This document provides guidelines for wound debridement of open fractures. It outlines the steps of debridement which include preparing the limb with a social wash and skin preparation, using tourniquet control to provide a bloodless field, assessing the skin, subcutaneous tissue, and muscle for viability, and applying appropriate dressings. It emphasizes the importance of thoroughly assessing tissue viability, potentially with a second look 24-48 hours later, and removing all nonviable tissue while preserving as much viable skin as possible. Immediate debridement is indicated for grossly contaminated wounds or compromised limbs and should be performed by senior surgeons in a semi-elective manner within 24 hours of injury.

1. WOUND DEBRIDEMENT OF OPEN FRACTURES - 1
BYPRAS GUIDELINES
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2. STEPS OF DEBRIDEMENT
Preparing the limb
 Social wash
 Prepped with antiseptic
 Tourniquet control
 Tissue assessment
 Injury classification planning definitive treatment
 Dressing

3. SOCIAL WASH Indication – To remove the particulate
debris on the surface of the limb
Procedure
After induction of anaesthesia the limb
is cleaned with soap solution with soft
brush

4. SKIN PREPARATION  Antiseptic solution is applied over the
entire the limb
 If the solution is alcohol based – avoid
contact with exposed tissues

5. TOURNIQUET CONTROL
Advantages
 Gives bloodless field
 If the anatomy is distorted, there is a high risk of injury to the neurovascular structures during wound
Disadvantage
 Unable to assess the signs of viability –
 Worsen the ischemia and reperfusion associated injury
Recommendation
 Need to apply the tourniquet but not to inflate

6. TISSUE ASSESSMENT Skin
 Nonviable skin must be excised
 In case of extensive flap laceration –
Ensure the much of preservation of
skin

7. TISSUE ASSESSMENT…
Subcutaneous tissue
 Zone of fat necrosis is often more extensive than that of the overlying skin
 Extension of the wounds along fasciotomy lines allows for access to S-tissue
 Assess the Zone of injury – Skin loss can extend over time

8. TISSUE ASSESSMENT…
Muscle
 Devitalized muscle may be difficult to assess, especially in cases of multiplanar degloving.
 The four ‘C’s should be looked for
1. Colour (pink not blue)
2. Contraction
3. Consistency (devitalized muscle tears in the forceps during retraction)
4. Capacity to bleed

9. DRESSING If definitive skeletal and soft tissue
reconstruction is not to be undertaken in
a single stage
1. A vacuum foam dressing
2. Antibiotic bead pouch( if there is
significant segmental bone loss)
is needed until definitive surgery is
performed.

10. A SECOND LOOK
 There will be occasions when the soft tissue damage is difficult to assess.
 A second look should be undertaken 24-48 h later.
 However, multiple serial debridement has been shown to be associated with worse outcomes
and is unnecessary.

11. DEGLOVING Forces leading to these injuries
1. Torsion
2. Crush
3. Avulsion

12. VIABILITY
OF
DEGLOVED
TISSUES
Assessment
Fixed staining - Thrombosis of subcutaneous veins
does not survive
Skin colour fails to blanch on digital pressure
Circumferentially degloved skin does not survive

14. IMMEDIATE WOUND DEBRIDEMENT
Indications
 Gross contamination of the wound
 Compartment syndrome
 A revascularized limb
 A multiply injured patient

15. RECOMMENDATION No advantage to debriding open
fractures within 6 h of the injury
Wound debridement
 Should be done by senior orthopaedic
and plastic surgeons
 Semi elective basis
 Within 24hr of injury period