医学资料开放骨胫腓骨折的二期处理

1、开放性胫腓骨骨折的二期处理 唐坚上海交通大学医学院附属第九人民医院 骨科上海市骨科内植物重点实验室开放性骨折定义骨折部位皮肤或粘膜破裂骨折与外界相通流行病学开放性骨折全部肢体骨折的3%21.3/100,000/年30% 为多发伤胫骨最多见（24%）严重程度（III度）百分比主要损伤机制引言上世纪：长骨开放性骨折 高死亡率WWI：股骨开放性骨折死亡率70%主流：早期截肢以挽救生命“closed treatment of war fractures”主流转向：开放伤口清创，石膏固定Trueta（1939）引言影响：大大降低开放性骨折感染率主流转向：延期闭合伤口在伤后47天，关闭伤口合并广泛软组织缺

2、损者，二期处理1943，青霉素Hampton（1955）Hampton OP Jr: Basic principles in management of open fractures; JAMA 1955; 159:417-419紧急处置气道（Airway） 呼吸与通气（Breathing） 循环（Circulation）神经功能评价（Disability） 充分暴露，避免遗漏隐匿损伤（Exposure）二期处理只要病人“稳定”，马上开始！重复全身体格检查！治疗方向转变抢救生命，挽救肢体Open tibial fractures with associated vascular injurie

3、s: prognosis for limb salvage. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. J Trauma. 1985 Mar;25(3):203-8.Ali AM, McMaster JM, Noyes D, Brent AJ, Cogswell LK. Experience of managing open fractures of the lower limb at a major trauma centre. Ann R Coll Surg Engl. 2015 May;97(4):287-90.保存功能，预防并发症开放性

4、骨折二期处理原则保护软组织外固定过渡伤口的闭合保护软组织保护血供防止坏死防止感染损伤控制损伤控制 可以理解为双重含义既控制原发损伤造成的严重后果 出血和污染使之不再发展又控制手术本身带来的损伤，保存软组织的活力，为后续治疗创造条件治疗目的预防感染获得骨折愈合重建软组织覆盖早期活动、功能锻炼Open tibial fractures with associated vascular injuries: prognosis for limb salvage. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. J Trauma. 1985 Mar;25(3)

5、:203-8.Ali AM, McMaster JM, Noyes D, Brent AJ, Cogswell LK. Experience of managing open fractures of the lower limb at a major trauma centre. Ann R Coll Surg Engl. 2015 May;97(4):287-90.治疗目的预防感染获得骨折愈合重建软组织覆盖早期活动、功能锻炼Open tibial fractures with associated vascular injuries: prognosis for limb salvage.

6、 Lange RH, Bach AW, Hansen ST Jr, Johansen KH. J Trauma. 1985 Mar;25(3):203-8.Ali AM, McMaster JM, Noyes D, Brent AJ, Cogswell LK. Experience of managing open fractures of the lower limb at a major trauma centre. Ann R Coll Surg Engl. 2015 May;97(4):287-90.预防感染，重中之重！预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折

7、固定创口闭合预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折固定创口闭合院前评价：ABCDEAAirway maintenance w/ cervical spine protectionBBreathing and ventilationCCirculation w/ hemorrhage controlDDisability : neurological statusEExposure : completely undress but prevent hypothermia预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折固定创口闭合Oestern-Tsc

8、herne损伤分类 * 注：* 适用于开放性和闭合性骨折AO分类 注：IO: 体被开放Gustilo-Anderson分类 1976以胫骨为模型，但可用于所有骨折1,025例开放骨折分类根据：伤口的大小1984，改良强调：软组织损伤程度污染程度Gustilo-Anderson I 度低能量损伤损伤方向：内外污染程度：清洁损伤程度：轻微骨折粉碎程度：简单骨膜剥脱：无至轻度Gustilo-Anderson II度低至中等能量损伤损伤方向：外内污染程度：中度损伤程度：中度，部分肌坏死骨折粉碎程度：简单至中度粉碎骨膜剥脱：中度Gustilo-Anderson IIIa度高能量损伤损伤方向：外内损伤程度

9、：重度，广泛肌坏死骨膜剥脱：广泛骨折粉碎程度：粉碎仍保留良好的软组织覆盖高能量损伤损伤方向：外内损伤程度：重度，广泛肌坏死骨膜剥脱：广泛骨折粉碎程度：粉碎仍保留良好的软组织覆盖Gustilo-Anderson IIIa度高能量损伤损伤方向：外内损伤程度：重度，广泛肌坏死，骨折粉碎软组织缺损，需皮/肌瓣覆盖骨膜剥脱：广泛Gustilo-Anderson IIIb度软组织缺损，外固定架临时固定损伤程度：重度，广泛肌坏死，骨折粉碎软组织缺损，需皮/肌瓣覆盖比目鱼肌瓣覆盖骨折部位Gustilo-Anderson IIIb度植皮覆盖创面Gustilo-Anderson IIIb度损伤程度：重度，广泛肌坏

