- Technical Considerations:
- consider debriding the wound with a separate set of surgical instruments / drapes
- exposure: extend the traumatic incision longitudinally in order to fully expose zone of injury;
- pressure irrigation
- debridement of open tibia fractures
- Arguments for Leaving Wound Open w/ Delayed Closure:
- traditionally, the surgeon will close surgical incisions made during the case but will leave the traumatic wound open;
- adresses compartment syndrome (if there is a concern)
- relief of skin tension
- leaving the wound open (w/ wound vac) maximizes drainage and wound tension (which is frequently present w/
primary closure);
- at 2nd look debridement (at 48-36 hrs), the edema will have diminished and the wound can be closed w/ less tension;
- alternatively if the wound cannot be closed tension free then soft tissue reconstruction is needed;
- ability to redebride devitalized muslce and tissue;
- ability to remove additional contaminants;
- references:
- Primary or delayed closure for open tibial fractures.
- Compartment syndrome in open tibial fractures.
- Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement
- Arguments for Primary Wound Closure (Immediate closure):
- note that the most frequently identified organisms in open tibial fractures are staph aureus and nocosomial organisms;
- leaving the wound closed allows easier examination of the extremity during the postoperative period;
- if there is a concern about wound tension, then consider making a limited posteromedial relaxing incision;
- this allows a proplyatic fasciotomy and yet this incision will be away from the fracture site to avoid fracture
nocosomial contamination;
- references:
- Aggressive treatment of 119 open fracture wounds.
- The 2-0 Ethilon test.
- Timing of closure of open fractures.
- Treatment of open tibial fractures with primary suture and Ilizarov fixation.
- Timing of closure of open fractures.
- Epidemiology of bacterial infection during management of open leg fractures.
- Comparison of delayed and primary wound closure in the treatment of open tibial fractures.
- Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.
- Early versus delayed closure of open fractures
- Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study.
- Primary Wound Closure after Open Fracture: A Prospective Cohort Study examining Non-Union and Deep Infection.
- Contaminated Wound Care:
- wound dressings:
- wound vac;
- antibiotic bead pouch:
- as noted by Keating, et al (1996), bead pouches help reduce the infection rate in open tibia frx from 16% to 4%;
- counting the beads and adding methylene blue helps ensure that none of the beads will be left behind at removal;
- references:
- Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate?
- Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases.
- bacterial cultures:
- Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
- Epidemiology of bacterial infection during management of open leg fractures.
- Efficacy of cultures in the management of open fractures.
Soft Tissue Reconstuction of the Leg
- References:
- Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures.
- Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.
- Christopher J. Lenarz, MD, et al.: "Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement"
- Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement
- Closure of the skin defect overlying infected non-union by skin traction.