Irrigation and Debridement of Open Fractures

Overview

Open fractures are surgical urgencies (Campbell). The injury has four components, each assessed separately: the fracture, soft-tissue damage, neurovascular involvement and contamination (AO). Debridement and irrigation are the mainstay of treatment; the aims of initial surgery are to save life and limb, decontaminate the wound, assess the injury for definitive classification and stabilize the fracture (Campbell, AO). Any wound in the same segment as a fracture is treated as an open fracture until proven otherwise by surgical exploration (Rockwood).

Classification (Campbell, AO)

• Classification is most reliable in the operating room after debridement (AO); interobserver variability is the main weakness (AO).

• The OTA open fracture classification grades skin, muscle, arterial injury, contamination and bone loss (Campbell).

• Reported infection rates: type I 0-2%, type II 2-7%, all type III 10-25% (IIIA 7%, IIIB 10-50%, IIIC 25-50%); amputation rates of 50% or more in type IIIC (Campbell).

Emergency Department Management

1. Assess the patient by ATLS principles ("life before limb"); about 29% of patients with open fractures have other injuries (Rockwood).

2. Control hemorrhage with pressure; use a tourniquet rarely (Campbell).

3. Record the neurovascular status before and after realignment; persistently weak pulses after realignment require Doppler or angiography (AO). An ankle-brachial index above 0.9 is normal (AO).

4. Antibiotics as early as possible, ideally within 1 hour of injury, without delaying transfer (Campbell, Rockwood). In one series, no fracture-related infection occurred when antibiotics were given within 66 minutes (Rockwood).

5. Tetanus prophylaxis in every open fracture (AO).

6. Photograph the wound, remove gross foreign material, apply a moist sterile dressing and leave it undisturbed until the operating room; splint the realigned limb (AO).

7. Cultures before or after debridement are of no value; obtain cultures only when there are clinical signs of infection, e.g., at the second debridement (Campbell, AO).

Systemic antibiotics (Campbell protocol)

• Short courses of a first-generation cephalosporin started as soon as possible significantly lower infection risk; prolonged courses are not supported (Campbell).

• For farm or fecal contamination, add penicillin (anaerobic coverage) (Campbell).

• Initial prophylaxis should not exceed 72 hours to avoid selecting resistant organisms (AO).

• Fluoroquinolones should not be used for prophylaxis because of their adverse effect on healing (Campbell).

Timing of Debridement

• Strict adherence to the 6-hour rule is not necessary; debride as soon as the patient is stable and resources allow (Campbell, AO, Rockwood).

• The risk of infection in type III open fractures, particularly of the tibia, rises by about 3% per hour of delay (Campbell).

• UK NICE guidance cited by Rockwood: highly contaminated wounds (agricultural, aquatic) immediately; type IIIA and IIIB fractures within 12 hours; all other long-bone open fractures within 24 hours.

• The thoroughness of excision appears more important than its timing; the initial debridement should be done by an experienced surgeon, ideally with a plastic surgeon present (AO, Rockwood).

Technique 58.2: Irrigation and Debridement of Open Wounds (Campbell)

1. Prepare the patient and skin; apply a sterile tourniquet if possible but do not inflate it.

2. Prepare and drape for wide exposure of the involved area (entire limb, possibly extending to the torso), using impermeable drapes.

3. Begin at the skin and proceed in an orderly fashion; excise devitalized skin until bleeding is visible at the skin edge. Progressive removal of skin is preferred over wide margins.

4. Remove contaminated and devitalized subcutaneous tissue in the same way.

5. Preserve superficial nerves if intact (infrequent).

6. Remove devitalized fat beneath the flaps down to clean, bleeding subcutaneous tissue.

7. Open the fascia to expose muscle and tendon; remove all devitalized muscle using the four Cs: color, contractility, circulation, consistency.

8. Trim completely severed tendons back to viable tendon; clean intact tendons rather than excising them.

9. Enlarge the wound to allow adequate debridement and exposure of the fracture. Remove devascularized bone, especially if highly contaminated. Remove contamination in the medullary canal by progressively removing bone with a saw or rongeur; avoid curettage of the canal to prevent proximal migration of infected material.

