1. BASIC SKILLS
Classification and Systematic approach to traumatic wound management
management 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?
Abstract
Acute 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 injuries
during times of armed conflict. The approach to management should B Neurovascular involvement
start on initial assessment using trauma resuscitation protocols. Once B Bone or joint involvement
life-threatening injuries have been managed, the wound should be thor- B Visceral involvement
oughly 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 RESUSCITATION
to management of open fractures should be systematic, involving both B Prophylaxis: tetanus, antibiotics
orthopaedic surgeons and plastic surgeons from the outset. B Photograph wound and then cover with dressing
B Analgesia/anaesthesia
Keywords Acute wounds; open fracture classification; open fracture B Exploration/debridement/washout
management; 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 approach
such, initial assessment and treatment should be systematic, and
B Closure: when, where and how?
subsequent management is tailored to each individual wound. The
general principles of wound management are outlined in Box 1. C Rehabilitation:
B Dressings
Types of wound B Splints?
B Physiotherapy/hand therapy
To gain a broad overview of wounds in a clinical context, the
terms simple and complex can be used:
Box 1
Simple wounds: involve skin and soft tissues without damage to
underlying bone or joint or neurovascular structures. They are
not heavily contaminated and do not have significant skin or soft The ASEPSIS scoring system1 assigns a number of scores to
tissue 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 suggest
neurovascular 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 or
The 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 wound
Livio Di Mascio MBBS FRCS(Tr Orth) is a Specialist Registrar in Trauma infection. This is primarily a tool for audit but it does highlight
and Orthopaedic Surgery at the Royal National Orthopaedic Hospital, the fact that not only wound characteristics, but also pre-existing
Stanmore, UK. Conflicts of interest: none declared. patient factors, will influence wound healing.
SURGERY 29:2 76 Ó 2010 Elsevier Ltd. All rights reserved.

2. BASIC SKILLS
Open fractures by the British Orthopaedic Association and British Association of
Plastic, Reconstructive and Aesthetic Surgeons in 2009.5
The presence of a soft tissue wound communicating with an
Traditional teaching has been that the timing of definitive
underlying fracture remains a true orthopaedic emergency. The
debridement should be within 6 hours of the injury. Karl Reyher, in
skin acts as a barrier preventing the invasion of microorganisms
1881, reported a decrease in mortality rates with the use of early
which 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 of
with 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 demonstrated
Current 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 are
commonly used to describe open fractures. It takes into account
achieved by timely, specialist surgery rather than emergency
a number of factors, not just the size of the associated wound.
surgery by less experienced teams. It should be noted that the
The presence or absence of a neurovascular injury, the degree of
guidelines are specifically for high-energy lower limb fractures
contamination (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 tool
wound 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 The
definitive grade should be assigned in theatre after thorough
debridement. Use of antibiotics
The use of antibiotics in traumatic wounds that do not involve bone
Management of traumatic wounds and open fractures or joint remains controversial. However, antibiotics should be
Early 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 and
published 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 have
Box 2 open fractures may also require urgent surgery. Where possible,
SURGERY 29:2 77 Ó 2010 Elsevier Ltd. All rights reserved.

3. 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 1
initial debridement and surgical stabilization should only take
place at specialist centres unless the patient cannot be transferred
safely.
Other indications for immediate surgery include vascular
compromise, requiring repair and revascularization, and
compartment syndrome. Lower limb fasciotomy should be
performed via a two-incision technique (Figure 1a and b) and must
not be delayed. It is important to appreciate that both open and
closed fractures are equally at risk from this complication, and
the presence of an open wound does not prevent raised intra-
compartmental pressure from developing.
Debridement
Debridement is the removal of foreign material, devitalized soft
tissue and bone and necrotic tissue from the wound. The use of
a tourniquet should be avoided. The skin edges should be excised
and appropriate wound extensions should be made so that all
parts of the wound can be adequately explored and the bone ends
delivered. The aim is to achieve a healthy, well-perfused and
stable 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 fluid
irrigation reduces bacterial count; at least 6 litres should be used,8
Figure 1 a A cross-sectional representation of the leg illustrating all four
but 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 of
further or embed contamination into the soft tissues themselves.9 the tibia is marked in green and the fasciotomy incisions are marked in
If possible bare bone and exposed articular surfaces should be blue. The perforators arising from the posterior tibial artery are shown in
covered with fascia. The skin should not be closed, although red. (From Standards for the Treatment of Open Fractures of the Lower
wound 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 in
prior to closure and usually should take place approximately conjunction, as inadequate initial debridement has been shown
48 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 dressings
declared itself. Again, a thorough irrigation is performed. If the can be extremely useful in dead-space management, whilst
initial 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.

4. 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 coverage
Figure 2 The wound edges have been excised and the wound debrided of
all devitalized tissues and foreign material in this open tibial fracture. If there is a soft tissue defect present and soft tissue coverage is
A bridging external fixator has been applied to achieve initial skeletal necessary and cannot be achieved then many options exist. The
stability. This will be exchanged for alternative definitive fixation at a later simplest method which will yield predictable soft tissue coverage
date. 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 for
Soft 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 joint
Skeletal stabilization approach of open fracture management with orthopaedic and
Loose fragments of bone that are devitalized and have lost their plastic surgeons. A
soft tissue attachment and blood supply are removed. Fracture
ends and large segments that fail to demonstrate signs of viability
are also removed. Major articular fragments are preserved as REFERENCES
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SURGERY 29:2 79 Ó 2010 Elsevier Ltd. All rights reserved.