BASIC SKILLS

Classification and Systematic approach to traumatic wound management

management of acute C History

wounds and open fractures  Location and size of wound?

 Associated tissue loss?
 Type or velocity of weapon?
Noel Lee
 Mechanism?
Livio Di Mascio  Energy involved?
 Associated thermal or chemical injury?
 Degree of contamination?
Abstract
 Need for involvement of multidisciplinary teams?
Acute traumatic wounds and open fractures potentially cause significant
morbidity and loss of function. Much of the management of these types C Examination
of injuries has been developed from the experience of military surgeons dur-  Associated injuries
ing times of armed conflict. The approach to management should start on  Neurovascular involvement
initial assessment using trauma resuscitation protocols. Once life-  Bone or joint involvement
threatening injuries have been managed, the wound should be thoroughly  Visceral involvement
debrided and the skeleton stabilized. In the presence of heavy contamina-
C Interventions
tion, the wound must be re-inspected after 48 hours to evaluate whether
 RESUSCITATION
further debridement is necessary and plans for soft tissue coverage can
 Prophylaxis: tetanus, antibiotics
be made. The approach to management of open fractures should be system-
 Photograph wound and then cover with dressing
atic, involving both orthopaedic surgeons and plastic surgeons from the
 Analgesia/anaesthesia
outset.
 Exploration/debridement/washout
Keywords Acute wounds; open fracture classification; open fracture  Haemostasis
management; traumatic wounds; wound classification; wound
 Skeletal stabilization
management
 Revascularization?
 Fasciotomies?

The aetiology of traumatic wounds is diverse and the mechanism, C Definitive management
pattern, location, energy imparted to the tissues and degree of  Multidisciplinary approach
contamination all play a role in their inherent ability to heal. As  Closure: when, where and how?
such, initial assessment and treatment should be systematic, and
C Rehabilitation
subsequent management is tailored to each individual wound. The
 Dressings
general principles of wound management are outlined in Box 1.
 Splints?
 Physiotherapy/hand therapy
Types of wound
To gain a broad overview of wounds in a clinical context, the
terms simple and complex can be used. Box 1

Simple wounds: involve skin and soft tissues without damage to

underlying bone or joint or neurovascular structures. They are
not heavily contaminated and do not have significant skin or soft
tissue loss.
Complex wounds: involve significant loss of skin or soft tissue.
The injury may also involve vital structures, bone or joints or
communicate with a hollow viscus. There may also be associated
neurovascular injury or a compartment syndrome. These types
of wounds often are heavily contaminated.
Noel Lee MBBS (London) MRCS (Edinburgh) is a Specialty Registrar in Trauma
and Orthopaedics at Barts and The Royal London Hospital, London, UK.
Conflicts of interest: none declared.
Livio Di Mascio MBBS (London) FRCS Ed (Tr & Orth) is a Consultant Ortho-
paedic and Upper Limb Surgeon at Barts and The Royal London Hos-
pital, London, UK. Conflicts of interest: none declared.
Wound classification
The use of scoring systems can be helpful as an audit and
research tool and to predict possible complications. There are
two scoring systems that are relevant to the acute traumatic
wound:
The ASEPSIS scoring system1 assigns a number of scores to
various wound characteristics evaluated during serial assessment
over a 5-day period. (Additional treatment, Serous discharge,
Erythema, Purulent discharge, Separation of deep tissues,
Isolation of bacteria, duration of hospital Stay). If the summated
score is greater than 20, this would suggest that wound infection
is present.
The National Nosocomial Infection Surveillance System
Score2 assigns one point for each of the following criteria:
 a non-clean wound (clean-contaminated, contaminated or
dirty wound)
 American Society of Anaesthesiology score of 3 or more

SURGERY 32:3 134 Ó 2014 Elsevier Ltd. All rights reserved.