10. After all dead tissue has been removed, irrigate with normal saline.

11. If closure is possible, suture the surgically created wound first and close the remaining wound loosely, over a drain if needed, without tension. Otherwise leave the wound open, keep bone, nerve and tendon moist, and use a bead pouch or negative pressure wound therapy (NPWT) dressing.

12. Decide on internal or external fixation after debridement. Reprepare and redrape, discard all debridement instruments and change gowns and gloves before fixation.

Wound extension and excision details (Rockwood, AO)

• Extend the wound longitudinally along fasciotomy lines to see deeper structures; in the tibia this protects perforators from the posterior tibial artery used for later fasciocutaneous flaps. Extension should be subfascial to avoid degloving (Rockwood, AO).

• The zone of injury is usually much larger than the skin wound, especially under large muscle masses (AO).

• Debride skin without tourniquet so bleeding edges can be judged; excise all avascular fascia (Rockwood).

• Muscle that does not contract to diathermy stimulation, changes color or tears away easily with a rongeur is devitalized; when in doubt excise rather than retain (Rockwood).

• Deliver the bone ends into the wound ("shotgun" maneuver) to inspect the canal; remove cortical fragments without soft-tissue attachment (a gentle pull test identifies them). Cancellous metaphyseal bone and large articular fragments may be retained if not grossly contaminated, after thorough cleaning and stable fixation (Rockwood).

• Small fragments with intact periosteum and soft tissue should be retained because they act as grafts; retained avascular fragments are probably the most frequent cause of persistent infection (Campbell).

• The 90% rule: each debridement removes about 90% of contaminants, leaving about 10% after the first, 1% after the second and 0.1% after the third (AO).

Irrigation

• Low-pressure, high-volume saline is the current consensus; high-pressure pulsatile lavage drives contaminants deeper, damages soft tissue and reduces early new bone formation (Campbell, Rockwood).

• The FLOW trial found very-low-pressure irrigation acceptable and soap no better than saline; soap was associated with more reoperations (Campbell, Rockwood).

• Antiseptic, antibiotic or surfactant additives have shown no clinical benefit and some are cytotoxic (Campbell, Rockwood).

Rockwood suggests at least 3 L for any open fracture, increasing with severity (often more than 9 L in type IIIB); AO notes the traditional recommendation of 10 L for type III wounds.

Local Antibiotics (AO, Rockwood, Campbell)

• Aminoglycoside-impregnated PMMA beads added to IV antibiotics reduced overall infection from 12% to 3.7% in a series of 1085 open fractures; the difference was significant mainly in type III fractures (AO).

• Typical preparation: 40 g PMMA mixed with 3.6 g tobramycin, formed into 5-10-mm beads on a nonabsorbable suture or wire (AO).

• In nailed open fractures, adding local antibiotics reduced infection in IIIB/IIIC injuries from 31% to 9% in a meta-analysis (Rockwood).

• Bead pouches reduce bacterial colonization more than NPWT in wounds that cannot be closed primarily (Campbell).

Repeat Debridement and Wound Closure

• Repeat debridement of most Gustilo type III fractures within 24-72 hours, and of any questionable wound regardless of type; repeat at 48-hour intervals until the wound is clean (Campbell).

• Do not close a wound that is not surgically clean, and never close skin under tension (Campbell).

• Primary closure is possible in most open fractures up to type IIIA without significant extra risk (Campbell).

• Definitive soft-tissue coverage should be achieved early, ideally within 72 hours and within 7 days (AO, Rockwood); a delay of more than 72 hours increases infection risk (Rockwood).

• Prolonged NPWT is associated with higher infection rates and must not replace early definitive coverage (AO).

Fracture Stabilization

• Use the method that provides adequate stability with minimal further damage to the zone of injury; type I wounds can be treated as closed fractures (Campbell).

• External fixation is widely used for temporary stabilization in severe soft-tissue injury or damage control. Convert to a nail as early as possible; if more than 14 days have passed, plan a pin holiday of more than 10 days with debridement and splinting before nailing (AO).

• Do not place definitive fixation until the wound is clean and definitive closure can be obtained (Campbell).

References

1. Whittle AP, Azar FM. General principles of fracture treatment. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 58, Technique 58.2.

2. Mosheiff R. Open fractures. In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 4.2. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)

3. Open fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 16. (Turkish edition: Erişkin Kırıkları.)