1. Assessment of tissue viability is difficult after open trauma and wound excision should be performed by consultant plastic and orthopaedic surgeons as a combined procedure.
2. Immediate surgical exploration is indicated in the presence of gross wound contamination, compartment syndrome, devascularised limb, or multiple injuries.
3. Wound extensions are used to facilitate wound excision and allow inspection of deeper structures. In the tibia these should follow fasciotomy lines.
4. Wound excision should be systematic to ensure all devitalised soft tissue and bone is removed whilst preserving the neurovascular bundles. Repeat wound excision may be required in the presence of tissues of doubtful viability whilst still respecting the timelines to reconstruction.
5. Low-pressure lavage with a high volume of tepid 0.9% saline completes the wound excision.
6. The injury is classified at the end of the final wound excision.
7. Closure of an open fracture wound should be a combined decision between orthopaedic and plastic consultants.
8. Definitive fracture fixation after wound excision should be undertaken as a distinctly separate operative procedure with re-prepping of the limb and opening of fixation instruments and implants at the time of stabilisation.
Early, thorough wound excision of the traumatic wound is probably the most important step in the prevention of infection after an open limb fracture. Devitalised tissues and foreign material facilitate the growth of microorganisms and constitute a barrier for the host’s defence mechanisms.
We made the decision that in this publication we would replace the term debridement with the term wound excision, both in our own narrative and when referring to the publications of others. This should lead the reader to the principle that successful separation of tissues that are contaminated or non-viable from those that are healthy and viable relies on surgical excision of the former. Surgical access to the area requiring excision will include an extension of the traumatic wound by incision. The change in terminology from debridement to wound excision then encourages the concept that completion of the process relies on more than just lavage and dilution of contaminants.
Surgical extension of the traumatic wound should be sufficient to allow a thorough assessment of all components of the injury and an accurate injury classification.
Dressings applied in the emergency room should only be removed when the patient is in the operating theatre. The dressings and splint are removed, the zone of injury and limb perfusion are re-examined, and a ‘social wash’ or ‘pre-wash’ of the limb is performed with a soapy chlorhexidine solution prior to formal prepping. A Cochrane review of preoperative bathing or showering with antiseptics in clean surgery provided no clear evidence of a reduction in surgical site infections (1). However, the surface of the injured limb is frequently contaminated with particulate matter and dried blood, and a gentle pre-wash creates a clean surface ready for formal skin antisepsis. The social wash also serves to identify any other injuries to the limb that may not have been readily apparent at initial assessment. The pre-wash is ideally performed in the anaesthetic room after induction to maintain theatre cleanliness. A tourniquet may be applied the limb and inflated for selected parts of the procedure. Photographs of open fracture wounds should be taken after the social wash, before the open wound is excised and at other key stages of management such as the end of wound excision. The photographs should be stored as part of the patient’s record (2, 3).
The patient is then transferred to the operating table and skin antisepsis undertaken to reduce the presence of microorganisms. Alcohol-based preparations have been found to be more effective for other surgical procedures (4). When alcoholic solutions are used, care must be taken to avoid contact with the open wound and pooling beneath a tourniquet.
The surgical equipment used for performing the wound excision must be kept separate from the equipment for the subsequent fracture stabilisation to facilitate the conversion of the contaminated wound into a clean wound and to reduce the risk of contaminating the fracture hardware. If primary wound closure or definitive soft tissue cover and definitive fracture fixation is anticipated at the end of the wound excision, the limb should be formally re-prepped and draped for the second stage with new sterile equipment.
Elastic recoil of the tissues at the moment of injury and first aid measures to realign and splint the limb may result in contaminated tissues remaining within the wound and the extent of tissue damage and contamination will not be immediately obvious. Formal wound extension is usually required to allow a systematic examination of the tissues and exposure of the fracture fragments. Regardless of the location of the traumatic wound, wound extensions must follow the fasciotomy lines (Figure 3.1). The majority of open tibial wounds are located in the anteromedial aspect of the tibia, with varying degrees of exposure of the tibial bone. The medial fasciotomy extension avoids further inadvertent exposure of the tibia and protects the posterior tibial artery perforators, which are vital for a local fasciocutaneous flap. The medial extension also allows inspection of the posterior tibial vessels and nerve if required and provides ready access to the recipient vessels for free flaps. It is important that the wound extensions are performed in the subfascial plane to avoid degloving.
