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OPEN FRACTURES

A suitable mantra for the treatment of open tibial fractures is:

· antibiotics

· debridement

· stabilization

· prompt soft-tissue cover

· rehabilitation.

Antibiotics are started immediately. A first- or second-generation cephalosporin is suitable for Gustilo grades I–IIIA wounds but more severe grades may benefit from Gram-negative cover as well (an aminoglycoside such as gentamicin is often used). With an adequate debridement, the antibiotics are continued for 24 hours in a grade 1 fracture and 72 hours in more severe grades. However, the evidence for prolonged antibiotic use is lacking and, not surprisingly, most infections from delayed closure of open tibial wounds tend to be by nosocomial hospital- acquired bacteria. These can be multiresistant organisms that are not covered by standard antibiotics, thus good debridement of the fracture and prompt cover remain the strongest defence against infection.

The wound should be photographed on first inspection in the emergency department using a Polaroid or digital camera, and then covered with a sterile dressing. The photograph can then be printed for inclusion in the patient’s case notes to serve as a record and prevent further disturbance to the wound. Adequate debridement is possible only if the original wound is extended. However, excise as little skin as possible and discuss wound extensions with a plastic surgeon, especially if there appears to be a need for local or free skin or muscle flaps. Ideally the debridement should be performed jointly with the plastic surgeon. All dead and foreign material is removed; this includes bone without significant soft-tissue attachments. Tissue of doubtful viability may be left for a second look in 48 hours. The wound and fracture site are then washed out with large quantities of normal saline.

Gustilo grade I injuries can be closed primarily–being a low-energy injury with a small wound, closure should be possible without skin tension – and the fracture then treated as for closed injuries. More severe wounds should, ideally, be closed at primary surgery as long as the debridement has been thorough and the skills of a plastic surgeon are at hand. If there is tissue of doubtful viability that requires another look, or a local flap cover deemed to be inappropriate, a second planned operation is needed. This allows further debridement and, hopefully, sufficient time to plan cover by free tissue transfer. Temporary cover of the exposed bone by using antibiotic beads sealed with an impervious plastic film can help reduce bacterial colonization. In general the aim should be to close the wound in the first 3–5 days.

It is important to stabilize the fracture. For Gustilo I, II and IIIA injuries, locked intramedullary nailing is permissible as definitive wound cover is usually possible at the time of debridement. For more severe grades of open tibial fracture, internal fixation should be performed only at the time of definitive soft tissue cover. If this is not feasible at the time of primary debridement, the fracture should be stabilized temporarily with a spanning external fixator. Exchange of the fixator for an intramedullary nail can be done at the point when definitive soft tissue cover is carried out – ideally within 5 days of the injury. Alternatively, definitive fracture management can be carried out using external fixation.

Severe grades of open fractures should, whenever possible, be managed from the outset under the combined care of an orthopaedic surgeon and a plastic surgeon.

---from 《Apley’s System of Orthopaedics and Fractures》

重點(diǎn)詞匯整理：

 mantra/?mɑ?ntr?,?m?ntr?/n. 咒語（尤指四吠陀經(jīng)典內(nèi)作為咒文或禱告唱念的）；頌歌;真言

rehabilitation. /?ri???b?l??te??n/

n. 復(fù)原;康復(fù)

second-generation cephalosporin第二代頭孢菌素

 /?sef?lo??sp??r?n/n. [藥] 頭孢菌素

 Gram-negative /ɡr?m ?neɡ?t?v/adj. [微] 革蘭氏陰性的

an aminoglycoside such as gentamicin is often used氨基糖苷類藥物如慶大霉素是常用的藥物

nosocomial hospital院內(nèi)感染

nosocomial hospital- acquired bacteria醫(yī)院獲得性細(xì)菌

multiresistant organisms多重耐藥菌

sterile dressing.消毒紗布包

 dequate debridement is possible only if the original wound is extended.只有當(dāng)原創(chuàng)面擴(kuò)大時(shí)，才能進(jìn)行充分的清創(chuàng)。

