Split Thickness Skin Grafting (SSG)

Split-thickness skin grafting (SSG) can be used¹ to cover clean wounds with adequate granulation tissue and a well vascularized wound bed.

The skin graft can be used to cover up granulation tissue, fat, muscle or fascia. It cannot be placed over bare bone (stripped of periosteum), bare cartilage or bare tendon – the graft will not survive on these surfaces due to lack of vascularization.

Covering the skin defect with an SSG can be delayed to when the wound is clean (after (serial) debridement) and covered in well-vascularized granulation tissue.

It is not necessary to wait for granulation tissue before skin grafting. This is a widespread mistake. A healthy wound bed without granulation tissue is preferred, which is why removal of the upper layer of granulation tissue is recommended before grafting, if it does not expose vital structures.

In wounds with exposed bone, tendons, neurovascular bundles or with a lot of dead space, a soft tissue flap is preferred over skin grafting to provide better cover and/or add volume to the defect.

Full-thickness Skin Grafting (FTG)

Full-thickness grafts (FTGs) are thicker and more resistant to contraction than split-thickness skin grafts (SSGs).

Harvesting an FTG creates a full thickness donor site defect that needs to be closed. This means the skin elasticity limits the amount of skin that can be harvested. Donor site morbidity is less in FTGs compared to SSGs because primary closure is possible.

The risk of failure of the take of an FTG is higher than of an SSG. This is because the thicker layer has higher requirements to survive the first couple of days before blood vessels connect with the new skin. However, an FTG is a very good solution in open fractures with wounds that have a healthy, well vascularized wound bed and no vital structures exposed.

Tissue expansion

Skin has biological capacities that allow it to extend its surface. Tissue expansion is a technique that plastic surgeons use to enlarge skin and underlying soft tissues over time.

The way skin behaves physically is important for determining how much of it can be safely moved. Key factors⁴ include:

• The extra skin available (the slack)
• Skin elasticity (both under normal and extended conditions)
• Biological and mechanical creep

Mechanical creep occurs when skin is physically stretched beyond its elasticity at a constant force, temporarily deforming the tissue. Biological creep is slow and gradual expansion in which continuous stretching stimulates the grow of new tissue, for example during pregnancy, weight gain or when applying the technique of tissue expansion.

During tissue expansion⁴, the goal is to optimize stress exerted on the skin to achieve maximum stretching of the skin, without exceeding the tensile strength of the skin, which would cause the skin to break down. 

Tissue expansion involves placing a silicone device under the skin and progressively inflating it with saline. The skin is stretched⁵ and new skin is formed, resulting in a gain of tissue.

Using tissue expansion, neighboring soft tissue defects can be covered with well-vascularized skin with similar characteristics in terms of sensation, hairiness, texture and color, while minimalizing donor site morbidity.

Disadvantages⁵ include:

• A high infection rate 
• The need for multiple surgeries
• The length of the process of gradual inflation
• A temporary cosmetic burden to the patient due to the device

Soft tissue expansion can be used in reconstruction of the lower leg, depending on the amount of tissue loss, the condition of the surrounding tissues and the patient's overall health.

However, tissue expansion is seldom used in acute open fracture care and rarely in chronic soft tissue defects in the legs. The skin in the lower leg is relatively tight and less elastic compared to other areas of the body, making it more difficult to expand the skin. After trauma, the tissue quality and vascularity could be compromised, increasing risk of exposure of the expander and infection.

Smaller wounds can be closed secondarily using a technique that combines tissue expansion with the swelling reduction over several days. This is done by applying elastic vessel loops or thick sutures to the wound edges and pulling them on a daily base a bit tighter. This is quite commonly used for fasciotomy wounds, for example.

Small wounds or wounds that cannot be closed primarily may be left open to heal by themselves, healing by secondary intention¹. The spontaneous wound healing process can be supported with conservative wound management. This strategy is often chosen for small wounds with a healthy wound bed, not for wounds with a fracture exposed.

