清创结合芒硝外敷治疗四肢严重开放损伤的病例对照研究
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摘要
目的:探讨严重开放骨折的简便易行的治疗方法。方法:2005年1月至2008年3月急诊病例(Gustilo-Anderson,ⅢB)33例。31例保肢成功,分为A、B两组。A组:16例(男14例,女2例);年龄21～55岁。急诊清创缝合后每天换药1～2次,通过两次清创,Ⅱ期植皮或游离皮瓣移植覆盖创面。B组:15例(男11例,女4例),根治性清创(皮肤、肌肉),常规充分筋膜间室减压,修复撕脱的骨膜,I期皮肤回植,包扎加用芒硝外敷,术后1周开始换药。术后评估两组脱套皮肤I期手术的存活率、累计手术次数、是否使用游离皮瓣、术后前2周累计换药次数,术后48h体温和血白细胞计数。结果:A组16例保肢成功,上肢10例,下肢6例,脱套皮肤平均存活率(77.88±4.21)%,其中5例运用游离皮瓣。B组15例,上肢10例,下肢5例,通过两次少量植皮愈合,平均皮肤存活率(97.53±3.09)%,无感染截肢和死亡病例。B组皮肤存活率优于A组(P<0.01),前2周换药累计次数B组少于A组(P<0.01),感染率和累计手术次数B组少于A组(P<0.01),所有患者随访大于3个月。结论:根治性清创结合芒硝外敷治疗四肢严重开放骨折,简便易行,适合突发事件(如地震)同时出现大量患者时运用。
Objective:To investigate simple and convenient methods for the treatment of severe open injuries of limbs.Methods:From 2005.1 to 2008.3,31 patients got limb salvage in 33 cases(Gustilo ⅢB) from emergency,which were divided into two groups(A and B).The 16 patients in Group A(14 male and 2 female) were treated with emergency debridement,se-quential dressing change,and finally with skin grafting or free flap.The 15 patients in Group B(11 male and 4 female) were treated with radical debridement(skin and muscle),decompression of fascial compartment routinely and repair of periosteal avulsion lesion.The patients in Group B were also treated with external application of Mangxiao(芒硝) postoperatively and dressing change for first time one week later.The clinical effects were assessed by the skin survival rate of degloving injury,the number of operative procedures(using free flap or not),the number of dressing changes in the first two weeks,body tempera-ture and white cell count(48 h after the first debridement).Statistical analysis was done with SPSS software.Chi square analy-ses was used to compare the enumeration data,and compare means with independent samples T test for measurement data.Re-sults:All the patients in Group A got limb salvage(10 patients were upper limb,6 patients were lower limb),and the mean skin survival rate of degloving injury was(77.88±4.21)%.Five patients in Group A were finally treated with free flap.All the pa-tients in Group B got limb salvage(10 patients were upper limb,5 patients were lower limb)by a few secondary skin grafting,and the mean skin survival rate of degloving injury was(97.53±3.09)%.The mean skin survival rate of Group B was obviously better than that of Group A(P<0.01).The number of dressing changes in the first two weeks in Group B was absolutely less than that of Group A(P<0.01).Also,infection rate and the number of operative procedures of Group B was significantly less than that of Group A(P<0.01).All the patients were followed up for at least 3 months.Conclusion:Radical debridement combined with external application of Mangxiao(芒硝) for the treatment of severe open fractures is simple,convenient and effective.It is better for a lot of people injured simultaneously in accident.
Objective:To investigate simple and convenient methods for the treatment of severe open injuries of limbs.Methods:From 2005.1 to 2008.3,31 patients got limb salvage in 33 cases(Gustilo ⅢB) from emergency,which were divided into two groups(A and B).The 16 patients in Group A(14 male and 2 female) were treated with emergency debridement,se-quential dressing change,and finally with skin grafting or free flap.The 15 patients in Group B(11 male and 4 female) were treated with radical debridement(skin and muscle),decompression of fascial compartment routinely and repair of periosteal avulsion lesion.The patients in Group B were also treated with external application of Mangxiao(芒硝) postoperatively and dressing change for first time one week later.The clinical effects were assessed by the skin survival rate of degloving injury,the number of operative procedures(using free flap or not),the number of dressing changes in the first two weeks,body tempera-ture and white cell count(48 h after the first debridement).Statistical analysis was done with SPSS software.Chi square analy-ses was used to compare the enumeration data,and compare means with independent samples T test for measurement data.Re-sults:All the patients in Group A got limb salvage(10 patients were upper limb,6 patients were lower limb),and the mean skin survival rate of degloving injury was(77.88±4.21)%.Five patients in Group A were finally treated with free flap.All the pa-tients in Group B got limb salvage(10 patients were upper limb,5 patients were lower limb)by a few secondary skin grafting,and the mean skin survival rate of degloving injury was(97.53±3.09)%.The mean skin survival rate of Group B was obviously better than that of Group A(P<0.01).The number of dressing changes in the first two weeks in Group B was absolutely less than that of Group A(P<0.01).Also,infection rate and the number of operative procedures of Group B was significantly less than that of Group A(P<0.01).All the patients were followed up for at least 3 months.Conclusion:Radical debridement combined with external application of Mangxiao(芒硝) for the treatment of severe open fractures is simple,convenient and effective.It is better for a lot of people injured simultaneously in accident.
引文
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[4]Sanders R,Swiontkowski M,Nunley J,et al.The management of fractures with soft tissue disruptions.J Bone Joint Surg Am,1993,75(5):778789.
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[7]Mcgrath L,Royston S.Fractures of the tibial shaft including acute compartment syndrome.Surgery Oxford,2003,21(9):231235.
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[9]蔡建萍,蒋辉.应用大黄芒硝治疗外科切口脂肪液化的体会.实用全科医学,2007,5(1):53.
[2]刘云鹏,刘沂.骨与关节损伤和疾病的诊断分类及功能评定标准.北京:清华大学出版社,2002.6.
[3]梁银澎,陈广双,郭万兴,等.原位清创植皮治疗下肢大面积皮肤脱套伤.中国医师杂志,2005,7(10):1404.
[4]Sanders R,Swiontkowski M,Nunley J,et al.The management of fractures with soft tissue disruptions.J Bone Joint Surg Am,1993,75(5):778789.
[5]Hohmann E,Tetsworth K,Radziejowski MJ,et al.Comparison of de-layed and primary wound closure in the treatment of open tibial fractures.Arch Orthop Trauma Surg,2007,127(2):131136.
[6]Mouёs CM,van den Bemd GJ,Heule F,et al.Comparing conven-tional gauze therapy to vacuum assisted closure wound therapy:a prospective randomised trial.J Plast Reconstr Aesthet Surg,2007,60(6):672681.
[7]Mcgrath L,Royston S.Fractures of the tibial shaft including acute compartment syndrome.Surgery Oxford,2003,21(9):231235.
[8]Schatzker J,Tile M.The rational of operative fracture care.Third Edition.New York:Springer Berlin Heidelberg,2005.4554.
[9]蔡建萍,蒋辉.应用大黄芒硝治疗外科切口脂肪液化的体会.实用全科医学,2007,5(1):53.
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