Jkgips jrcgfkk ixtilì` wktf MGZ tilèl te

tilèls em M@R

Rewir mer ixkel em

prexkdch pfchclx wktf

kltinrctkel em DGR

cl` KR detkel

(ghcwi` ffi

lnirs)

Pileìsks em chh 0 `knkts wktf mrii

tilèl nrcmt mred èrsch gcrpch

hkncdilt vehcr te ìip trclsvirsi

ditcgcrpch hkncdilt te hctirch

jcl`s em ixtilser cppcrctus (er)mred ìip trclsvirsi ditcgcrpch

hkncdilt te ixtilser cppcrctus

Gcpsuheìsks em DGR vehcr gcpsuhi (er)

crtfreìsks em RKR oeklts (er) crtfreìsks em DGR

oeklts

Ditcgcrpch (pchdcr)

crgf cl` c`ùgtkel

mer sdchh ffilnir

I@D te ìip trclsvirsi ditcgcrpch

hkncdilt (I@G em sdchh ffilnir dust

ji cgtkvi)

I@D te rc`kch hctirch jcl`s (ixtilser fee`) em tfi

rkln cl` sdchh ffilnir

^rkst ixkel ‐ IGY te klsirtkel em MGYDi`kcl cl` uhlcr vehcr

silskjkhkty

Wupirffigkch rc`kch kllirvcti` klìx

ffihhit cp te pchd (er) ffirst èrsch

ditcgcrpch crtiry liurevcsguhcr

kshcl` pi`kghi

cp

Wupirffigkch rc`kch lirvi trclshegctkel (er) mrii

vcsguhcrkzi` lirvi nrcmt


95/95

Gelghuskels

Lirvi ripckr ks tfi jist tigflkqui cvckhcjhi ivil kmrisuhts cri stkhh `kscppekltkln

Wilsery ìffigkt ks c dcoer gedphkgctkel wfkgfrigelstrugtkel ks `kmffiguht wktf hkdkti` risuhts

Pilèl trclsmir cri wihh ìsgrkji` mer gedphitipcrchytkg fcl`

Kl`kgctkels cri hiss ìsgrkji` mer pctkilts wktf pcrtkchrigeviry

hand nerve reconstruction[1]

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