Initial Wound Management -Irrigation and Fixation

Four high (Bhandari 2015, Petrisor 2011, Anglen 2005, Gao 2019)) and three moderate (Olufemi 2017, Ovsaka 2016, Pinto 2019) quality articles informed the recommendation on wound irrigation and five high (Garg 2019, Mohseni 2011, Galal 2018, Keating 1997, Konbaz 2019), fifteen moderate (Antich-Adrover 1997, Henley 1998, Tornetta 1994, Tu 1995, Holbrook 1989, Bali 2011, Avilucea 2016, Zhang 2016, Bach 1989, Pal 2015, Nuomi 2005, Finkemeier 2000, Ma 2006, Pinto 2019, Al-Hourani 2019), and twenty-four low quality (Nikolic 2018, D’Alleyrand 2014, Sun 2021, Ganji 2011, Memon 2014, Erturk 2013, Pollak 2010, Alberts 1999, Rohde 2007, Inan 2007, Zhao 2019, Wei 2014, Yokoyama 1995, Revak 2021, Stoddart 2020, Kayali 2009, Danoff 2015, Lee 2009, Ziran 2004, Tareen 2019, Gupta 2015, Williams 1995, Yokoyama 1999, Uchiyama 2016) articles informed the fixation statements. While there is a plethora of evidence seeking to answer questions surrounding appropriate management of the soft tissue injuries associated with major extremity trauma, the majority of evidence is of lower quality or not generalizable to this entire population.

There has been work to attempt to address the important questions regarding what solution is best for initial management and irrigation of open wounds in the setting of major trauma. Work by Anglen (2005) has shown with convincing evidence that there is little help and potential harm to additives such as soap and antibiotics. Saline alone is sufficient for initial irrigation of these wounds. The FLOW group and others have shown that there is no significant difference in outcomes when looking at very low, low, or high-pressure irrigation in the management of these wounds. There are also initial cost considerations regarding these different treatment options. Using saline and very low-pressure devices for the delivery in initial management of open wounds is not only appropriate but has the added advantage of saving cost in an environment where this is often a consideration.

When surgeons are faced with decisions regarding initial management of open wounds and fractures in patients who suffer major extremity trauma, there is no algorithm that fits all patients and injuries. A significant body of research has attempted to answer this question. We can safely say that, in appropriate settings, definitive fixation of fractures and closure of traumatic wounds is appropriate. If, in a treating surgeon’s opinion, the wounds are not amenable to immediate closure, temporizing fixation (of which there are many different possibilities) and wound management until such time that definitive management is feasible is a prudent course of action. While there are some high-quality studies that assist us in making this recommendation, our group decided to downgrade from a strong to moderate strength of recommendation because of the large differences among studies that discuss outcomes in these settings. No patient and injury combination are ever the same. Every factor must be taken into consideration when making these decisions. 

Benefits & Harms
The benefits of appropriate management of the soft tissue injury associated with major extremity trauma far outweigh the potential harms. Soft tissue integrity is essential for appropriate extremity function and protection of the underlying structures. The harm of inappropriate or inadequate soft tissue management can be significant.

Outcome Importance 

Favorable outcomes of soft tissue injury associated with major extremity trauma allows for significant secondary benefits including decreased initial hospital length of stay and fewer operative interventions, both freeing resources to address additional patients. By diminishing the risk of deep infection, the economic burden of care for these patients can potentially be reduced, again increasing the opportunity to utilize valuable healthcare resources more efficiently. Treatment failure as a result of infection almost invariably results in additional procedures, rehospitalization, and prolonged antibiotics, delaying rehabilitation and frequently eliminating affected individuals from the workforce. The specter of late  amputation after failed limb-salvage is often a very real consideration and may sometimes be the preferred definitive reconstructive option. These important issues can clearly have dramatic socioeconomic implications, not only with regards to the necessary health care but also in terms of lost wages, possible divorce, dissolution of the nuclear family, depression, social isolation, and workers compensation claims.

Cost Effectiveness/Resource Utilization
While the costs associated with appropriate soft tissue management in major extremity trauma can be sequela of complications.

Acceptability
Appropriate soft tissue management is generally accepted as important although specific details regarding the most appropriate management continues to be a topic of important scholarly work.

Feasibility
Appropriate management of these soft tissue injuries is highly feasible, and an important facet of existing trauma systems that will continue to be further refined moving forward.

Future Research
Further research is required to definitively answer important questions surrounding the appropriate management of soft tissue injuries associated with major extremity trauma.

• What is the most appropriate initial management of extremities in the setting of major soft tissue
• injury with and without fracture?
• What irrigation solutions are most appropriate and at what pressure?
• When is temporizing fixation and delayed coverage more appropriate than definitive fixation and
• primary soft tissue closure?