Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIX: Wounds and Injuries of Bones and Joints

General Principles

United States Department of Defense
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The forward surgeon should manage open injuries of bones and joints according to the following general principles:

1. Evaluation. One must initially determine the extent of the wound and of the structures involved. In high-velocity missile wounds, tissues and structures at some distance from the actual wound tract may be damaged and require debridement.
2. Prophylaxis. Parenteral antibiotic treatment and tetanus prophylaxis should be initiated at the earliest opportunity. In general, broad spectrum antibiotic coverage for both Gram-negative and Gram-positive organisms is recommended. Since all open war wounds are contaminated and present a risk of developing tetanus, all of these individuals should receive a 0.5 cc IM tetanus toxoid booster injection. Antibiotics and tetanus coverage should never be construed as a substitute for adequate wound cleansing and debridement.
3. Debridement. Generous incisions should be the rule. Such incisions permit better exploration of the wound, facilitate removal of foreign material (clothing, soil, vegetation, accessible metal fragments), and allow more complete excision of all devitalized tissue. In general, small, detached bone-chip fragments should be removed, but major in situ fragments with significant soft tissue attachments should be retained. Copious irrigation of the wound, with pulsatile lavage if possible, is mandatory. Property performed debridement provides the basis for prevention of infection and the success of all future treatments, including reconstructive surgical procedures. Definitive surgery, primary closure of wounds, relaxing skin incisions, and nerve and tendon repair have no place at this stage of treatment.
4. Arthrotomy. Penetrating joint wounds require arthrotomy irrigation, thorough surgical exploration, and debridement.
5. Vascular repair and fasciotomy. These are the only appropriate definitive procedures performed at the time of initial wound surgery. Vascular injuries should be addressed through "wounds of election" and fasciotomies should be routinely performed following vascular repairs. If possible, an attempt should be made to cover the vascular repair with viable soft tissue; however, the wound should be left open.
6. Leave wound open. Perhaps the most important principle after debridement of way wounds is to leave the wound open. Bleeding points are controlled, but otherwise no attempt at wound closure is made, and drains are usually not necessary.
7. Nonocclusive dressing and immobilization. The wound is covered with a sterile, bulky, nonocclusive dressing and the extremity appropriately immobilized by plaster splints or a plaster cast which is immediately bivalved. In some cases, external skeletal fixation may be utilized.
8. Documentation. It is important to document in the medical record all operative findings, particularly vascular, neural, tendon, or muscle damage, in addition to the more obvious skeletal injury. This information is vital to subsequent care providers as the patient progresses through the evacuation chain. If a plaster dressing is used, this information can also be briefly documented with a marking pen on the plaster itself.

Adherence to these general principles at all treatment levels will substantially enhance the likelihood of functional recovery and minimal morbidity.

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