It is important to keep the wound clean and moist, by covering it with the right dressings, including dressings with antimicrobial properties in case of contamination or infection.

Dry wounds - Wounds are occasionally left exposed to air for hours before being covered again, but this practice is unnecessary. During that time, the body simply recreates a moist environment by forming a scab: an ideal breeding ground for microorganisms. Even if a wound presents dry, it should be rehydrated, reassessed and covered, rather than left exposed.

Hypergranulation tissue

Hypergranulation tissue² can occur due to excessive inflammation in the proliferative phase of wound healing³, when tissue over grows beyond the wound surface. Hypergranulation tissue bleeds easily, and at a certain point, it inhibits epithelialization of the wound, thus stalling wound healing⁴.

Hypergranulation tissue can appear³

• Red,
• Uneven,
• Granular,
• Discolored,
• Raised,
• Swollen,
• Spongy.

Hypergranulation can arise due to multiple factors⁴ causing excessive inflammation, such as infection, friction on the wound area or the presence of foreign bodies, use of SSD for longer than one week, nutritional deficit or stress.

The cause of hypergranulation should be treated if hypergranulation is undesired. 

As a ‘healing by secondary intention’ strategy, allowing hypergranulation to take place can be helpful in covering small areas of exposed vital structures that are too small for flap coverage or in settings where the skills to perform flap surgery are not available.

Treatment of hypergranulation tissue

Treat small areas of hypergranulation tissue with topical agents that reduce moisture. For example²:

• Zinc oxide ointment
• Silver nitrate stick (apply Vaseline to the healthy skin surrounding the burn to protect it)
• Oxytetracycline hydrochloride and hydrocortisone acetate (Terra-Cotril®)
• Papaya
• Topical Steroid, Class III or V

Larger areas of undesired hypergranulation tissue may require surgical excision², because an excess of granulation tissue may contribute to extensive fibrosis in the long term. Excision of these larger areas of hypergranulation should be followed by skin grafting to cover the wound. Successful grafting will also decrease the chance of recurrence of hypergranulation.

Cortical bone fenestration – how to perform

In traumatic open fracture wounds, bone is often exposed. These wounds should usually be closed with local or free flaps. In certain cases, when these techniques are not available, healing by secondary intention may be chosen as a strategy.

If the periosteum has been stripped of the bone or if it was not kept moist, the cortical bone⁶ will be poorly vascularized and may not generate granulation tissue. In this case, healing by secondary intention is inhibited. Bone stripped of periosteum is also at risk of necrosis.

To promote wound healing and prevent bone necrosis, cortical bone fenestration⁶ can be performed. Cortical bone fenestration accesses the bone marrow by fenestrating the outer cortex of the bone. This activates marrow fibroblasts to promote the formation of granulation tissue. 

In this treatment, it is extremely important to prevent drying out. If the wound dries out, the negative aspects of bone fenestration are much bigger than the positive ones

After the patient has received (local) anesthesia and the wound bed has been debrided and prepared for closure, approximate the wound edges and close with sutures¹.

Minimize tension to avoid wound dehiscence, scarring and necrosis by not only suturing on an epidermal level, but also on a dermal level. For dermal closure, absorbable sutures can be used. Sutures on the lower extremity can be removed after 10-14 days. Adhesive tapes (Steri-Strips), staples and glue are also options for primary wound closure.

Be aware: one of the most common mistakes is to aim for primary closure in situations when the amount of healthy skin is insufficient. This results in closure of the skin under tension, leading to secondary wound breakdown, often with necrosis, and a larger defect than the original wound.

In reconstructive surgery of the extremity, the primary goal¹ is to restore or maintain function. Skeletal structure, vascularization, innervation and skin integrity are key factors in attaining this goal.

Reconstructive ladder for tissue defects

There are various options available for wound closure.

We recommend you choose the simplest approach that is expected to be effective².

