骨科英文书籍精读（25）｜开放性骨折的治疗原则
PRINCIPLES OF TREATMENT
All open fractures, no matter how trivial they may seem, must be assumed to be contaminated; it is important to try to prevent them from becoming infected. The four essentials are:
· Antibiotic prophylaxis.
· Urgent wound and fracture debridement.
· Stabilization of the fracture.
· Early definitive wound cover.
Sterility and antibiotic cover
The wound should be kept covered until the patient reaches the operating theatre. In most cases co-amoxiclav or cefuroxime (or clindamycin if penicillin allergy is an issue) is given as soon as possible, often in the Accident and Emergency department. At the time of debridement, gentamicin is added to a second dose of the first antibiotic. Both antibiotics provide prophylaxis against the majority of Gram-positive and Gramnegative bacteria that may have entered the wound at the time of injury. Only co-amoxiclav or cefuroxime (or clindamycin) is continued thereafter; as wounds of Gustilo grade I fractures can be closed at the time of debridement, antibiotic prophylaxis need not be for more than 24 hours. With Gustilo grade II and IIIA fractures, some surgeons prefer to delay closure after a ‘second look’ procedure. Delayed cover is also usually practised in most cases of Grade IIIB and IIIC injuries. As the wounds have now been present in a hospital environment for some time, and there are data to indicate infections after such open fractures are caused mostly by hospital-acquired bacteria and not seeded at the time of injury, gentamicin and vancomycin (or teicoplanin) are given at the time of definitive wound cover. These antibiotics are effective against methicillin-resistant Staphylococcus aureus and Pseudomonas, both of which are near the top of the league table of responsible bacteria. The total period of antibiotic use for these fractures should not be greater than 72 hours (Table 23.1)
---from 《Apley’s System of Orthopaedics and Fractures》P706-707
重点词汇整理：
trivial /ˈtrɪviəl/adj. 不重要的，琐碎的；琐细的
assumed to假定
Antibiotic prophylaxis.预使用防性抗生素
debridement. /di'bri:dmənt/n. [外科] 清创术；扩创术；创伤切开法
prophylaxis /ˌproʊfəˈlæksɪs/n. [医] 预防；预防法
Gram-positive and Gramnegative bacteria革兰氏阳性菌和革兰氏阴性菌
co-amoxiclav or cefuroxime (or clindamycin)复合-阿莫西林或头孢呋辛（或克林霉素）
hospital-acquired bacteria院内细菌
gentamicin and vancomycin (or teicoplanin)庆大霉素和万古霉素(或替考拉宁）
methicillin-resistant Staphylococcus aureus and Pseudomonas耐甲氧西林金黄色葡萄球菌和假单胞菌
near the top of the league table of responsible bacteria（这两种细菌）都接近致病菌排行榜的首位
百度翻译：
治疗原则
所有开放性骨折，无论看起来多么微不足道，都必须被认为受到了污染；重要的是要设法防止它们受到感染。四个要素是：
· 抗生素预防。
·紧急伤口和骨折清创。
·骨折稳定。
·早期明确的伤口覆盖。
无菌和抗生素覆盖
在病人到达手术室之前，伤口应该一直盖上。在大多数情况下，通常在事故和紧急情况下，应尽快给予联合阿莫西林或头孢呋辛（或克林霉素，如果青霉素过敏）。在清创时，庆大霉素被添加到第二剂量的第一种抗生素中。这两种抗生素对大多数革兰氏阳性菌和革兰氏阴性菌都有抑制作用，这些细菌可能在受伤时进入伤口。此后仅继续使用阿莫西拉夫或头孢呋辛（或克林霉素）；由于Gustilo一级骨折的伤口可以在清创时闭合，抗生素预防不需要超过24小时。对于Gustilo II级和IIIA级骨折，一些外科医生更喜欢在“第二次检查”后延迟闭合。在大多数IIIB和IIIC级损伤的情况下，通常也采用延迟覆盖。由于伤口已经在医院环境中存在了一段时间，而且有数据表明，此类开放性骨折后的感染主要是由医院获得的细菌引起的，而不是在受伤时播种的，因此在确定伤口覆盖时给予庆大霉素和凡可霉素（或替考拉宁）。这些抗生素对耐甲氧西林的金黄色葡萄球菌和假单胞菌都是有效的，这两种细菌都接近致病菌排行榜的首位。这些骨折使用抗生素的总时间不应超过72小时（见下表）