Wound Care: Debridement, Coverage, and Antibiotic Utilization

Abstract

Summary We advocate aggressive treatment for open fractures initiated in the emergency department with gross wound debridement and systemic antibiotic prophylaxis. A first generation cephalosporin is given for all open fractures, and an aminoglycosides is added for grade III open fractures. Emergent, aggressive surgical debridement with wound extension is required for all non-viable and contaminated tissue. Debridement should be performed within 6 to 8 hours from the time of injury. We stabilize fractures early with either external fixation or open reduction and internal fixation. Surgical wound extensions are primarily closed, and traumatic wounds are loosely approximated or temporarily covered with a synthetic wound cover or bead pouch. Repeat debridements at 24-to 72-hour intervals are required to remove devitalized, contaminated tissue. Once an adequate clean bed is obtained, aggressive coverage and closure of soft tissue wounds is a necessity, ideally within 5 to 7 days after the injury. In summary, by following these aggressive principles of open fracture management, a regional trauma center should expect an approximate 10% to 20% incidence of deep infection in the face of grade III open fractures, and a lower incidence of infection in grade I and II open fractures.