Non-Pharmacologic Management

Thorough surgical debridement and irrigation – ideally within 24 hours of initial presentation

1. Debridement
   • The extent of the injury can be better determined once the wound is irrigated and gross contamination is removed. Devitalized tissue and foreign material promote bacterial growth and proliferation and this also constitutes a barrier for the host’s defense mechanism.
   • Debridement should be performed in the OR and this can provide a final diagnosis on the classification of open fracture.
   • Surgical extension of the wound allows assessment of the degree of soft tissue damage and contamination.
   • Skin and subcutaneous tissue are sharply debrided back to bleeding edges
   • Muscle is debrided until bleeding is visualized. This identifies viable muscle.
   • Bone fragments without soft tissue attachments are avascular and should be removed. While articular fragments, provided that they are large enough and reconstruction is possible, should be preserved even if there is no attached blood supply.
   • Repeat debridement: after 24-48 hours based on the degree of contamination and soft tissue damage
   • The goal is a clean wound with viable tissues and no infection.
2. Irrigation
   • This mechanically removes foreign bodies and reduces the bacterial concentration.
   • Bacitracin solution and nonsterile castile soap solution are used but bacitracin shows increased rate of wound-healing problems
   • High-pressure pulsatile lavage is more effective that low-pressure lavage in removing adherent bacteria if more than 6 hours has elapsed since the injury

Wound management with soft tissue coverage

1. Primary wound closure: if there is no severe tissue damage and contamination of soil or fecal matter, antibiotics are administered, debridement and irrigation are done, and wound edges can be approximated with no tension
2. Partial wound closure: for less severe injuries as in Type I and II open fractures but only for the surgical extension leaving the injury wound open to be closed in delayed method
3. Delayed wound closure: recommended in injuries with extensive soft tissues damage and gross contamination; prevents anaerobic conditions, permits drainage, allows for repeat debridement within 24-48 hours, gives time for identification of viable tissues, facilitates antibiotic bead-pouch technique
   • Wound undergoing delayed wound closure should not be left exposed to prevent proliferation of nosocomial pathogens. Instead, use the antibiotic bead-pouch technique or negative-pressure wound therapy.
4. Soft Tissue Reconstruction: Performed within the first week from injury, ideally within 72 hours. In Type IIB and C Open Fractures, adequate coverage may not be possible and soft tissue reconstruction may be required. This well-vascularized soft tissue promotes:
   • Fracture healing
   • Delivery of antibiotics, and
   • Action of the host defense mechanisms; and
   • Provides durable coverage to avoid secondary contamination

Stable fracture fixation, if needed

• Stability at the fracture site helps:
  • Prevent further injury to the soft tissues
  • Enhances the host response to contaminating organisms.
  • Facilitates wound and patient care
  • Allows early motion and functional rehabilitation of extremity
• Choice of stabilization method is dependent upon:
  • Hemodynamic status
  • Fracture location and injury pattern
  • Extent of soft injury
• Intermedullary nailing: for diaphyseal fractures of the lower extremity
• Plate and screw fixation: intra-articular and metaphyseal fractures
• External fixation: for damage control situations as in Type IIIC Open fractures and unstable polytrauma patients