Choice of reconstructive technique depends on multiple factors³, such as:

• Location of the defect after wound debridement
• Size of defect after wound debridement
• Depth of defect after wound debridement
• The availability of flaps
• Donor site morbidity.

Minimal tension wound closure decreases the risk of wound dehiscence, scarring and necrosis. 

The reconstructive ladder² is a traditional way to depict the different closure options for wounds, ranging from the simplest to most sophisticated option.

A basic version of the reconstructive ladder for open fractures:

1 Healing by secondary intention

2 Primary closure

3 Skin graft

4 Tissue expansion

5 Local flap

6 Regional flap

7 Free tissue transfer

The field of reconstructive surgery has evolved, and alternative ways of looking at the list of reconstructive options have been proposed, like the reconstructive elevator or reconstructive supermarket. Techniques like the use of bioengineered tissue and allo-transplantation complement the traditional options.

Patient optimization and local wound bed preparation

For information on the optimal timing of definitive soft tissue reconstruction, see Multidisciplinary treatment of open fractures.

In an elective setting, patient optimization and wound bed preparation¹ play an important role in outcomes.

Patient optimization includes:

• (Re)assessment and optimization of cardiopulmonary function.
• Smoking cessation, both pre- and postoperatively. Nicotine abuse impedes wound healing and wound vascularization.
• Improvement of the limb circulation by vascular surgeons if required.
• Good nutrition. Protein deficiency especially negatively influences wound healing.
• Glucose control in diabetic patients. Hyperglycemia may increase risk of infection and wound dehiscence.

Wound bed preparation includes: 

• Obtaining hemostasis and cleansing the wound. 
• Removing foreign bodies, debriding devitalized tissue and thoroughly irrigating the wound with saline solution.
• Antibiotic treatment.

After cleaning the wound in the emergency room (ER), debridement in the operating theater (OT) is crucial.

Debridement is the removal of dead, damaged or infected tissue. It’s one of the most underestimated aspects of surgical care and to perform it well requires a lot of experience. Preferably debridement is performed multidisciplinary with the orthopedic trauma surgeon and plastic surgeon together.

Theoretical, debridement may involve specific medical techniques, which can be:

• Mechanical (rinsing/swapping/pulse lavage/brushing)
• Chemical (e.g. Eusol)
• Enzymatic (e.g. NexoBrid)
• Biological (e.g. maggot therapy)
• Surgical

We focus on surgical debridement here, as this is the most important technique:

Surgical debridement¹ aims to convert a contaminated wound surgically into a clean surgical wound to prevent infection, promote wound healing and create a wound bed suitable for grafting or soft tissue reconstruction.

It may be necessary to perform surgical debridement multiple times to achieve this goal but preferably as soon as possible. However, even in very experienced hands this can be difficult. After multiple debridements and ongoing necrosis or infection, it may be needed to evaluate whether a patient would be better off with amputation of the extremity instead of reconstruction.

Beware that in the first few days after trauma, an open fracture patient may still develop compartment syndrome.

Assessment of viability

The most important, but also most difficult step in the debridement is to distinguish viable from non-viable tissue. You should protect all viable tissue, especially critical structures such as the nerves and vessels.

Granulation tissue² consists of newly formed collagen and capillaries. It appears red, moist, and has a cobblestone texture. It is well vascularized and bleeds easily.

Remove all contused and devitalized tissue in and beyond the zone of injury. Conserving contused or partially devascularized tissue could increase the need for multiple debridements, but it could also result in fibrosis or scarring, which compromises soft tissue reconstruction.

Non-viable tissues include:³

• Slough tissue - which is caused by prolonged inflammation and consists of dead cells or debris. Slough tissue appears yellow, brown, tan, gray or even green in color. It can be either stringy and loose or viscous/thick and sticking to the wound bed.
• Necrotic tissue - which is dead tissue that is no longer able to heal, causing it to inhibit the formation of granulation tissue. It also acts as a breeding ground for pathogens and should thus be removed. Necrotic tissue appears black or brown and can be either hard and dry or leathery soft and wet.

