SLR - March 2020 - Natalie A. Coriaty

Wound Irrigation for Open Fractures

Reference: Heckmann N, Simcox T, Kelley D, Marecek G. Wound Irrigation for Open Fractures. Journal of Bone and Joint Surgery. 2020 Jan 8 (1).

Scientific Literature Review

Reviewed By: Natalie A. Coriaty, DPM
Residency Program: Kaiser Permanente North Bay Consortium – Vallejo, CA

Podiatric Relevance: Open fractures to the lower extremity are common, but treatment options are disparate. While standard treatment steps include antibiotics, irrigation, and deformity reduction, there exists significant differences in ways to approach each step. The current study reflects upon the irrigation component of treating open fractures. It is a review article that assesses the method and type of irrigation that results in the lowest rates of infection. The review addresses volume, pressure, type and timing of irrigation.

Methods: The current study is a review that analyzes both historically relevant and current research concerning the irrigation of open fractures. It includes cadaveric, animal and human study models.

Results: The review shows that there is still substantial variety in the applications of irrigation to open fractures. The study reflects upon strengths and weaknesses of both high pressure lavage and gravity lavage. Pulse lavage better disrupts the biofilm created by bacterial colonies in wounds that have delayed irrigation when compared with gravity lavage. In contrast, high pressure lavage washes away viable bone growth factors and cells as well as breaks down trabecular bone. This slows bone and soft tissue healing. It may also force bacteria deeper into tissues. In a discussion of additives to saline, plain normal saline was shown to be least aggravating to injured soft tissues than saline with additive. More over, plain saline also removed bacteria at similar rates as saline with antiseptics, surfactants, and antibiotics. With regards to timing of irrigation, the article discussed irrigation before six hours as being ideal due to bacteria’s ability to form a mature biofilm at 10 hours. However, there is no consistent evidence that proves a significant difference between early and moderately delayed irrigation times. “The solution to pollution is dilution” is the single definitive statement the study stated. Larger volumes of irrigation result in lower rates of infection.

Conclusions: The goal of irrigation is to remove non-viable tissue and contamination while simultaneously minimizing damage to brutalized soft and osseous tissues. Though there are numerous methods of delivery and additives that can be attempted when irrigating, none have definitively proved to be superior to saline with gravity flow. Furthermore, the toxicity of the irrigating agents and destructive nature of high pressure lavage have been shown to delay healing of soft tissue and bone. Ultimately, the study relates that the optimal irrigation plan involves gentle application sterile plain saline, in large volumes, as soon as possible after the incident. The soft tissue envelope undergoes significant trauma with open fractures and needs delicate care and meticulous management. Given the high rate of infection and complications with open fractures, it is vital to hone our practice to ensure the greatest outcomes for patients. 

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