儿童足踝部开放性损伤的处理

Treatment of open injury of foot and ankle in children

目的探讨儿童足踝部开放性损伤的特点、治疗方法及临床疗效。方法回顾性分析2004年2月至2010年6月收治的35例足踝部损伤的病历资料，男22例，女13例；年龄3-14岁，平均8-4岁。交通伤28例，利器切割及机器辗绞伤7例。左18例，右17例，均为单侧；前中足5例，后足及踝部30例。其中合并骨折30例。按照Gustilo分型，Ⅰ型5例、Ⅱ型8例、Ⅲ型22例。I型、Ⅱ型及早期收治的10例Ⅲ型病例在急诊行清创缝合或（和）骨折复位内固定术＋皮瓣移植术；后期收治的12例Ⅲ型病例一期行清创、闭式负压引流术＋石膏外固定或克氏针临时固定，二期行骨折复位（伴或不伴植骨）内固定＋皮瓣移植术。结果30例患儿获得随访，随访时间6-89个月，平均38．7月。2例Ⅱ型患儿术后伤口皮肤局部坏死，行植皮术愈合；10例Ⅲ型患儿一期行急诊手术，手术次数2～6次，平均3．6次；创面愈合时间3～15周，平均8.3周。1例出现慢性骨髓炎，窦道残留，经多次病灶清除植骨后痊愈；2例足踝及小腿外侧肌肉坏死行皮瓣移植．术后3年因瘢痕组织挛缩出现足踝部内翻畸形，行外固定架矫形后正常行走。12例行分期治疗的Ⅲ型患儿皮瓣均存活，色泽及弹性良好，愈合时间3-8周，平均6．8周。伴发足踝部骨折者骨折愈合良好。按Maryland标准评分，优17足、良9足、中3例、差1例，优良率为86．7％。结论儿童足踝部创伤以车祸伤为多见；按损伤程度分级分期治疗可取得较好临床疗效。

Objective To investigate the clinical characteristics, treatment methods, and clinical outcomes of open injury of foot and ankle in children. Methods From February 2004 to June 2010, 35 children with open injury of foot and ankle were treated, including 22 males and 13 females, aged from 3 years to 14 years （average, 8.4 years）. Twenty-eight cases resulted from traffic accidents; 7 cases occurred from sharp instruments and machine-related crush injuries. Thirty cases were associated with bone fractures, and according to the Gustilo classification of open fractures, five cases were Type I injuries, eight cases were Type II injuries and 22 cases were Type III. Twenty three cases （type I, type II and type III） underwent sur- gical debridement and/or internal fixation with skin flap grafting. Twelve type III cases underwent debride- ment, temporary Kirschner wire or plaster fixation and VSD in the first stage of treatment. In the second stage of treatment, fracture reduction and internal fixation （with or without bone graft） ＋ skin flap grafting was performed in all 12 cases. Results Thirty patients （85.7%） were followed-up for an average of 38.7 months （range, 6-89 months）. Skin grafting was performed in two Type II cases that developed necrosis in parts of the wound. Wound healing time was an average of 8.3 weeks （range, 3-15 weeks）. One Type III case suffered chronic osteomyelitis with the formation of a sinus tract. Two cases suffered from club foot ab~ normalities 3 years postoperatively. All three patients above mentioned healed after treatment. In 12 type III patients with staged treatment, the flap survived, and its color and elasticity were good. Healing time ranged from 3 to 8 weeks （average, 6.8 weeks）. According to the Maryland standard, 17 cases were excellent, 9 good, 3 fair, and 1 bad; the excellent and good rate was 86.7%. Conclusion Traffic accidents are the major causes of open foot and ankle trauma in children. A good surgical outcome can be achieved when patients receive staged treatment that is appropriate to injury severity.