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Debridement

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 injured and devitalized tissue, blood clots, foreign bodies, and for the control of hemorrhage. This is a procedure that is carried out initially to stop the continuous destructive process of the wound and to prepare it for the initial reparative phase of wound healing. The definitive procedure (delayed primary closure) is performed at a later date.

There are many differences between the management of wounds in a combat theater and in civilian practice. When a surgeon is first indoctrinated into forward surgery, he feels that leaving war wounds open is incomplete treatment because in civilian surgery the initial care is a definitive reparative procedure. Definitive surgery cannot be carried out in the forward hospital initially because: (1) usually the time lag is longer for war casualties than for civilian casualties; (2) after initial treatment, a war casualty must be evacuated at an early date to a hospital further to the rear, thus making it impossible for proper immobilization of the injured area; and (3) because of evacuation, the patient must be cared for by various physicians. These physicians cannot be as familiar with the condition of the wound as the surgeon who treated the patient initially. Careful postoperative observation for wound infection, excessive swelling, or necrosis of injured tissue is impractical during transportation.

Since these factors make it impossible to follow the patient closely from the time of injury to the completion of wound healing, it is necessary that a safe procedure be followed so that uniformly good results can be obtained. Thus the initial phase of treatment in the forward hospital consists of an adequate incision and excision of devitalized tissue. Delayed primary closure 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 Medical Service 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 time lag. The skin about the wound should be shaved, washed with a detergent containing hexachlorophene, and thoroughly irrigated.

Skin. Débridement of the skin may be divided into two aspects: first, exposure of the depth of the wound by adequate incision and, second, excision of the devitalized skin. In order to reach the base of the wound for excision of devitalized tissue, it is necessary to enlarge the skin defect by a long incision. Inadequate incisions give poor exposure to the deeper portion of the wound, which may result in incomplete removal of devitalized tissue and difficulty in control of hemorrhage. Skin at the point of entrance of a missile may be shredded, discolored and very dirty; but it may still be viable. Wide excision of skin is unnecessary. In general, approximately 1/8 inch of skin should be excised from the injured wound edge.

Longitudinal incisions should be used in extremity wounds to prevent contracture and to permit easier dissection of deep muscle planes. A Z-type incision is desirable where wounds are present in a flexion crease about a joint.

At the completion of the debridement, the skin is allowed to remain open except in wounds of the scalp, face, neck and scrotum. In injuries to 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 to a minimum; and the edges should be undermined, if necessary, in order that approximation can be made without tension.

Subcutaneous Tissue. Débridement of the subcutaneous tissue is not difficult. The entire layer of subcutaneous tissue must be excised in very dirty wounds. In other instances, most of the injured fat, debris and blood clots can be removed by irrigation.

Fascia. It is difficult to determine when fascia is viable, but it must be excised when it is shredded and dirty. The fascia should be incised for at least the entire length of the skin incision to allow adequate observation of the underlying muscle and to prevent constriction and necrosis of the muscle when postoperative swelling occurs. The fascia must remain open to provide adequate drainage of the deeper tissues. Without proper drainage of the base of the wound, serum and blood may accumulate to form a 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 made in order to give adequate relaxation.


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Muscle. Muscle is the most important and difficult tissue to débride. Dead muscle produces an excellent medium for the growth of bacteria in the wound. The infection of greatest clinical significance is caused by organisms of the Clostridium welchii group. Clostridial myositis frequently necessitates the amputation of an extremity and may even cause loss of life.

Muscle is difficult to débride because the operating surgeon has 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 of the muscle, its consistency, its contractility and its ability to bleed.

A study was conducted by the Surgical Research Team in Korea in an attempt to determine the value of various criteria for viability of muscle. They obtained 60 muscle biopsies at the time of débridement and graded them as to color, consistency, contractility and ability to bleed. These biopsies were then studied by the pathologist and categorized according to minimal, slight, moderate, severe and complete necrosis. In correlating the gradation of various criteria with the amount of necrosis in the microscopic sections, it was found that consistency, contractility and ability to bleed were acceptable, dependable criteria. There was less correlation between color and amount of necrosis.

The actual technic of débridement is important because these criteria must be carefully evaluated. Adequate exposure and illumination into all portions of the wound are essential. The wound must be irrigated frequently to wash out clots in order to obtain a better view of the muscle. Hemostasis is sometimes difficult, but it must be maintained during operation in order to permit proper visualization. Bold excision of dead muscle is required. Great care must be taken to prevent surgical injury to vital structures in the deeper muscle layers.