Granulation tissue looks very vital, but it is also very contaminated. You should take this into consideration and if it can be safely exchanged for a well vascularized flap, this is recommended.

To limit blood loss, infiltrate the wound and donor site subcutaneously with a vasoconstrictor and/or a topical hemostatic agent, such as epinephrine solution soaked in sterile gauze.

An example of a solution is “jungle juice”, containing: 

• 20ml 2% lidocaine
• 80ml sterile saline
• 0.5ml 1:1000 adrenaline solution

For limb surgery, tourniquets can be used. Always record the length of time the tourniquet⁴ has been applied for and do not exceed 120 minutes for the upper limb and 180 minutes for the lower limb.

When the wound is being excised to the level of the fascia, electrosurgery can minimize blood loss.

Other ways to limit blood loss include:

• Topical hemostatic agents such as thrombin and fibrinogen
• Tranexamic acid⁵
• Prevention of hypothermia
• Opting for a staged debridement
• Compression dressings
• Elevating the limb

Debridement technique

1 Remove all devitalized tissue with a scalpel, scissors, dermatome and/or a sharp medical spoon.

2 First remove the top layer from the tissue, thereby removing the contaminated area. Cut⁶ perpendicular to the wound edges, especially is there is slack to facilitate dermal apposition during closure.

3 Also cut away wound edge contamination or crush that could not be removed by cleaning.

4 Rinse⁶ the wound after debridement to clear out debris.

Assessment after debridement

Assessment of the wound bed after debridement should be systematic. This is the point at which the definitive Gustilo–Anderson classification should be determined, as any classification prior to debridement is provisional.

A well-vascularized, viable wound bed with punctate bleeding is essential for good graft take.

Check for:

• Perfusion – red/pink, firm tissue with punctate bleeding and adequate capillary refill
• Contamination – debris, pus or foul smell indicating infection
• Soft tissue injury – extent of damage and periosteal stripping
• Exposed structures – bone, tendon or implants
• Vascular injury – presence and need for repair

When surgical debridement results in a clean wound and the bone can be fixed with a definitive fixation, definitive soft tissue coverage is required.

In many situations, a two-stage approach is chosen. In such cases, apply an NPT system, or use wet gauzes as temporary coverage to keep the wound moist.

During a second stage, preferably the following day, check the viability of the wound again. If clean and vital, the fixation and soft tissue coverage can be performed.

After cleaning and surgical debridement in the operating theater, you can apply the Gustilo-Anderson (GA) classification and make a plan for the fracture and soft tissue.

The debridement can be followed by temporary fracture stabilization and a temporary wound coverage (VAC of wet dressings) or by definitive fracture fixation and soft tissue management if feasible. Be aware that internal fixation should always be performed together with definitive soft tissue coverage.

Knowledge and skills to be able to perform basic wound care is important for all soft tissue injuries, not only soft tissue injuries with a broken bone.

Choosing your type of wound care

Adequate use of wound dressings and topical agents is important for keeping the wound bed moist and clean, which allows wound healing. When vital structures such as bone, tendons, blood vessels and/or nerves are exposed and the wound cannot be closed primarily after debridement, wound care is indicated to bridge time to definitive soft tissue coverage with a flap.

In wounds without vital structures exposed, primary closure should also be performed as soon as possible. Skin grafting is recommended as soon as there is a healthy wound bed, this is often possible immediately after debridement. In infected and/or contaminated wounds, an extra debridement might be needed. In specific situations granulation tissue may help to achieve a graftable wound bed, but be aware that an open fracture is unlikely to heal without good soft tissue coverage and that waiting for granulation tissue to cover an open fracture is seldomly successful.

For information on the initial management of the wound in the emergency room, including how to stop lethal hemorrhage, initial cleaning and coverage in the emergency room, see Pre-hospital care for open fractures and Initial evaluation and management in open fractures in the ER.

