手部创面的细菌分布研究

目的 探讨开放性手外伤创面常见污染细菌的种类及敏感抗生素。方法 200例开放性手外伤，于急诊室、手术室刷洗创面后、清创后、关闭伤口前分四次取材，作细菌培养及药敏试验。结果 急诊室、手术室刷洗创面后，清创后及关闭伤口前的细菌检出率分别为71.5%（143／200）、74.0%（148／200）、33.5%（67／200）及25.50%（51／200）。术后伤口感染率为3.5%（7／200）。对环丙沙星及头孢噻肟敏感性最高。结论 开放性手外伤创面菌种分布广泛，以革兰氏阳性菌为主，彻底的清创及保持手术室常用器具的清洁是降低术后感染的有效措施。     

开放手外伤彻底清创术的重要性（附77例报告）

目的：清楚开放手外伤的彻底清创术对伤口感染愈合的影响。方法：对77例开放手外伤在彻底清创前、后做了伤口的细菌培养，观察了伤口细菌培养的阳性率、阴性率、愈合率。结果：清创术前细菌培养的阳性率及阴性率各为96．1％及3．9％，清创术后各为7．8％及92．2％。伤口一期愈合率为97．4％（75例），二期愈合率为2．6％（2例），术后94．8％（73例）未应用抗生素治疗。结论：由于彻底清创术后细菌的阳性率很低，大多数病例的伤口均可一期愈合，看来，对于彻底清创后的手外伤病例，即使不应用抗生素，也同样可以达到理想的治疗目的。     

手部创面的修复

清创是把一个污染的创口转化为“无菌”的创口，是防止感染的重要步骤，及时正确的闭合创面是预防手和前臂开放性损伤感染的有效措施。如创面不及时闭合，必将发生不同程度的感染、渗出、水肿、粘连直至僵硬而影响手及前臂功能，所以把早期闭合创面作为治疗手和前臂开放性损伤的原则之一。     

手部压砸伤的急诊处理及功能恢复

目的：探讨急诊处理手部压砸伤的方法和疗效。方法：对132例患者，用无创技术彻底清创，骨折内固定后修复断伤的各种组织，用游离皮瓣，岛状皮瓣或带蒂皮瓣修复手部软组织的缺损，伤口愈合后辅以理疗及活血化瘀的中药泡手，术后尽早进行康复训练，结果：90例在术后随访2－18个月，42例失访，按肌腱评定标准（TAM）评定，手功能恢复优28例，良30例，中21例，差11例，优良率为64．4％。结论：急诊手部压砸伤的正确处理，创面的覆盖和术后早期功能锻炼对手功能恢复的优劣有一定的影响。     

手部油漆高压注射伤的治疗

目的：探讨手部高压注射伤急诊清创及二期修复闭合创面的方法。方法对6例手部油漆高压注射伤患者,急诊于显微镜下行彻底清创手术,若不能一期清除干净,则将伤口敞开,二次清创闭合创口。结果本组4例一期愈合,2例经二期手术扩创后愈合。术后功能恢复优5例,良1例,6例患者均重返工作岗位。结论对于手部油漆高压注射伤的治疗,早期清创,开放伤口,必要时重复清创及二期闭合创面,可以获得较好的治疗效果。     

骨科固定物与感染治疗新进展

感染作为骨科手术最常见和复杂的并发症，早已成为骨科医生所面临的极富挑战性的难题之一。资料显示：闭合性骨折的感染率（约1．5％）远较开放性骨折低3％～40％，约60％以上的开放性骨折在损伤时受到了细菌的污染。目前常用的处理开放性骨折的方法包括彻底清创、去除包括挫灭和失去活力的不健康组织、大量液体对伤口的冲洗、固定骨折以及软组织覆盖关闭创面等处理措施，以避免骨与软组织的感染。但是，尽管采取了上述积极的流程，仍有一部分患者发生了感染。正如AO组织于2006年第二届“固定物与感染”会议上指出：在10年内已有相当多的从微生物学、诊断学、组织病理学、临床治疗学等方面研究的进展，     