Bone. In comminuted fractures, an effort is always made to leave bone fragments in situ. Likewise small bone chips should not be removed if they are in close approximation to the fracture as they will usually grow and act as a graft. If the chips are scattered throughout the wound, they should be removed, as they may act as foreign bodies. In all fractures, the bone is covered either by placing muscle over the exposed area or by approximating the skin loosely in cases where muscle and subcutaneous tissue are absent. Fractures are reduced manually. The extremity is then placed in a cast to preserve length and immobilize the injured part.

Joint Spaces. Injuries to the joint spaces are treated by opening the joint and removing any foreign bodies. The joint space is irrigated with saline solution. The joint capsule is closed and reinforced


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by suturing subcutaneous tissue over it. Loose particles of cartilage must be removed or they will act as foreign bodies.

Débridement of Various Regions

Wounds of the Scalp. Débridement of wounds of the scalp is carried out, layer by layer, by excision of devitalized tissue and by thorough irrigation and primary closure. This type of treatment is possible because the increased blood supply to the scalp promotes rapid healing. Hemostasis may be difficult, but can be achieved by sutures approximating the wound edges. In some instances, it becomes necessary to make lateral, relaxing incisions to release sufficient skin for primary closure of the wound. Since pressure dressings are difficult to apply to this area, wounds of the scalp should be checked at frequent intervals so that hematoma formation will not be overlooked.

Wounds of the Face. The primary consideration in treating wounds of the face, especially about the oral cavity, is the maintenance of an adequate airway. A tracheotomy must be performed in those instances where profuse bleeding into the nasopharynx makes the establishment of an airway difficult. After an adequate airway is assured, the bleeding points should be controlled, the entire wound cleansed, and devitalized tissue excised. Wounds of the face are also closed by primary suture, principally for cosmetic reasons. Wounds in this area heal well because of the excellent blood supply to the face. If a fracture of the mandible or maxilla is present, the teeth should be wired in apposition.

Wounds of the Neck. Wounds of the neck present three essential problems: (1) obstruction of the airway, (2) trauma to a large blood vessel, and (3) injury to the esophagus and trachea. At the slightest indication of 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 conservative management of an underlying vascular injury is elected. Simple wounds of the neck are débrided and closed by primary suture. Deeper wounds require drainage.

The patient must be examined closely to determine the course of the missile after its entrance into the neck. X-ray examinations are of great value in assisting in this procedure, especially when a foreign body is retained. If it cannot be ascertained whether the missile has traversed the trachea or esophagus, exploration of the neck with exposure of the esophagus and trachea is necessary. An incision is made along the anterior border of the sternocleidomastoid muscle. After the subcutaneous tissue has been incised, it is possible to dissect between


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fascial planes and expose the trachea and esophagus. If these structures have been injured, they are repaired with interrupted sutures. Rubber tissue drains are placed at the base of the wound and brought out at the upper and 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 require careful examination preoperatively to determine the extent of damage and the presence of bone, nerve and vascular involvement. An accurate record should be made of these findings. Various types of wounding agents produce different patterns of tissue damage. For instance, a high-velocity missile will usually produce a small wound of entrance and of exit, with massive destruction of tissue within the extremity. Lower-velocity missiles of comparable size produce less cavitation and internal muscle destruction. It must be emphasized that all missile wounds of soft tissue are characterized by greater muscle damage than is apparent from the external examination of the injured part. Routine roentgenograms of the extremities are advised for the detection of retained metallic fragments.

The wound should be exposed by enlarging the skin opening in both directions by a longitudinal incision. Through-and-through wounds should be explored by adequate longitudinal incision on each side. In all large wounds and in wounds in which vascular involvement is suspected, a pneumatic tourniquet should be placed about the extremity before operation. It need not be inflated unless difficult hemorrhage is encountered. In many instances, an inflated tourniquet will cause troublesome bleeding by increasing venous engorgement.

The surgeon should have a thorough knowledge of the anatomy of the involved region to avoid unnecessary trauma to blood vessels and nerves during excision of devitalized tissue. Extensive fasciotomies are necessary in order to prevent the necrosis which may result from muscle swelling.

