1 Open fractures: immediate care: When the case first presents, ensure that the following procedures are carried out in every case: (1) Take a bacteriology swab from the wound. (2) Commence a short course of appropriate antibiotics (see p. 50). (3) Cover the wound with care, using sterile dressings (to reduce the risks of secondary (hospital) infection). (4) Apply temporary splintage (e.g. a plaster back shell, or if appropriate, an inflatable splint).

2 Type I, technically open fractures: (1) The risks of infection are slight and are unlikely to be lessened by wide exposure (although this is advocated by some). The wound should be thoroughly cleaned (2) and a sterile dressing applied locally (3). Thereafter the method of supporting the fracture must be decided (see p. 80 and also Regional Injuries). If a plaster cast is being applied there must be allowance for swelling, e.g. by using a backshell or by splitting a cast applied over copious wool.

3 Type I, open from within out: The wound is small with clean or minimally bruised, viable edges (1). The skin edges may be minimally excised, and the wound extended (2) to allow a thorough inspection of the soft tissues and bone ends. It is unlikely that much will be required in the form of excision of contaminated or avascular tissue to achieve a thorough debridement. Advantage may be taken of the exposure to allow an accurate open reduction of the fracture.

4 Type I ctd: Carry out a thorough (preferably pulsatile) wound lavage. Up to 10 L of normal saline may be used (followed by some with 2 L of bacitracin-polymyxin solution (1)). Primary closure of the skin is not advisable, but it may be helpful to use subcutaneous anchoring sutures (2) to prevent undue retraction and aid secondary suture. Apply a dressing which ensures the tissues remain moist (e.g. saline-soaked swabs over vaseline gauze). Attention must then be paid to fixation of the fracture.

5 Type I ctd: Inspect the wound after 48 hours; if necessary, perform any secondary debridement. If the wound remains clean, the aim should be to carry out a (delayed primary) wound closure under repeat antibiotic cover at 5 days (1). If the wound cannot be closed without tension, any remaining defect should be covered with a split-skin meshed graft (2) (which allows the escape of exudate). If the wound is dirty, then it should be treated by radical excision of all necrotic and infected tissue every 2–3 days until clean and ready to be grafted.

6 Type II open fractures: These should be managed along similar lines. In Type III injuries perform a rigorous lavage and debridement (with, if needed, wound enlargement): all foreign material must be removed along with any completely devitalised tissue (including small bone fragments). The wound should be left open dressed, or a vacuum dressing applied. To facilitate wound management (conducted as in Frame 5) an external fixator or locked intramedullary nail may be the best way to hold the fracture.

7 Type III ctd: If bone is exposed, the aim should be to get it covered within 5 days, to reduce the risks of secondary infection, and the initial application of a negative pressure dressing is usually advised. Split skin grafts will only survive if applied to a vascular bed, so that they cannot be used over open joints, bone devoid of periosteum, and tendons without paratenon. Thought must be given to future access (e.g. for bone grafting should union fail). In these circumstances other methods of cover must be employed. These should only be undertaken by a surgeon experienced in plastic surgical techniques, and consultation with a plastic surgeon prior to the initial procedure, with later transfer to a Plastic Surgical Unit is highly desirable.

The local fascio-cutaneous flap: This is the commonest and most useful technique. These flaps include skin and fascia, but not muscle. (Skin flaps in the lower limb which do not include the fascial layer have a poor record of success.) Distally-based flaps are sometimes used to cover defects in the distal third of the leg. Careful planning of the flap is required. In the example (left) of the defect (1) to be covered, the anterior limb (2) of the flap to be raised is placed 1–2 cm posterior to the posteromedial border of the tibia. The posterior limb (3) may cross the midline. After the flap has been raised and swung (4), the resulting defect is covered with split skin grafts.

9 Degloving injuries (a): Here an extensive area of skin is torn from its underlying attachments and thereby deprived of its blood supply. In the hand or arm it is commonly caused by the limb being crushed between rollers (1), the so-called wringer injury; in the leg, trunk or pelvis it may result from the shearing effect of a vehicle wheel in a run-over accident.