Open Fracture Treatment: Wound Debridement, Fracture Stabilization and Soft Tissue Reconstruction

Open fracture treatment includes a number of steps that will be explained in this article

Management in Emergency department

ATLS trauma protocol
Take full history and examination of the injuries
Grade the fractures according to the Gustilo Anderson classification
Give antibiotic cover using IV antibiotics
Cleaning of the wounds and splinting
Initially no attempt should be made to remove anything other than gross contamination and then cover with simple sterile saline soaked dressing
Then the limb should be brought out to length and correct alignment and splinted or casted
After emergency department management, patient is transferred to the operating room

Surgery

Surgery consist of wound debridement and a form of fracture stabilization method

This is done either as emergency surgery (immediately after the injury) or urgent surgery ( in less than 24 hours after the injury)

Indications of emergency surgery include

Gross contamination of the wound
Dysvascular limb requiring vascular repair
Compartment syndrome requiring fasciotomy
All other open fractures should undergo debridement and fixation within 24 hours, the earlier the better, the expertise of the team is more important

During surgery

Use of general anesthesia => better for muscle relaxation and patient comfort
Tourniquet is applied and inflated only to allow the identification of neurovascular structures and careful assessment of tissue integrity and then deflated to allow assessment of capacity of soft tissue and bone to bleed
Using tourniquet induces tissue ischemia in already badly injured limb so inflate only when necessary and deflate it back
Initial pre scrubbing of the limb is performed to remove gross contaminants

Wound debridement

The wound edges are excised and the wound extended proximally and distally far enough for all traumatized tissue to be seen and assessed including the fractured bone ends, also it should take into account surgical exposure required for fracture stabilization and flapping or grafting procedures needed
Examination of the fracture surfaces cannot be adequately performed without extracting the bone from within the wound, the simplest method is to bend the limb in the same manner in which it was forced at the moment of injury
All contaminated and dead tissue should be excised including skin, fat, fascia, muscle and bone
Muscle viability is assessed according to the four Cs: color, contractility, consistency and capacity to bleed
Major peripheral nerves and vessels should be identified and protected
Soft tissues under the bone should also be examined and debrided carefully
Finally the wound is irrigated extensively with warmed normal saline (around 6 L) at low pressure to remove remaining contaminants
No benefit from pulsatile lavage (force contaminant deeper into tissue) , no benefit from adding antibiotics

Fracture stabilization

Fracture stabilization is important in getting the bone to heal, reducing infection risk, assist recovery of the soft tissues and control pain
After wound debridement, patient repositioned on the table with traction, surgical team rescrub, limb should be re prepared and re draped, and new instruments should be used
Definitive fracture fixation is performed whenever possible depending if the debridement was adequate
but if there is extensive contamination and debridement wasn’t adequate (e.g. in blast injuries) , definitive fixation can’t be performed safely at the first procedure and temporary external fixation is required

Wound closure

Primary wound closure done at the first procedure only if:

The patient has no significant comorbidities like DM, decrease immunity
The patient fully resuscitated
No gross contamination left in the wound
Debridement is complete and residual tissues are healthy
The fracture has been stabilized
The wound can be closed without tension

If the above criteria cannot be met and the patient need second procedure then the wound is left open and delayed primary closure is performed at the second procedure

Interrupted sutures are preferred to continuous sutures: more stable, precise alignment, localized wound drainage and monitoring

Drains of no value

Low pressure vacuum dressing is applied to help minimize wound edge edema

Repeated debridement (second procedure)

If there is doubt about the viability of the tissues, the wound left open and dressed for a second look within 48-72 hours

Dressing: best for these wounds are either a bead pouch consisting of a string of gentamicin beads under an adhesive dressing or a vacuum dressing

The patient then brought back to theatre after 48 hours for repeated assessment and debridement of the wound, several procedures maybe needed until debridement is complete

Soft tissue reconstruction

Plastic surgeon task to reconstruct soft tissue
Tissue loss or wound edema may mean that the wound cannot be closed without tension, preventing either primary or delayed primary closure, and soft tissue coverage with a flap or graft is required
Grafting or flapping should be performed as soon as possible and within 6 days after the injury
You should also know about the soft tissue reconstructive ladder to understand the available options for soft tissue coverage, you will study this more in plastic surgery rotation

Soft tissue reconstructive ladder

Healing by secondary intention: the idea is that you leave the wound to heal by itself through granulation, no sutures no anything except for dressing, and that is only used for small residual skin defects
Primary tissue closure: primary closure only possible if two healthy viable skin edges can be brought together without tension, using sutures, glue, …
Grafting: skin graft can be applied to a healthy vascularized tissue such as muscle or fat but not directly to bone or tendon or metalwork
Local tissue transfer (local flap): this is needed to cover bone, tendon or metalwork. The flap may contain skin, fat, fascia, muscle or combination with its blood supply. Local flap are brought from area adjacent to the wound. Local flap maybe random (supplied by un named artery) or axial (supplied by named artery)
Regional tissue transfer (regional flap): flap from the nearby location as the wound
Free tissue transfer (free flap): flap from distant site

Bone defect reconstruction

There might be residual defect in the bone after debridement
You can’t bone graft immediately after debridement to control infection, the bone graft require well vascularized tissue around it, it also require healed soft tissue around it and stable fracture => so for that you have to wait until grafting
So after debridement you either stabilize the fracture out to length with external or internal fixation and address the defect at a later procedure, the defect maybe filled with cement to maintain a gap to later fill it with bone graft
Or you shorten the limb acutely (so you stabilize it at shorter length by get the edges to be in direct contact to each other), either definitively in upper limbs or temporarily in lower limbs (you do later procedure for lengthening it again)
Acute skeletal shortening can decrease the effective size and complexity of soft tissue defect (so it is beneficial)

In the ward

Limb is elevated and its circulation is carefully monitored
Antibiotics continued for 1 day after surgery if Gustilo grade 1 or for 3 days for other Gustilo grades