Wound Closure Initial Wound Care of Tibial Fractures

- Technical Considerations: 
        - consider debriding the wound with a separate set of surgical instruments / drapes 
        - exposure: extend the traumatic incision longitudinally in order to fully expose zone of injury; 
        - pressure irrigation
        - debridement of open tibia fractures
        - Arguments for Leaving Wound Open w/ Delayed Closure:
                 - traditionally, the surgeon will close surgical incisions made during the case but will leave the traumatic wound open;
                 - adresses compartment syndrome (if there is a concern)
                 - relief of skin tension
                       - leaving the wound open (w/ wound vac) maximizes drainage and wound tension (which is frequently present w/
                                primary closure);
                       - at 2nd look debridement (at 48-36 hrs), the edema will have diminished and the wound can be closed w/ less tension;
                       - alternatively if the wound cannot be closed tension free then soft tissue reconstruction is needed;
                 - ability to redebride devitalized muslce and tissue;
                 - ability to remove additional contaminants;
                 - references:
                       - Primary or delayed closure for open tibial fractures.
                       - Compartment syndrome in open tibial fractures
                       - Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement
 
        - Arguments for Primary Wound Closure (Immediate closure):
                 - note that the most frequently identified organisms in open tibial fractures are staph aureus and nocosomial organisms;
                 - leaving the wound closed allows easier examination of the extremity during the postoperative period;
                 - if there is a concern about wound tension, then consider making a limited posteromedial relaxing incision;
                       - this allows a proplyatic fasciotomy and yet this incision will be away from the fracture site to avoid fracture
                                 nocosomial contamination; 
                 - references:
                        - Aggressive treatment of 119 open fracture wounds. 
                        - The 2-0 Ethilon test.
                        - Timing of closure of open fractures.
                        - Treatment of open tibial fractures with primary suture and Ilizarov fixation.
                        - Timing of closure of open fractures.
                        - Epidemiology of bacterial infection during management of open leg fractures.
                        - Comparison of delayed and primary wound closure in the treatment of open tibial fractures. 
                        - Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.
                        - Early versus delayed closure of open fractures
                        - Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study.
                        - Primary Wound Closure after Open Fracture: A Prospective Cohort Study examining Non-Union and Deep Infection.

           - Contaminated Wound Care:
                 - wound dressings:
                 - wound vac;

                 - antibiotic bead pouch:
                        - as noted by Keating, et al (1996), bead pouches help reduce the infection rate in open tibia frx from 16% to 4%;
                        - counting the beads and adding methylene blue helps ensure that none of the beads will be left behind at removal;
                        - references:
                                - Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate?
                                - Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases.
                 - bacterial cultures:
                               - Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
                               - Epidemiology of bacterial infection during management of open leg fractures.
                               - Efficacy of cultures in the management of open fractures.

 



Soft Tissue Reconstuction of the Leg
- References:
      - Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures.
      - Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.
      - Christopher J. Lenarz, MD, et al.: "Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement"
      - Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement
      - Closure of the skin defect overlying infected non-union by skin traction. 



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Sunday, January 29, 2017 6:13 am