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我们正在精读国外经典骨科书籍《Apley’s System of Orthopaedics and Fractures》，想要对于骨科英文形成系统认识，为以后无障碍阅读英文文献打下基础，请持续关注。
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》 重点词汇整理： mantra/ˈmɑːntrə,ˈmæntrə/n. 咒语（尤指四吠陀经典内作为咒文或祷告唱念的）；颂歌;真言 rehabilitation. /ˌriːəˌbɪlɪˈteɪʃn/ n. 复原;康复 second-generation cephalosporin第二代头孢菌素 /ˌsefəloʊˈspɔːrɪn/n. [药] 头孢菌素 Gram-negative /ɡræm ˈneɡətɪv/adj. [微] 革兰氏阴性的 an aminoglycoside such as gentamicin is often used氨基糖苷类药物如庆大霉素是常用的药物 nosocomial hospital院内感染 nosocomial hospital- acquired bacteria医院获得性细菌 multiresistant organisms多重耐药菌 sterile dressing.消毒纱布包 dequate debridement is possible only if the original wound is extended.只有当原创面扩大时，才能进行充分的清创。 Tissue of doubtful viability可疑有活性的组织 a local flap cover deemed to be inappropriate被认为不合适的局部皮瓣 deem/diːm/vt. 认为，视作；相信vi. 认为，持某种看法；作某种评价 antibiotic beads抗生素骨水泥珠链 impervious plastic film不透水塑料薄膜 /ɪmˈpɜːrviəs/adj. 不受影响的，无动于衷的；不能渗透的 permissible/pərˈmɪsəbl/adj. 可允许的；获得准许的 definitive /dɪˈfɪnətɪv/adj. 最后的；最佳的；最权威的；（邮票）普通标准型的 definite /ˈdefɪnət/adj. 一定的；确切的 feasible /ˈfiːzəbl/adj. 可行的；可能的；可实行的 spanning external fixator跨越外固定架 有道翻译（仅供参考，建议自己翻译）： 开放性骨折 治疗开放性胫骨骨折的合适咒语是： ·抗生素 ·清创术 ·稳定 ·迅速覆盖软组织 ·康复。 立即开始使用抗生素。第一代或第二代头孢菌素适用于Gustilo I-IIIA级伤口，但更严重的级别也可能受益于革兰氏阴性覆盖（通常使用氨基糖苷类药物，如庆大霉素）。在充分清创的情况下，对于1级骨折，抗生素持续24小时，对于更严重的骨折，抗生素持续72小时。然而，长期使用抗生素的证据是缺乏的，毫不奇怪，大多数胫骨开放性伤口延迟愈合引起的感染往往是由医院获得性细菌引起的。这些可能是多重耐药的生物体，没有覆盖标准的抗生素，因此良好的清创骨折和及时覆盖仍然是最强的防御感染。 在急诊室第一次检查时，应使用宝丽来或数码相机拍摄伤口，然后用无菌敷料覆盖伤口。然后可以打印照片，将其包含在患者的病例笔记中，作为记录，防止对伤口造成进一步的干扰。只有在原有伤口扩大的情况下才有可能进行充分的清创。然而，切除尽可能少的皮肤和讨论伤口的扩展与整形外科医生，尤其是如果似乎有必要局部或游离皮肤或肌肉皮瓣。理想情况下，清创术应与整形外科医生联合进行。所有死亡和异物都被清除；包括没有明显软组织附着的骨骼。存活能力可疑的组织可在48小时后再次检查。然后用大量生理盐水冲洗伤口和骨折部位。 Gustilo I级损伤可以主要闭合-是一种低能量损伤，伤口较小，闭合时应无皮肤张力-然后将骨折作为闭合性损伤进行治疗。更严重的伤口，理想情况下，应该在初次手术时关闭，只要清创已经彻底和整形外科医生的技能在手。如果有存疑的组织需要再次检查，或局部皮瓣覆盖被认为是不合适的，需要第二次计划的手术。这允许进一步清创，希望有足够的时间计划覆盖自由组织转移。用不透水的塑料薄膜密封的抗生素珠暂时覆盖暴露的骨骼，有助于减少细菌定植。一般来说，目标应该是在头3-5天内闭合伤口。 稳定骨折很重要。对于Gustilo I、II和IIIA损伤，允许使用交锁髓内钉，因为清创时通常可以覆盖明确的伤口。对于更严重等级的开放性胫骨骨折，应仅在确定软组织覆盖时进行内固定。如果在初次清创时不可行，则应使用跨越式外固定器暂时固定骨折。固定器与髓内钉的交换可以在确定的软组织覆盖完成时进行——最好是在受伤后5天内。或者，可以使用外固定器进行明确的骨折治疗。 严重程度的开放性骨折应尽可能在骨科医生和整形医生的联合治疗下从一开始就进行治疗。 |
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