超声清创法在烧伤残余创面中的应用及其临床疗效

目的探讨超声清创法在烧伤残余创面中的应用及其临床疗效。方法采用回顾性队列研究方法。2017年8月—2021年8月解放军联勤保障部队第980医院收治64例符合入选标准的烧伤残余创面患者, 根据对残余创面采用的清创方法, 将患者分为超声清创组[34例, 男22例、女12例, 年龄(31±13)岁]和传统清创组[30例, 男19例、女11例、年龄(32±13)岁]。对2组患者创面行相应的清创后, 根据患者创面所在部位及皮源情况选择邮票皮片或大张皮片进行移植治疗。对于Ⅰ期手术后未愈合创面, 则行二次清创+植皮术, 2组创面的清创方式均分别同其Ⅰ期。术后3 d, 采用药物敏感试验检测创面中细菌情况并计算细菌阳性率。术后7 d, 计算创面中皮片成活率及皮下血肿发生率。出院时, 统计患者创面愈合时长及清创次数并计算二次清创率。对数据行独立样本t检验或χ2检验。结果术后3 d, 超声清创组创面感染金黄色葡萄球菌者2例、铜绿假单胞菌者2例, 传统清创组创面感染金黄色葡萄球菌者5例、铜绿假单胞菌者3例、鲍曼不动杆菌者1例、肺炎克雷伯菌者1例、阴沟肠杆菌者1例;超声清创组创面细菌阳性率明显低于传统清创组(χ...     

真空负压封闭技术加外固定器治疗肢体开放性骨折

目的 探讨真空负压封闭技术(VS)加外固定器治疗四肢严重开放性骨折的效果。方法 近4年来收治63例四肢严重开放性骨折患者，采用VS加外固定器治疗，清创后骨折用Orthofix单边外固定器固定，创面或创腔内用Vacuseal材料覆盖，接负压封闭吸引，6～10d后二期缝合、植皮或皮瓣转移。结果 63例患者创面均愈合，浅表感染3例(4．8％)和针道感染13例19针(7．5％)；骨折愈合53例(84．1％)，延迟愈合或不愈合10例(15．9％)。平均愈合时间6．5个月。结论 VS技术结合外固定架固定治疗四肢严重开放性骨折，在迅速有效地稳定骨折的同时，能安全有效地封闭创面，缩短二期创面修复时间，促进骨折愈合，减少并发症；其方法简单有效，值得临床推广应用。     

开放性损伤清创前后细菌学调查及药敏检测

从 1991年起 ,我们随机对 138例开放性损伤的病例在清创前取伤口血液和清创后缝合伤口前再取伤口血液做细菌培养和药敏检测。1　临床资料本组 138例 ,男性 116例 ,女性 2 2例 ;年龄 8岁～ 5 8岁 ,平均年龄 31 39岁。病例中有开放性骨折 89例 ,按开放性骨折分类标准[1] :Ⅰ型 15例 ,Ⅱ型 35例 ,ⅢＡ 型 19例 ,ⅢＢ 型 13例 ,Ⅲｃ 型 7例。单纯肌腱断裂 35例 ,软组织撕裂伤 14例。从外伤到手术时间 0 5～ 6小时 ,平均 1 5小时。2　结果2 1　细菌培养 (见表 1)表 1　 138例伤面清创前、后细菌种类及出现频率 (普通培养 )细菌种类清创前清创后…     

开放性骨折清创期细菌培养的应用价值

目的 讨论四肢开放性骨折时清创前、后细菌培养的应用意义。方法 分析自从1995年4月以来，89例93处开放骨折清创期采用定量细菌培养结果和深部感染关系。结果 清创前培养阳性率81．7％；伤口感染率为22．6％，深部感染8．5％。清创前培养结果的价值明显不如清创后结果。结论 清创前细菌培养应当废弃，用Gustilo分类加清伤后伤口污染程度来估计开放骨折是否发生深部感染更有用。     

Use of antimicrobials in the management of open fractures.

