5. After prep and drape, the planned extensions are marked out.
6. In this particular case and in general, wound extensions should be
performed in a direction that allows for reconstructive procedures
to be performed as well as allowing access to muscle and vascular
structures that would be used for flap coverage.
7. In this circumstance, a fracture extending into the joint, the extension
distally will allow access to the joint just medial to the tibialis anterior
tendon. The proximal extension is made posteriorly to allow access to the
neurovascular pedicle in case free flap converage is necessary.
8. Before extending the wound, the skin margin of the open
fracture is debrided of approximately 1 to 2mm of soft
tissue.
9. After the skin is marked with the knife,
the edge is removed.
10. After the nonviable skin is removed, the wound
extensions are made proximally and distally until
completely healthy tissue is identified.
11. The clamp is pointing to intact, healthy periosteum
in an area that is proximal to the stripped fracture area.
13. Both ends of the bone need to be delivered and cleaned
with a curette. The curette should be used to remove all
nonviable tissue and all of the clot from the cortical bone.
14.
15. With retraction of the bony fragments, all free fragments are removed.
Any bone fragment that can be pulled gently out of the wound should
be removed. Any fragment without significant soft tissue attachment
will be prone to infection and cannot remain.
17. After complete debridement of all nonviable tissue and
bone is carried out, copious irrigation is performed. A
higher pressure pulse lavage can be used on the bone.
18. A low-pressure lavage should be used for soft tissues
to avoid damage to those tissues.
19. SAPHENOUS VEIN
It is very important to preserve all superficial venous
channels in the cases of open fracture, as drainage is
essential to keeping the swelling down.
20. After initial debridement, separate prep and drape is generally performed
before fixation. After separate prep and drape, the bone is stabilized. In
this case, the initial stabilization is with a spanning external fixator, with the
plan of definitive fixation at a later date.
22. If the open fracture wound can be brought together without
tension, it should be, otherwise a bead pouch technique or
vacuum system might be applied.
23. In this figure, the vertical mattress sutures are
all placed prior to tying any of them.
24. By retracting on the vertical mattress sutures, wound
tension is released allowing for closure in this case.
