This topic has been presented by my lovely wife during her Orthopaedic rotation in HRPZ. My challenge is to redesign the slide using Zen approach. And Alhamdulillah it went very well. Good job Honey. http://slideskills.com http://wanyusof.com

2. surgical
approach

3. surgical
wound debridement
approach
primary fixation
vs
external fixation
Intraoperative irrigation

4. surgical
wound debridement
approach
primary fixation
vs
external fixation
intraoperative Irrigation

5. Do we even need to do
operative debridement?

6. Orcutt et al.: No significant difference, BUT*
50 type 1 & 2 open fractures
less infection in non-op group (3% vs 6%)
less delayed union in non-op group (10% vs 16%)
Yang et al.: 0% infections **
91 type 1 open fractures treated without formal
debridement
*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual
Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.
**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin
Orthop Relat Res 2003. 410: 289-294.

7. “Even if the benefits of formal I&D were
insignificant for low grade fractures, operative
debridement is still required for proper wound
classification.”
*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone
Joint Surg Am. 2006 Dec; 88(12):2739-48.
Huge risk not to explore and debride!
“Open fractures graded on the basis of
superficial characteristics are often
misclassified.”

8. When to go in?

9. “Historically, the 6-hour rule has been
employed as the time limit within which an
open fracture should be taken to the
operating room for initial debridement*”
*Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones:
retrospective and prospective analyses.
Gustilo RB, Anderson JT
J Bone Joint Surg Am. 1976 Jun; 58(4):453-8.

10. Several studies suggest that the timing of
surgery is less important than the
adequacy of debridement and early use
of antibiotics.
Gustillo and Anderson's classic article concluded “Open fractures
require emergency treatment, including adequate debridement and
copious irrigation.”
Patzakis and Wilkins documented infection rates of
(6.8%) of 396 for wounds debrided within 12 h, and (7.1%) of
708 for those debrided after 12 h.
Bednar and Parikh reviewed 82 adult open
fractures and found no statistically significant
difference in deep infection rates for those treated
within 6 h compared with those treated within 24 h.

11. Influencing factors
surgeon availability
patient's physiologic status
operating room availability

12. Strict adherence to the emergent 6-hour rule
does not seem to be justified based on
empiric evidence available in the literature*
*Review Timing of débridement of open fractures. Pollak AN J Am Acad
Orthop Surg. 2006; 14(10 Spec No.):S48-51.

13. however….

14. In certain scenarios…..
Eg. Type III injuries with vascular injury and/or
gross fecal or soil contamination.

15. If surgery for an open fracture is to be delayed, temporizing
treatment should include
• sterile and antiseptic coverage
• provisional splinting with attention paid to basic
length, rotation, and alignment.
• A preliminary fracture reduction may need to be
performed in the emergency room.

16. The goals of treatment for open fractures
are to prevent infection, get the
broken bones to heal, and restore
function.
Open fractures should be taken to the
operating room in an urgent manner using
appropriate surgical judgment.

17. Irrigation
and

18. Objectives
Detection & removal of foreign material
Detection & removal of nonviable tissues
Reduction of bacterial contamination
Creation of a wound that can tolerate residual
bacterial contamination & heal without infection

19. Beginning with skin & subcutaneous fat ->
methodical, layer-by-layer debridement
Wounds should be extended & excised
to allow adequate exposure
One must be conservative in excision
of skin, particularly at a premium
Any non-viable, damaged, or
contaminated fascia excised

20. Beginning with skin
& subcutaneous fat

21. Beginning with skin &
subcutaneous fat ->
methodical, layer-by-
layer debridement
Methodical, layer-by-
layer debridement

22. Beginning with skin &
subcutaneous fat ->
methodical, layer-by-
layer debridement
Any
nonviable, damage
d, or contaminated
fascia excised