The role of antibiotic therapy in open fractures is secondary to adequate debridement, irrigation, and definitive wound care. Experimental and clinical studies indicate that parenteral administration of appropriate antibiotics within three hours after injury helps to prevent wound sepsis. Intial wound cultures of 158 open fracture wounds revealed bacterial growth in 70.3%. Eighty-six were Gram-positive, 57 were Gram-negative, and 32 yielded mixed bacterial growth. Sensitivity studies of these organisms suggest that cephalothin sodium is the most effective antibiotic for prophylaxis. In a prospective study from 1969 to 1975, treatment of 520 patients was as follows: debridement, copious irrigation, and primary closure for types 1 and 2 fractures and secondary closure for type 3 fractures. No primary internal fixation was done except in vascular injuries. Cultures were taken of all wounds and antibiotics were given before surgery and for three days postoperatively. In type 3 open fractures, severe soft tissue injury, and segmental or traumatic amputation, the infection rate was 9%, compared to a 44% infection rate in the retrospective study from 1955 to 1968.     

Initial management of open hand fractures in an emergency department

We retrospectively reviewed the cases of patients with open hand fractures and/or dislocations managed at our institution between 2001 and 2009. The management protocol consisted of irrigation and debridement, reduction (if necessary), splinting, and antibiotics administration in the emergency department. Patients with vascular compromise or severe mangling open wounds were taken to the operating room for treatment. Data regarding demographics, wound size and modified Gustilo-Anderson classification, and timing of interventions were recorded. Included in the study were 145 cases (91 class III, 41 class II, and 13 class I injuries). In 102 cases, definitive and final management took place in the emergency department; in the other 43 cases, additional management took place in the operating room. Antibiotics were administered within 4 hours after injury, and irrigation and debridement were performed within 6 hours. Each of the 2 infections (1.4%) developed in a class III injury. In open hand fractures, particularly type I and type II wounds, the protocol we followed can be appropriate when the injury is not the severe mangling type and does not require acute vascular repair.     

Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience.

OBJECTIVE: The purpose of the study is to define those patient variables that contribute to morbidity and mortality of median sternotomy wound infection and the results of treatment by debridement and closure by muscle flaps. BACKGROUND: Infection of the median sternotomy wound after open heart surgery is a devastating complication associated with significant mortality. Twenty years ago, these wounds were treated with either open packing or antibiotic irrigation, with a mortality approaching 50% in some series. In 1975, the authors began treating these wounds with radical sternal debridement followed by closure using muscle or omental flaps. The mortality of sternal wound infection has dropped to < 10%. METHODS: The authors' total experience with 409 patients treated over 20 years is described in relation to flap choices, hospital days after sternal wound closure, and incidence rates of morbidity and mortality. One hundred eighty-six patients treated since January 1988 were studied to determine which patient variables had impact on rates of flap closure complications, recurrent sternal wound infection, or death. Variables included obesity, history of smoking, hypertension, diabetes, poststernotomy septicemia, internal mammary artery harvest, use of intra-aortic balloon pump, and perioperative myocardial infarction and were analyzed using chi square tests. Fisher's exact tests, and multivariable logistic regression analysis. RESULTS: The mortality rate over 20 years was 8.1% (33/49). Additional procedures for recurrent sternal wound infection were necessary in 5.1% of patients. Thirty-one patients (7.6%) required treatment for hematoma, and 11 patients (2.7%) required hernia repair. Among patients treated since 1988, variables strongly associated with mortality were septicemia (p < 0.00001), perioperative myocardial infarction (p = 0.006), and intra-aortic balloon pump (p = 0.0168). Factors associated with wound closure complications were intra-aortic balloon pump (p = 0.0287), hypertension (p = 0.0335), and history of smoking (p = 0.0741). Factors associated with recurrent infection were history of sternotomy (p = 0.008) and patients treated for sternal wound infection from 1988 to 1992 (p = 0.024). Mean hospital stay after sternal wound reconstruction declined from 18.6 days (1988-1992) to 12.4 days (1993-1996) (p = 0.005). To clarify management decisions of these difficult cases, a classification of sternal wound infection is presented. CONCLUSIONS: Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.     

Aggressive treatment of 119 open fracture wounds.

