Medical Science Publication No. 4, Volume 1
DEBRIDEMENT*
CAPTAIN ALVIN W. BRONWELL,MC
MAJOR CURTIS P. ARTZ,MC
AND
CAPTAIN YOSHIO SAKO,MC
Débridement is a surgical procedure for the removal of injuredand devitalized tissue, blood clots, foreign bodies, and for the controlof hemorrhage. This is a procedure that is carried out initially to stopthe continuous destructive process of the wound and to prepare it for theinitial reparative phase of wound healing. The definitive procedure (delayedprimary closure) is performed at a later date.
There are many differences between the management of wounds in a combattheater and in civilian practice. When a surgeon is first indoctrinatedinto forward surgery, he feels that leaving war wounds open is incompletetreatment because in civilian surgery the initial care is a definitivereparative procedure. Definitive surgery cannot be carried out in the forwardhospital initially because: (1) usually the time lag is longer for warcasualties than for civilian casualties; (2) after initial treatment, awar casualty must be evacuated at an early date to a hospital further tothe rear, thus making it impossible for proper immobilization of the injuredarea; and (3) because of evacuation, the patient must be cared for by variousphysicians. These physicians cannot be as familiar with the condition ofthe wound as the surgeon who treated the patient initially. Careful postoperativeobservation for wound infection, excessive swelling, or necrosis of injuredtissue is impractical during transportation.
Since these factors make it impossible to follow the patient closelyfrom the time of injury to the completion of wound healing, it is necessarythat a safe procedure be followed so that uniformly good results can beobtained. Thus the initial phase of treatment in the forward hospital consistsof an adequate incision and excision of devitalized tissue. Delayed primaryclosure is completed at a later date, usually in another hospital.
*Presented 21 April 1954,to the Course on Recent Advances in Medicine and Surgery, Army MedicalService Graduate School, Walter Reed Army Medical Center, Washington, D.C.
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Débridement of Different Types of Tissue
All wounds should be treated exactly the same, regardless of the timelag. The skin about the wound should be shaved, washed with a detergentcontaining hexachlorophene, and thoroughly irrigated.
Skin. Débridement of the skin may be divided into twoaspects: first, exposure of the depth of the wound by adequate incisionand, second, excision of the devitalized skin. In order to reach the baseof the wound for excision of devitalized tissue, it is necessary to enlargethe skin defect by a long incision. Inadequate incisions give poor exposureto the deeper portion of the wound, which may result in incomplete removalof devitalized tissue and difficulty in control of hemorrhage. Skin atthe point of entrance of a missile may be shredded, discolored and verydirty; but it may still be viable. Wide excision of skin is unnecessary.In general, approximately 1/8inch of skin should be excised from the injured wound edge.
Longitudinal incisions should be used in extremity wounds to preventcontracture and to permit easier dissection of deep muscle planes. A Z-typeincision is desirable where wounds are present in a flexion crease abouta joint.
At the completion of the debridement, the skin is allowed to remainopen except in wounds of the scalp, face, neck and scrotum. In injuriesto the hand, all attempt should be made to give cover to vital structures.This can be done by approximating the skin loosely with one or two sutures.In wounds about the face and scalp, excision of skin should be kept toa minimum; and the edges should be undermined, if necessary, in order thatapproximation can be made without tension.
Subcutaneous Tissue. Débridement of the subcutaneous tissueis not difficult. The entire layer of subcutaneous tissue must be excisedin very dirty wounds. In other instances, most of the injured fat, debrisand blood clots can be removed by irrigation.
Fascia. It is difficult to determine when fascia is viable, butit must be excised when it is shredded and dirty. The fascia should beincised for at least the entire length of the skin incision to allow adequateobservation of the underlying muscle and to prevent constriction and necrosisof the muscle when postoperative swelling occurs. The fascia must remainopen to provide adequate drainage of the deeper tissues. Without properdrainage of the base of the wound, serum and blood may accumulate to forma pabulum for bacterial growth and subsequent infection. In most instances,the fascia is incised along the direction of its fibers. In some instances,such as in wounds of the fascia lata, a cruciate incision must be madein order to give adequate relaxation.
