equipped operation theatre. The sooner the wound can be dealt with
adequately the smaller is the risk of infection arising from contaminating
organisms.
Principles of treatment
The object is to clean the wound and, whenever necessary, to remove all dead
and devitalised tissue and all extraneous material, leaving healthy wellvascularised tissues that are able to ward off infection from the organisms that
must inevitably remain even after the most meticulous cleansing.
The extent of the operation required depends upon the size and nature of
the wound. It is important that the wound should not be subjected to repeated
examination, but should be kept covered with a sterile dressing until it can be
visualised under optimum conditions in the operating room. The simplest type
of case is that in which there is merely a small puncture wound caused by a
sharp spike of bone forcing its way through the skin. In such a case it is often
clear, when the wound is carefully inspected, that there is no serious contamination, and it may be unnecessary to do more than to clean the area with
water or a mild detergent solution. At the other extreme is the grossly contaminated wound of a gunshot injury, with severe tearing and bruising of the
soft tissues over a wide area, and often with much comminution of the bone.
Then the only hope of preventing serious infection lies in a most painstaking
cleansing of the wound with the removal of all devitalised tissue, and in the
avoidance of immediate skin closure.
Technique of operation for major wounds
The operation is begun by enlarging the skin wound, if this is necessary, to
display clearly the extent of the underlying damage. The whole wound is then
flushed with copious quantities of water or saline to remove as completely as
possible all contaminating dirt: at the same time any pieces of foreign matter
such as shreds of clothing are picked out with forceps. In general, the emphasis
should be on thorough cleaning of the tissues rather than on drastic excision;
nevertheless, tissue that is obviously dead should be excised (Fig. 3.20), and it
is particularly important that dead or devascularised muscle be removed in
order to reduce the risk of infection by gas-forming organisms (gas gangrene).
Bone fragments that are small and completely detached may be removed, but
large fragments, which usually retain some soft-tissue attachments, should be
preserved. Damage to a major blood vessel is dealt with, according to circumstances, by ligation, suture or vein grafting. The ends of severed nerve trunks
may be tacked lightly together with one or two sutures, to facilitate later
definitive repair.
The question of skin closure
Only if a wound is of a cleanly incised type, very recent, and without any sign
of contamination, may immediate suture be considered. In general, the rule
should be that a major wound communicating with a fracture, in which it must
be assumed that pathogenic organisms have gained entry, should never be
sutured primarily. To suture such a wound, especially a gunshot wound, is to
risk disastrous infection. Instead, the wound after cleansing should be left open
and dressed with a sterile covering. In such a case, delayed closure may be
undertaken as soon as it is clear that infection has been aborted or overcome.
This technique of delayed primary suture has become standard practice in
the management of high-energy gunshot wounds, which are always heavily
contaminated, and the temptation to suture such a wound immediately should
always be resisted.
Methods of skin closure.
Whether skin closure is undertaken primarily or after
an interval, the ideal method is by direct suture of the skin edges; but this is not
always feasible. Whether it is practicable or not depends upon the amount of
skin destroyed and lost in the injury. If the skin loss is negligible and the skin
edges can be brought together without tension, direct suture should be carried
out. But if the skin edges will not come together easily, the wound should be
closed initially by a free split-skin graft. Where there has been extensive
damage or loss of the underlying soft tissue and muscle it may be necessary to
cover the bone by mobilising a muscle pedicle. Exceptionally a vascularised
full-thickness graft may be required, but this more complex procedure would
normally require the assistance of a specialised plastic surgical unit.
Treatment of the fracture
Once the wound has been dealt with, the treatment of the fracture itself should
follow the general principles already suggested for closed fractures. The only
difference is that in open fractures there should be a greater reluctance to resort
to operative methods of fixation, especially if there seems to be a serious risk of
infection; if it is decided that metallic internal fixation must be employed the
metal should be placed well away from the wound. If the fracture is unstable
and unsuitable for treatment by traction or by simple splintage alone, external
fixation by pins inserted into the bone fragments and fixed to a rigid external
bar (Fig. 3.15, p. 42) is often the method of choice rather than internal fixation.
Supplementary treatment in cases of open fracture
Antibiotics. A course of treatment with a broad-spectrum antibiotic, such as a
third-generation cephalosporin, should be begun immediately and continued
until the danger of infection is past.
Prophylaxis against tetanus. A patient who has previously been immunised
against tetanus by tetanus toxoid should be given a booster dose of toxoid. If
the patient has not previously been immunised it is wise to begin immunisation with a standard dose of toxoid and to follow this up with a second
dose 6 weeks later.
Precautions
In severe open fractures, with perhaps considerable loss of blood, there is a
greater liability to shock than there is in closed fractures, and appropriate
measures of resuscitation are often required.As with any major fracture, especially when the limb is encased in a plaster
splint, careful watch must always be kept on the state of the arterial circulation,
so that immediate action may be taken if signs of ischaemia should develop.
Patients treated for open fractures must be watched closely for signs that
may indicate infection. The temperature chart should always be noted: any
large sustained rise of temperature should be taken as an indication to inspect
the wound. When there has been much contusion of muscle the possible
development of gas gangrene must always be borne in mind.
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