Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity.

Open fractures of the lower extremity accompanied by extensive soft-tissue damage can be effectively managed by a collaborative approach between orthopedic and plastic surgeons. The fundamental concepts of this aggressive, systematic approach are adequate debridement and soft-tissue healing by delayed primary intention. The protocol that has evolved at the MIEMSS Shock Trauma Unit involves emergency radical debridement of all devitalized soft tissue and bone fragments together with external stabilization of the fractured extremity. The zone of injury, which is often not apparent at presentation, is determined by serial debridements performed in the operating room over several days. When the wound is defined, soft-tissue closure is obtained with local or free muscle transfer. In very high energy-induced trauma, local muscle flaps are often involved in the zone of injury or are inadequate to cover the resultant defects. Free muscle transfers that provide large amounts of undamaged, well-vascularized tissue are therefore the reconstructive alternative of choice for such injuries. Bone defects are bridged 4 to 6 weeks after soft-tissue closure with cancellous or vascularized fibula grafts depending on defect size. This regimen, which has virtually eliminated the problem of infection, has been successful in salvaging and rehabilitating these severely injured lower extremities.