1.2.1 Skin preparation

While there are several different solutions available for effective skin disinfection, it seems important that their application is carried out according to the specific instructions of the producer and the guidelines of the hospital. The solution must have completely dried before the skin is incised. In general, open wounds should be debrided of large foreign bodies such as dirt, large pieces of gravel and leaves prior to surgical prep because they have to be removed anyway and it is difficult to fully decontaminate them.

Superficial abrasions with embedded gravel, rocks or other foreign debris require special attention. The wound may be gently debrided prior to surgical scrub with a scrub brush of the type used to scrub the surgeon′s hands. Care must be taken to ensure that no additional damage to the soft tissue is caused by overly aggressive, course debridement. The goal is to remove loose material, which might come free during the surgical scrub. However, in some cases, material has become embedded in the full thickness of the dermis and should be removed during the surgical debridement.

Iodine-containing preparations (ie, Betadine^®, Braunol^®) are relatively toxic to underlying soft tissues and thus are often avoided in cases of open wounds. They also impair osteogenesis and should not be used on exposed bone. Alcohol-based preparations can basically present a risk of fire when electrocautery is used and the alcohol has not dried.

1.2.2 Use of the tourniquet

Tourniquets are often used in extremity surgery to reduce bleeding and to facilitate difficult preparation, for example when dissecting a flap, its pedicle or the recipient vessels. With careful intraoperative hemostasis, however, a tourniquet is not routinely required, particularly during the debridement procedure. Continuous assessment of punctate bleedings during debridement is essential to decide whether the tissues are viable or not. The prolonged application of a tourniquet may increase edema formation after its release due to reperfusion of the limb, exacerbating the edema, which will occur as a result of the fracture. This differs from elective surgery, where there is no preexisting edema or inflammation.

1.2.3 Planning incisions

The skin incision should provide the most adequate and least harmful exposure for the planned fixation of a specific fracture. It should be extensile, which is best done with straight incisions rather than curved ones. Most described approaches make use of Langer lines, sometimes also called cleavage lines. They are topological lines drawn on a map of the human body along which the skin has the least flexibility. They correspond to the natural orientation of collagen fibers in the dermis. These lines represent small folds in the skin, which allow stretching of the skin perpendicular to the lines. They can easily be seen by gently pinching the skin or by examining areas such as joints where they allow flexion and extension of the joint ( Fig 1.2-1a–b ). If a surgeon can choose where and in which direction to place an incision, he or she may decide to cut in the direction of Langer lines. Incisions made parallel to Langer lines may heal better and produce less scarring than those cutting across and thus minimize contracture and restriction of motion. The orientation of stab wounds relative to Langer lines can have a considerable impact upon the presentation of the wound.

Ideally, the incision should not cross bone prominences such as the olecranon or medial malleolus, but rather gently curve around them to avoid having a scar on a potential pressure area. The surgeon should also take into consideration the possible need for later surgery, ie, secondary knee arthroplasty after a proximal tibial fracture or a secondary closure of a defect with a local or regional flap (chapter 10.4, 10.5).

If more than one incision is planned, care should be taken not to compromise the vascularity of the skin bridge. Generally, a skin bridge should be performed as wide as possible, bearing in mind an adequate width-to-length ratio of the randomly perfused flap (chapter 10.3). This ratio will vary depending on the flap′s location (eg, lower extremity versus upper extremity, thigh versus lower leg). The surgeon should be aware that swelling, bruising or internal degloving of the tissue between incisions are cause for concern. Also, the location of the incisions must be considered with regard to closure and the resulting scar. Skin which overlies bone prominences is less resistant to shear because there is less subcutaneous tissue. The resulting scar is often prone to hypersensitivity and tends to be unstable.

Surgeons may also be confronted with an old scar or skin graft near the site they would like to make a new incision. If the scar is more than 6 months old, surgeons may safely proceed to make a new incision where they deem necessary without regard for creating a nonviable skin bridge. Skin grafts may be incised as soon as they have completely taken (generally 6 weeks after application), though the graft should not be undermined.

A situation which often arises is the issue of a transverse laceration. This laceration compromises the skin distal to it because it disrupts the longitudinal blood flow within the fascia. However, usually there is also an associated fracture or tendon laceration. This requires extension of the wound to allow adequate exposure for inspection, debridement and eventually repair. Extension can be performed in two ways.

The surgeon may decide to extend in a Z-fashion ( Fig 1.2-2a ) or in a T-fashion ( Fig 1.2-2b ). The theoretical advantage of extending the incision perpendicular to the transverse incision is to reestablish blood flow by ingrowth of vessels adjacent to the zone of injury as the blood flow to the skin distal to the laceration is compromised. The distance from healthy skin to the edge of the incision is longer in a Z-incision than in a T-incision as shown in Fig 1.2-2c–d . Extension of the wound using a perpendicular incision is preferred. Acute angles should be avoided.

Despite the benefits of a minimally invasive approach [1], short incisions are not necessarily better than longer ones. Too much traction on the wound edges and extensive subcutaneous dissection can result in poor healing and scarring. Furthermore, the surgeon should be aware that stab incisions for placement of percutaneous screws may put nerves in jeopardy (eg, superficial fibular nerve). For the management of open fractures consult chapter 7.

Finally, it is generally agreed that the less time skin is open, the lower the risk of infection, especially in cases of trauma. However, this should not imply that a less than ideal reduction of the joint should be accepted for the sake of shorter operative time. Organizing an experienced team, not delegating the procedure to less-experienced colleagues, and moving purposefully through the case are ways to decrease operative time without compromising outcome.

1.3.1 Choice of instruments

Related posts:

6 Treatment strategies 8 Principles of wound closure and coverage 9 Wound conditioning 5 Preoperative assessment and classification of soft-tissue injuries 10 Wound closure and coverage techniques (II) 11Complications

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