10、死，骨折粉碎软组织缺损，需皮/肌瓣覆盖高能量损伤截肢、感染风险增加III 型损伤 + 需要修复的主要血管损伤Gustilo-Anderson IIIc度软组织损伤程度与感染发生率相关Gustilo-Anderson分类的重要性Gustilo et al. Current Concepts Review The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.软组织损伤程度与感染发生率相关软组织损伤程度与骨折愈合时间相关Gustilo-Anderson分类的重要性Gustilo et

11、 al. Current Concepts Review The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.Grade123A3B3CInfectionRates0-2%2-7%10-25%10-50%25-50%Fracture Healing (weeks)21-2828-2830-3530-35Amputation Rate50%软组织损伤程度与骨折愈合时间相关Gustilo-Anderson分类的重要性Gustilo et al. Current Concepts R

12、eview The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.软组织损伤程度与感染发生率相关软组织损伤程度与骨折愈合时间相关Gustilo-Anderson分类的重要性Gustilo et al. Current Concepts Review The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.Grade123A3B3CInfectionRates0-2%2

13、-7%10-25%10-50%25-50%Fracture Healing (weeks)21-2828-2830-3530-35Amputation Rate50%预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折固定创口闭合前瞻性、双盲、随机对照研究感染率13.9% 安慰剂组9.7% 青霉素 & 链霉素治疗组2.3% 1代头孢治疗组预防性应用抗生素的重要性Patzakis et al. 1974Patzakis et al. The Role of Antibiotics in the Management of Open Fractures. The Journal of

14、 Bone and Joint Surgery 1974;56:532-541.应用何种抗生素？1代头孢氨基糖甙类青霉素I度II度+/- III度+/-农场伤/战伤Gustilo et al. Current Concepts Review The Management of Open Fractures. Journal of Bone and Joint Surgery. 1990;72:299-304.Tsukayama DT, Gustilo RB. Antibiotic management of open fractures. In: Greene W, ed. AAOS Inst

15、ructional Course Lectures. Park Ridge: American Academy of Orthopaedic Surgeons, 1990:487-490.Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy

16、 in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33.Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.Olszewski D, Streubel PN, Stucken C, Ricci WM, Hoffmann MF, Jones CB, Sietsema DL, Tornetta P 3rd.The

17、 Fate of Patients with a Surprise Positive Culture After Nonunion Surgery. J Orthop Trauma. 2015 Aug 8.1104例，开放性骨折结果：伤后3小时内应用抗生素显著降低感染率感染率：4.7% 伤后3小时内，应用抗生素7.4% 伤后3小时，应用抗生素预防性应用抗生素的时机Patzakis et al. 1989Patzakis et al. Factors influencing infection rate in open fracture wounds. Clin Orthop. 1989;243

18、:36-40.1000多例开放性骨折结果：伤后3小时内应用抗生素显著降低感染率感染率：4.7% 伤后3小时内，应用抗生素7.4% 伤后3小时，应用抗生素预防性应用抗生素的时机Patzakis et al. 1989Patzakis et al. Factors influencing infection rate in open fracture wounds. Clin Orthop. 1989;243:36-40.尽早应用抗生素目前尚无定论伤后应用抗生素 1天 VS. 5天无显著性差异抗生素用多长时间？Dellinger et al. 1988Dellinger EP, Caplan ES

19、, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9.抗生素用多长时间？目前推荐：2472 hr预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折固定创口闭合1973 Robson感染界值：105个细菌/克组织损伤至达到界值时间：5.17 hr1995

20、 Kindsfater et al: 47例 G2/3 开放性骨折，感染率：7%，5小时内清创38%，5小时后清创清创时限Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310.Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30.Kindsfater K1, Jonassen EA.