23. skin
subcutaneous
tissue
muscle
bone

25. Muscle : Viable? (4C’s)Indicator Description
Colour • least reliable sign for muscle viability
• surface tissue may be discoloured due to
contusion or local vasocontriction
• Non-viable: dark-coloured
Consistency • ability to rebound to initial shape after grasping
with forceps (may be most reliable early sign)
• Viable: firm
• Non-viable: mushy, soft
Contractility • assessed by observing retraction with pinch of
forceps or by observing stimulus with
electrocautery device
Circulation • may be difficult to detect early due to vasospasm
• Non-viable: absence of bleeding from its cut
surface

26. Significant function retained
even if 10% of a muscle belly &
its tendon preserved
Certain wounds may require
serial debridements

27. Where coverage of tendons
by soft tissue not
possible, paratenon is
essential for tendon survival
– do not debride paratenon
but copiously irrigate

28. If not obviously contaminated, & if contribute to reconstruction of
#, bone can be retained as bone graft
 Unattached bone should be discarded
Bone debridement initially can be conservative
- if infection intervenes, early aggressive redebridement important
Critical to preserve periosteum where bone will not be immediately
covered by soft tissue

29. surgical
wound debridement
approach
primary fixation
vs
external fixation
intraoperative irrigation

30. surgical
wound debridement
approach
primary fixation
vs
external fixation
Intraoperative irrigation

31. “The removal of contaminating debris and
the decrease of potentially infective bacterial
loads decrease the chances of acute and
chronic infection”
*Review Wound irrigation in musculoskeletal injury. Anglen JO. J Am Acad
Orthop Surg. 2001 Jul-Aug; 9(4):219-26.

32. Protocol*
*Review Wound irrigation in musculoskeletal injury. Anglen JO. J Am Acad Orthop
Surg. 2001 Jul-Aug; 9(4):219-26.
3L
3L 3L
3L 3L 3L

33. Low to medium pressure lavage device is
recommended as higher-pressure devices have
been associated with added tissue or bone damage*
*High and low pressure irrigation in contaminated wounds with exposed bone.
Bhandari M, Thompson K, Adili A, Shaughnessy SG
Int J Surg Investig. 2000; 2(3):179-82.

34. Lack of evidence-based recommendations in the literature to
guide surgeons on the appropriate additives for irrigations.**
**Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A
prospective, randomized study. Anglen JO. J Bone Joint Surg Am. 2005 Jul; 87(7):1415-22.

35. Normal Saline
isotonic and the most commonly used wound
irrigation solution due to safety(lowest toxicity)
and physiologic factors.
A disadvantage is that it does not cleanse
dirty, necrotic wounds as effectively as other
solutions.

36. contains no antimicrobial or bacteriostatic
agents or added buffers.
often used in irrigation particularly in
developing countries, as a less expensive
alternative to hypotonic and may cause
hemolysis
readily absorbed by the tissues during
surgical procedures; therefore, its use under
such conditions is not recommended.
Sterile Water

37. in the event that normal saline or sterile
water are not available.
a few studies have shown potable water
to be as effective at reducing bacterial
counts as normal saline.
Potable Water

38. broad spectrum antimicrobial solution
effective against a variety of pathogens
including Staphylococcus aureus.
- similar wound infection rates have been
reported in adult and pediatric populations
with saline irrigation versus 1% povidone-
iodine*.
A disadvantage is its cytotoxicity to healthy
cells and granulating tissues. The solution
dries and tends to discolor skin. It may also
cause local irritation to the periwound skin.
*Chisholm CD, Cordell WH, Rogers K, Woods JR. Comparison of a new pressurized saline canister versus syringe irrigation
for laceration cleansing in the emergency department. Ann Emerg Med. Nov 1992;21(11):1364-7.
*Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide poisoning. Toxicol Rev. 2004;23(1):51-7.
Povidone Iodine