 Tissue of doubtful viability可疑有活性的組織

a local flap cover deemed to be inappropriate被認(rèn)為不合適的局部皮瓣

deem/di?m/vt. 認(rèn)為，視作；相信vi. 認(rèn)為，持某種看法；作某種評(píng)價(jià)

antibiotic beads抗生素骨水泥珠鏈

impervious plastic film不透水塑料薄膜

 /?m?p??rvi?s/adj. 不受影響的，無動(dòng)于衷的；不能滲透的

permissible/p?r?m?s?bl/adj. 可允許的；獲得準(zhǔn)許的

definitive /d??f?n?t?v/adj. 最后的；最佳的；最權(quán)威的；（郵票）普通標(biāo)準(zhǔn)型的

definite /?def?n?t/adj. 一定的；確切的

 feasible  /?fi?z?bl/adj. 可行的；可能的；可實(shí)行的

spanning external fixator跨越外固定架

有道翻譯（僅供參考，建議自己翻譯）：

開放性骨折

治療開放性脛骨骨折的合適咒語是：

·抗生素

·清創(chuàng)術(shù)

·穩(wěn)定

·迅速覆蓋軟組織

·康復(fù)。

立即開始使用抗生素。第一代或第二代頭孢菌素適用于Gustilo I-IIIA級(jí)傷口，但更嚴(yán)重的級(jí)別也可能受益于革蘭氏陰性覆蓋（通常使用氨基糖苷類藥物，如慶大霉素）。在充分清創(chuàng)的情況下，對(duì)于1級(jí)骨折，抗生素持續(xù)24小時(shí)，對(duì)于更嚴(yán)重的骨折，抗生素持續(xù)72小時(shí)。然而，長期使用抗生素的證據(jù)是缺乏的，毫不奇怪，大多數(shù)脛骨開放性傷口延遲愈合引起的感染往往是由醫(yī)院獲得性細(xì)菌引起的。這些可能是多重耐藥的生物體，沒有覆蓋標(biāo)準(zhǔn)的抗生素，因此良好的清創(chuàng)骨折和及時(shí)覆蓋仍然是最強(qiáng)的防御感染。

在急診室第一次檢查時(shí)，應(yīng)使用寶麗來或數(shù)碼相機(jī)拍攝傷口，然后用無菌敷料覆蓋傷口。然后可以打印照片，將其包含在患者的病例筆記中，作為記錄，防止對(duì)傷口造成進(jìn)一步的干擾。只有在原有傷口擴(kuò)大的情況下才有可能進(jìn)行充分的清創(chuàng)。然而，切除盡可能少的皮膚和討論傷口的擴(kuò)展與整形外科醫(yī)生，尤其是如果似乎有必要局部或游離皮膚或肌肉皮瓣。理想情況下，清創(chuàng)術(shù)應(yīng)與整形外科醫(yī)生聯(lián)合進(jìn)行。所有死亡和異物都被清除；包括沒有明顯軟組織附著的骨骼。存活能力可疑的組織可在48小時(shí)后再次檢查。然后用大量生理鹽水沖洗傷口和骨折部位。

Gustilo I級(jí)損傷可以主要閉合-是一種低能量損傷，傷口較小，閉合時(shí)應(yīng)無皮膚張力-然后將骨折作為閉合性損傷進(jìn)行治療。更嚴(yán)重的傷口，理想情況下，應(yīng)該在初次手術(shù)時(shí)關(guān)閉，只要清創(chuàng)已經(jīng)徹底和整形外科醫(yī)生的技能在手。如果有存疑的組織需要再次檢查，或局部皮瓣覆蓋被認(rèn)為是不合適的，需要第二次計(jì)劃的手術(shù)。這允許進(jìn)一步清創(chuàng)，希望有足夠的時(shí)間計(jì)劃覆蓋自由組織轉(zhuǎn)移。用不透水的塑料薄膜密封的抗生素珠暫時(shí)覆蓋暴露的骨骼，有助于減少細(xì)菌定植。一般來說，目標(biāo)應(yīng)該是在頭3-5天內(nèi)閉合傷口。

穩(wěn)定骨折很重要。對(duì)于Gustilo I、II和IIIA損傷，允許使用交鎖髓內(nèi)釘，因?yàn)榍鍎?chuàng)時(shí)通?？梢愿采w明確的傷口。對(duì)于更嚴(yán)重等級(jí)的開放性脛骨骨折，應(yīng)僅在確定軟組織覆蓋時(shí)進(jìn)行內(nèi)固定。如果在初次清創(chuàng)時(shí)不可行，則應(yīng)使用跨越式外固定器暫時(shí)固定骨折。固定器與髓內(nèi)釘?shù)慕粨Q可以在確定的軟組織覆蓋完成時(shí)進(jìn)行——最好是在受傷后5天內(nèi)?；蛘?，可以使用外固定器進(jìn)行明確的骨折治療。

嚴(yán)重程度的開放性骨折應(yīng)盡可能在骨科醫(yī)生和整形醫(yī)生的聯(lián)合治療下從一開始就進(jìn)行治療。