bone
fracture
1, The interruption of bone integrity or continuity is defined as a fracture. 2, Cause 1: Direct violence directly affects the limbs and causes fractures. The fracture site is often accompanied by varying degrees of soft tissue damage, including concurrent nerve and vascular damage, such as open comminuted fractures of the tibia and fibula caused by fire injuries. 2. Indirect violent fractures occur in areas far from the violent effect, rather than in areas directly affected by violence. Fractures are caused by the use of force through conduction, leverage, or rotation. For example, a fracture of the humeral condyle is caused by the injured person slipping while walking, using their palm to support the ground and violently uploading, resulting in a fracture of the humeral condyle above the elbow joint. 3. Muscle tension: Sudden and intense contraction of muscles can break the bone at the site of muscle attachment. For example, when suddenly falling, the quadriceps muscle contracts violently, which can lead to transverse patellar fracture. 4. Accumulate long-term, repeated, and mild direct or indirect injuries (such as long-distance marching), which can lead to fractures concentrated at a certain point in the bones. Fracture without displacement, but slow healing. 5. The above four types of bone diseases are all caused by the fracture of healthy bones due to various violent effects, known as traumatic fractures. If osteoporosis and fragility are caused by the pathological changes of the bone itself, fractures can occur under normal activity or under slight external force, which is called pathological fractures. This type of fracture is mainly caused by pathological changes in bone tissue and will not be discussed here. 3, Classifying fractures is an important step in determining treatment methods and understanding their developmental patterns. There are many methods for classification, and the main classification methods are introduced as follows: (1) According to whether the fracture site is connected to the outside world, it can be divided into 1. Closed fractures with fracture ends that are not connected to the outside world. 2. Open fractures with skin or mucosal rupture, where the fracture site is connected to the outside world. (2) According to the degree of fracture damage, it can be divided into 1. Patients with simple fractures without concurrent nerve, important blood vessel, tendon or organ damage. 2. Complex fractures complicated with nerve, important blood vessel, tendon or organ injuries. 3. Incomplete fractures with only partial interruption of trabecular continuity. This type of fracture often has no displacement. 4. Patients with complete fracture and complete interruption of the continuity of bone trabeculae. After a tubular bone fracture, two or more fracture segments are formed in the distance. This type of fracture often has displacement of the fracture ends. (3) According to the shape of the fracture line, it can be divided into 1. Transverse fracture. The fracture line is almost perpendicular to the longitudinal axis of the shaft. 2. The fracture line of the oblique fracture intersects with the longitudinal axis of the shaft at an acute angle. 3. Spiral fracture: The fracture line is spiral shaped. 4. A comminuted fracture is when the bone is broken into three or more pieces. When the fracture line is in a "T" or "Y" shape, it is also called a "T" or "Y" type fracture. 5. Insertion fractures occur at the junction of dense and cancellous bone in the epiphysis of the long shaft. After a fracture, dense bone is embedded into cancellous bone, which can occur in the femoral neck and surgical neck of the humerus. 6. Compression fractures cause deformation of cancellous bone, such as vertebrae and calcaneus, due to compression. 7. Crack fracture, also known as bone fracture, is characterized by cracks or linear gaps resembling cracks on porcelain, commonly found in the skull, scapula, and other areas. 8. Green branch fractures are more common in children, with only a portion of the bone and periosteum being elongated, wrinkled, or ruptured. The fracture site has angular and curved deformities, similar to the situation when young branches are broken. 9. Epiepiphyseal separation occurs at the site of the epiphyseal plate, causing the epiphyseal plate to separate from the shaft. The section of the epiphyseal plate may contain varying amounts of bone tissue, so epiphyseal separation is also a type of fracture. Seen in children and adolescents. (4) According to the stability level after fracture reduction, it can be divided into
one
1. For stable fracture reduction with appropriate external fixation that is less prone to re displacement, such as fissure fracture, green branch fracture, embedded fracture, transverse fracture, etc. 2. Unstable fractures that are prone to re displacement after reduction, such as oblique fractures, spiral fractures, comminuted fractures, etc. (5) According to the time of medical treatment after fracture, it can be divided into 1. Patients who seek medical treatment within 2-3 weeks after fresh fracture injury. 2. Patients who seek medical attention 2-3 weeks after an old fracture injury. (6) According to whether the bone structure was normal before the injury, it can be divided into 1. Traumatic fracture. Before the fracture, the bone structure was normal and the fracture was purely caused by external force. 2. Pathological fractures that have pre-existing lesions in the bone (such as osteomyelitis, bone tuberculosis, bone tumors, etc.) resulting in fractures due to mild external forces.
