The open change – a change with damage of integuments, is more rare than a mucous membrane at which there is a message between area of a change and the external environment. Open fractures of bones of extremities are more often observed. The trauma is followed by pain, hypostasis and deformation. In the field of damage there is a wound, sometimes in it otlomk of bones are looked through. The diagnosis is exposed on the basis of clinical signs and results of a X-ray analysis. The treatment which is usually combined: Wound PHO with the subsequent immobilization, after healing of a wound is possible out of - or an intra focal osteosynthesis.
Open change – injury of a bone at which the area of a change is reported with the external environment through a skin or mucous membrane wound. Makes 8-10% of total number of injuries of a skeleton. Can result from falling, blows, road incidents, technogenic and natural disasters. At high-traumatic damages combinations to other injuries are often observed: the closed fractures of bones of a trunk and extremities, a stupid injury of a stomach, ChMT, injury of a thorax etc.
Open changes belong to the category of difficult damages as at such injuries the risk of infection of all elements of a bone with development of sharp osteomyelitis and other complications sharply increases. Quite often there are difficulties when fixing otlomk that is connected with need to keep access to a wound for performing bandagings, and also impossibility to execute a planned focal osteosynthesis before full healing of a wound surface. Treatment of open changes is performed by experts in the field of traumatology.
Taking into account features of injury of skin allocate two types of open changes: initially open – arisen at the time of traumatic influence and again open – formed after a while after a trauma as a result of the shift of otlomk and damage of integuments by a fragment of a bone (for example, at the wrong transportation). As a rule, at initially open changes wounds of the bigger area are observed, it is frequent – strongly polluted, with foreign matters (clothes pieces, sand, the earth, etc.). Existence of a small wound from the end of an otlomk of a bone, vystoyashchy from it, is characteristic of again open changes. Plentiful pollution of a wound surface are observed seldom, foreign matters in a wound are absent.
In clinical practice O. N. Markova and A. V. Kaplan's classification in which for designation of the size and a damage rate use system of figures and letters is applied:
- I – the size of a wound is up to 1,5 cm.
- II – the size of a wound is 2-9 cm.
- III – the size of a wound is more than 10 cm.
- And – a change with insignificant limited damage of soft fabrics. Viability of soft fabrics is kept or slightly broken.
- B – a change with damage of soft fabrics of moderate severity. Partial or full violation of viability of fabrics in a limited zone is observed.
- In – a change with heavy damage of soft fabrics and violation of their viability on a considerable extent.
Besides, the type IV designating changes with extremely heavy damage of fabrics is in addition entered into this classification: razmozzheniye, crush, smashing and violation of integrity of the main arteries.
All open changes are considered bakterialno as polluted. The microbic invasion of a wound can become the reason of a number of complications: anaerobic, putrefactive, purulent, and also development of tetanus. The probability of emergence of infectious complications increases during the easing immunity, violations of local blood circulation, availability of impractical fabrics and extensive damages. Fire changes as in such cases the considerable massif of impractical fabrics is always formed are especially dangerous in this sense, in a wound there are foreign matters, and local blood supply worsens owing to a contusion.
The main method of tool diagnosis of open fractures is the X-ray analysis of the damaged segment. In some cases for assessment of a condition of myagkotkanny structures MRT can be appointed in addition. At open changes there is rather high risk of violation of integrity of nerves and vessels, at suspicion on existence of such damages consultation of the neurosurgeon or vascular surgeon is necessary.
At open changes, regardless of the wound sizes, its surgical processing is shown. Optimum terms of surgical intervention – the first hours after a trauma. During operation the traumatologist deletes all impractical fabrics, including – the polluted small bone fragments and special nippers "skusyvat" the polluted ends of large otlomk. Freely lying pure otlomk are not subject to removal. The doctor washes out a wound antiseptics, takes in skin and, if necessary - muscles, without imposing seams on a fastion.
At major defects of skin for the prevention of a necrosis before suture carry out poslablyayushchy cuts of a wound on each side. In some cases carry out primary skin plasticity. Upon termination of processing in a wound establish drainages. A contraindication for imposing of primary seams are the extensive polluted and smashed wounds with an otsloyka of soft fabrics, and also existence of symptoms of a local infection (hypostasis and hyperaemia of skin at the edges of a wound, purulent or serous separated). If imposing of primary seams is impossible, in the subsequent on a wound impose primary delayed (in 3-5 days), early (in 7-14 days) or late (through 2 and more than a week) secondary seams. An indispensable condition of the delayed ushivaniye of a wound is satisfactory condition of the patient and lack of signs of an acute purulent inflammation.
