Role of Cultures in the Emergency Room
Radiographic Imaging and Other Diagnostic Studies
Role of Biochemical Markers
Classifications and Scores for Open Fractures
Salvage or Amputation?
Debridement and Lavage
Plaster Casts and Traction
External Skeletal Fixation
Primary Internal Fixation
Acute Management of Bone Loss
Primary Closure of Wounds
Timing of Wound Cover
Zone of Injury
Source of Infection in Open Injuries
The Timing of Soft Tissue Cover
Type of Cover
Negative Pressure Wound Therapy
Author’s Preferred Treatment
Fix and Primary Closure
Fix and Delayed Closure
Fix and Skin Grafting
Fix and Early Flap
Fix and Delayed Flap
Our Unit treats more than 300 type IIIb injuries every year and our choice of reconstruction pathway is guided by the GHOIS. In an analysis of 965 injuries treated in a 3-year period, we found that the limb reconstruction pathway that was selected followed one of a number of options which are shown in Table 10-22. It must be stressed that an essential requirement for success is a thorough debridement by an experienced “Orthoplastic” team. Bone stabilization is tailored to the fracture requirements and the skin cover is undertaken as early as possible. The individual skin score is used to choose the method of wound cover and the total score guides the time of treatment (Fig. 10-34).
Injuries with a skin Score of 1 and 2 have no skin loss at injury or during debridement. When contamination is low and there has been a satisfactory debridement, these patients are suitable for direct suturing. The total score must be <9 as this indicates low-energy violence and the chances of postoperative swelling or compartment syndrome are low. Stable skeletal fixation and bleeding skin margins which are opposed without tension are the prerequisites for primary closure. It should be noted that the length of the wound is not a criterion (Fig. 10-33).
Injuries with skin score of 1 or 2, but with either a total score of >9 or with moderate or severe contamination are not treated by primarily closure. A higher score of >9 indicates high-energy violence and a reassessment at 48 or 72 hours is necessary. A delayed closure is performed if the wound characteristics at a second look debridement allow closure. If additional debridement is required at the time of the second look leading to further skin and soft tissue resection, the patient is managed by a staged flap protocol.
A skin score of 3 indicates skin loss either at injury or during debridement. In skin score 3 the wound either does not expose the fracture site or there is adequate soft tissue cover. A classic example is open fractures of femur where good soft tissue cover is usually present after skeletal stabilization. Here simple wound management by split skin grafting possible.
A skin score of 3 or 4 indicates skin loss either at injury or during debridement. If the wound exposes bone, articular cartilage, tendons, or a vascular anastomosis site, a flap is necessary. The type of the flap will be determined by the location and size of the defect and the structures that are exposed. Again timing is guided by the total score of GHOIS. An early flap can be done if the total score is less than 9. This indicates a lower-energy injury and a more definable zone of injury.
We do not favor the traditional reconstructive ladder philosophy but rather would choose the most appropriate procedure that best suits the injury as defined by the bone and soft tissue defect. Often a well-performed free tissue transfer gives better functional results and can even make the difference between salvage and amputation.
A fix and delayed flap protocol is performed whenever there is severe contamination or the total score is >10. The duration of delay will depend on the condition of the wound, the swelling of surrounding soft tissues and the presence of infection. If, during the relook procedure, the wound is not suitable for flap cover the use of NPWT following another debridement is an attractive option.
A score of 5 in any of the tissue scores and a total score of >9 indicates a limb that is not suitable for immediate or even early reconstruction. These limbs have considerable associated bony and soft tissue injury or loss. Often the wound may not be ready for reconstruction even after a few weeks. Here the option of immediate or early application of NPWT at the initial procedure must be seriously considered. The expertise of a skilled plastic surgical team with microsurgical reconstruction capability and an orthopedic team capable of bone reconstruction and regeneration techniques is essential. If this is not available, patients must be expeditiously transferred to a center where such facilities are available. The choice and timing of the reconstruction method must be made on an individual patient basis.