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Muscle. Muscle is the most important and difficult tissue todébride. Dead muscle produces an excellent medium for the growthof bacteria in the wound. The infection of greatest clinical significanceis caused by organisms of the Clostridium welchii group. Clostridialmyositis frequently necessitates the amputation of an extremity and mayeven cause loss of life.
Muscle is difficult to débride because the operating surgeonhas no clear-cut criteria or tests by which to judge the viability of muscle.Usually the surgeon draws upon his past experience in observing color ofthe muscle, its consistency, its contractility and its ability to bleed.
A study was conducted by the Surgical Research Team in Korea in an attemptto determine the value of various criteria for viability of muscle. Theyobtained 60 muscle biopsies at the time of débridement and gradedthem as to color, consistency, contractility and ability to bleed. Thesebiopsies were then studied by the pathologist and categorized accordingto minimal, slight, moderate, severe and complete necrosis. In correlatingthe gradation of various criteria with the amount of necrosis in the microscopicsections, it was found that consistency, contractility and ability to bleedwere acceptable, dependable criteria. There was less correlation betweencolor and amount of necrosis.
The actual technic of débridement is important because thesecriteria must be carefully evaluated. Adequate exposure and illuminationinto all portions of the wound are essential. The wound must be irrigatedfrequently to wash out clots in order to obtain a better view of the muscle.Hemostasis is sometimes difficult, but it must be maintained during operationin order to permit proper visualization. Bold excision of dead muscle isrequired. Great care must be taken to prevent surgical injury to vitalstructures in the deeper muscle layers.
Bone. In comminuted fractures, an effort is always made to leavebone fragments in situ. Likewise small bone chips should not beremoved if they are in close approximation to the fracture as they willusually grow and act as a graft. If the chips are scattered throughoutthe wound, they should be removed, as they may act as foreign bodies. Inall fractures, the bone is covered either by placing muscle over the exposedarea or by approximating the skin loosely in cases where muscle and subcutaneoustissue are absent. Fractures are reduced manually. The extremity is thenplaced in a cast to preserve length and immobilize the injured part.
Joint Spaces. Injuries to the joint spaces are treated by openingthe joint and removing any foreign bodies. The joint space is irrigatedwith saline solution. The joint capsule is closed and reinforced
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by suturing subcutaneous tissue over it. Loose particles of cartilagemust be removed or they will act as foreign bodies.
Débridement of Various Regions
Wounds of the Scalp. Débridement of wounds of the scalpis carried out, layer by layer, by excision of devitalized tissue and bythorough irrigation and primary closure. This type of treatment is possiblebecause the increased blood supply to the scalp promotes rapid healing.Hemostasis may be difficult, but can be achieved by sutures approximatingthe wound edges. In some instances, it becomes necessary to make lateral,relaxing incisions to release sufficient skin for primary closure of thewound. Since pressure dressings are difficult to apply to this area, woundsof the scalp should be checked at frequent intervals so that hematoma formationwill not be overlooked.
Wounds of the Face. The primary consideration in treating woundsof the face, especially about the oral cavity, is the maintenance of anadequate airway. A tracheotomy must be performed in those instances whereprofuse bleeding into the nasopharynx makes the establishment of an airwaydifficult. After an adequate airway is assured, the bleeding points shouldbe controlled, the entire wound cleansed, and devitalized tissue excised.Wounds of the face are also closed by primary suture, principally for cosmeticreasons. Wounds in this area heal well because of the excellent blood supplyto the face. If a fracture of the mandible or maxilla is present, the teethshould be wired in apposition.
Wounds of the Neck. Wounds of the neck present three essentialproblems: (1) obstruction of the airway, (2) trauma to a large blood vessel,and (3) injury to the esophagus and trachea. At the slightest indicationof obstruction of the airway, a tracheotomy must be performed immediately.To delay for definite signs of obstruction may be fatal.
