骨科英文书籍精读（26）｜开放性骨折的清创原则
Debridement
The operation aims to render the wound free of foreign material and of dead tissue, leaving a clean surgical field and tissues with a good blood supply throughout. Under general anaesthesia the patient’s clothing is removed, while an assistant maintains traction on the injured limb and holds it still. The dressing previously applied to the wound is replaced by a sterile pad and the surrounding skin is cleaned.The pad is then taken off and the wound is irrigated thoroughly with copious amounts of physiological saline. The wound is covered again and the patient’s limb then prepped and draped for surgery.
Many surgeons prefer to use a tourniquet as this provides a bloodless field. However this induces ischaemia in an already badly injured leg and can make it difficult to recognize which structures are devitalized. A compromise is to apply the tourniquet but not to inflate it during the debridement unless absolutely necessary.
Because open fractures are often high-energy injuries with severe tissue damage, the operation should be performed by someone skilled in dealing with both skeletal and soft tissues; ideally this will be a joint effort by orthopaedic and plastic surgeons. The following principles must be observed:
Wound excision The wound margins are excised, but only enough to leave healthy skin edges.
Wound extension Thorough cleansing necessitates adequate exposure; poking around in a small wound to remove debris can be dangerous. If extensions are needed they should not jeopardize the creation of skin flaps for wound cover if this should be needed. The safest extensions are to follow the line of fasciotomy incisions; these avoid damaging important perforator vessels that can be used to raise skin flaps for eventual fracture cover.
23.26 Wound extensions for access in open fractures of the tibia Wound incisions (extensions) for adequate access to an open tibial fracture are made along standard fasciotomy incisions: 1 cm behind the posteromedial border of the tibia and 2–3 cm lateral to the crest of the tibia as shown in this example of a two-incision fasciotomy. The dotted lines mark out the crest (C) and posteromedial corner (PM) of the tibia (a). These incisions avoid injury to the perforating branches that supply areas of skin that can be used as flaps to cover the exposed fracture (b). This clinical example shows how local skin necrosis around an open fracture is excised and the wound extended proximally along a fasciotomy incision (c,d).
Delivery of the fracture Examination of the fracture surfaces cannot be adequately performed without extracting the bone from within the wound. The simplest (and gentlest) method is to bend the limb in the manner in which it was forced at the moment of injury; the fracture surfaces will be exposed through the wound without any additional damage to the soft tissues. Large bone levers and retractors should not be used.
Removal of devitalized tissue Devitalized tissue provides a nutrient medium for bacteria. Dead muscle can be recognized by its purplish colour, its mushy consistency, its failure to contract when stimulated and its failure to bleed when cut. All doubtfully viable tissue, whether soft or bony, should be removed. The fracture ends can be nibbled away until seen to bleed.
Wound cleansing All foreign material and tissue debris is removed by excision or through a wash with copious quantities of saline. A common mistake is to inject syringefuls of fluid through a small aperture – this only serves to push contaminants further in; 6–12 L of saline may be needed to irrigate and clean an open fracture of a long bone. Adding antibiotics or antiseptics to the solution has no added benefit.
Nerves and tendons As a general rule it is best to leave cut nerves and tendons alone, though if the wound is absolutely clean and no dissection is required – and provided the necessary expertise is available – they can be sutured.