All devitalized muscle must be excised. In areas of small muscle mass where excessive excision may jeopardize function, such as the forearm and hand, débridement should be conservative. In areas of large muscle masses, such as the thigh and buttocks, débridement must be more radical. Devitalized tissue remaining in deep muscle bundles gives rise to serious infections, septicemia and clostridial myositis; whereas the incidence 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 should be exposed, explored and repaired prior to actual débridement of the wound. This is particularly true in the femoral triangle and in the popliteal 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 that the procedure may be conducted in a bloodless field. The minimum amount of tissue, especially skin, should be removed. The surgeon should be conservative in amputation of digits. Blood clots and debris should be washed out and devitalized tissue excised. No attempt should be made at this time to repair or tag nerves or tendons. Only small, loose chips of bone should be removed. Bone fragments may be aligned by manual reduction. Finally, the wound should be thoroughly irrigated and the skin approximated loosely by one or two sutures 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. In addition, tight closure of hand wounds is frequently followed by infection beneath the skin, thus delaying wound healing and producing a greater loss of function. The hand should then be splinted in a position of function. The tips of the fingers should remain exposed for observation of circulatory status.

Superficial Wounds of the Abdomen and Chest. Almost all superficial wounds of the chest and abdomen are débrided and left open. After débridement, deep sucking wounds of the chest are closed tightly in layers. In massive wounds of the abdominal wall, the peritoneum and fascia should be closed and the skin should be left open. Incisions for abdominal exploration and for colostomy should never be made through the wound.

General Aspects of Débridement

Immediately after admission, antibiotics should be given. The intravenous route is preferred in order to assure adequate blood levels. Postoperatively, antibiotics should be given routinely for a maximum of 5 days and thereafter only on specific indications. All patients should receive tetanus toxoid or antitoxin. Gas gangrene antitoxin is of no value. The prevention of clostridial myositis depends upon the adequacy of the débridement.

Not all débridements are simple surgical procedures. The small, superficial wound is not difficult to débride. Débridement of moderate-size, soft-tissue wounds can usually be carried out by the surgeon and a scrub technician. In more extensive débridements, the surgeon requires a first assistant. Not infrequently, greater bleeding is encountered than is expected; and an excessive amount of blood loss occurs because technical assistance is not available to provide adequate exposure. Because of the slow, constant loss of blood from the damaged muscle, hemorrhage is always greater than the surgeon anticipates.


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When several areas of the body require débridement, it is wise to use two teams in an attempt to decrease the operating time and the blood loss.

Some larger wounds are not difficult to débride; but they require expert 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 wounds of the buttock and upper thigh. These wounds present two difficult aspects, namely, control of hemorrhage and determination of the exact amount of muscle to be excised. A tourniquet cannot be applied to control hemorrhage. It is almost impossible to achieve adequate pressure for hemostasis by a dressing. General oozing may continue from the massive muscle area after débridement and ligation of all visible bleeding points. When a large amount of muscle is involved, it is difficult to determine the exact amount to be excised. When high-velocity missiles cause wounds of the thigh or buttock, frequently they carry damage along fascial planes and between the muscle bundles. If devitalized deep muscle remains, clostridial myositis or pockets of infection may develop. In large wounds of the buttocks and upper thigh, it is wise to take a "second look" on the second and third postoperative day. At that time, remaining necrotic tissue is easily recognized and further débridement can be carried out.

Large missile fragments in soft-tissue wounds are removed. Small fragments are removed if easily accessible. If further trauma is required to effect their removal, they are allowed to remain in place. Plain catgut is preferred for ligatures, since foreign-body reactions are not uncommon following the use of silk.

After careful hemostasis has been achieved, the open wound should he covered with fine-mesh gauze and a large occlusive pressure dressing applied. Packing the wound with gauze prohibits drainage. When plaster casts are applied for the immobilization of fractures, a longitudinal, half-inch segment should be removed and the circular dressings cut down to the skin. This procedure prevents undue pressure when edema occurs.

Summary

Débridement, or the excision of devitalized tissue, is the initial treatment for all soft-tissue wounds. Long incisions into skin should be made to insure adequate exposure of the deepest portion of the wound.

The incision in the fascia should be of sufficient length to provide adequate decompression of the underlying edematous muscle.


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Consistency, contractility and ability to bleed appear to be the most reliable criteria for the determination of viability of muscle. Inadequate removal 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. Blood vessels, tendons, nerves, bone, testicles and open joint spaces should be covered by loose approximation of the surrounding tissue or skin. All other soft-tissue wounds should be let open.

Débridement is most difficult to carry out in large wounds of the buttocks and upper thigh.

Experiences in the Korean conflict have re-emphasized the safety and efficacy of débridement and delayed primary closure in the management of soft-tissue wounds.