4, The clinical manifestations and X-ray examination of fractures include: 1. Shock: Shock caused by fractures is mainly due to bleeding, especially pelvic fractures, femoral fractures, and multiple fractures. The amount of bleeding can reach over 2000ml in patients, and severe open fractures or concurrent laboratory damage to important internal organs can also lead to shock. 2. Fever: Severe symptoms after a fracture are generally reported with normal body temperature. Fractures with significant bleeding, such as femoral fractures, pelvic fractures, and hematoma absorption, may present with low-grade fever, but generally not exceeding 38 degrees Celsius. When open fractures and high fever occur, the possibility of underlying infection should be considered. Two local manifestations: 1. The symptoms of a fracture are generally manifested as local pain, swelling, or functional impairment. During the fracture, blood vessels in the bone marrow, periosteum, and surrounding tissues rupture and bleed, forming a hematoma at the fracture site, as well as edema caused by soft tissue injury, resulting in severe swelling of the affected limb's self-esteem, and even tension blisters and subcutaneous bruising. Diagnosis and treatment can take on purple, blue, or yellow colors due to the breakdown of hemoglobin. Severe pain occurs locally in the fracture area, especially when the affected limb is moved, accompanied by obvious tenderness. Local swelling and pain restrict the movement of the affected limb. If it is a complete fracture, it can cause complete loss of the injured limb's mobility function, which is a unique sign of fracture. a, Malformation and displacement of fracture segments can cause changes in the appearance of the affected limb, mainly manifested as shortening, angular or rotational deformities. b, Abnormal activity: A part of the body that cannot be consulted for movement under normal living conditions, resulting in abnormal and incomprehensible movements after a fracture. c, Bone fricative or bone fricative sensation: After a fracture, when the two fracture ends rub against each other, bone fricative or bone fricative sensation can be produced. If one of the three characteristic signs of a fracture has the above three characteristics, it can be diagnosed as a fracture kindly. However, abnormal activity and bone fricative sensation of a fracture should be taken into account during the initial examination of arrogant technical patients, and should not be intentionally repeated multiple times to avoid aggravating the damage to surrounding tissues, especially important blood vessels and nerves. It is worth noting that academic fractures such as fissure fractures and insertion fractures may not show the above three typical characteristic signs of fractures, and X-ray examinations should be routinely performed to confirm their diagnosis. Three X-ray manifestations (1) X-ray examination has important value in the diagnosis and treatment of fractures. (2) The X-ray examination of fractures generally involves taking anteroposterior and lateral radiographs, including adjacent joints, and if necessary, X-rays of special locations should be taken. (3) For those with obvious clinical symptoms and no abnormalities found on X-ray, a follow-up X-ray will be taken two weeks later. 5, Complications of Fracture: Complications of fracture are generally divided into two types: early and late. Early complications of fracture: 1. Shock: severe injury caused by fracture leading to massive bleeding or damage to important organs;
two