39. Controversial use
Several studies have shown hydrogen
peroxide to be ineffective in reducing
bacterial count*
Cytotoxic to healthy cells and granulating
tissues**
*Leyden JJ. Bartelt NM. Comparison of topical antibiotic ointments, a wound protectant and antiseptics for the treatment of
human blister wounds contaminated with S. aureus. J Fam Pract. Jun 1987;24(6):601-4
**Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg. Mar 1985; 120(3):267-70
Hydrogen Peroxide

40. American Medical Association: the
effervescing cleansing action may act
as a chemical debriding agent to help
lift debris and necrotic tissue when used
at full strength
If used, irigation with NS is
recommended*
Hydrogen Peroxide
*Rodeheaver GT. Wound cleansing, wound irrigation, wound disinfection. In: Krasner D, Kane D, Chronic Wound Care: A Clinical
Source Book for Healthcare Professionals. 2nd. Wayne, PA: Health Management Publications, Inc; 1997:97-108

41. is it relevant?

42. Lee et al. studied pre- and post debridement
cultures of open wounds*
Only 8% of organism cultured eventually caused
infection. Conversely 7% of patients with negative
cultures eventually become infected.
*Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res 1997; 339:71-5

43. Study of wound infections after open
fractures by Carsenti-Etesse et al.
92% of infections after open fractures were
caused by nosocomial bacteria, rather than by
the initially cultured organism*
*Carsenti-Etesse H, Doyon F, Desplaces N, et al. Epidemiology of bacterial infection during management of
open leg fractures. Eur J Clin Microbiol Infect Dis 1999; 18:315-23

45. Routine cultures of traumatic or clean surgical
wounds are not recommended
*Bhandari M et al. (2012) Evidence-based orthopedics. Oxford. Blackwell Publishing Ltd
Superficial wound swab cultures of a
suspected wound infection are of little value
Intraoperative deep cultures if positive can
help guide antibiotic therapy if an organism is
isolated

46. surgical
wound debridement
approach
primary fixation
vs
external fixation
intraoperative irrigation

47. surgical
wound debridement
approach
primary fixation
vs
external fixation
Intraoperative irrigation

48. Role
For skeletal stability to minimise further
soft tissue insult

49. Clean, healthy wound
Mild, minimal soft tissue
injury
Early presentation <6H
Primary Fixation

50. Joint can be reduced and stabilised
temporarily in an adequate position
while awaiting decrease of any
swelling and allows soft tissue
healing
Can be applied almost always and
everywhere
Severe soft tissue damage and
contamination
External Fixation

51. Advantages Disadvantages
Easy and quick Pin track infections
Relatively stable
fixation
Malalignment
No further damage
done
Delayed union
Avoids hardware in the
open wound
Allows wound care

53. A surgeon may consider amputating a limb that
has sustained
(1) a high-grade open fracture
(2) severe vascular injury
(3) significant nerve damage

54. Amputation rates for open fractures that require vascular
repair (Gustilo type IIIC) range from 40% in a to 88%*.
Russell et al. consider a type IIIC fracture with nerve
injury an absolute indication for amputation**.
In this same spirit, Lange et al. recommend amputation for
patients with posterior tibial nerve impairment***.
*Helfet DL, Howey T, Sanders R, et al: Limb salvage vs amputation: preliminary results of the MESS.
Clin Orthop 256:80-86, 1990
**Russel WL, Sailors DM, Whittle TB, et al: Limb salvage vs traumatic amputation: a decision based
on a seven-part predictive index. Ann Surg 213:473-481, 1991
***Lange RH, Bach AW, Hansen ST Jr, et al: Open tibial fractures with associated vascular injuries:
prognosis for limb salvage. J Trauma 25:203-208, 1985

55. Mangled Extremity Severity Score (MESS)
Used to select lower extremity injury that
warrant primary amputation
Allows evaluation of patients with normal
perfusion
– Vascular injury has not been clearly defined
Has been widely referenced as the trauma
limb-salvage index for lower extremity
trauma

56. V-elocity of injury
I-schaemia
S-hock
A-ge
“VISA gives you double frequent flyer
points after 6 hours”
Score doubles for ischaemia >6 hours