21、Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995 Apr;9(2):121-7.6 hour rule反方超过6小时也行6 hour rule？OR NOT1993 Bednar and Parikh.3.4% vs 9%；82例开放性股骨/胫骨骨折2004 Ashford et al.11% vs 17%；48例开放性骨折（澳大利亚）2004 Spencer et al.10.1% vs 10.9%; 142例开放性骨折（英国）2003 Pol

22、lack et al.315例开放性骨折2005 Skaggs et al. 554例儿童开放性骨折Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.Ashford RU, Mehta JA, Cripps

23、R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6.Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R Coll Surg

24、 Engl. 2004;86:108-12.Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 200

25、3 Oct 9-11; Salt Lake City, UT.Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.” JBJS-A 2005. 87:8-12清创时限 6 hr VS. 6 hrNo significant difference before or after 6 hours!与清创时间相比，

26、更重要的是：清创彻底与否软组织覆盖时间2005 Skaggs et al.若10pm后，留待上午清创，或24小时内清创除非合并.神经血管危象严重软组织污染骨筋膜室综合征Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.Werner CM, Pierpont Y, Pollak AN: The urgency of surgical dbridement in the manage

27、ment of open fractures. J Am Acad Orthop Surg. 2008 Jul;16(7):369-75.Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children. Principles of Evaluation and Management. JBJS-A. 2005;87:2784-2798.清创时限 6 hr VS. 6 hrWithin 24 hours!1988 Orcutt et al. 50例，1 & 2度开放性骨折；清创与否，无显著差异，但是非手术治疗组，感染率更低 (3% vs 6%)

28、非手术治疗组，骨折延迟愈合更少 (10% vs 16%)2003 Yang et al.91例，1度开放性骨折，均未清创/冲洗感染率：0%所有开放性骨折都需要清创吗？Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.Yang EC, Eisler J. “Treat

29、ment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res 2003. 410: 289-294.彻底清创是所有类型开放骨折的标准治疗方式！尽管对于低度开放性骨折而言，标准清创术的帮助可能不大，但清创术仍是正确损伤分类的基础！不探查、不清创，风险远远大于得益！所有开放性骨折都需要清创吗？Okike K, Bhattacharyya T: Trends in the management of open fractures. A critic

30、al analysis. J Bone Joint Surg Am. 2006 Dec;88(12):2739-48.Okike K指出（2006）彻底清创是所有类型开放骨折的标准治疗方式！尽管对于低度开放性骨折而言，标准清创术的帮助可能不大，但清创术仍是正确损伤分类的基础！不探查、不清创，风险远远大于得益！所有开放性骨折都需要清创吗？Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec;88(12):27

31、39-48.Okike K指出（2006）彻底清创是所有类型开放性骨折的标准治疗方式！“D&I” not “I&D”!急诊手术首次清创极为重要目的清除所有异物切除所有失活组织减少细菌数量将创口变为清洁、有活力的伤口清创术Our most common judgement error has been the delayed excision of nonviable bone”骨清创Chapman and Olson, Fractures, Ed 4, 1996.骨清创原则去除所有小至中等大小的游离骨块保留较大的关节骨块大的游离皮质骨块保留感染率：21%去除感染率：9%Edwards 推荐：可

32、先予保留，有利于恢复肢体长度、对线，并防止旋转；然而，一旦感染，则在清创时必须去除死骨（Dead bone）坏死肌肉（Dead muscle）死腔（Dead space）重复清创?如果必要，2448小时后重复清创清创原则避免“3Ds”液体量？灌洗方式高压 or 低压脉冲式 or 持续灌洗何种液体消毒剂抗生素溶液洗涤剂生理盐水伤口灌洗液体量无共识，越多越好Anglen推荐：1度：3L (3L袋，1袋) 2度：6L (3L袋，2袋） 3度：9L (3L袋，3袋)灌洗方式常规冲洗，非脉冲式脉冲式：增加组织损伤污染带入深部伤口灌洗3L袋何种液体抗生素溶液增加费用产生耐药伤口愈合问题过敏反应伤口灌洗与非

33、消毒表面活性剂（肥皂）比较，抗生素溶液无优势！第一次冲洗、高度污染 表面活性剂（肥皂液）清洁伤口冲洗（重复冲洗） 生理盐水感染伤口 肥皂液，然后用抗生素溶液Anglen 推荐预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折固定创口闭合时机清创、灌洗、血管修复（必要时）完毕后依据骨折类型软组织损伤程度，合并损伤情况患者一般状况骨折固定Gustilo I 型同闭合性骨折疗效与闭合性骨折相似骨折固定Gustilo II & III 型骨折粉碎、不稳定，常需手术固定重建骨骼长度、对线，并纠正旋转有利于软组织修复、骨折愈合减少死腔及血肿体积降低炎性反应减少渗出及组织水肿有利于组织再血管

34、化骨折固定适应症开放性上臂、前臂开放性骨干骨折开放性关节内骨折不推荐开放性下肢骨干骨折接骨板固定Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res. 1989 Apr;(241):89-94.适应症下肢大部分骨干骨折优点不加重软组织损伤保留骨膜血供缺点损伤骨内膜血供手术时间长于外固定架固定髓内钉固定Finkemeier CG, Schmidt AH, Kyle RF, Tem

