In theatre

This involves debridement, stabilisation and closure.

Debridement aims to explore the wound, excise dead tissue and remove foreign material. The dressing previously applied to the wound is replace by a sterile pad. The surrounding skin is cleaned and shaved. The pad is then removed and the wound thoroughly irrigated with saline, and then, an antibacterial agent. The tissues are then dealt with in order:

• skin - excised sparingly
• fascia - divided extensively so as not to impair circulation
• muscle - viable muscle is beefy-red, firm, contracts when incised with a scalpel, and bleeds when cut; non- viable muscle is identified and removed
• blood vessels - tie large vessels, clamp small ones
• nerves and tendons - generally left alone if cut; suture only if the wound is clean and dissection unnecessary
• bone - excise sparingly; remove only if totally detached or grossly contaminated; gently clean fracture surfaces and replace in the correct position
• joints - close synovium and capsule if damaged; drain only if severely contaminated

Current thinking is that stable fixation of the fracture is important. External fixators are used commonly but plating and nailing are sometimes necessary. Nailing of grade I and II open fractures of the femur, tibia and humerus is safe and practised in the best units. Nailing of grade III open fractures is contraversial.

Wound closure should be delayed. Some units perform primary closure on grade I open fractures.