骨科英文书籍精读（27）｜开放性骨折的伤口处理及固定
Wound closure
A small, uncontaminated wound in a Grade I or II fracture may (after debridement) be sutured, provided this can be done without tension. In the more severengrades of injury, immediate fracture stabilization and wound cover using split-skin grafts, local or distant flaps is ideal, provided both orthopaedic and plastic surgeons are satisfied that a clean, viable wound has been achieved after debridement. In the absence of this combined approach at the time of debridement, the fracture is stabilized and the wound left open and dressed with an impervious dressing. Adding gentamicin beads under the dressing has been shown to help, as has the use of vacuum dressings. Return to surgery for a ‘second look’ should have definitive fracture cover as an objective. It should be done by 48–72 hours, and not later than 5 days. Open fractures do not fare well if left exposed for long and multiple debridement can be self-defeating.
Stabilizing the fracture
Stabilizing the fracture is important in reducing the likelihood of infection and assisting recovery of the soft tissues. The method of fixation depends on the degree of contamination, length of time from injury to operation and amount of soft-tissue damage. If there is no obvious contamination and definitive wound cover can be achieved at the time of debridement, open fractures of all grades can be treated as for a closed injury; internal or external fixation may be appropriate depending on the individual characteristics of the fracture and wound. This ideal scenario of judicious soft-tissue and bone debridement, wound cleansing, immediate stabilization and cover is only possible if orthopaedic and plastic surgeons are present at the time of initial surgery.
If wound cover is delayed, then external fixation is safer; however, the surgeon must take care to insert the fixator pins away from potential flaps needed by the plastic surgeon!
The external fixator may be exchanged for internal fixation at the time of definitive wound cover as long as (1) the delay to wound cover is less than 7 days; (2) wound contamination is not visible and (3) internal fixation can control the fracture as well as the external fixator. This approach is less risky than introducing internal fixation at the time of initial surgery and leaving both metalwork and bone exposed until definitive cover several days later.
Aftercare
In the ward, the limb is elevated and its circulation carefully watched. Antibiotic cover is continued but only for a maximum of 72 hours in the more severe grades of injury. Wound cultures are seldom helpful as osteomyelitis, if it were to ensue, is often caused by hospital-derived organisms; this emphasizes the need for good debridement and early fracture cover.
---from 《Apley’s System of Orthopaedics and Fractures》P708-710
重点词汇整理：
provided /prəˈvaɪdɪd/conj. 假如，倘若v. 提供，给予（provide 的过去式和过去分词）
split-skin grafts, local or distant flaps分离式植皮、局部或远处皮瓣
viable /ˈvaɪəbl/adj. 可行的；能养活的；能生育的
impervious dressing 不透水敷料
gentamicin beads 庆大霉素链珠
vacuum dressings 负压敷料（VSD）
fare well 顺利，过得好，告别
self-defeating /ˌself dɪˈfiːtɪŋ/adj. 弄巧成拙的；不利于自己的企图的
internal or external fixation 内/外固定
individual characteristics个人特征
ideal scenario of judicious 明智的理想方案
judicious /dʒuˈdɪʃəs/adj. 明智的；头脑精明的；判断正确的
fixator pins 固定器针
metalwork /ˈmetlwɜːrk/n. 金属制品；金属加工vt. 金属加工
In the ward,在病房内
Wound cultures 伤口培养
百度翻译：
伤口闭合
一级或二级骨折中的未受污染的小伤口可以（清创后）缝合，前提是可以在没有张力的情况下缝合。在较严重的损伤中，只要骨科和整形外科医师都认为清创后伤口干净、有活力，使用分离式植皮、局部或远处皮瓣立即稳定骨折和覆盖伤口是理想的。在清创时没有这种联合入路的情况下，骨折稳定，伤口保持开放，并用不透水敷料包扎。在调味品下面添加龙胆素珠子有助于改善，真空调味品的使用也是如此。回到手术室进行“第二次检查”时，应以明确的骨折覆盖为目标。应在48-72小时内完成，且不迟于5天。如果长时间暴露在外，开放性骨折的情况就不太好，而多次清创可能会自取灭亡。
稳定骨折
稳定骨折对于降低感染的可能性和帮助软组织恢复非常重要。固定方法取决于污染程度、从损伤到手术的时间和软组织损伤的程度。如果在清创时没有明显的污染，并且可以获得明确的伤口覆盖，所有等级的开放性骨折都可以作为闭合性损伤进行治疗；根据骨折和伤口的个体特征，内固定或外固定可能是合适的。只有当骨科和整形外科医师在初次手术时处于压力状态时，这种明智的软组织和骨清创、伤口清洗、立即稳定和覆盖的理想方案才可能实现。
如果伤口覆盖延迟，那么外固定更安全；但是，外科医生必须注意将固定针插入整形外科医生需要的潜在皮瓣之外！
只要（1）伤口覆盖延迟少于7天；（2）伤口污染不明显；（3）内固定能控制骨折和外固定器，外固定器可在确定伤口覆盖时更换为内固定器。这种方法比在初次手术时采用内固定和暴露在金属制品和骨上直到几天后确定覆盖的方法风险小。
术后护理
在病房里，四肢抬高，并仔细观察其循环。抗生素覆盖是持续的，但在更严重的损伤中最多只能覆盖72小时。伤口培养很少有帮助，因为骨髓炎，如果它是接踵而至，往往是由医院衍生的有机体造成的，这强调了良好的清创和早期骨折覆盖的必要性。