Negative pressure therapy

Negative Pressure Therapy (NPT) or Vacuum Assisted Wound Care (VAC) involves applying sub-atmospheric pressure to the wound. It is applied to improve the quality of the wound bed by stimulating blood flow to the wound bed, removing exudate and reducing edema.

Indications for the use of NPT¹:

• Temporary wound treatment - awaiting definitive soft tissue reconstruction.
• Difficult wounds - Management of slow healing or deep open wounds
• Exposed vital structures – If vital structures like bone or tendons are exposed, but neither primary closure nor flap surgery are possible, then NPT can be used.
• Skin graft support - When applied on top of skin grafts, NPT can support graft survival.

Apply the NPT system according to the instructions and leave in place for several days, usually between 3 and 5 days. When the NPT system is removed, evaluate the condition of the wound and decide whether to continue with the NPT.

Other wound dressings

Standard dressings

Choice of dressing² depends on multiple factors, such as the type of wound, the stage of wound healing and the amount of exudate produced by the wound.If soft tissue coverage is not immediately performed after wound excision, use a temporary dressing² that avoids wound desiccation and infection and minimizes the number of dressing changes.

How to dress a wound:

1 Prepare the patient with adequate pain management 30 minutes before the dressing change.

2 Ensure that all materials are ready before starting to dress the wound.

3 Work in the cleanest manner possible, using clean gloves that must be changed in between patients. Sterile gloves can be used but are not necessary.

4 For each patient, use a new basic dressing pack.

5 Before dressing the wound, clean the wound using mild soap, water or saline solution.

6 Cover all parts of the wound completely to prevent the edges of the wound from drying out.

7 If possible, select a dressing technique that enables the patient to exercise when that is allowed.

The frequency of dressing changes depends on the type of wound and type of topical agent used. Redress contaminated wounds daily. When removing dressings, do it gently, otherwise newly formed tissue will be damaged. If the dressing is adherent to the wound, soak it with water and wash the wound gently after removing the dressing.

Always consider cleaning the wound, since no dressing beats a decent clean.

Every dressing change is an opportunity for surgical debridement with or without the need for anesthesia.

Be aware that dressing changes (even without debridement) can be very painful and adequate pain management is required.

Modern hydrocolloid dressings

Occlusive wound therapy provides a moist wound environment. When the inner layer of the dressing comes into contact with exudate, a gel forms. This facilitates autolytic debridement of the wound.
Example: Duoderm®

Use
Use for low to moderate exudating wounds.

Foam dressings

Foam dressings¹ are made out of semipermeable polyurethane and consist of cells that can hold fluids. Foam dressings have a cushioning effect and have the potential to absorb large amounts of exudate depending on the thickness of the dressing².

Use
Use for wounds that produce exudate.

Silver dressings

Silver dressings are thought to reduce the risk of invasive infection. If used for prolonged time, silver dressings could cause local and systemic toxicity. Reserve these dressings for critically colonized or infected wounds.

Hydrogel dressings

These are high water content gel dressings that facilitate autolytic debridement of the wound and assist with maintaining a moist wound environment.

Use
Use for wounds that produce exudate.

Fiber dressings

These calcium alginate dressings are absorbent, biodegradable and derived from seaweed. They maintain a moist wound environment that stimulates healing, while limiting wound secretions and minimizing bacterial contamination.

Use
These dressings are suitable for moderate to high levels of wound exudate. They are useful for large abdominal or upper torso scald burns, or to cover a donor site.

Topical agents

The basic principle of all agents is to provide a moist environment, which promotes wound healing. For open fractures moist gauzes are sufficient in the ER and vacuum assisted wound care (VAC) is first choice after debridement in the operating theatre.

For wound management of smaller wounds and wounds cannot be closed with flap, many different topical agents are used for wound care around the world. Here we introduce some of the most frequently recommended agents, based on expert opinion.

Please adhere to local wound care protocols, if available.

Silver sulfadiazine cream (SSD)

This agent has a broad antibacterial spectrum, acting against both Staphylococcus aureus and Pseudomonas aeruginosa. It's widely used as burn cream for burn wounds.