---from 《Apley’s System of Orthopaedics and Fractures》P707-708
重点词汇整理：
cleansing /'klɛnzɪŋ/n. 彻底清洁；洗清；清洁霜adj. 清洁的；有去污作用的v. 清洗；净化；免除（某人）的罪过；治愈（cleanse 的现在分词）
necessitate /nəˈsesɪteɪt/vt. 使成为必需，需要；迫使
adequate exposure充分暴露
poke/poʊk/n. 戳；刺；袋子；懒汉vt. 刺，捅；戳；拨开vi. 刺，捅；戳；伸出；刺探；闲荡
debris /dəˈbriː/n. 碎片，残骸
jeopardize /ˈdʒepərdaɪz/vt. 危害；使陷危地；使受危困
fasciotomy incisions;筋膜切开术切口;
fasciotomy /fæʃi'ɔtəmi/n. [外科] 筋膜切开术
perforator vessels 穿支血管
perforator /'pə:fəreitə/n. 穿孔器；穿孔员
the crest of the tibia 胫骨脊
crest/krest/n. [物] 波峰；冠；山顶；顶饰vi. 到达绝顶；形成浪峰
dotted lines mark 虚线标记
local skin necrosis 局部皮肤坏死
devitalized tissue 失活组织
a nutrient medium for bacteria细菌的营养培养基
mushy/ˈmʌʃi/adj. 糊状的；感伤的，多愁善感的
consistency /kənˈsɪstənsi/n. [计] 一致性；稠度；相容性
nibble /ˈnɪbl/n. 轻咬；啃；细咬vt. 细咬；一点一点地咬；吹毛求疵
foreign material 异物，外来杂质
saline /ˈseɪliːn/n. 盐溶液；生理盐水adj. 盐的，含盐的；咸的
A common mistake is to inject syringefuls of fluid through a small aperture – this only serves to push contaminants further in。一个常见的错误是通过小孔注入液体----这只会将污染物进一步推入。
aperture /ˈæpərtʃʊr/n. 孔，穴
antibiotics or antiseptics抗生素或防腐剂
solution/səˈluːʃn/
n. 解决方案；溶液；溶解；解答
added benefit.额外收益
dissection/dɪˈsekʃn,daɪˈsekʃn/n. 解剖，切开；解剖体；详细查究
suture/ˈsuːtʃər/n. 缝合；缝合处；缝合用的线vt. 缝合
百度翻译：
清创术
手术的目的是使伤口没有异物和死亡组织，留下一个干净的手术场地和整个组织良好的血液供应。在全身麻醉下，病人的衣服被脱掉，而助手保持对受伤肢体的牵引力并保持静止。先前敷在伤口上的敷料被无菌垫代替，周围皮肤被清洁。然后取下垫子，用大量生理盐水彻底冲洗伤口。伤口再次被覆盖，病人的四肢随后被准备好并披上手术衣。
许多外科医生喜欢使用止血带，因为这提供了一个无血的领域。然而，这会在已经严重受伤的腿上引起缺血，并使人们很难识别哪些结构是失活的。一个折衷的办法是使用止血带，但除非绝对必要，否则不要在清创过程中给止血带充气。
由于开放性骨折通常是高能量损伤，组织损伤严重，手术应由擅长处理骨骼和软组织的人员进行；理想情况下，这将是骨科和整形外科医生的共同努力。必须遵守以下原则：
伤口切除 伤口边缘被切除，但只够留下健康的皮肤边缘。
伤口延伸 彻底清洁需要充分暴露；在小伤口周围戳来戳去碎片可能是危险的。如果需要扩张，则不应危及创口皮瓣的制作，如果需要的话。最安全的延长是遵循筋膜切开切口的路线；这些可以避免损伤重要的穿支血管，这些血管可以用来提升皮瓣，以最终覆盖骨折。
23.26胫骨开放性骨折的伤口延长切口（延长）沿标准筋膜切开切口进行，以充分进入开放性胫骨骨折：胫骨后内侧缘后1cm，胫骨顶部外侧2-3cm，如双切口筋膜切开术示例所示。虚线标出胫骨（a）的嵴（C）和后内侧角（PM）。这些切口避免了对穿支的损伤，穿支是皮肤的一部分，可作为皮瓣覆盖暴露的骨折（b）。这个临床例子显示了开放性骨折周围的局部皮肤坏死是如何切除的，伤口沿着筋膜切开切口（c，d）向下延伸。
如果不从伤口内取出骨头，就不能对骨折表面进行充分的骨折检查。最简单（也是最温和）的方法是弯曲肢体，使其在受伤时处于受迫状态；骨折表面将暴露在伤口中，而不会对软组织造成任何额外损伤。不应使用大型骨杠杆和牵开器。
去除失活组织失活组织为细菌提供营养培养基。死亡的肌肉可以通过它的紫色，它的糊状稠度，它在刺激时不能收缩，它在割伤时不能流血来识别。所有可疑的活组织，无论是软组织还是骨性组织，都应该切除。骨折端可以被咬掉，直到看到出血为止。
伤口清洁所有异物和组织碎片通过切除或用大量生理盐水冲洗去除。一个常见的错误是通过一个小孔注射大量的液体-这只会将污染物进一步推入；可能需要6-12升的生理盐水来冲洗和清洁长骨的开放性骨折。在溶液中添加抗生素或防腐剂没有额外的好处。
神经和肌腱作为一般规则，最好不要割伤神经和肌腱，但如果伤口绝对干净，不需要解剖——如果有必要的专业知识——它们可以缝合。