Concepts in wound irrigation of open fractures: 'Where we came from, and where are we now?

Pulsatile lavage systems and their potential to penetrate soft tissue

BACKGROUND

In orthopedic and trauma surgery, pulsatile lavage systems are used to clean soft tissue. This may be necessary in septic surgeries or in case of contaminated wounds after trauma. Positive features such as reduction of bacterial contamination and removal of foreign particles are counterbalanced by negative aspects such as bacterial seeding in deeper tissue layers, damage to various tissues and even cases of air embolism.

PURPOSE

The aim of this prospective experimental in vitro study was to compare impact pressure and flow rate in three different pulsatile lavage systems and to determine, whether these parameters alter their ability to reach deeper soft tissue layers.

METHODS

To test the penetration of soft tissue, the muscle tissue was flushed with contrast medium instead of saline fluid and afterwards scanned by computed tomography.

RESULTS

Impact pressure and flow rate showed significant differences between the different systems. There were no significant differences between the three devices in terms of total penetration volume, but there were significant differences in penetration depth.

CONCLUSION

In this study, we found that higher impact pressure leads to deeper penetration and therefore bacteria are likely to be transferred to deeper tissue layers.

Management of conflict injuries to the upper limb. Part 1: assessment and early surgical care

Upper limb injuries are common in conflict zones. The functions of the upper limb are impossible to replicate with prosthetic replacement and wherever possible attempts should be made to preserve the limb with further secondary reconstruction aimed at restoration of function. Casualty assessment, haemorrhage control and resuscitation are simultaneously undertaken at the receiving medical facility. Primary surgical management involves decontamination and debridement, skeletal stabilization, restoration of vascularity, compartment fasciotomy where indicated and wound temporization with dressings. Operative findings and interventions should be documented and if evacuation of the casualty is possible, copies should be provided in the medical records to facilitate communication in the chain of care. Secondary procedures are required for further assessment and debridement prior to planning reconstruction and definitive fracture stabilization, nerve repair, wound cover or closure.