Evaluation and Treatment

Early and Thorough Wound Debridement

- Prehospital care of extremity wounds is covered in the Tactical Combat Casualty Care guidelines and in the Acute Traumatic Wound Management in Prolonged Field Care CPG, 24 Jul 2017. In general, suspected fractures should be splinted whenever possible once life-threatening injuries have been addressed. Open wounds should be treated as soon as possible with antibiotics; either oral or IV antibiotics are acceptable depending on the situation and the patient’s ability to swallow the medication. Traction splints may be utilized for femur fractures, however, are not required and other splinting methods may be more expedient. A pelvic binder is indicated in cases of severe lower extremity injury and may be utilized in conjunction with a traction splint.
- Far-forward medical facilities may not have the capability to perform surgical debridement, but early irrigation with removal of gross contaminants may be possible at any level of care and should be performed as soon as possible after injury.
- During the initial examination, the neurologic and vascular exam of the affected extremities should be carefully documented and the affected extremity evaluated for signs of acute compartment syndrome (ACS). Accurate documentation for the next role of care is necessary to determine any evolution of ACS or neurovascular injury.
- A thorough irrigation and surgical debridement should be performed as early as possible.4
  - Remove debris and devitalized tissue.
  - Bone fragments without soft tissue attachment (i.e. muscle, periosteum) or that are easily removed, should be excised with the exception of large articular fragments.
  - All viable tissue should be preserved in order to afford receiving physicians the greatest number of reconstructive options.
  - Tag transected nerves and tendons to facilitate identification of structures during reconstruction.
  - Treat open fractures with prophylactic antibiotics, primarily 1st generation cephalosporin and tetanus toxoid as soon as possible.5-9 While there currently is no evidence to support broader spectrum antibiotics, Gram negative organisms are commonly cultured initially and during the treatment of subsequent infection.10 The use of topical antibiotics is becoming more prevalent and has been shown effective in preventing subsequent infection.11