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系統識別號 U0026-1801201417583000
論文名稱(中文) 從生物力學觀點探討扳機指手術前後之表現
論文名稱(英文) Biomechanical Aspects of Trigger Finger before and after Pulley Release Surgery
校院名稱 成功大學
系所名稱(中) 生物醫學工程學系
系所名稱(英) Department of BioMedical Engineering
學年度 102
學期 1
出版年 103
研究生(中文) 盧思靜
研究生(英文) Szu-Ching Lu
學號 P88971212
學位類別 博士
語文別 英文
論文頁數 72頁
口試委員 指導教授-蘇芳慶
口試委員-周有禮
口試委員-杜元坤
口試委員-林高田
口試委員-周一鳴
口試委員-張志仲
口試委員-郭立杰
口試委員-徐秀雲
中文關鍵字 扳機指  生物力學  肌腱力量  術後復健  環狀腱鞘解離術 
英文關鍵字 trigger finger  biomechanics  tendon force  rehabilitation  pulley release 
學科別分類
中文摘要 扳機指為臨床常見之手部疾患,扳機現象為典型症狀,患者需花費較大的力氣去克服卡住的屈指肌腱才能將手指頭伸直,若保守治療無法解除不適,臨床上建議進行第一環狀腱鞘解離手術,然而針對某些患者需解離部份第二環狀腱鞘才得以完全舒緩症狀。目前並無量化資料描述扳機現象發生時的肌腱力量,因此本論文的第一個目的為建立生物力學模型以推算扳機現象發生時的肌腱力量;此外,部份扳機指患者於手術後仍對手指功能之恢復不甚滿意,故本論文的第二個目的為提出具明確治療目標與療程的復健計畫,並量化探討該復健計畫對於扳機指術後手功能恢復的影響;環狀腱鞘解離後會對手功能造成影響,而目前對於不同程度環狀腱鞘解離後所造成的生物力學特性變化並不清楚,因此本論文的第三個目的為探討不同程度環狀腱鞘解離對於肌腱滑動效率與肌腱力臂所造成的影響。

為探討克服扳機現象時的肌腱張力,實驗中使用客製化的儀器將手指由屈曲的狀態拉直並同步測量拉伸過程所需的力量,而動作分析系統被應用於量測手指動作及外力方向,共測量十指有明顯扳機現象的手指,透過力矩平衡方程式與最小平方差的方法估算肌腱力量,研究結果發現在十位受試者中扳機現象發生時深層屈指肌腱的力量大於、小於或幾乎等於淺層屈指肌腱的力量,且受試者的手指關節卡在不同的角度,此結果可能意味著不同部位的肌腱卡在環狀腱鞘中。本論文提出為期四周的扳機指術後復健計畫,招募具有關節攣縮問題的扳機指患者分為術後接受復健的介入組共九人與術後沒有接受復健的控制組共十二人,以動作分析系統量測受試者執行共五個姿勢的連續動作時的關節角度變化與手指動作空間,比較手術前後的手功能表現,結果發現介入組在手指動作空間、遠端及近端指間關節的活動角度與整體手指關節活動角度相較於控制組有顯著的進步,術後復健對於有關節攣縮問題的扳機指患者之手功能恢復應有所助益。為探討不同環狀腱鞘解離所造成的影響,實驗中使用八具手部屍體樣本,共施測八指中指,使用動作分析系統量測關節角度變化,並使用線性位移感應器同步測量肌腱滑動量,以線性擬合的方式估算肌腱力臂,探討環狀腱鞘完整、第一環狀腱鞘解離、第一與半第二環狀腱鞘解離、第一與第二環狀腱鞘解離等四種情況下屈指肌腱的滑動效率與相對於掌指關節的力臂變化,結果發現解離至半第二環狀腱鞘並不會顯著影響深層屈指肌腱滑動效率、淺層與深層屈指肌腱相對於掌指關節之力臂,可建議臨床手術於必要時延伸解離至半第二環狀腱鞘。

本論文從生物力學觀點探討扳機指手術前後之表現,建立生物力學模型推算扳機現象發生時的肌腱力量,並量化呈現扳機指術後復健療程對手指功能的助益,亦藉由人類手部樣本探討不同程度環狀腱鞘解離所帶來的影響,本論文從運動學與力學方面的量化資訊增進對扳機指生物力學特性的瞭解,以期待研究結果能應用於促進扳機指的臨床治療。
英文摘要 Trigger finger is a common problem in hand clinics. “Triggering” describes the catching and sudden release phenomenon during finger extension movement. The first annular (A1) pulley release surgery has been used to treat trigger finger for over a century. The release is required to extend to the second annular (A2) pulley to completely alleviate the symptoms for certain patients. The tendon force at triggering is unknown. Thus the first aim of this dissertation was to develop a biomechanical model estimating the tendon force at triggering. Besides, the postoperative finger function was unsatisfying in some patients. Therefore, the second aim was to propose a practical postoperative rehabilitation protocol with clear treatment goals and programs and provide the quantitative evaluation of finger function. The pulley release surgery may lead to hand function change. However, the effects of the different extent of pulley release have not been well explored. Hence, the third aim was to investigate the effects of the different extent of pulley release on the tendon excursion efficiency and the changes of tendon moment arms.

