BASIC SKILLSClassiﬁcation and Systematic approach to traumatic wound managementmanagement of acute C History:wounds and open fractures B Location and size of wound? B Associated tissue loss? B Type or velocity of weapon?Livio Di Mascio B Mechanism? B Energy involved? B Associated thermal or chemical injury? B Degree of contamination?AbstractAcute traumatic wounds and open fractures potentially cause signiﬁcant B Need for involvement of multidisciplinary teams?morbidity and loss of function. Much of the management of these types C Examination:of injuries has been developed from the experience of military surgeons B Associated injuriesduring times of armed conﬂict. The approach to management should B Neurovascular involvementstart on initial assessment using trauma resuscitation protocols. Once B Bone or joint involvementlife-threatening injuries have been managed, the wound should be thor- B Visceral involvementoughly debrided and the skeleton stabilized. The wound must be re-inspected after 48 hours to evaluate whether further debridement is C Interventions:necessary and plans for soft tissue coverage can be made. The approach B RESUSCITATIONto management of open fractures should be systematic, involving both B Prophylaxis: tetanus, antibioticsorthopaedic surgeons and plastic surgeons from the outset. B Photograph wound and then cover with dressing B Analgesia/anaesthesiaKeywords Acute wounds; open fracture classiﬁcation; open fracture B Exploration/debridement/washoutmanagement; traumatic wounds; wound classiﬁcation; wound management B Haemostasis B Skeletal stabilization B Revascularization?The aetiology of traumatic wounds is diverse and the mechanism, B Fasciotomies?pattern, location, energy imparted to the tissues and degree of C Deﬁnitive management:contamination all play a role in their inherent ability to heal. As B Multidisciplinary approachsuch, initial assessment and treatment should be systematic, and B Closure: when, where and how?subsequent management is tailored to each individual wound. Thegeneral principles of wound management are outlined in Box 1. C Rehabilitation: B DressingsTypes of wound B Splints? B Physiotherapy/hand therapyTo gain a broad overview of wounds in a clinical context, theterms simple and complex can be used: Box 1Simple wounds: involve skin and soft tissues without damage tounderlying bone or joint or neurovascular structures. They arenot heavily contaminated and do not have signiﬁcant skin or soft The ASEPSIS scoring system1 assigns a number of scores totissue loss. various wound characteristics evaluated during serial assessment over a 5-day period. (Additional treatment, Serous discharge,Complex wounds: involve signiﬁcant loss of skin or soft tissue. Erythema, Purulent discharge, separation of deep Tissues,The injury may also involve vital structures, bone or joints or Isolation of bacteria, duration of hospital Stay.)communicate with a hollow viscus. There may also be associated If the summated score is greater than 20, this would suggestneurovascular injury or a compartment syndrome. These types that wound infection is present.of wounds often are heavily contaminated. The National Nosocomial Infection Surveillance System Score2 assigns one point for each of the following criteria:Wound classiﬁcation A non-clean wound (clean-contaminated, contaminated orThe use of scoring systems can be helpful as an audit and research dirty wound).tool and to predict possible complications. There are two scoring American Society of Anaesthesiology score of 3 or more.systems that are relevant to the acute traumatic wound: An operative time more than the 75th centile for similar procedures. The higher the score, the greater the probability there is woundLivio Di Mascio MBBS FRCS(Tr Orth) is a Specialist Registrar in Trauma infection. This is primarily a tool for audit but it does highlightand Orthopaedic Surgery at the Royal National Orthopaedic Hospital, the fact that not only wound characteristics, but also pre-existingStanmore, UK. Conﬂicts of interest: none declared. patient factors, will inﬂuence wound healing.SURGERY 29:2 76 Ó 2010 Elsevier Ltd. All rights reserved.