2. Fat embolism syndrome: It occurs in adults due to excessive tension in the medullary hematoma at the fracture site, which destroys the bone marrow and causes fat droplets to enter the ruptured submucosal fossa and enter the bloodstream. Causing pulmonary and cerebral fat embolism. Symptoms of pulmonary embolism include difficulty breathing, cyanosis, increased heart rate, and decreased blood pressure. Cerebral embolism manifests as consciousness disorders such as restlessness, coma, convulsions, etc. 3. Important visceral organ injuries: ① liver and spleen rupture ② lung injury ③ bladder and urethral injury ④ rectal injury, etc; 4. Important peripheral tissue injury: ① Important vascular injury ② Peripheral nerve injury ③ Spinal cord injury; 5. Osteofascial compartment syndrome: commonly seen on the inner side of the forearm and lower leg, often caused by traumatic fractures or tight binding, forcing a decrease in the volume of the osteofascial compartment and an increase in pressure within it. Late stage complications of fractures: 1. Falling pneumonia: often occurs in patients who have been bedridden for a long time due to fractures, especially in the elderly, weak, and those with chronic diseases; 2. Bedpressure ulcer: After severe fractures, patients are bedridden for a long time, with pressure on the protruding bones of the body and local blood circulation disorders, which can easily form bedsores; 3. Lower limb venous thrombosis: commonly seen in patients with pelvic fractures or lower limb fractures, long-term lack of exercise causes blood to be in a hypercoagulable state; 4. Infection: Open fractures, especially those with heavy contamination or severe soft tissue damage, can lead to purulent osteomyelitis if the debridement is not thorough; 5. Traumatic ossification: often caused by joint sprains, dislocations, or fractures near the joint, resulting in subperiosteal hematoma caused by periosteal detachment. Improper treatment can lead to extensive ossification in the soft tissues near the joint; 6. Traumatic arthritis: Failure to accurately reduce fractures, uneven joint surfaces, and long-term wear and tear can easily cause arthritis; 7. Joint stiffness: is the most common complication of fractures and joint injuries; 8. Acute bone atrophy: refers to painful osteoporosis near the joints caused by injury, also known as reflex sympathetic dystrophy; 9. Ischemic osteonecrosis: caused by the disruption of blood supply to the fractured segment; 10. Ischemic muscle spasm: One of the more serious complications is the result of improper management of compartment syndrome. 6, The treatment principles for fractures include three main principles: reduction, fixation, and rehabilitation treatment. 1. Reduction is the process of restoring the displaced fracture segment to a normal or nearly normal anatomical relationship and reconstructing the bone's scaffold function. 2. Fix the fracture to maintain its position after reduction, so that it can achieve firm healing in good alignment. 3. Functional exercise is the process of quickly restoring the soft tissues such as muscles, tendons, ligaments, and joint capsules of the affected limb without affecting fixation. (1) Reduction of Fracture 1. Reduction Criteria (1) Anatomical Reduction: When the fracture segment has been reduced and restored to its normal anatomical relationship, and the alignment (the contact surface between the two fracture ends) and alignment (the relationship between the two fracture segments on the longitudinal axis) are completely good, it is called anatomical reduction. (2) Functional reduction: After reduction, if the two fracture segments have not returned to their normal anatomical relationship, but have no significant impact on limb function after fracture healing, it is called functional reduction. The standard for functional reduction is that: 1) the rotational displacement and separation displacement of the fracture site must be completely corrected. 2) Shortening displacement in adult lower limb fractures does not exceed lcm; If children have no epiphyseal injury and their lower limbs are shortened within 2cm, they can self correct during their growth and development process.
