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

Case-control studies on debridement combined with external application of Mangxiao(芒硝) for the treatment of se-vere open injuries of limbs

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 Ⅲ B ） 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,sequential 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 temperature and white cell count（48 h after the first debridement ）. Statistical analysis was done with SPSS software. Chi-square analyses was used to compare the enumeration data, and compare means with independent samples T test for measurement data. Results ： 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 degtoving injury was （77.884.21）%. Five patients in Group A were finally treated with free flap. All the patients 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.