BASIC SKILLSOpen fractures by the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons in 2009.5The presence of a soft tissue wound communicating with an Traditional teaching has been that the timing of deﬁnitiveunderlying fracture remains a true orthopaedic emergency. The debridement should be within 6 hours of the injury. Karl Reyher, inskin acts as a barrier preventing the invasion of microorganisms 1881, reported a decrease in mortality rates with the use of earlywhich would otherwise colonize and infect the fracture site. debridement during the Franco-Prussian War. Later in 1898, Frei-Infection complicating a fracture may well lead to non-union drich demonstrated in a guinea pig model that the effectiveness ofwith subsequent deformity and loss of function and may culmi- debridement of a soft tissue wound was limited to about 6 hours.nate in chronic deep bone infection which is difﬁcult to eradicate. This has never been reproduced although it has been demonstratedCurrent preference in terminology is to describe such fractures as that starting broad-spectrum antibiotics within 3 hours of injury will‘open fractures’ rather than compound injuries. reduce infection rates by almost 40%.6 The Gustilo and Anderson3 classiﬁcation (Box 2) is the most The new guidelines have recognized that the best outcomes arecommonly used to describe open fractures. It takes into account achieved by timely, specialist surgery rather than emergencya number of factors, not just the size of the associated wound. surgery by less experienced teams. It should be noted that theThe presence or absence of a neurovascular injury, the degree of guidelines are speciﬁcally for high-energy lower limb fracturescontamination (farmyard injuries are grade III injuries), energy where a signiﬁcant soft tissue defect, vascular injury or contami-transfer (degree of fragmentation and periosteal stripping) and nation exists. The guidelines also are, however, a very useful toolwound dimensions are used to classify the injury. It has been in guiding treatment in all open fractures.shown that the grade correlates with the risk of infection.4 Thedeﬁnitive grade should be assigned in theatre after thoroughdebridement. Use of antibiotics The use of antibiotics in traumatic wounds that do not involve boneManagement of traumatic wounds and open fractures or joint remains controversial. However, antibiotics should beEarly administration of systemic antibiotics and timely surgical administered as soon as possible in all open fractures, and prefer-debridement, skeletal stabilization and delayed wound closure ably within 3 hours.6 Organisms that require coverage include:are the mainstay principles of treatment in open fractures. Staphylococcus species, Pseudomonas species, Enterococcus, Initial guidelines for the management of open fractures were Escherichia coli, Proteus species, Enterobacter, Klebsiella andpublished in 1997. This guidance has subsequently been revised Serratia species. The current guidelines recommend the use of co-amoxyclav (1.2 g) or cefuroxime (1.5 g) 8-hourly and are continued until wound debridement. Clindamycin 600 mg 6-hourly can be GustiloeAnderson open fracture classiﬁcation3 used if penicillin allergy exists. At the time of ﬁrst debridement, co-amoxyclav (1.2 g) or cefuroxime (1.5 g) should be given along Grade I: The wound is less than 1 cm long. It is usually a moder- with gentamicin (1.5 mg/kg) at induction of anaesthesia. This ately clean puncture, through which a spike of bone has pierced should be continued until soft tissue cover is achieved or for the skin. There is little soft-tissue damage and no sign of crushing a maximum of 72 hours, whichever is sooner. injury. The fracture is usually simple, transverse, or short oblique, Gentamicin (1.5 mg/kg) and either vancomycin (1 g) or with little fragmentation. teicoplanin (800 mg) should be administered at induction of anaesthesia at the time of deﬁnitive skeletal stabilization and Grade II: The laceration is more than 1 cm long, and there is no deﬁnitive soft tissue closure. Vancomycin should ideally be given extensive soft-tissue damage, ﬂap, or avulsion. There is slight or 90 minutes prior to surgery and these agents should not be moderate crushing injury, moderate fragmentation of the fracture, continued postoperatively.5 and moderate contamination. Tetanus prophylaxis Grade III: These are characterized by extensive damage to soft The introduction of a comprehensive infant vaccination pro- tissues, including muscles, skin, and neurovascular structures, grammes in the 1960s has dramatically reduced the incidence of and a high degree of contamination. The fracture is often caused tetanus in the UK although there are still approximately 10 cases by high-velocity trauma, resulting in a great deal of fragmentation per year.7 Tetanus contamination is more likely in wounds that and instability. are contaminated with soil or manure, and deep wounds that C III A e Soft tissue coverage of the fractured bone is adequate. contain devitalized tissue, especially muscle. Current guidelines C III B e Extensive injury to, or loss of soft tissue, with perios- are illustrated in Table 1. teal stripping and exposure of bone, massive contamination, and severe fragmentation of the fracture. After debridement Timing of surgery and irrigation a local or free ﬂap is needed for coverage. C III C e Any open fracture that is associated with an arterial Unless heavily contaminated by marine, agricultural or sewage injury that must be repaired, regardless of the degree of soft material the initial debridement should take place by a senior tissue injury. orthopaedic and plastic surgeon on a dedicated routine trauma operating list. Some patients who are multiply injured and haveBox 2 open fractures may also require urgent surgery. Where possible,SURGERY 29:2 77 Ó 2010 Elsevier Ltd. All rights reserved.