Example
Flammazine ®

Honey mixture

This agent is composed of 1/3 honey and 2/3 ghee/vegetable oil/glycerin/water. It has antibacterial properties, acting against Staphylococcus aureus and many other bacteria.

Example
Bee honey

Honey mixture

This agent acts effectively against Pseudomonas. Acetic acid may be useful in resource deprived settings, since it is relatively inexpensive and widely available.

Example
Diluted vinegar

Povidone-iodine

Povidone-iodine acts against Staphylococcus aureus. Using 5% or 10% betadine solution is recommended.

Example
Betadine ®

Silver nitrate solution

This agent acts against Pseudomonas and can be used to treat hypergranulation.

Example
0.5% AgNO₃

Fusidic acid

Fusidic acid acts against Staphylococcus aureus. However, the bacteria develop resistance after approximately 1 week of use. Therefore, another topical antibiotic should be used after 1-2 weeks.

Example
Mupirocin (Bactroban®) or tetracycline ointment.

Sodium hypochlorite solution in paraffin

This agent is used to remove slough from a ‘dirty’ or highly contaminated wound bed, and to induce granulation tissue formation.

Example
Eusol

Polyhexanide and propyl betaine-based gel

Fusidic acid acts against Staphylococcus aureus. However, the bacteria develop resistance after approximately 1-2 week of use. Therefore, another topical antibiotic should be used after 1-2 weeks.

Example
Prontosan ®

Wound healing depends on many factors, including its cause, extent, the occurrence of contamination or an infection and on wound treatment. Before thinking about techniques that can help wounds to heal its important to understand the different phases because despite differences in etiology and pathophysiology, all wounds heal in a dynamic process that has four main phases:

1 Hemostasis

2 Inflammatory

3 Proliferative

4 Remodeling

Knowledge on these phases is important for adequate wound care.

As a basic rule we can state that most wounds will eventually heal if the person injured remains alive.

In complex wounds with tissue loss, especially in severe open fractures, this may happen after a very long time of waiting / conservative wound management, and with loss of function of the limb. That's why health care workers can interfere and improve the conditions for the wound to heal quickly and with good limb function preserved. Multiple factors influence the remodeling phase and should be taken into account in wound management, including:

Systemic factors – the nutritional status of the patient, comorbidities and medications influencing mobility and perfusion and immune status.

Local factors – wound location, tissue loss, infection, mechanical stress on the wound and the presence of foreign bodies.

During all four phases wound healing can be supported:

1 Hemostasis phase (time of injury)

The main goal of the hemostasis phase¹ is to stop bleeding. Blood vessels constrict to stop bleeding and form blood clots. We can assist in this phase to help to stop bleeding by compression (preferably on the wound with a gauze + bandage, or a temporary tourniquet when local compression is not enough (this is rarely the case).

2 Inflammatory phase (time of injury to day 3)

The main goals of the inflammatory phase¹are to prevent infection during healing, degrade necrotic tissue and activate signals required for wound repair. This phase is characterized by swelling and redness. Increased vasodilatation and fluid extravasation are key components of this phase. Neutrophils and monocytes infiltrate the site of injury, initiating an immune response. This immune response is sustained by the recruitment of macrophages by cytokines. In chronic wounds, normal healing progression usually becomes arrested in the inflammatory stage. The presence of necrotic tissue, foreign material and bacteria result in the abnormal production of matrix metalloproteinases, which alter the balance of inflammation and impair the function of the cytokines. Timely antibiotic treatment can help to prevent deep infection.

3 Proliferative phase (day 4 to week 2-6)

In the proliferative phase¹, the wound is rebuilt with connective tissue to promote granulation. Keratinocytes and fibroblasts are activated by cytokines and growth factors. Keratinocytes migrate over the wound to restore the vascular network and assist closure. Fibroblasts produce collagen that deposits in the wound¹. In small wounds and wounds that have been closed by primary closure this may leed to a closed wound with scar tissue. In bigger wounds vascularized soft tissue flaps or skin grafts are needed to achieve adequate wound healing.

