开放性骨折创面的细菌学定量分析及其临床意义

Quantitative Bacteriology Analysisin Wound Management of Open Fractures and Its Clinical Significance

目的：明确开放性骨折创面常见污染细菌的种类、数量和分布特点，探讨正确进行清创手术、骨折固定和闭合创口的方法，以减少术后感染的发生率。方法：将开放性骨折清创前创面组织分为４种类型：（１）创面失活坏死组织（Ａ）；（２）皮下脂肪组织（Ｂ）；（３）肌肉或肌间结缔组织（Ｃ）；（４）创袋、创腔内组织（Ｄ）。将清创后创面组织分为２种类型：（１）原组织（Ｅ）；（２）切后组织（Ｆ）。本研究对４３例４８处开放性骨折清创前、后创面不同组织取材进行了细菌学定量分析，并观察了本组病人的清创效果、创口闭合及发生感染等情况。结果：（１）本组开放性骨折创面出现频率较高的污染细菌是金黄色葡萄球菌、Ｄ群链球菌、蜡样芽胞杆菌、枯草杆菌等革兰阳性细菌，革兰阴性细菌出现频率较少；（２）清创前细菌密度在创面Ａ组织中最高，在Ｂ、Ｃ组织中较低，在Ｄ组织中最低；细菌种类数在Ａ、Ｂ、Ｃ三种组织中无明显差异，在Ｄ组织中较少；（３）Ｆ组织标本的细菌检出率明显低于Ｅ组织；（４）Ⅲ度开放性骨折创面清创后细菌检出率明显高于Ⅰ、Ⅱ度开放性骨折创面。结论：实施彻底的清创手术，采用骨外固定器固定骨折，对污染严重、受伤时间超过６小时的Ⅲ度开放性骨折延迟闭合创口是减少术后感染发?

?Objective: To investigate the common species,the number and the distribution of bacterial flora contaminated in the wounds of open fractures and to improve themethods for reducing infection rate of open fractures. Methods: By gross observations,the tissues in the wound of open fracture were classified and identified in the following way: before debridement: (1)devitalized or necrotic tissues(A), (2)subcutaneous fat(B),(3)muscles or intermuscular connective tissues(C), (4)tissues in the sac or cavity of the wound(D) and after debridement: (1)original tissues(E), (2)the excised tissues(F). Before and after debridement,different tissue specimens (0.5cm3,each) of 48 open fractures in 43 patients were obtained according to the classification mentioned above. Quantitative cultures were done for bacterial enumeration and identification and efficacy of the debridements,wound closures and development of infections in this series cases were evaluated. Results: (1) The most frequently isolated organisms in present study were staphylococcus aureus,streptococcus group D,Bacillus cereus and Bacillus subtilis,which belong to grampositive organisms. (2) Before debridement,the density of organisms in specimen A was significantly higher than that in specimen B or C or D and there was no significant difference in bacterial species among specimen A, B and C. Both bacterial density and species in specimen D were lower compared with those in other three kinds of specimens.(3) After debridement positive rate of bacterial cultures in the wounds of type Ⅲ open fractures was evidently higher than those in the wounds of type Ⅰ and Ⅱ open fractures and in specimen F respectively. Conclusion: Correct debridement,the use of external fixation device for stabilization and delayed closure of severely type Ⅲ open fractures injured over 6 hours are important steps for prevention of infection.