open fracture ,wound debridement,principles,evidence based,protocol,antibiotc,lavage

1. WOUND DEBRIDEMENT
DR.S.SENTHIL SAILESH
SENIOR ASSISTANT PROFESSOR IOT
MMC RGGGH

2. Facts in open fractures
 Contamination rate of wound in open fractures is 65 %.
 Chances of infection in LL open # is 3 times more than UL
open fractures
 Infection rate,
 Gustilo type 1 -7%
 type 2 -11%
 type 3-18 to 56%

3. What will you do next

4. Antibiotic
 Patzakis (RCT) effectiveness of antibiotic in posttraumatic
wound
 No antibiotic -14% infection rate
 Cephalosporins - 2.4% infection rate

5. When will you
start antibiotic

6. Antibiotic
 ASAP ,atleast <1hrs
 Early timing of antibiotics - single important factor
in reducing infection

7. What antibiotic
to give

8.  Cephalosporins
 G&A open fracture type
 type 1-cefazolin dose-2gms/8hrly
 Type 2-cefazolin dose-2gms/8hrly
 Type 3-cefazolin dose-2gms/8hrly +
aminoglycosides doze-5mg/kg

9. How long will you
give
3-5 DAYS

10. Debridement
Removal of foreign
materials, necrotic
tissues from the open
wound to reduce
pathogen load and
help in wound healing

11. When to debride

12. Debride
 Urgent, emergently, ASAP
 Atleast <6hrs
 Study- bacterial counts reached infection threshold in open fracture at mean of 5.17hrs
 Study- type2&3fractures debrided
 <5hrs -7% infected
 >5hrs -38% infected
 Delay and poor debridement are deleterious to the patient

13. How to debride
 Sharp debridement
 Superficial to deep (skin to bone)
 Skin
 2mm of skin edges to e removed till bleeding is present
 Incision to be extended
 Contused and questionable skin to e left initially
 Subcutaneous tissue
 Excise all devitalized tissue.
 These tissues have a sparse blood supply and on subsequent debridement, further devitalization
may become apparent.

14. debri
 Fascia
 contaminated & necrosed to e removed
 Muscle
 removal of non viable muscle(deep group necrose first)
 Cgeck for colour,consistency,cotractaility
 Bone
 Remove necrosed tissue from fracture ends, medullary cavity
 small fragments without attachment is removed
 large fragments ,retained for reduction purpose
 Cartilage
 must e preserved
 reduction and joint reconstuction

15. Irrigation of
Wound
WHICH FLUID?
NORMAL
SALINE

16. How much
 Type 1 — 3litres
 Type2 --- 6litres
 Type3 --- 9litres

17. How to irrigate

18. How to irrigate
 Gravity flow(<5psi)
 3 liter NS suspended 6-8 feet high with
compressile tubing
 Low pressure flow
 50ml syringe (5to10psi) pulse lavage in low
pressure mode
 High pressure flow
 jet lavage(>20psi)

19. How about role of antiseptic and
antibiotic during wash
 No role
(betadine,chlorhexidine,ethanol,etc)
 These are toxic to host cells, affect microvascular flow ,endothelial
intergrity, woud healing

20. How about soaps
 Soaps directly disrupt the adhesion and clumping of bacteria
from wound
 Castile soap, green soap
 Considered for heavily contaminated wound
 Doesn’t reduce deep infection rate

21. FLOW STUDY
 Fully powered fluid lavage on open wound
 Study from 2009 to 2013
 41 sites in US, Canada,Aus,india
 2551 open fractures
 Reoperation in one year (wound, infection, nonunion)
 Conclusion
 Reop rate in gravity lavage = high pressure lavage = low pressure
lavage
 Reop more in soap + saline irrigation compared to saline alone

22. Secondary debridement
 If required 48-72hrs later
 Wound closure

23. Wound closure
 EARLY – within 24-72 hrs
 Recommended in Type I, II, selected III A #s
 Debridement performed within 12 h, no excess skin loss primarily or
secondarily during debridement, skin approximation possible without
tension, no gross soil or other similar contamination, and no vascular
insufficiency
 DELAYED
 LATE beyond 3 days
 A valuable adjunct to wound closure has been the wound vacuum-
assisted closure device
 Helps to reduce edema, enhancing granulation tissue formation, and
increasing local blood flow

24. Skin Cover
 Early soft tissue coverage or wound closure is ideal
 Increased risk of infection beyond 7 days
 Can place antibiotic bead-pouch in open dirty wounds
 Ideally, coverage of the open fracture should take place after one
to two formal debridement
 Ideally all open fractures are left open to prevent anaerobic
atmosphere and delayed closure is attempted at 2-7 days based
on severity of contamination

25. conclusion
 Antibiotic – IV urgently, no role in irrigation
 Debridement - asap, follow principles for soft tissue and
bone
 Irrigation – only NS, method - gravity flow
 Wound closure - based on wound status, primary - plastic
cover

26. Thank You