Assessment of tissue viability is difficult and wound excision should be performed jointly by consultant plastic and orthopaedic surgeons (2). A systematic approach to wound excision is recommended, working from the wound margin to the centre and from the superficial structures to the deep layers of the wound. The wound extensions must allow inspection of the deep posterior muscle compartment in severe injuries to identify devitalised muscle, foreign material, and bone fragments driven into the tissues at the time of injury. A gradient of tissue damage is usually encountered, with obvious non-viable tissue at the points of greatest injury, surrounded by zones of variable tissue damage.
Tourniquet use is determined by surgical preference. A bloodless field allows identification of major neurovascular structures, facilitates soft tissue wound excision by avoiding blood staining, and also limits blood loss. However, prolonged tourniquet times should be avoided to prevent ischaemia and reperfusion injury (5). The tourniquet must be deflated after wound excision to formally assess tissue viability and achieve haemostasis.
Skin is relatively resilient but is vulnerable to direct crush and torsion/avulsion injuries, which may damage the septocutaneous and musculocutaneous perforators and cause necrosis. Early signs of skin necrosis include fixed staining (non-blanching on digital pressure) or subcutaneous vein thrombosis, but the extent of necrosis may be difficult to determine within the first 24–48 hours of injury. Contused skin at the margins of the open wound should be carefully excised to leave edges that bleed from the dermis.
Subcutaneous fat injury is easily missed, with potentially serious consequences. Fat is vulnerable to injury by direct compression and the extent of fat necrosis will often extend beyond the skin injury (see Chapter 4).
Devitalised muscle can be difficult to assess and the traditional method of assessment of is by the four ‘C’s: colour (pink not blue), contraction, consistency (devitalised muscle tears in the forceps during retraction), and capacity to bleed. A 1956 study of excised specimens from 12 war wounds found that consistency, contractility, and capacity to bleed were reliable predictors of muscle damage, whilst the colour was not (6). However, a more recent histopathological study showed that neither the four Cs nor the surgeons’ impression correlated with histologic appearance (7). The analysis of 36 muscle biopsies found that 60% of specimens labelled borderline or necrotic by the surgeon were shown to comprise normal muscle on histopathological examination (7). These findings undermine current wound excision practices and suggest that surgeons may excise potentially viable muscle. Equally, retained dead muscle may lead to deep infection, emphasising the importance of consultant surgeons experienced in trauma management working together to achieve optimal outcomes.
Cortical bone has a relatively poor blood supply and assessment of viability is difficult. Small bone fragments with tenuous soft tissue attachments, which dislodge or separate easily during a steady pull (the ‘tug test’), should be removed owing to their poor blood supply. Larger bone fragments should be carefully inspected for fracture edge or cortical bleeding. Fracture fragments should not be regarded as bone graft. Necrotic fragments and avascular fracture ends are unlikely to contribute to fracture union and may serve only as a nidus for infection. If there is doubt regarding the viability of bone ends or fragments, they should probably be removed. Large articular cartilage fragments attached to cancellous bone may be preserved, provided they are large enough to contribute to articular stability. Such fragments should be thoroughly cleaned with scrubbing, curettage, and lavage prior to reduction and fixation with absolute stability.
The main bone ends should be carefully delivered through the wound or appropriate wound extensions and the extent of periosteal stripping determined. The bone ends are cleared of haematoma with curettes and saline irrigation, and the medullary canal is inspected for debris. Occasionally road debris is embedded in the bone ends and must be meticulously removed. Fracture viability is inferred from the capacity of the bone ends to bleed, which is seen as a punctate ooze. Care must be taken not to mistake bleeding from the medullary canal for viability from a stripped fracture end, and periodic saline irrigation and suction help maintain visibility. Non-viable fracture ends may require resection with a cooled saw blade or large rongeur until bleeding bone is seen.
