Wound excision Wound excision to be under taken under strict aseptic condition, must be systematic and complete. Lavage is done with normal saline or distilled water. For final irrigation mixture of bacitracin and polymyxin solution is preferable. Wound incision must be large enough to facilitate exposure and inspection. The following structures are debrided : skin, fascia and tendons,muscles, and bones.
Low pressure versus high pressure (pulse lavage)
Saline alone versus additives (antiseptics, antibiotics, or soap/detergents)
“If there is the slightest doubt in the surgeon’s mind as to whether there has been adequate debridement of the wound after an open fracture, the wound should not be closed regardless of the type of open fracture. For the surgeon who manages only an occasional open fracture, the safe rule is not to close the wound”
Allows early mobilisation and rehabilitation of the patient
Skeletal traction is indicated for type I and type II open fracture of femoral shaft.
Wound is allowed to heal followed by internal fixation in 10 to 14 days.
Safe and reliable method of achieving bony stability in open fracture.
Major disadvantage is pin tract infection, but can be considerably reduced with proper pin insertion and care.
Amputation Can a functional,viable extremity be achieved ? Can the the time and expense of saving the extremity be justified ? Absolute indication of amputation : Type III C injury with posterior tibial nerve disruption. Type III C injury with soft tissue loss, massive contamination with severely comminuted segmented fracture or massive bone loss.