 BASIC SKILLS
 an operative time more than the 75th centile for similar
procedures.
The higher the score, the greater the probability there is wound
infection. This is primarily a tool for audit, but it does highlight
the fact that both wound characteristics as well as pre-existing
patient factors will influence wound healing.
Open fractures
The presence of a soft tissue wound communicating with an
underlying fracture remains a true orthopaedic emergency. The
skin acts as a barrier preventing the invasion of microorganisms
that would otherwise colonize and infect the fracture site.
Infection complicating a fracture may well lead to non-union
with subsequent deformity and loss of function, and may
culminate in chronic deep bone infection that is difficult to
eradicate. Current preference in terminology is to describe such
fractures as ‘open fractures’ rather than compound injuries.
The Gustilo and Anderson3 classification (Box 2) is the most
commonly used to describe open fractures. It takes into account a
number of factors, not just the size of the associated wound. The
presence or absence of a neurovascular injury, the degree of
contamination (farmyard injuries are grade III injuries), energy
transfer (degree of fragmentation and periosteal stripping) and
wound dimensions are used to classify the injury. It has been
shown that the grade correlates with the risk of infection.4 The
definitive grade should be assigned in theatre after thorough
debridement.
Gustilo and Anderson open fracture classification3
Grade I: The wound is less than 1 cm long. It is usually a moderately
clean puncture, through which a spike of bone has pierced the skin.
There is little soft-tissue damage and no sign of crushing injury. The
fracture is usually simple, transverse or short oblique, with little
fragmentation.
Grade II: The laceration is more than 1 cm long, and there is no
extensive soft-tissue damage, flap or avulsion. There is slight or
moderate crushing injury, moderate fragmentation of the fracture and
moderate contamination.
Grade III: These are characterized by extensive damage to soft tis-
sues, including muscles, skin and neurovascular structures, and a
high degree of contamination. The fracture is often caused by high-
velocity trauma, resulting in a great deal of fragmentation and
instability.
III A e Soft tissue coverage of the fractured bone is adequate.
III B e Extensive injury to, or loss of soft tissue, with periosteal
stripping and exposure of bone, massive contamination, and severe
fragmentation of the fracture. After debridement and irrigation a local
or free flap is needed for coverage.
III C e Any open fracture that is associated with an arterial injury that
must be repaired, regardless of the degree of soft tissue injury.
Box 2
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Management of traumatic wounds and open fractures
Early administration of systemic antibiotics and timely surgical
debridement, skeletal stabilization and delayed wound closure
are the mainstay principles of treatment in open fractures.
Initial guidelines for the management of open fractures were
published in 1997. This guidance has subsequently been revised
by the British Orthopaedic Association and British Association of
Plastic, Reconstructive and Aesthetic Surgeons in 2009.5
Traditional teaching has been that the timing of definitive
debridement should be within 6 hours of the injury. Karl Reyher,
in 1881, reported a decrease in mortality rates with the use of
early debridement during the Franco-Prussian War. Later in
1898, Freidrich demonstrated in a guinea pig model that the
effectiveness of debridement of a soft tissue wound was limited
to about 6 hours, but this has never been reproduced. A pro-
spective study in Australia has shown that an average time to
debridement of 8 hours did not alter the outcome of their pa-
tients.6 However, it has been demonstrated that starting broad-
spectrum antibiotics within 3 hours of injury will reduce infec-
tion rates by almost 40%.7
The new guidelines have recognized that the best outcomes
are achieved by timely, specialist surgery rather than emergency
surgery by less experienced teams. It should be noted that the
guidelines are specifically for high-energy lower limb fractures
where a significant soft tissue defect, vascular injury or
contamination exists. The guidelines also are, however, a very
useful tool in guiding treatment in all open fractures.
Use of antibiotics
The use of antibiotics in traumatic wounds that do not involve
bone or joint remains controversial. However, antibiotics should
be administered as soon as possible in all open fractures, and
preferably within 3 hours.7 Organisms that require coverage
include: Staphylococcus species, Pseudomonas species, Entero-
coccus, Escherichia coli, Proteus species, Enterobacter, Klebsiella
and Serratia species.
The current guidelines recommend the use of co-amoxyclav
(1.2 g) or cefuroxime (1.5 g) 8-hourly and are continued until
wound debridement. Clindamycin 600 mg 6-hourly can be used if
a penicillin allergy exists. At the time of first debridement, co-
amoxyclav (1.2 g) or cefuroxime (1.5 g) should be given along
with gentamicin (1.5 mg/kg) at induction of anaesthesia. This
should be continued until soft tissue cover is achieved or for a
maximum of 72 hours, whichever is sooner.
Gentamicin (1.5 mg/kg) and either vancomycin (1 g) or teico-
planin (800 mg) should be administered at induction of anaesthesia
at the time of definitive skeletal stabilization and definitive soft tis-
sue closure. Vancomycin should ideally be given 90 minutes prior to
surgery and these agents should not be continued postoperatively.5
Tetanus prophylaxis
The introduction of a comprehensive infant vaccination pro-
grammes in the 1960s has dramatically reduced the incidence of
tetanus in the UK, although there are still approximately 10 cases
per year.8 Tetanus contamination is more likely in wounds that
are contaminated with soil or manure, and deep wounds that
contain devitalized tissue, especially muscle. Current guidelines
are illustrated in Table 1.
135 Ó 2014 Elsevier Ltd. All rights reserved.
 BASIC SKILLS