Débridement is not performed in wounds of the neck when conservativemanagement of an underlying vascular injury is elected. Simple wounds ofthe neck are débrided and closed by primary suture. Deeper woundsrequire drainage.
The patient must be examined closely to determine the course of themissile after its entrance into the neck. X-ray examinations are of greatvalue in assisting in this procedure, especially when a foreign body isretained. If it cannot be ascertained whether the missile has traversedthe trachea or esophagus, exploration of the neck with exposure of theesophagus and trachea is necessary. An incision is made along the anteriorborder of the sternocleidomastoid muscle. After the subcutaneous tissuehas been incised, it is possible to dissect between
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fascial planes and expose the trachea and esophagus. If these structureshave been injured, they are repaired with interrupted sutures. Rubber tissuedrains are placed at the base of the wound and brought out at the upperand lower angles of the incision and the wound is then closed. If indicated,the contralateral side is similarly treated.
Wounds of the Extremities. Wounds of the extremities requirecareful examination preoperatively to determine the extent of damage andthe presence of bone, nerve and vascular involvement. An accurate recordshould be made of these findings. Various types of wounding agents producedifferent patterns of tissue damage. For instance, a high-velocity missilewill usually produce a small wound of entrance and of exit, with massivedestruction of tissue within the extremity. Lower-velocity missiles ofcomparable size produce less cavitation and internal muscle destruction.It must be emphasized that all missile wounds of soft tissue are characterizedby greater muscle damage than is apparent from the external examinationof the injured part. Routine roentgenograms of the extremities are advisedfor the detection of retained metallic fragments.
The wound should be exposed by enlarging the skin opening in both directionsby a longitudinal incision. Through-and-through wounds should be exploredby adequate longitudinal incision on each side. In all large wounds andin wounds in which vascular involvement is suspected, a pneumatic tourniquetshould be placed about the extremity before operation. It need not be inflatedunless difficult hemorrhage is encountered. In many instances, an inflatedtourniquet will cause troublesome bleeding by increasing venous engorgement.
The surgeon should have a thorough knowledge of the anatomy of the involvedregion to avoid unnecessary trauma to blood vessels and nerves during excisionof devitalized tissue. Extensive fasciotomies are necessary in order toprevent the necrosis which may result from muscle swelling.
All devitalized muscle must be excised. In areas of small muscle masswhere excessive excision may jeopardize function, such as the forearm andhand, débridement should be conservative. In areas of large musclemasses, such as the thigh and buttocks, débridement must be moreradical. Devitalized tissue remaining in deep muscle bundles gives riseto serious infections, septicemia and clostridial myositis; whereas theincidence of these complications is not so great in the more superficial,open wounds of the hand and forearm.
When major vascular laceration is suspected, the blood vessel shouldbe exposed, explored and repaired prior to actual débridement ofthe wound. This is particularly true in the femoral triangle and in thepopliteal areas.
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Wounds of the Hand. In débridement of wounds of the hand,preservation of maximum function is essential. In all cases of hand injury,it is very important that a torniquet be placed on the arm in order thatthe procedure may be conducted in a bloodless field. The minimum amountof tissue, especially skin, should be removed. The surgeon should be conservativein amputation of digits. Blood clots and debris should be washed out anddevitalized tissue excised. No attempt should be made at this time to repairor tag nerves or tendons. Only small, loose chips of bone should be removed.Bone fragments may be aligned by manual reduction. Finally, the wound shouldbe thoroughly irrigated and the skin approximated loosely by one or twosutures over the deep structures. If the skin on the hand is closed tightly,swelling and further loss of skin may occur as a result of necrosis. Inaddition, tight closure of hand wounds is frequently followed by infectionbeneath the skin, thus delaying wound healing and producing a greater lossof function. The hand should then be splinted in a position of function.The tips of the fingers should remain exposed for observation of circulatorystatus.
