Primary soft tissue management in open fracture

Abstract

Debridement of soft tissue and bone in an open fracture situation to minimize infection risk and achieve primary skin closure, or to provide conditions for early soft tissue coverage. Indications are Gustilo-Anderson gradeI-III A-C open fractures. Contraindications are injuries requiring amputation, burns, and life-threatening injuries which make appropriate treatment temporarily impossible. Removal of gross contamination and macroscopic contaminants; debridement of the wound; complete resection of contaminated and dirty tissue; sparse step-by-step resection of contaminated or non-vital wound and bone margins until vital, bleeding tissue begins; low-pressure irrigation with isotonic irrigation fluid; diagnostic biopsies for microbiological testing; reduction of dead space by interpositioning of muscle or cement spacers loaded with local antibiotics; primary wound closure if tension-free closure possible; otherwise, if resources and knowhow permit and satisfactory clean debridement was achieved, local flap; if flap impossible, debridement not satisfactory, secondary tissue necrosis likely, potential remaining contamination or contamination with fecal matter, then vacuum-assisted closure therapy. Wound inspection on the second postoperative day, generous indication for second-look surgery after 36-48 h, wound inspection on the second postoperative day, wound inspection every other day, primary antibiotic prophylaxis with afirst- or second-generation cephalosporin (e. g., cefuroxime), and adaptation of antibiotic therapy according to susceptibility screening. Infection rates of 2-4.7% are reported for immediate primary wound closure in Gustilo-Anderson gradeI, II, and III A open fractures. For Gustilo-Anderson gradeIII B, good wound healing, bony consolidation, and no need for secondary surgery was reported in 86.7% when primary wound closure was achieved.