BASIC SKILLS Guidelines for tetanus prophylaxis Immunization status Give tetanus Give tetanus diphtheria toxoid? immune globulin? Clean/minor wound Unknown or 3 doses of Yes No absorbed tetanus toxoid 3 doses of absorbed No (unless 10 years No tetanus toxoid since booster) All other wounds Unknown or 3 doses of Yes Yes absorbed tetanus toxoid 3 doses of absorbed No (unless 5 years No tetanus toxoid since booster)Table 1initial debridement and surgical stabilization should only takeplace at specialist centres unless the patient cannot be transferredsafely. Other indications for immediate surgery include vascularcompromise, requiring repair and revascularization, andcompartment syndrome. Lower limb fasciotomy should beperformed via a two-incision technique (Figure 1a and b) and mustnot be delayed. It is important to appreciate that both open andclosed fractures are equally at risk from this complication, andthe presence of an open wound does not prevent raised intra-compartmental pressure from developing.DebridementDebridement is the removal of foreign material, devitalized softtissue and bone and necrotic tissue from the wound. The use ofa tourniquet should be avoided. The skin edges should be excisedand appropriate wound extensions should be made so that allparts of the wound can be adequately explored and the bone endsdelivered. The aim is to achieve a healthy, well-perfused andstable tissue bed with a low bacterial count. Skin ﬂaps or under-mining should be avoided so as not to compromise vascularity.The viability of muscle is assessed by the four Cs: colour,consistency, contractility and capacity to bleed. The use of ﬂuidirrigation reduces bacterial count; at least 6 litres should be used,8 Figure 1 a A cross-sectional representation of the leg illustrating all fourbut only after a clean wound is obtained. The use of high-pressure compartments. b An illustration of the recommended incisions for fas-pulsatile lavage is not recommended as this may damage tissues ciotomy and wound extensions in the leg. The subcutaneous border offurther or embed contamination into the soft tissues themselves.9 the tibia is marked in green and the fasciotomy incisions are marked inIf possible bare bone and exposed articular surfaces should be blue. The perforators arising from the posterior tibial artery are shown incovered with fascia. The skin should not be closed, although red. (From Standards for the Treatment of Open Fractures of the Lowerwound extensions performed during debridement can be closed as Limb, by kind permission of BOA/BAPRAS.)long as there is no soft tissue tension. An important part of traumatic wound management is the It is important to highlight that it is recommended that senior‘second look’ procedure. This is a further inspection of the wound orthopaedic and plastic surgeons perform these procedures inprior to closure and usually should take place approximately conjunction, as inadequate initial debridement has been shown48 hours following initial debridement. During this procedure, to contribute to poor outcomes following open fractures.further debridement is performed if devitalized/necrotic tissue has The use of antibiotic-loaded beads or vacuum foam dressingsdeclared itself. Again, a thorough irrigation is performed. If the can be extremely useful in dead-space management, whilstinitial wound is heavily contaminated a ‘third look’ or even more deﬁnitive soft tissue cover is achieved (Figure 2). They them-may be required. selves, however, should not be used for deﬁnitive management.SURGERY 29:2 78 Ó 2010 Elsevier Ltd. All rights reserved.