Superficial Wounds of the Abdomen and Chest. Almost all superficialwounds of the chest and abdomen are débrided and left open. Afterdébridement, deep sucking wounds of the chest are closed tightlyin layers. In massive wounds of the abdominal wall, the peritoneum andfascia should be closed and the skin should be left open. Incisions forabdominal exploration and for colostomy should never be made through thewound.
General Aspects of Débridement
Immediately after admission, antibiotics should be given. The intravenousroute is preferred in order to assure adequate blood levels. Postoperatively,antibiotics should be given routinely for a maximum of 5 days and thereafteronly on specific indications. All patients should receive tetanus toxoidor antitoxin. Gas gangrene antitoxin is of no value. The prevention ofclostridial myositis depends upon the adequacy of the débridement.
Not all débridements are simple surgical procedures. The small,superficial wound is not difficult to débride. Débridementof moderate-size, soft-tissue wounds can usually be carried out by thesurgeon and a scrub technician. In more extensive débridements,the surgeon requires a first assistant. Not infrequently, greater bleedingis encountered than is expected; and an excessive amount of blood lossoccurs because technical assistance is not available to provide adequateexposure. Because of the slow, constant loss of blood from the damagedmuscle, hemorrhage is always greater than the surgeon anticipates.
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When several areas of the body require débridement, it is wiseto use two teams in an attempt to decrease the operating time and the bloodloss.
Some larger wounds are not difficult to débride; but they requireexpert judgment to determine the proper amount of muscle to be removed.Débridement of large wounds is not a task for the immature surgeon;it requires the ability of the more experienced.
One of the great problems in surgery is the management of massive woundsof the buttock and upper thigh. These wounds present two difficult aspects,namely, control of hemorrhage and determination of the exact amount ofmuscle to be excised. A tourniquet cannot be applied to control hemorrhage.It is almost impossible to achieve adequate pressure for hemostasis bya dressing. General oozing may continue from the massive muscle area afterdébridement and ligation of all visible bleeding points. When alarge amount of muscle is involved, it is difficult to determine the exactamount to be excised. When high-velocity missiles cause wounds of the thighor buttock, frequently they carry damage along fascial planes and betweenthe muscle bundles. If devitalized deep muscle remains, clostridial myositisor pockets of infection may develop. In large wounds of the buttocks andupper thigh, it is wise to take a "second look" on the secondand third postoperative day. At that time, remaining necrotic tissue iseasily recognized and further débridement can be carried out.
Large missile fragments in soft-tissue wounds are removed. Small fragmentsare removed if easily accessible. If further trauma is required to effecttheir removal, they are allowed to remain in place. Plain catgut is preferredfor ligatures, since foreign-body reactions are not uncommon followingthe use of silk.
After careful hemostasis has been achieved, the open wound shouldhe covered with fine-mesh gauze and a large occlusive pressure dressingapplied. Packing the wound with gauze prohibits drainage. When plastercasts are applied for the immobilization of fractures, a longitudinal,half-inch segment should be removed and the circular dressings cut downto the skin. This procedure prevents undue pressure when edema occurs.
Summary
Débridement, or the excision of devitalized tissue, is the initialtreatment for all soft-tissue wounds. Long incisions into skin should bemade to insure adequate exposure of the deepest portion of the wound.
The incision in the fascia should be of sufficient length to provideadequate decompression of the underlying edematous muscle.
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Consistency, contractility and ability to bleed appear to be the mostreliable criteria for the determination of viability of muscle. Inadequateremoval of devitalized muscle may lead to clostridial myositis and septicemia.
After adequate débridement, wounds of the scalp, face and neck,and sucking wounds of the chest should be closed by primary suture. Bloodvessels, tendons, nerves, bone, testicles and open joint spaces shouldbe covered by loose approximation of the surrounding tissue or skin. Allother soft-tissue wounds should be let open.
Débridement is most difficult to carry out in large wounds ofthe buttocks and upper thigh.
Experiences in the Korean conflict have re-emphasized the safety andefficacy of débridement and delayed primary closure in the managementof soft-tissue wounds.
