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.