4 Remodeling phase (up to 18 months after wound closure)

In the remodeling phase¹, collagen in the wound matures and strengthens. The scar becomes softer, stronger and less visible. Scar therapy may be considered to reduce pain, itching and to improve appearance.

After the primary survey of advanced trauma life support (ATLS), do a secondary assessment of the limb. Pay special attention to neurovascular concerns, motor function of the limb and the soft tissues.

To conduct a comprehensive physical examination of the lower limb, you need good knowledge of its anatomy.

Physical examination includes three steps

Although often discussed separately from fracture management, soft tissue management is an integral part of open fracture care and starts from the moment of injury. Early bleeding control, wound protection, irrigation, temporary dressing, and splinting are all part of this process. The timing of definitive soft tissue coverage is crucial, as delayed management is associated with higher rates of infection and poorer outcomes.

What is soft tissue management?

In high resources settings, the management of open fractures is often divided between an orthopedic trauma surgeon focusing on the bone injury and a plastic surgeon managing the soft tissues. We strongly advocate fore this multidisciplinary approach, as it reduces complications and improves outcomes. But it's an artificial devision and in many settings the plastic surgeon is not available, and even in high resources settings only for the more complex open fractures.

Timing

The treatment of the traumatic wound needs to start as soon as reasonable.¹ According to British guidelines definitive soft tissue coverage should be performed within 72 hours.²

It's important to realize that the soft tissue management starts at the site of injury where the bleeding needs to be stopped and the wound covered with protective dressing and temporary splinting. See our guide on Pre-hospital care for open fractures

Carry out temporary conservative management of the soft tissues with rinsing and wet dressings in the emergency room. See our guide on Initial evaluation and management in open fractures in the ER.

Then, start making an integrated open fracture treatment plan.

As an important basic rule: All open fractures need cleaning and surgical debridement in the operation theater as soon as possible after the injury.

Gustilo-Anderson classification

After cleaning and surgical debridement in the operating theater, you can apply the Gustilo-Anderson (GA) classification and make a plan for the fracture and soft tissue:

The debridement can be followed by temporary fracture stabilization and a temporary wound coverage (VAC of wet dressings) or by definitive fracture fixation and soft tissue management if feasible. Be aware that internal fixation should always be performed together with definitive soft tissue coverage.

Here, we provide more information on the one-stage or two-stage soft tissue management:

One-stage management

Clear indications for a one-stage procedure include primary amputation and GA grade 1 injuries; both facilitate a form of primary closure of the soft tissues.

Early fixation and definitive soft tissue coverage is associated with better outcomes, including reduced deep infection rates. Therefore, you should perform soft tissue coverage at the earliest safe opportunity. This depends on the circumstances of the patient, injury and available resources.

In well-equipped and staffed facilities, primary soft tissue reconstruction can also be performed in grade 2 and 3 injuries in selected patients, when the debridement can be performed adequately in one session.

Internal fixation should only be performed if definitive soft tissue reconstruction is achieved at the same time.

Two-stage management

If soft tissue coverage is not achieved at the same time as wound debridement, it is advisable to perform this within 72 hours if the circumstances allow it.

Reasons to opt for delayed soft tissue reconstruction:

• Gustillo grading - In higher Gustillo grade fractures (especially in crush injuries), assessment of the viability of the tissue can be challenging in the acute phase. Also, viability of tissues may deteriorate in the first few days. Therefore, serial debridements may be needed before definitive soft tissue reconstruction. If a definitive reconstruction is performed before the demarcation has settled, a secondary reconstructive plan may be needed.
• Fitness - Patiënt is not fit for surgery (multi-trauma with other life treating injuries).
• Equipment or expertise - Lack of essential equipment or expertise which may imply the need for referral.

General principles of conservative wound management and reconstructive surgery.