To estimate the tendon forces in trigger fingers, a biomechanical model with moment equilibrium equations and method of least squares was developed. The “pulling tester” was designed to pull the tested finger from flexion to extension and provide the synchronic measurement of the pulling force, and a motion capture system was used to record the finger motion and the direction of the pulling force. Ten fingers presented significant triggering effect were tested. The tendon tension of flexor digitorum profundus (FDP) was greater than, less than, or equal to that of flexor digitorum superficialis (FDS) at triggering in the ten subjects. Besides, the finger joints were locked at different angles. These results may imply that varied parts along the flexor tendons were trapped in the annular pulley system.

A four-week rehabilitation protocol was proposed for trigger finger after percutaneous pulley release surgery. Trigger finger patients with joint contracture problems were recruited. Nine subjects were in the intervention group, which received the postoperative rehabilitation after surgery. Twelve subjects were in the control group, which received no therapy after surgery. A motion capture system was used to measure the finger joint rotation and the fingertip workspace during a sequent movement of five postures. The intervention group presented significantly better improvement than the control group in the fingertip workspace, the range of motion of distal and proximal interphalangeal joints, and the total active range of motion. The proposed rehabilitation protocol might be helpful for trigger finger patients with joint contracture problems.

To understand the effects of the different extent of pulley release, four conditions of pulley integrity were investigated, including pulley intact, A1 pulley release, half A2 pulley release, and complete A2 pulley release. Eight cadaveric hands were used in the experiment, and a total of eight middle fingers were tested. The joint rotation was measured by a motion capture system, and the tendon excursion was measured by linear position sensors. The tendon moment arm was determined by the linear fitting result. The results present no significant change between A1 and half A2 pulley release in the FDP excursion efficiency, and the moment arms of FDP and FDS with respect to the metacarpal phalangeal joint. To relieve the discomfort, if necessary, the pulley release may extend to the half proximal A2 for trigger finger patients.

This dissertation provides the investigations of trigger finger before and after pulley release surgery from biomechanical perspectives. A biomechanical model was developed to estimate the tendon force at triggering in trigger finger, and the results of ten subjects were provided. Besides, a postoperative protocol with clear treatment goals and programs was proposed for trigger finger after the percutaneous pulley release surgery, and the benefits of the rehabilitation protocol were quantitatively proved. In addition, the effects of different extent of pulley release on the tendon excursion efficiency and moment arms were evaluated. Hopefully the biomechanical investigations will improve the understanding of trigger finger, provide suggestions for clinical practice, and further help in developing better assessment and treatment programs.
論文目次 摘要 I
Abstract II
誌謝 IV
List of Tables VIII
List of Figures IX
Chapter 1 General Introduction 1
1.1 Research Background 1
1.2 Motivations 6
1.3 Specific Aims 7
1.4 Dissertation Outline 8
Chapter 2 Quantifying Catch-and-Release: The Extensor Tendon Force Needed to Overcome the Catching Flexors in Trigger Fingers 9
2.1 Introduction 9
2.2 Methods 11
2.2.1 Materials and Procedures 11
2.2.2 Biomechanical Modeling 15
2.2.3 Force Ratio 18
2.3 Results 19
2.4 Discussion 22
Chapter 3 Effects of the Postoperative Rehabilitation for Trigger Finger after Ultrasound-guided Percutaneous A1 Pulley Release Surgery on Quantitative Finger Function Evaluation 26
3.1 Introduction 26
3.2 Methods 28
3.2.1 Participants 28
3.2.2 Surgical Procedures 30
3.2.3 Rehabilitation Programs 30
3.2.4 Quantitative Finger Function Evaluation 33
3.2.5 Data Analysis 36
3.2.6 Statistical Analysis 37
3.3 Results 38
3.4 Discussion 41
Chapter 4 Effects of Different Extent of Pulley Release on Tendon Excursion Efficiency and Tendon Moment Arms 46
4.1 Introduction 46
4.2 Methods 48
4.2.1 Specimen Preparation 48
4.2.2 Four Conditions of Pulley Integrity 48
4.2.3 Instruments 49
4.2.4 Tendon Excursion Efficiency Measurement 50
4.2.5 Tendon Moment Arm Measurement 50
4.2.6 Data Analysis 51
4.2.7 Statistical Analysis 52
4.3 Results 53
4.4 Discussion 56
Chapter 5 Summary and Future Work 59
5.1 Summary of the Present Work 59
5.2 Suggestions for the Future Work 61
References 64
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