BACKGROUND: The purpose of this study was to determine whether immediate primary closure of open fracture wounds can be performed without increasing the incidence of infections and delayed unions/nonunions. Although the traditional management of these injuries has been open treatment, a trend toward immediate primary closure has evolved on our service. METHODS: All open fractures presenting to an urban Level I trauma center during a 42-month period were reviewed. Of the 127 patients with open fractures, 90 patients (119 open fractures) were initially treated at the above institution within 24 hours of injury, had fractures proximal to the carpus or tarsals, and were followed-up until fracture union. All patients underwent emergent wound irrigation and debridement. The method of fracture immobilization and timing of wound closure was left to the discretion of the attending orthopedic surgeon. Immediate primary closure was used in 22 of 25 Grade I open fractures (88%), 37 of 43 Grade II fractures (86%), 24 of 32 Grade IIIa fractures (75%), 4 of 12 Grade IIIb fractures (33%), and 0 of 7 Grade IIIc fractures (0%). RESULTS: Eight fractures (7%) were complicated by a deep wound infection/osteomyelitis, and 19 fractures (16%) developed a delayed union/nonunion. Statistical analysis revealed no significant difference in delayed/nonunion and infection rates between immediate and delayed closures. CONCLUSION: Immediate primary closure of open fracture wounds after a thorough debridement by an experienced fracture surgeon appears to cause no significant increase in infections or delayed union/nonunions. In addition, early closure may decrease the requirement for subsequent debridements and soft-tissue procedures, thereby minimizing surgical morbidity, shortening hospital stays, and reducing costs. We feel that a randomized, prospective study of this aggressive approach to open fracture care is warranted.     

Efficacy of debridement and primary closure of contaminated wounds: a comparison of methods

Proper management of highly contaminated traumatic wounds frequently requires delayed primary closure of healing by secondary intention to prevent subsequent infection. This animal study compares the efficacy of various wound debridement methodologies to prevent infection following primary closure of treated contaminated wounds. Forty-four Sprague-Dawley rats with uniform, paravertebral incisions were studied. Each wound was inoculated with a standard amount of Staphylococcus aureus bacteria and allowed to remain open for two hours. Each wound was treated before wound closure by one of four debridement methods: (1) surgical scrubbing, (2) high-pressure irrigation, (3) ultrasonication, or (4) soaking. The control animals' wounds were closed without debridement. At 7 days, each animal was evaluated for the presence of gross infection and wound induration. Ultrasound, with a 25% incidence of gross infection, compared with irrigation (75%), scrubbing (82%), and soaking (89%) provided significant protection from subsequent abscess formation. The control group uniformly developed infection (100%). The average amount of induration after ultrasonication (1.35 +/- 0.56 cm) was also significantly less than irrigation (2.07 +/- 0.75 cm), scrubbing (1.95 +/- 0.34 cm), and soaking (1.73 +/- 0.22 cm). Our data demonstrate that ultrasonic wound debridement has exciting potential as a new debridement technique for contaminated traumatic wounds.     

Comparison of bacteria isolated from open fractures following debridement and subsequent infection

BackgroundOne of the major objectives for the management of open fractures is to prevent bone and soft tissue infection. Here, we identified species and drug sensitivities of bacterial isolates recovered during open fracture debridement and after infection and compared the results between the two time points.MethodsA total of 61 hospitalized patients with open fractures who developed post-operative wound infection between October 2016 and December 2017 were included in this study. The cohort included 43 males and 18 females aged between 4 and 72 years. Patients were admitted to hospital 1–14 h after injury. Samples were collected after debridement and after infection and submitted for bacterial culture. Resulting isolates were identified using a VITEK 2 Bacterial Identification System and tested for drug sensitivity using the disc diffusion method. Results from the two time points were then compared.ResultsThe positive bacterial culture rate following debridement was relatively low (14/61, 22.9%). In addition, bacteria cultured after debridement were generally inconsistent with those cultured after wound infection, with a concordance rate of only 3.3% (2/61). Gram-negative bacteria accounted for 91.3% (63/69) of isolates recovered from wound infections following surgery, among which Acinetobacter baumannii was baumannii was the predominant pathogen, accounting for 49.3% (42/69) of all isolates. Overall, 60.8% (42/69) of postoperative infections were caused by multi-drug resistant bacteria, with A. baumannii isolates accounting for 80.9% (34/42) of these cases. Rates of cefoperazone/sulbactam resistance were relatively low among the isolates (15/34, 44.1%), and most isolates showed a sensitive or intermediate resistance phenotype.ConclusionsResults of bacterial culture after debridement could not predict pathogenic bacteria causing postoperative infection. Therefore, we propose that open fracture infections are predominantly nosocomial and are mainly caused by multidrug-resistant Gram-negative bacteria. Further attention should be paid to the control of these pathogens in clinical settings.     

