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.