Guidelines for tetanus prophylaxis

Immunization status Give tetanus diphtheria toxoid? Give tetanus immune globulin?

Clean/minor wound
Unknown or <3 doses of absorbed tetanus toxoid Yes No
>3 doses of absorbed tetanus toxoid No (unless >10 years since booster) No
All other wounds
Unknown or <3 doses of absorbed tetanus toxoid Yes Yes
>3 doses of absorbed tetanus toxoid No (unless >5 years since booster) No

Table 1

Timing of surgery this procedure, further debridement is performed if devitalized/

necrotic tissue has declared itself. Again, a thorough irrigation is
Unless heavily contaminated by marine, agricultural or sewage
performed. If the initial wound is heavily contaminated a ‘third
material, the initial debridement should take place by a senior
look’ or even more may be required.
orthopaedic and plastic surgeon on a dedicated routine trauma
It is important to highlight that it is recommended that senior
operating list. Some patients who are multiply injured and have
orthopaedic and plastic surgeons perform these procedures in
open fractures may also require urgent surgery. Where possible,
conjunction, as inadequate initial debridement has been shown
initial debridement and surgical stabilization should only take
to contribute to poor outcomes following open fractures.
place at specialist centres unless the patient cannot be transferred
The use of antibiotic-loaded beads or vacuum foam dressings
safely.
can be extremely useful in dead-space management, whilst
Other indications for immediate surgery include vascular
definitive soft tissue cover is achieved (Figure 2). They them-
compromise, requiring repair and revascularization, and
selves, however, should not be used for definitive management.
compartment syndrome. Lower limb fasciotomy should be per-
Soft tissue cover should be achieved if possible within 72 hours
formed via a two-incision technique (Figure 1a and b ) and must
and should not be delayed beyond 7 days.
not be delayed. It is important to appreciate that both open and
closed fractures are equally at risk from this complication, and
Skeletal stabilization
the presence of an open wound does not prevent raised intra-
compartmental pressure from developing. Loose fragments of bone that are devitalized and have lost their
soft tissue attachment and blood supply are removed. Fracture
Debridement ends and large segments that fail to demonstrate signs of viability
are also removed. Major articular fragments are preserved as
Debridement is the removal of foreign material, devitalized soft
long as they can be reduced and fixed with absolute stability.
tissue and bone and necrotic tissue from the wound. The use of a
Fracture stabilization may consist of temporary spanning
tourniquet should be avoided. The skin edges should be excised
external fixation at the time of initial debridement (Figure 2). If this
and appropriate wound extensions should be made so that all
is then converted to internal fixation this should be done as soon as
parts of the wound can be adequately explored and the bone
possible. Ideally this can be done at the planned ‘second look’, but
ends delivered. The aim is to achieve a healthy, well-perfused
should not be delayed beyond 10 days. Beyond this, infection is a
and stable tissue bed with a low bacterial count. Skin flaps or
risk. Internal fixation with intramedullary devices or plates and
undermining should be avoided so as not to compromise
screws is safe if there is minimal contamination and soft tissue
vascularity. The viability of muscle is assessed by the four Cs:
cover is achieved at the same time as insertion of the implant.
colour, consistency, contractility and capacity to bleed. The use
Modern multiplanar and circular fixators can be used if there
of fluid irrigation reduces bacterial count; at least 6 litres should
is a significant contamination or segmental bone loss. When
be used,9 but only after a clean wound is obtained. The use of
external fixators are used, ‘safe corridors’ for pin placement
high-pressure pulsatile lavage is not recommended as this may
should be utilized to avoid damaging underlying structures or
damage tissues further or embed contamination into the soft
compromising later plastic surgical reconstruction.
tissues themselves.10 If possible, bare bone and exposed articular
surfaces should be covered with fascia. If heavy contamination
Wound closure
existed, the skin should not be closed, although wound exten-
sions performed during debridement can be closed as long as There are three types of wound healing which depend on the
there is no soft tissue tension. timing and technique involved.
If tissue loss is not present and the wound is clean and has
received adequate debridement the skin can be closed without Primary closure: in this method wounds heal by ‘first intention’.
tension. However, if there is heavy contamination presentation The wound edges are approximated without delay and the ad-
or significant tissue debridement was necessary it is essential to vantages are that there is a shorter time to healing and the
perform a ’second look’ procedure. This is a further inspection of cosmetic result is good. Not all traumatic wounds should be
the wound prior to closure and usually should take place closed in this way due to either the presence of contamination,
approximately 48 hours following initial debridement. During tissue loss or an underlying bone injury.

