The objectives of debridement

21
The objectives of debridement 1 ) Extension of traumatized wound to allow identification of zone of injury 2 ) Detection & removal of foreign material, especially organic foreign material 3 ) Detection and removal of nonviable tissues 4 ) Reduction of bacterial contamination 5 ) Creation of a wound that can tolerate the residual

description

The objectives of debridement. 1)Extension of traumatized wound to allow identification of zone of injury 2)Detection & removal of foreign material, especially organic foreign material 3)Detection and removal of nonviable tissues 4)Reduction of bacterial contamination - PowerPoint PPT Presentation

Transcript of The objectives of debridement

Page 1: The objectives of debridement

The objectives of debridement

1)Extension of traumatized wound to allow identification of zone of injury

2)Detection & removal of foreign material, especially organic foreign material

3)Detection and removal of nonviable tissues 4)Reduction of bacterial contamination

5)Creation of a wound that can tolerate the residual bacterial contamination and heal without infection

Page 2: The objectives of debridement

Factors of muscle viability

ColorConsistency

Capacity to bleedContractility

Page 3: The objectives of debridement

BoneIn general, small bits of cortical bone that are free of any soft tissue attachments should be

removed. Completely devascularized bone segments should

be debrided .

Page 4: The objectives of debridement

Summury of debridement

The surgeon should have a plan for wound debridement.

• A careful inspection of the initial skin and dermis followed by inspection of subcutaneous fat, then muscle, and finally bone

• Repeat débridement after 24 to 48 hours based on the degree of contamination and soft-tissue damage.

• In injuries requiring muscle flap coverage, débridement also should be repeated at the time of soft-tissue reconstruction.

Page 5: The objectives of debridement

The Importance of Skeletal Stability

1)Restore length and alignment.2)Restore articular surfaces.

3)Allow access to the traumatic wound 4)Facilitate further reconstruction procedures

5)Allow early use of the limb 6)Facilitate fracture union and return of function

Page 6: The objectives of debridement

Immobilization in Plaster

Plaster-of-Paris casts have limitations in the treatment of open fractures because they may make access to the wound difficult and because they involve a circumferential hard dressing on a limb with the potential for swelling, which can contribute to compartment syndrome.

Cast immobilization may be appropriate for type I open

Page 7: The objectives of debridement

Skeletal Traction and Suspension

Balanced skeletal traction, usually as a temporary method, can be used effectively in the femur and occasionally the tibia

Page 8: The objectives of debridement

External Skeletal Fixation

In the 1970s and early 1980s, external fixation became the fracture stabilization method of choice for the treatment of most open fractures of long

bones.

Today, external fixation is most often indicated for type IIIB and IIIC open fractures of the tibia and fibula, and in open fractures of the pelvis.

Page 9: The objectives of debridement

External fixation advantages:

(a) easily and rapidly applied.(b) excellent stability

(c) , minimal soft tissue trauma so the risk of w ound infection is minimized .

(d) allow early joint motion

(e) offers the option of easily redisplacing the fracture at subsequent

debridements .(f) , may be used as a temporizing frame

restoring the limb to length)“ traveling traction”( u ntil definitive

fixation can be performed.

Page 10: The objectives of debridement

The disadvantages of external fixators

(a) for complex fractures with large, wounds application can be complex

and time consuming.

(b) the pins entrap musculotendinous, units restricting range of

motion .

(c) inappropriate technique of pin insertion may lead to bone necrosis or

, early loosening of pins and subsequent pin track infection.

Page 11: The objectives of debridement

Indications for External Fixation

internal fixation traditionally is thought to be safest where the risk of infection is the lowest.

external fixation is indicated where the risk of infection is the highest

Page 12: The objectives of debridement

Postoperative Management of External Fixation

The primary cause of pin infection is loosening of the pin.

The most effective method of skin care is simple cleansing of the entire external fixation frame, pin tracks, and skin daily with any standard commercial bathing soap

to which the patient is not allergic.

Page 13: The objectives of debridement

pilon fractures

pilon fractures with severe soft tissue injuries. a bridging frame with fixation to the calcaneus and the forefoot is advisable.

Page 14: The objectives of debridement

DEFINITIVE WOUND MANAGEMENT

Primary ClosureDelayed Primary Closure

Leaving Wounds OpenSplit-Thickness Skin GraftsFlap Coverage

Page 15: The objectives of debridement

Delayed Primary Closure

Advantages of leaving the wound open 1. keep the fascial and skin edges separated . 2. minimizes the risk of anaerobic infection.

• Ordinarily, the wound is not exposed on the ward for inspection until the time of delayed primary closure, 2 to 5 days after injury.

• Small wounds, especially in type I open fractures, may be allowed to heal secondarily.

Page 16: The objectives of debridement

The trendconflicts with the trend toward early closure of open fractures recommendations for routine débridement of open fractures .

While the goal is thorough débridement at the time of the initial presentation, it is possible that poly-trauma or other concerns may cause the surgeon to doubt the adequacy of the initial débridement. In addition, it may be difficult to evaluate muscle viability in the acute setting. In

these instances, repeat débridement is certainly appropriate ..

Page 17: The objectives of debridement

V.A.C

Recently, vacuum-assisted closure (V.A.C, San Antonio Texas) has emerged as a useful method of

1 )accelerating wound-healing by reducing chronic edema 2 )increasing local blood flow

3 )and enhancing granulation tissue formation.

Page 18: The objectives of debridement

Split-Thickness Skin Grafts

In most cases where the wound bed is composed of viable vascularized soft tissues, (STSG) provides the best method of closure.

Page 19: The objectives of debridement

Flap Coverage

When soft tissue loss is extensive and closure by primary suture or split-thickness skin graft is not possible, flaps become

necessary.

most flaps are best done at approximately 5 days after injury

Page 20: The objectives of debridement

• Soft-tissue reconstruction should be done early, within the first 7 days.

• Delays beyond this period have been associated with increased complications related to the flap or infection under the flap.

• Some have advocated that flap coverage be done within 72 hours.

Page 21: The objectives of debridement

Proximal third tibia fractures can be covered with gastrocnemius rotation flap

Middle third tibia fractures can be covered with soleus rotation flap

Distal third fractures usually require free flap for coverage