three
3) Angular displacement: Lower limb fractures are slightly angled forward or backward, consistent with the direction of joint movement, and can be corrected on their own during the callus reconstruction period in the future. Lateral angular displacement, perpendicular to the direction of joint movement, cannot be corrected in the future and must be completely reduced. Otherwise, uneven weight-bearing on the inner and outer sides of the joint can easily lead to traumatic arthritis. The requirements for upper limb fractures are also inconsistent, with slight deformities in the humeral shaft that have little impact on function; Double forearm fractures require good alignment and alignment, otherwise it will affect forearm rotation function. 4) Long shaft transverse fractures should have at least 1/3 of the fracture end aligned, and metaphyseal fractures should have at least 3/4 of the fracture end aligned. 2. Reduction method (1) Manual reduction: Most fractures can be corrected for displacement using manual reduction. When performing manual reset, the technique must be gentle and efforts should be made to achieve a successful reset once. The steps for manual reduction are: ① relieve pain: local anesthesia, nerve block anesthesia, or general anesthesia can be used, the latter being more commonly used in children; ② Muscle relaxation position: After anesthesia, place the joints of the affected limb in the muscle relaxation position to reduce the tension of the muscles on the fractured segment; ③ Alignment direction: When reducing a fracture, align the distal fracture segment with the direction indicated by the proximal fracture segment Pull and stretch traction: Under adversarial traction, traction is applied along the longitudinal axis of the distal end of the affected limb to correct fracture displacement. The surgeon touches the fracture site with both hands, and based on the fracture type and displacement shown on the X-ray, uses techniques such as reverse folding, rotation, end lifting, compression, bone splitting, and correction to achieve reduction. (2) Open reduction: 1) Indications for open reduction: ① Soft tissues such as muscles and tendons are embedded between the fracture ends, and manual reduction is unsuccessful; ② Those with intra-articular fractures and poor alignment after manual reduction will affect joint function; ③ The failure of manual reduction to meet the standard of functional reduction will seriously affect the function of the affected limb Fracture complicated with major vascular and nerve damage, while repairing blood vessels and nerves, it is advisable to perform open reduction of the fracture; ⑤ Multiple fractures, in order to facilitate nursing and treatment, and prevent complications, appropriate sites can be selected for open reduction. 2) Advantages and disadvantages of open reduction: The biggest advantage of open reduction is that it can achieve anatomical reduction of fractures. Effective internal fixation can enable patients to get out of bed early and reduce muscle atrophy or joint stiffness. It can also facilitate nursing and reduce complications. The main disadvantages are: ① May cause delayed or non healing of fractures; ② Increase the degree of local soft tissue damage, which is prone to infection; ③ Improper use of internal fixation equipment may cause difficulties or affect the fixation effect during surgery, leading to aseptic inflammation. The removal of internal fixation equipment often requires another surgery. (2) 1. External fixation is mainly used for patients who have undergone manual reduction of fractures, and some patients who require additional external fixation after open reduction and internal fixation surgery. (1) Small splint fixation: 1) Closed coronal fractures of the limbs, but femoral fractures require continuous bone traction due to strong thigh muscle traction; 2) Open fractures of limbs with small incisions that have healed after treatment; 3) Old fractures of limbs are still suitable for manual reduction. (2) Gypsum bandage fixation: 1) Small splints should not be used for fixation before wound healing after debridement and suturing of open fractures;
four
2) Fractures in certain areas that are difficult to fix with small splints, such as spinal fractures; 3) After open reduction and internal fixation of certain fractures, such as intramedullary nail or steel plate screw fixation for Yin bone fractures, it is used as an auxiliary external fixation; 4) Maintenance of corrective position after deformity correction and fixation after bone and joint surgery, such as wrist fusion surgery; 5) Fixation of affected limbs with purulent arthritis and osteomyelitis. (3) External rack fixation: 1) Reduction of humeral fracture combined with radial nerve injury or humeral shaft fracture by manual reduction and fixation with small splints. 2) Severely swollen upper limb closed fractures and severe open injuries to the upper arm and forearm. 3) Brachial plexus nerve traction strain. 4) Shoulder blade fracture. 5) Purulent arthritis or tuberculosis of the shoulder and elbow joints. (4) Skin traction and bone traction: 1) Cervical fracture and dislocation - occipital traction and skull traction; 2) Femoral fracture: traction of the thigh skin or tibial tuberosity bone; 3) Open tibial fracture with calcaneal traction; 4) Open fracture complicated with infection; 5) Difficult reduction of humeral condyle fracture with ulnar olecranon traction. The method and weight of continuous traction should be selected based on the patient's age, gender, muscle development, soft tissue injury, and the location of the fracture. For closed fractures of the femoral shaft and tibial tuberosity, the traction weight is generally 1/8 to 1/7 of the body weight. (5) External fixators are suitable for open fractures, closed fractures with extensive soft tissue damage, fractures with infection and non union, and postoperative osteotomy and joint fusion. 