The goal in the treatment of open fractures is to restore the limb’s normal function as much as possible. Therefore, the bone needs to heal. To obtain bone healing, adequate soft tissue coverage is essential. When tissue is lost, the gap can sometimes be closed by shortening the limb, but to restore good function, preserving as much limb length as possible is a key principle.¹

Reconstruction of function
Soft tissue management is more than coverage of the bone. It's good to realize that different soft tissue structures represent different functions in a limb. It implicates reconstruction of essential functions that are lost.

Contents

We advocate for an integrated approach with a treatment plan that involves both bone and soft tissues. Before reading more about the soft tissue management, we recommend to read this chapter first:

How to make an integrated treatment plan for open fractures

Afterward, you can find information on soft tissue management and decision-making in different resource settings here, including:

• Examination of a soft tissue defect and implications of lost or damaged soft tissue structures
• The stages of wound healing
• Performing wound care
• Performing surgical debridement
• Primary wound closure
• Healing by secondary intention
• Harvesting skin grafts
• A practical guide on specific soft tissue reconstruction techniques using flaps

In open fractures, successful outcomes depend on both adequate fracture fixation and appropriate soft tissue management ². Therefore, soft tissue management deserves at least as much attention as fracture fixation.

An open fracture is a soft tissue injury associated with a broken bone

Soft tissue management may include the treatment of injuries to:

• Skin
• Subcutaneous tissue
• Muscles
• Blood vessels
• Tendons
• Nerves

Knowledge about the properties and anatomy of these structures is crucial in managing soft tissue injuries. Treatment requires not only clinical and surgical skills but also communication skills to facilitate teamwork in a multidisciplinary approach.

The goal of soft tissue management is twofold¹:

1 To attain adequate soft tissue coverage and/or repair of vital structure to regain normal function.

2 To achieve patient satisfaction on the appearance of the wound area with, very importantly, no painInadequate soft tissue management increases the risk of complications, including: Infection, bone necrosis, non-union, severe pain and can lead to severe function loss and/of secondary amputation.

History of soft tissue management

Primary amputation was often standard of care for severe injuries up until World War I. Due to contamination and subsequent high infection rates, mortality rates were high.  In this period the first pioneers in the field of plastic surgery started to explore ways to treat soft tissue defects. Famous examples are Sir Harold Gillies, Vladimir Filatov and Johannes Esser.

Limb salvage gained in popularity around World War II, after the invention of penicillin, which was first used on humans in the beginning of the 1940s. 

The first lower leg reconstructions were performed using delayed flaps, such as the cross-legged flap, and local and regional flaps. Later, it was recognized that well-vascularized leg muscles themselves could also serve to cover defects ³, such as muscles in the posterior leg compartment to cover tibial wounds. 

^{An example of a pedicled flap of the right thigh to cover a defect of the left lower leg (Esser Inlay, Johannes Esser 1940)}

Microsurgery revolutionized reconstructive surgery, leading to the development of free flaps in the 1960s. These allow for the transplantation of tissue with its own blood supply from a healthy part of the body (the donor site) to the defect (the acceptor site).

The surgical evolution has continued ever since, leading the use of pedicled, perforator-based propeller flaps and even perforator to perforator flaps in some high resource settings. Other advancements in lower limb reconstruction ¹ include the use of negative pressure wound therapy, tissue expansion and dermal substitutes.

The evolution of multidisciplinary open fracture care
Today's recommended approach to open fracture management, involving a plastic surgeon for the soft tissues and a trauma,- or orthopeadic surgeon for the bone problem, has evolved from the way the specialties developed in high-income countries. The high resources settings 'orthoplastic' model exists because it is believed that specific expertise from the two different specialties need to be brought into the operation room by two different specialists that both have specific qualities to obtain good outcomes, especially if they work as a dedicated multidisciplinary team. In many settings worldwide, this approach is not possible because of lack of specialists, one doctor needs to be able to address both bone and soft tissues.