骨科英文书籍精读（24）｜开放性骨折的初期治疗
TREATMENT OF OPEN FRACTURES INITIAL MANAGEMENT
Patients with open fractures may have multiple injuries; a rapid general assessment is the first step and any lifethreatening conditions are addressed (see Chapter 22).
The open fracture may draw attention away from other more important conditions and it is essential that the step-by-step approach in advanced trauma life support not be forgotten.
When the fracture is ready to be dealt with, the wound is first carefully inspected; any gross contamination is removed, the wound is photographed with a Polaroid or digital camera to record the injury and the area then covered with a saline-soaked dressing under an impervious seal to prevent desiccation. This is left undisturbed until the patient is in the operating theatre. The patient is given antibiotics, usually co-amoxiclav or cefuroxime, but clindamycin if the patient is allergic to penicillin.Tetanus prophylaxis is administered: toxoid for those previously immunized, human antiserum if not. The limb is then splinted until surgery is undertaken.
The limb circulation and distal neurological status will need checking repeatedly, particularly after any fracture reduction manoeuvres. Compartment syndrome is not prevented by there being an open fracture; vigilance for this complication is wise.
CLASSIFYING THE INJURY
Treatment is determined by the type of fracture, the nature of the soft-tissue injury (including the wound size) and the degree of contamination. Gustilo’s classification of open fractures is widely used (Gustilo et al., 1984):
Type 1 – The wound is usually a small, clean puncture through which a bone spike has protruded. There is little soft-tissue damage with no crushing and the fracture is not comminuted (i.e. a low-energy fracture).
Type II – The wound is more than 1 cm long, but there is no skin flap. There is not much soft-tissue damage and no more than moderate crushing or comminution of the fracture (also a low- to moderate-energy fracture).
Type III – There is a large laceration, extensive damage to skin and underlying soft tissue and, in the most severe examples, vascular compromise. The injury is caused by high-energy transfer to the bone
and soft tissues. Contamination can be significant.
There are three grades of severity. In type III A the fractured bone can be adequately covered by soft tissue despite the laceration. In type III B there is extensive periosteal stripping and fracture cover is not possible without use of local or distant flaps. The fracture is classified as type III C if there is an arterial injury that needs to be repaired, regardless of the amount of other soft-tissue damage.
The incidence of wound infection correlates directly with the extent of soft-tissue damage, rising from less than 2 percent in type I to more than 10 percent in type III fractures.
---from 《Apley’s System of Orthopaedics and Fractures》P687-688
重点词汇整理：
assessment /əˈsesmənt/n. 评定；估价
gross contamination 恶心的污染物
gross /ɡroʊs/n. 总额，总数adj. 总共的；粗野的；恶劣的；显而易见的；恶心的
Polaroid or digital camera 宝丽来（拍立得相机）或数码相机
a saline-soaked dressing用盐水浸泡的敷料
impervious seal 不透水密封
impervious /ɪmˈpɜːrviəs/adj. 不受影响的，无动于衷的；不能渗透的
seal/siːl/n. 密封；印章；海豹；封条；标志vt. 密封；盖章
desiccation /ˌdesɪˈkeɪʃn/n. 干燥
This is left undisturbed until the patient is in the operating theatre在病人进入手术室之前，这一过程不受干扰。
undisturbed /ˌʌndɪˈstɜːrbd/adj. 安静的；镇定的；未被扰乱的
co-amoxiclav or cefuroxime,联合阿莫司或头孢呋辛
clindamycin /,klində'maisin/n. 克林霉素
allergic to penicillin.对青霉素过敏。
Tetanus /ˈtetnəs/n. [内科] 破伤风；强直
prophylaxis /ˌproʊfəˈlæksɪs/n. [医] 预防；预防法
toxoid for those previously immunized, human antiserum if not. 以前免疫过的人使用类毒素，如果没有，则使用人类抗血清。
manoeuvres/məˈnuːvər/v. （使谨慎或熟练地）移动；操控，使花招；诱使，诱导
Compartment syndrome筋膜室综合征
vigilance /ˈvɪdʒɪləns/n. 警戒，警觉；失眠症
spike /spaɪk/n. 长钉，道钉vt. 阻止；以大钉钉牢；用尖物刺穿
protrude/proʊˈtruːd/v. 伸出，突出；
laceration, /ˌlæsəˈreɪʃn/n. 裂伤；撕裂；割破
vascular compromise血管的损伤 /ˈkɑːmprəmaɪz/n. 妥协，和解；
correlates directly直接相关
百度翻译：
开放性骨折的治疗
开放性骨折的患者可能有多处损伤；快速全面评估是第一步，任何危及生命的情况都会得到解决（见第22章）。
开放性骨折可能会将注意力从其他更重要的情况转移开，因此，在晚期创伤生命支持中，一步一步的方法是必不可少的。
当骨折准备好处理时，首先仔细检查伤口；去除任何严重的挫伤，用宝丽来或数码相机拍摄伤口，以记录损伤情况，然后用盐水浸泡的敷料覆盖在不透水的密封下，防止干燥。在病人进行手术前，不受干扰。给病人使用抗生素，通常是联合阿莫司或头孢呋辛，但如果病人对青霉素过敏，则使用克林霉素。使用破伤风预防措施：以前免疫过的人使用类毒素，如果没有，则使用人类抗血清。然后用夹板固定四肢，直到手术完成。
肢体循环和远端神经状态需要反复检查，特别是在任何骨折复位操作后。腔室综合征不会因开放性骨折而被阻止；警惕这种并发症是明智的。
伤害分类
治疗取决于骨折类型、软组织损伤的性质（包括伤口大小）和污染程度。Gustilo's clas sification of open breaks被广泛使用（Gustilo et al.，1984）：
1型-伤口通常是一个小的，干净的穿刺，通过它骨头刺突出来。软组织损伤小，无压碎，骨折未粉碎（即低能量骨折）。
II型-伤口超过1厘米长，但没有皮瓣。软组织损伤不多，骨折不超过中度粉碎或粉碎（也是低至中度能量骨折）。
III型-有大裂伤，皮肤和底层软组织广泛受损，在最严重的例子中，血管受损。损伤是由于高能量转移到骨头上造成的
还有软组织。污染可能很严重。
严重程度分为三级。在ⅢA型骨折中，尽管骨折处有撕裂伤，但仍能被软组织充分覆盖。在III型B中，如果不使用局部或远处的皮瓣，就不可能有延伸性骨膜剥离和骨折覆盖。如果存在需要修复的动脉损伤，不管其他软组织损伤的程度如何，骨折被归类为III C型。
伤口感染的发生率与软组织损伤的程度直接相关，从I型骨折的不到2%上升到III型骨折的10%以上。