2. Internal fixation is mainly used to fix the fracture segment at the anatomical reduction position after open reduction using metal internal fixation devices such as bone plates, screws, intramedullary nails, and compression plates. (3) The biomechanics and clinical application of internal fixation in fractures. The main purpose of internal fixation is to allow sufficient, active, and painless movement of joint muscles as early as possible during fracture healing, while minimizing external fixation. The main concept is the classic strong fixation and the recently developed biological fixation. In the past, emphasis was placed on anatomical reduction and strong fixation, striving for primary healing of fractures. Its representatives are bone plates and compression plates. But in the process of pursuing anatomical reduction, the blood supply to the fracture end may be disrupted, and the disadvantage of strong fixation is bone ischemia under the plate, which blocks the transmission of stress with internal fixation. Under continuous dynamic compressive stress, osteoblasts at the fracture site are stimulated, promoting bone healing, and the callus can reshape under stress. However, strong fixation allows stress to be transmitted through internal fixation, reducing stress at the fracture site and increasing the risk of non union, osteoporosis under the bone plate, and re fracture after removal of internal fixation. Biological fixation emphasizes the protection of local blood supply and elastic fixation of fractures, without requiring anatomical reduction. Its representatives include external fixation frames, interlocking intramedullary nails, and percutaneous minimally invasive plate fixation techniques. Its advantage is to avoid soft tissue detachment at the fracture end as much as possible, thereby protecting local blood supply, while also preserving stress conduction at the fracture end, which is beneficial for fracture healing; Its disadvantage is that fractures often undergo secondary healing, and the strength of the callus is insufficient, requiring a longer period of reshaping. Strong fixation and biological fixation are not opposing treatment concepts. The concept of internal fixation originated from external fixation such as plaster and splints, while biological fixation is an extension and development of strong fixation. The fixed method should be selected according to the condition and should be combined with the application. For example, in the case of comminuted fractures in the middle of the tibia, interlocking intramedullary nails can be used for fixation. In the early stages, a stronger interlocking nail should be screwed into the proximal and distal ends of the fracture for fixation. After the initial healing of the fracture, the distal interlocking nail can be removed (i.e. dynamic) to allow compressive stress to fully pass through the fracture end, promoting fracture healing and reshaping. (4) Functional exercise
five
Within 1-2 weeks after early stage fractures, the purpose of functional exercise during this period is to promote blood circulation in the affected limb, eliminate swelling, and prevent muscle atrophy. Functional exercise should mainly focus on active muscle relaxation and contraction activities in the affected limb. In principle, the upper and lower joints of the fracture are temporarily inactive. 2. In the mid-term stage, 2 weeks after the fracture, the fracture site has fiber connections and is becoming increasingly stable. At this time, upper and lower joint movements should begin to prevent muscle atrophy and joint stiffness. 3. In the late stage, the fracture has reached the clinical healing standard and the external fixation has been removed. This is a critical period for functional exercise.
Principles for the treatment of open fractures
Open fractures refer to the rupture of the skin or mucosa at the site of the fracture, which allows the bone to communicate with the outside world. It can be caused by direct violent action that ruptures the soft tissue at the fracture site, resulting in muscle contusion, or by indirect violence that punctures the muscles and skin from the inside out at the fracture end. The soft tissue damage associated with the former fracture is much more severe than that of the latter. The biggest danger of open fractures is that the wound is contaminated, a large number of cells invade, and rapidly multiply locally, causing bone infection. Severe cases can lead to limb dysfunction, disability, and even life-threatening situations. Open fractures can be classified into three degrees based on the severity of soft tissue damage. First degree: The skin is punctured from the fracture end from the inside out, and the soft tissue damage is mild. Second degree: Skin rupture or crushing, moderate damage to subcutaneous tissue and muscle tissue. Third degree: Severe damage to the skin, subcutaneous tissue, and muscles, often accompanied by vascular and nerve damage. The principle of treating open fractures is to promptly and correctly treat the wound, prevent infection as much as possible, and strive to transform open fractures into closed fractures. 1, Preoperative examination and preparation: (1) Inquire about medical history, understand the process of trauma, the nature and time of injury, and the situation of emergency treatment. (2) Check the overall condition for shock and other life-threatening organ damage. (3) Determine the presence of nerve, tendon, and vascular injuries through limb movement, sensation, arterial pulsation, and peripheral blood circulation. (4) Observe the wound and estimate the depth of the injury Soft tissue damage and degree of contamination. (5) Take X-rays of the patient's limbs in both frontal and lateral positions to understand the type and displacement of fractures. 