BASIC SKILLS Secondary closure: healing by ‘secondary intension’ is employed where a wound is left open and heals mainly by the formation of granulation tissue and wound contraction. This process can be lengthy and the cosmetic result is less favourable but is employed where a tissue defect is present and local plastic cover is inappropriate (for example: ulcers and abscess cavities). Tertiary closure: healing by ‘third intension’ involves delayed closure of a wound. The wound edges are left open and then closed after a variable period of time. This technique is used for open fractures and contaminated wounds and requires thorough debridement and wound irrigation as previously described. Soft tissue coverageFigure 2 The wound edges have been excised and the wound debrided ofall devitalized tissues and foreign material in this open tibial fracture. If there is a soft tissue defect present and soft tissue coverage isA bridging external ﬁxator has been applied to achieve initial skeletal necessary and cannot be achieved then many options exist. Thestability. This will be exchanged for alternative deﬁnitive ﬁxation at a later simplest method which will yield predictable soft tissue coveragedate. Antibiotic-loaded cement beads have been employed to assist in is the most appropriate. The simplest technique for reconstruc-dead-space management. tion is a partial or full-thickness skin graft; however this must be placed on a stable healthy bed of muscle and is not suitable forSoft tissue cover should be achieved if possible within 72 hours coverage of exposed bone, tendon or hardware. In these situa-and should not be delayed beyond 7 days. tions local skin ﬂaps, region skin ﬂaps or free tissue transfers may be necessary and highlight the importance of a jointSkeletal stabilization approach of open fracture management with orthopaedic andLoose fragments of bone that are devitalized and have lost their plastic surgeons. Asoft tissue attachment and blood supply are removed. Fractureends and large segments that fail to demonstrate signs of viabilityare also removed. Major articular fragments are preserved as REFERENCESlong as they can be reduced and ﬁxed with absolute stability. 1 Byrne DJ, Malek MM, Davey PG, Cuschieri A. Postoperative wound Fracture stabilization may consist of temporary spanning scoring. Biomed Pharmacother 1989; 43: 669e73.external ﬁxation at the time of initial debridement (Figure 2). If this 2 Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection ratesis then converted to internal ﬁxation this should be done as soon as by wound class, operative procedure, and patient risk index. Nationalpossible. Ideally this can be done at the planned ‘second look’ but Nosocomial Infections Surveillance System. Am J Med 1991 Sep 16;should not be delayed beyond 10 days. Beyond this, infection is 91: 152Se7.a risk. Internal ﬁxation with intramedullary devices or plates and 3 Gustilo RB, Anderson JT. Prevention of infection in the treatment of onescrews is safe if there is minimal contamination and soft tissue thousand and twenty-ﬁve open fractures of long bones: retrospectivecover is achieved at the same time as insertion of the implant. and prospective analyses. J Bone Joint Surg Am 1976 Jun; 58: 453e8. Modern multiplanar and circular ﬁxators can be used if there 4 Sorger JI, Kirk PG, Ruhnke CJ, et al. Once daily, high dose versusis a signiﬁcant contamination, or segmental bone loss. When divided, low dose gentamicin for open fractures. Clin Orthop Relat Resexternal ﬁxators are used, ‘safe corridors’ for pin placement 1999 Sep; 366: 197e204.should be utilized to avoid damaging underlying structures of 5 Nanchahal J, Nayagam D, Moran C, Barrett S, Sanderson F, Pallister I.compromising later plastic surgical reconstruction. Standards for the management of open fractures of the lower limb. BOA and BAPRAS guidelines, 2009.Wound closure 6 Patzakis MJ, Wilkins J. Factors inﬂuencing infection rate in open frac-There are three types of wound healing which depend on the tures wounds. Clin Orthop Relat Res 1989 Jun; 243: 36e40.timing and technique involved: 7 Rushdy AA, White JM, Ramsay ME, et al. Tetanus in England and Wales, Primary closure: in this method wounds heal by ‘ﬁrst inten- 1984e2000. Epidemiol Infect 2003 Feb; 130: 71e7.tion’. The wound edges are approximated without delay and the 8 Gustilo RB, Simpson L, Nixon R, et al. Analysis of 511 open fractures.advantages are that there is a shorter time to healing and the Clin Orthop Relat Res 1969 SepteOct; 66: 148e54.cosmetic result is good. Not all traumatic wounds should be 9 Draeger RW, Dirschl DR, Dahners LE. Dt of cancellous bone:closed in this way due to either the presence of contamination, a comparison of irrigation methods. J Orthop Trauma 2006 NoveDec;tissue loss or an underlying bone injury. 20: 692e8.SURGERY 29:2 79 Ó 2010 Elsevier Ltd. All rights reserved.