SURGERY 32:3 136 Ó 2014 Elsevier Ltd. All rights reserved.

 BASIC SKILLS
Figure 1 (a) A cross-sectional representation of the leg illustrating all four
compartments. (b) An illustration of the recommended incisions for fas-
ciotomy and wound extensions in the leg. The subcutaneous border of
the tibia is marked in green and the fasciotomy incisions are marked in
blue. The perforators arising from the posterior tibial artery are shown in
red. From Standards for the Treatment of Open Fractures of the Lower
Limb, by kind permission of BOA/BAPRAS.
Secondary closure: healing by ‘secondary intention’ is employed
where a wound is left open and heals mainly by the formation of
granulation tissue and wound contraction. This process can be
lengthy and the cosmetic result is less favourable, but is
employed where a tissue defect is present and local plastic cover
is inappropriate (e.g. ulcers and abscess cavities).
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Figure 2 The wound edges have been excised and the wound debrided of
all devitalized tissues and foreign material in this open tibial fracture. A
bridging external fixator has been applied to achieve initial skeletal sta-
bility. This will be exchanged for alternative definitive fixation at a later
date. Antibiotic-loaded cement beads have been employed to assist in
dead-space management.
Tertiary closure: healing by ‘third intention’ involves delayed
closure of a wound. The wound edges are left open and then
closed after a variable period of time. This technique is used for
open fractures and contaminated wounds and requires thorough
debridement and wound irrigation as previously described.
Soft tissue coverage
If there is a soft tissue defect present and soft tissue coverage is
necessary and cannot be achieved, then many options exist. The
simplest method that will yield predictable soft tissue coverage is
the most appropriate. The simplest technique for reconstruction
is a partial or full-thickness skin graft; however, this must be
placed on a stable healthy bed of muscle and is not suitable for
coverage of exposed bone, tendon or hardware. In these situa-
tions local skin flaps, region skin flaps or free tissue transfers
may be necessary, and highlight the importance of a joint
approach of open fracture management with orthopaedic and
plastic surgeons as early flap coverage has been shown to reduce
infection rates.11 A
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 BASIC SKILLS
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