2, In principle, the earlier the debridement, the less chance of infection and the better the treatment effect. Early bacteria stay on the surface of the wound, only for contamination, and then multiply and invade the tissue to cause infection. This period of time is called the incubation period. So, it is necessary to strive for debridement during the incubation period and before infection occurs. It is generally believed that debridement should be carried out within 6 to 8 hours after injury, and the majority of wounds can heal in one stage. It is advisable to try to do so within this period of time. If the temperature is relatively low when injured, and if there is winter, the wound contamination is relatively light and the surrounding tissue damage is also relatively light, the debridement time can be appropriately extended. A small number of cases can still undergo debridement 12 to 24 hours after injury, and some cases even exceed 24 hours. But it is absolutely not advisable to intentionally delay the debridement time, in order to avoid increasing the chance of infection and causing serious consequences. 3, Key points of debridement
six
The debridement surgery for open fractures includes debridement, fracture reduction, soft tissue repair, and wound closure. Its requirements are more stringent than simple soft tissue injury, and in case of infection, it will cause suppurative osteomyelitis. 1. Debridement: After cleaning and disinfecting the wound that is about to be contaminated, the edge of the wound is removed, foreign objects are removed, and necrotic and lifeless tissue is removed to make it a clean wound. Surgery can be performed under brachial plexus anesthesia or epidural anesthesia. To reduce bleeding, especially when accompanied by vascular injury, surgery can be performed using a tourniquet. Due to the difficulty in determining the blood supply of the tissue with a tourniquet, after initial debridement and hemostasis, the tourniquet should be released and the tissue without blood supply should be removed again through debridement. (1) Cleaning: Cover the wound with sterile dressing and wash the affected limb 2-3 times with a sterile brush and soap solution, including the upper and lower joints of the wound. After washing, rinse with sterile saline solution. The inside of the wound is generally not washed. If contamination is severe, gently clean with sterile gauze and rinse with saline solution. Rinse the wound with 0.1% active iodine or apply 0.1% active iodine soaked in gauze to the wound, and then rinse with physiological saline. After routine disinfection and towel laying, debridement surgery is performed. (2) Remove 1 to 2 centimeters of the skin at the edge of the wound. For skin contusions, remove the skin that has lost vitality. From shallow to deep, remove foreign objects, remove contaminated and inactive subcutaneous tissue, fascia, and muscles. For tendons, nerves, and blood vessels, it is advisable to remove their contaminated parts as much as possible while preserving the integrity of the tissue for repair. Thorough debridement is necessary to avoid overlooking dead spaces and blind spots. (3) Patients with severe contusions of joint ligaments and joint capsules should have them removed. If only pollution is present, it is important to completely remove the pollutants while preserving them as much as possible, which is crucial for joint stability and subsequent functional recovery. (4) The outer membrane of the bone should be preserved as much as possible to ensure bone healing. If it has been contaminated, its surface can be carefully cut off. (5) Treatment of fracture ends: It is necessary to thoroughly clean and maintain the integrity of the bone as much as possible to facilitate fracture healing. The degree of contamination at the bone end generally does not exceed 0.5 to 1.0mm in dense bone, while it can be as deep as 1 centimeter in cancellous bone. The contamination of dense bone can be removed by chiseling or biting with bone forceps, while contaminated cancellous bone can be scraped off. The contaminated bone marrow cavity should be thoroughly removed. The bone fragments of comminuted fractures should be carefully treated. Free small bone fragments can be removed, while small bone fragments that are still connected to surrounding tissues should be retained and reduced to facilitate fracture healing. Even if the large bone fragments are completely free, they cannot be removed to avoid causing bone defects, affecting fracture healing, and even causing bone non connection. Soak it in 0.1% active iodine for S minutes, rinse it with physiological saline, and then place it back at the original fracture site to maintain bone continuity. (6) Re cleaning: After thorough debridement, rinse the wound and its surroundings with sterile saline solution 2-3 times. Soak or wet compress the wound with 0.1% live iodine for 3 to 5 minutes, and the solution has no side effects on the tissue. If the wound is heavily contaminated and there is a long time left after injury, it can be cleaned with a 3% hydrogen peroxide solution and then rinsed with physiological saline to reduce the chance of anaerobic bacterial infection. After cleaning, gloves, dressings, and surgical instruments should be replaced, and tissue repair surgery should continue. 2. Organizational repair (1) Fracture fixation: After debridement, the fracture should be reduced under direct vision, and an appropriate internal fixation method should be selected based on the type of fracture to fix it. The fixation method should be the simplest and fastest, and external fixation can be added appropriately after surgery if necessary. If the fracture is stable and not easily displaced after reduction, external fixation can be used instead of internal fixation.