35、pleman DC, Varecka TF: A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000 Mar-Apr;14(3):187-93.实心髓内钉感染风险低于空心髓内钉然而，扩髓后，髓内钉内固定更稳定比较扩髓和不扩髓两种方式髓内钉固定治疗胫骨开放性骨折发现：疗效及并发症方面，均无显著差异

36、髓内钉固定 扩髓 or 不扩髓Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J.Influence of type of medullary nail on the development of local infection. An experimental study of solid and slotted nails in rabbits; .J Bone Joint Surg Br. 1994 Nov;76(6):955-9.Keating JF, OBrien PJ, Blachut PA, M

37、eek RN, Broekhuyse HM: Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997 Mar;79(3):334-41.Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF: A prospective, randomized study of intrame

38、dullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000 Mar-Apr;14(3):187-93.Keatinget al. 1997Finkemeier et al. 2000适应症污染较重，软组织损伤广泛不适用于髓内钉固定环形外固定架可用于开放性关节周围骨折联合有限内固定，用于关节内开放性骨折临时固定，拟二期转换为内固定外固定架固定优点操作简便、快速相对稳定的固定不加重骨损

39、伤便于创面处理外固定架固定缺点钉道感染、松动对线不良延迟愈合依从性差外固定架固定时限28d 28d外固定架固定更换内固定 “safety interval”14d14d外固定架固定更换内固定时机Ueno M, Yokoyama K, Nakamura K, chino M, Suzuki T, Itoman M: Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open t

40、ibial fractures: A report of four successful cases. Injury 2006;37: 289-294.感染率增加 p0.05%感染率下降 p0.01%预 防 感 染院前评价与处置损伤分类预防性应用抗生素清创、灌洗骨折固定创口闭合创面闭合回顾性研究 5年随访296例开放性骨折其中，III度占24%255例一期闭合创口，结果：表浅感染：11%深部感染：4.7%Moola et al. 201441例二期闭合创口，结果：表浅感染：12.2%深部感染：12.2%创面闭合回顾性研究 5年随访296例开放性骨折其中，III度占24%255例一期闭合创口，结

41、果：表浅感染：11%深部感染：4.7%Moola et al. 201441例二期闭合创口，结果：表浅感染：12.2%深部感染：12.2%创面闭合一期创面闭合的相对禁忌症清创不彻底污染严重农场伤或伤口淡水浸渍延迟处理 12 hr抗生素延迟应用患者全身状况不佳Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic thera

42、py in open fracture wounds.” JOT 2000. 14: 529-533.Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.” JBJS-B 2000. 82(7): 959 966.Hohmann E, Comparison of delayed and primary wound clos

43、ure in the treatment of open tibial fractures. Arch Orthop Trauma Surg 2007创面闭合处理方法湿 或 干 敷料半透膜抗生素骨水泥珠链VAC（持续负压闭合伤口）Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11.Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp

44、 B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007Ostermann PA, Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint

45、 Surg Br 1995开放骨折治疗方案 软组织比骨更重要！充分考虑软组织条件选择合理的治疗方案同样的骨折，选择不同的治疗方法，结果大不相同充分考虑软组织条件选择合理的治疗方案钢板内固定外固定架结果大不相同 一定要重视软组织的损伤程度创口闭合方式一期闭合二期闭合皮肤移植就近瓣局部皮瓣远隔皮瓣游离皮瓣组织扩张I 度开放性骨折IIIb 开放性骨折II/IIIa 开放性骨折Unfortunately it requires more judgement and courage to do a primary amputation than it does to salvage the limb o

46、f a patient with a severe open tibia fracture.”截肢术Heatley, BMJ, 1988截肢术Langes绝对指征:热缺血时间 6 hr胫神经断裂，不可修复MESS截肢指征：7分特殊问题骨缺损的处理骨缺损 紧急处理外固定抗生素骨水泥珠链软组织覆盖消毒、回植？骨缺损 二期处理自体骨移植松质骨皮质骨带血管骨移植同种异体骨移植松质骨皮质骨DBM牵引成骨骨搬运挽救性手术骨缩短术Case 徐XX 男 19 岁2012.3.6 树上摔落，右胫腓骨开放骨折 II 度，当地急诊行切开复位钢板内固定术上海第九人民医院唐坚教授提供病例术后10天，伤口流脓并发烧，转入DUKE医学中心清创去除内固定，感染控制后一周内固定（髓内钉+钢板）+抗生素骨水泥背阔肌肌瓣转移术，游离植皮回国后门诊随访3次手术