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.