电烧伤患者血清肌酸磷酸激酶变化的临床意义

目的　探讨血清肌酸磷酸激酶 (craetinephosphokinase ,CK)同工酶 (CK MM )的变化对电烧伤患者肌肉感染、坏死的诊断价值。　方法　高压电击伤与电弧烧伤各 17例分为A、B两组。A组为手术证实有明显的肌肉坏死者 ,B组为手术证实无肌肉坏死者。分别监测患者伤后、术前及术后血清CK MM的浓度 ,同期进行血、尿常规 ,肝、肾功能及创面细菌计数检查 ,并以 2 0例正常人血清CK MM值为对照。结果　 (1)A组伤后及扩创术后 1d血清CK MM的浓度显著升高 ,达正常对照组的 6倍 ;术后 3d 15例降至正常 ,2例因创面感染CK MM仍维持较高水平 ,经再次扩创抗感染处理后降至正常。其变化与手术所见、外周血白细胞计数变化及创面细菌计数相一致。 (2 )B组植皮术前及术后CK MM值轻度升高。　结论　CK MM可作为电击伤肌肉感染、坏死的监测指标 ,具有较高的特异性和敏感性。     

Treatment of open fractures of the hand in the emergency department

Current guidelines suggest early surgical treatment of open fractures. This rule in open hand fractures is not well supported and may be unpractical. Furthermore, desirable debridement and washout can be obtained in the emergency department (ED). The purpose of this study was to evaluate the relationship between the level of contamination, quality of washout in the emergency room, and the development of infection. Sixty-one patients with open fractures of the hand were retrospectively reviewed for demographic and fracture characteristics, and other complications. The infection rate was 14.8%. Contamination was present in 43 patients (70.5%). One thousand milliliters or more were used to obtain a grossly clean wound in 43 patients (70.5%). No significant relationship was found between fracture type, finger involved, hand dominance, comorbidities, and development of infection. The amount of fluid used for washout was significantly related to infection (P = 0.047), whereas wound contamination was not (P = 0.259). Type of oral antibiotic was significantly related to infection (P = 0.039). The level of contamination was not a significant factor in predicting infection, whereas the amount of fluid used for washout and the oral antibiotic type were significant factors in preventing infection. Since administration of intravenous antibiotics and thorough wound cleansing can be performed on open hand fractures in the ED under adequate anesthesia, most open fractures in the hand do not need to be treated early in the operating theater.     

Comparison of delayed and primary wound closure in the treatment of open tibial fractures

INTRODUCTION: Primary wound closure in the management of open tibial fractures has generally been discouraged. Several prior studies suggest that infections are not caused by the initial contamination, but are instead the result of organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation could therefore be considered a reasonable option. MATERIALS AND METHODS: We analysed 95 patients with open tibial fractures (Gustilo-Anderson type 1 to 3A) treated with primary fracture stabilisation and either delayed wound closure (group I) or primary wound closure (group II), with a minimum follow-up of 12 months. RESULTS: Group I included 46 patients with a mean age of 30.2 years (16-56), and a mean follow-up of 13.5 months (12-18). Group II included 49 patients with a mean age of 33.4 (18-69), and a mean follow up of 13.7 months (12-16). One infection developed in group I (2%), and two infections developed in group II (4%). This difference was not found to have any statistical significance. CONCLUSION: Our results support other recent reports that the infection rate is not increased following primary wound closure after thorough debridement of less severe open fractures. The length of stay following primary closure (group II) was significantly shorter, and that should result in substantially more cost effective care of these serious injuries. We conclude that primary wound closure is a safe option in properly selected cases. Prospective multi-centre studies are needed to further evaluate the safety and efficacy of this treatment alternative.