Existence of the polluted wound quite often significantly limits possibilities of the traumatologist on immediate restoration of normal interposition of otlomk. Carrying out the closed repozition is often complicated as rough manipulations in the field of a wound cannot be carried out. Problematic is also a deduction of otlomk by means of a plaster bandage as at least within 10 days it is necessary to provide access to a wound for performing bandagings.
Tactics of treatment is chosen taking into account features of damage and a condition of the patient. The osteosynthesis with use of a submersible metalwork is used seldom as existence of primary bacterial pollution sharply increases probability of suppuration. Absolute contraindications to primary osteosynthesis are shock, intensive bleeding, the extensive, smashed and plentifully polluted wounds. At impossibility to adequately compare otlomk in such cases apply a temporary plaster bandage or skeletal extension, and in the subsequent, after healing of a wound and improvement of a condition of the patient carry out the delayed osteosynthesis.
Perspective technique of treatment of open changes are compression devices. Among advantages of this method – lack of a metalwork in the field of a change (it allows to reduce risk of suppuration) and preservation of free access to a wound at reliable fixing of otlomk. Along with quick, also conservative ways of treatment – skeletal extension and plaster bandages are widely used. And that, and other option have the advantages and shortcomings.
Skeletal extension gives the chance to keep access to a wound and if necessary to carry out additional correction of provision of otlomk. Essential "minus" of this way is the long compelled patient's immovability fraught with an atrophy of muscles and development of post-traumatic contractures. The plaster bandage in most cases allows the patient to keep rather high level of physical activity, however sometimes complicates access to a wound and immobilizes 2 or more joints of the affected extremity.
Along with PHO and recovery of the normal provision of otlomk, treatment of open changes surely includes antibiotic treatment, anesthesia, physiotherapeutic procedures and LFK. In the presence of traumatic shock at the initial stage antishock events with the subsequent correction of a condition of all bodies and systems are held. In the rehabilitation period of patients direct to LFK and physical therapy.
First place on prevalence among open changes at adults is won by fractures of bones of a shin (54,7-78% of total number of open injuries of a skeleton). Such changes often meet at the combined and multiple injuries and approximately in 50% of cases are complicated by suppuration. Formation of defect of a bone tissue, not union and false joints becomes the result of similar damages in 17% of cases. The reason of such quantity of complications and unsatisfactory results of treatment are high-energy injuries (for example, at road incidents), serious condition of patients at receipt and anatomic features of this segment of an extremity.
At open fractures of a tibial bone often there is a defect of soft fabrics on the perednevnutrenny surface of a shin. It is caused by the fact that in the field the tibial bone almost closely adjoins to skin and is separated from it only by a thin strip of friable connecting fabric. Such wounds badly heal, quite often are complicated by osteomyelitis and an osteonecrosis and often demand carrying out primary or secondary skin plasticity.
Medical tactics is defined by a condition of the patient and features of a change. At the isolated injuries actively are used compression devices, at the combined damages at an early stage skeletal extension, and in the subsequent, after healing of a wound is, as a rule, imposed, the osteosynthesis of bones of a shin is carried out by a plate, screws or the blocking cores, or the extra focal osteosynthesis is carried out by Ilizarov's device.
At children, unlike adults, open fractures of bones of a forearm, as a rule, arising when falling on a hand meet more often. Tactics of treatment is defined by features of a children's organism – a combination of high regenerative ability to weak resistance to an infection. During PHO excise only the crushed or kneaded, obviously omertvevayushchy sites of skin. Bone otlomk usually do not delete, and carefully clear and compare. In the presence of considerable pollution freely lying fragments mechanically clear, plentifully wash out solutions of anti-septic tanks, stack on some time in solution of antibiotics, and then establish back to the area of defect.
Nekrotizirovanny muscular tissue is the favorable environment for development of an infection therefore in the course of PHO carefully examine the injured muscles and excise impractical sites (dim, gray, not bleeding, with the lowered turgor and lack of elastic resistance). The polluted hypodermic cellulose is also subject to excision. At an ushivaniye of edge of a wound have to be compared without tension as at children in such cases regional necroses often develop. If necessary carry out poslablyayushchy cuts or carry out primary skin plasticity.
Repozition and deduction of otlomk is made by the same methods, as at adults. Usually at the initial stage use plaster steaks or the closed bandages with a window for bandagings. In the subsequent if necessary carry out an open osteosynthesis a plate, a pin, screws or spokes. Imposing of the device of Ilizarov at fractures of bones of a forearm is possible both at the time of receipt, and in later terms, after healing of a wound. The forecast at such damages at children usually favorable.