The aims of irrigation are to remove blood and particulate debris, to reduce the bacterial count, and facilitate tissue visibility. However, irrigation of open wounds has the potential to drive debris and bacteria into the deep layers of the wound (8) and should only be undertaken after adequate surgical removal of macroscopic contaminants and devitalised tissue. The FLOW study examined the effect of irrigation pressures and the use of soap or saline solutions in open fracture wounds (9). The authors found no benefit with high-pressure lavage and noted increased re-operation rates with soap solution. We recommend the use of a minimum of 3 litres of low-pressure saline lavage aided with digital agitation of the tissues as appropriate.
Wound cultures from wound excision of acute open fractures do not directly correlate with later infection. One study of cultures taken during the initial wound excision highlighted either no growth (76%) or skin flora only (26%), and no isolates were implicated with cases of subsequent infection (10). In another study of 245 cases of open fracture, post-wound excision cultures were shown to have a greater prognostic value than that of pre-wound excision culture (11). However, of the cases that became infected, the infecting organism was present on post-wound excision cultures only 42% of the time. The author concluded that pre-wound excision and post-wound excision bacterial cultures from open fracture wounds are of essentially no value (11).
Classification of open fractures
Classifying open fractures is an important step in assessing the severity of the injury, directing treatment and determining prognosis. The development of an all-encompassing classification system for open fractures has proven difficult due to the difficulties of accurately characterising the multiple tissues involved in the injury. Although several classification systems for open fractures have been proposed, the Gustilo–Anderson classification first described in 1976 for open tibial fractures is the most widely used (12). After reviewing their initial classification of the most severe open injuries, Gustilo et al. subsequently modified the classification system into its current form in 1984 and the grading has since been applied to open fractures in all regions of the body (13, 14).
Type I fractures are low-energy injuries with a wound of less than 1 cm and no muscle damage or contamination. Typical fracture patterns include spiral and oblique fractures with minimal comminution.
Type II fractures are higher-energy injuries with a wound greater than 1 cm, mild-to-moderate muscle trauma, periosteal stripping, and contamination. The fracture patterns reflect the higher energy and include bending wedge, segmental, and comminuted fractures.
Type III injuries reflect high-energy trauma and the original classification was modified into three subtypes in order of worsening prognosis (13).
Type IIIA are due to high-energy trauma, irrespective of the size of the wound but there is adequate soft tissue coverage of the fractured bone despite extensive soft tissue laceration or flaps.
Type IIIB fractures are associated with more extensive soft tissue injury loss, periosteal stripping, and bone exposure necessitating formal soft tissue cover. This is usually associated with massive contamination.
Type IIIC injuries are open fractures associated with arterial injury requiring repair, i.e. a devascularised limb.
Although the Gustilo–Anderson classification has prognostic value for predicting infection (14), the grading is not ideal and has been shown to have relatively poor inter-observer reliability (15). In addition, there are only two categories of severe fractures (types IIIB and IIIC), which cannot be subclassified based on potentially important injury characteristics (16). In view of the limitations of the Gustilo–Anderson classification, assessment of all open fractures should include the mechanism of injury, the appearance of the soft tissue envelope and its condition in the operating room, the level of likely bacterial contamination, and the specific characteristics of the fracture (14). Hence the definitive assessment of an open fracture is best accomplished after formal surgical exploration and wound excision rather than in the emergency department (17).
Traditionally, delayed wound closure was the accepted approach to prevent deep infection in open fractures, particularly infection caused by Clostridia species or other anaerobic organisms (18). Primary wound closure in selected cases has the potential advantage of protection against hospital-acquired (nosocomial) infections. In addition, immediate wound closure may reduce the number of surgeries required and allow earlier mobilisation and discharge from hospital (19). A number of studies have suggested that primary closure in appropriately selected subjects results in acceptable patient outcomes with low rates of infection (19, 20). The difficulty lies in defining which wounds are amenable to early closure. Immediate wound closure should only be performed after a joint decision by experienced orthopaedic and plastic consultants working at a high-volume trauma centre, and patients must be closely monitored to assess for surgical site infection.
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