The objectives of debridement 1)Extension of traumatized wound to allow identification of zone of injury 2)Detection & removal of foreign material, especially organic foreign material 3)Detection and removal of nonviable tissues 4)Reduction of bacterial contamination 5)Creation of a wound that can tolerate the residual bacterial contamination and heal without infection

Factors of muscle viability Color Consistency Capacity to bleed Contractility

Bone In general, small bits of cortical bone that are free of any soft tissue attachments should be removed. Completely devascularized bone segments should be debrided.

Summury of debridement The surgeon should have a plan for wound debridement. A careful inspection of the initial skin and dermis followed by inspection of subcutaneous fat, then muscle, and finally bone Repeat d é bridement after 24 to 48 hours based on the degree of contamination and soft-tissue damage. In injuries requiring muscle flap coverage, d é bridement also should be repeated at the time of soft-tissue reconstruction.

The Importance of Skeletal Stability 1)Restore length and alignment. 2)Restore articular surfaces. 3)Allow access to the traumatic wound 4)Facilitate further reconstruction procedures 5)Allow early use of the limb 6)Facilitate fracture union and return of function

Immobilization in Plaster Plaster-of-Paris casts have limitations in the treatment of open fractures because they may make access to the wound difficult and because they involve a circumferential hard dressing on a limb with the potential for swelling, which can contribute to compartment syndrome. Cast immobilization may be appropriate for type I open

Skeletal Traction and Suspension Balanced skeletal traction, usually as a temporary method, can be used effectively in the femur and occasionally the tibia

External Skeletal Fixation In the 1970s and early 1980s, external fixation became the fracture stabilization method of choice for the treatment of most open fractures of long bones. Today, external fixation is most often indicated for type IIIB and IIIC open fractures of the tibia and fibula, and in open fractures of the pelvis.

External fixation advantages: (a) easily and rapidly applied. (b) excellent stability (c) minimal soft tissue trauma, so the risk of wound infection is minimized. (d) allow early joint motion (e) offers the option of easily redisplacing the fracture at subsequent debridements. (f) may be used as a temporizing frame, restoring the limb to length ( “ traveling traction ” ) until definitive fixation can be performed.

The disadvantages of external fixators (a) for complex fractures with large wounds, application can be complex and time consuming. (b) the pins entrap musculotendinous units, restricting range of motion. (c) inappropriate technique of pin insertion may lead to bone necrosis or early loosening of pins, and subsequent pin track infection.

Indications for External Fixation internal fixation traditionally is thought to be safest where the risk of infection is the lowest. external fixation is indicated where the risk of infection is the highest

Postoperative Management of External Fixation The primary cause of pin infection is loosening of the pin. The most effective method of skin care is simple cleansing of the entire external fixation frame, pin tracks, and skin daily with any standard commercial bathing soap to which the patient is not allergic.

pilon fractures pilon fractures with severe soft tissue injuries. a bridging frame with fixation to the calcaneus and the forefoot is advisable.

DEFINITIVE WOUND MANAGEMENT Primary Closure Delayed Primary Closure Leaving Wounds Open Split-Thickness Skin Grafts Flap Coverage

Delayed Primary Closure Advantages of leaving the wound open 1.keep the fascial and skin edges separated. 2.minimizes the risk of anaerobic infection. Ordinarily, the wound is not exposed on the ward for inspection until the time of delayed primary closure, 2 to 5 days after injury. Small wounds, especially in type I open fractures, may be allowed to heal secondarily.

The trend conflicts with the trend toward early closure of open fractures recommendations for routine d é bridement of open fractures. While the goal is thorough d é bridement at the time of the initial presentation, it is possible that poly- trauma or other concerns may cause the surgeon to doubt the adequacy of the initial d é bridement. In addition, it may be difficult to evaluate muscle viability in the acute setting. In these instances, repeat d é bridement is certainly appropriate..

V.A.C Recently, vacuum-assisted closure (V.A.C, San Antonio Texas) has emerged as a useful method of 1) accelerating wound-healing by reducing chronic edema 2) increasing local blood flow 3) and enhancing granulation tissue formation.

Split-Thickness Skin Grafts In most cases where the wound bed is composed of viable vascularized soft tissues, (STSG) provides the best method of closure.

Flap Coverage When soft tissue loss is extensive and closure by primary suture or split- thickness skin graft is not possible, flaps become necessary. most flaps are best done at approximately 5 days after injury

Soft-tissue reconstruction should be done early, within the first 7 days. Delays beyond this period have been associated with increased complications related to the flap or infection under the flap. Some have advocated that flap coverage be done within 72 hours.

Proximal third tibia fractures can be covered with gastrocnemius rotation flap Middle third tibia fractures can be covered with soleus rotation flap Distal third fractures usually require free flap for coverage