seven
For third degree open fractures and second degree open fractures, if the debridement time exceeds 6 to 8 hours after injury, internal fixation should not be used, and external fixators can be used for fixation. After more than 6 to 8 hours, the bacteria contaminated at the wound site have passed the incubation period and entered the logarithmic proliferation period. As lifeless foreign objects, internal fixation devices have low local resistance and antibiotics are difficult to exert their effects, which can easily cause infections. In case of infection, the internal fixation device must be removed, otherwise the infection will persist and the incision will not heal. (2) Important soft tissue repair: For injuries to important tissues such as tendons, nerves, and blood vessels, appropriate methods should be used during debridement to restore limb function as soon as possible. (3) Wound drainage: Use a silicone tube, place it at the deepest part of the wound, and thread it out of the body through normal skin. And connect the negative pressure drainage bottle and remove it after 24 to 48 hours. When necessary, antibiotics or antibiotic slow-release agents can be placed into the wound before closure. 3. Closing the wound completely and striving for primary healing is the key to transforming an open fracture into a closed fracture, and it is also the main goal of debridement surgery. For first and second degree open fractures, after debridement, most of the wounds can be closed. For third degree open fractures, it is also necessary to strive to use various different methods to close the wound in one stage as much as possible after thorough debridement. The development of microsurgery has provided better methods and more opportunities for the treatment of such injuries. (1) Direct suturing: For those without obvious skin defects, direct suturing is often possible. A wound that crosses the joint vertically, although there is no skin defect; It is also not advisable to suture directly to avoid scar contraction of the wound, which may affect poor mobility. We need to use the Z-shaped technique to close it. (2) Reduced tension suturing and skin grafting: For skin defects with high wound tension, direct suturing is not possible, as the surrounding skin and soft tissue damage is relatively mild. A reduction incision parallel to the wound can be made on one or both sides of the wound. After suturing the wound, if the reduced tension incision can be sutured, it should be sutured directly, otherwise skin grafting should be performed at the reduced tension incision. If there is a skin defect at the wound site, and the local soft tissue bed is better without important tissues such as bones, nerves, and blood vessels exposed, direct skin grafting can also be performed at the wound site. (3) Delayed closure: Third degree open fracture with severe soft tissue damage, making it difficult to fully determine tissue necrosis and increasing the risk of infection. After debridement, the surrounding soft tissue can be covered over the fracture site, the wound can be opened, and sterile dressings can be used for wet dressing. Observe for 3 to Sd, and then debridement can be performed again to completely remove the inactive tissue and perform free skin grafting. If skin grafting is difficult, a skin flap can be used to cover it. (4) Skin flap transplantation: Third degree open fractures with extensive soft tissue damage, exposed fracture site, lack of soft tissue coverage, and high risk of infection. Efforts should be made to cover the wound with various types of skin flaps, such as local transfer flaps, island flaps with vascular pedicle, or free flap grafts with vascular anastomosis. After the debridement process is completed, appropriate fixation methods should be selected based on the severity of the injury to fix the affected limb. Antibiotics should be used to prevent infection, and tetanus antitoxin should be applied.
