Preparations for open fractures

The patient with an open extremity fracture is usually brought into the operating suite with a lying splint (e.g. air chamber splint). Usually sterile bandages have already been applied to the wound by the emergency doctor (O Fig. 9.7).

In the emergency room, the emergency doctor reports about the extent of the injury so that the wound does not have to be uncovered and inspected again here (risk of contamination).

The patient is usually placed under anaesthetic already in the resuscitation room, but at the latest on arrival in the operating theatre; under certain circumstances, this may already take place on the emergency stretcher to save the patient from the pain of transfer.

It is advisable to keep the required materials in a special cabinet or mobile unit which can be positioned at the anaesthesia induction sluice without any problems. It is important that the utensils required to prepare surgery for closed and open fractures are always at the ready.

The washing trolleys we use keep adequate quantities of the following materials at the ready (see also O Fig. 9.8): 4 non-sterile razors, 4 non-sterile disposable gloves, 4 non-sterile, absorbent disposable sheets, 4 sterile razors, 4 sterile gloves,

4 sterile absorbent disposable sheets, 4 sterile hand brushes, 4 sterile bacteriology tubes, 4 sterile disposable drapes,

4 sterile saline bowls (separate bowl and washing utensils for every open fracture!), 4 compresses without contrasting stripe! 4 saline solution in i-l bottles (also from the warming cabinet), 4 washing lotion, 4 disinfectant.

After placing the patient under anaesthetic, the fracture splint is removed, the affected extremity is held up under longitudinal tension by an assistant who wears disposable gloves for protection, and the sterile bandage is removed.

After removing the sterile bandage, a first swab is taken from the wound for forensic reasons before cleansing the wound. According to the protocol valid in our institution, an intravenous antibiotic was already administered in the emergency room.

An absorbent disposable sheet (sterile if the extremity is put down in between!) is placed under the injured extremity to soak up any dripping blood and the washing lotion and disinfectant.

If necessary the wound or operating site is shaved as sparsely as possible, dry or wet, with a sterile disposable razor, taking note of the fact that the shaved hairs can only be removed efficiently from the skin with a strip of plaster after a dry shave.

Under continuing longitudinal tension to avoid further damage to the soft tissues, the injured extremity is now washed by an assistant who already wears sterile gloves (O Fig. 9.9).

Fig. 9.7. Fracture splints for the lower extremities
Fig. 9.8. Prepared washing utensils
Fig. 9.9. Cleaning the injured extremity

The extremity is lathered thoroughly with sterile compresses and a saline washing solution mixed in a sterile saline bowl. The patient could be shaved with a wet shave at this point, but this is not advisable in our opinion because it is difficult to remove the shaved hair.

The wound is then cleansed firstly by removing any residual coarse dirt. Larger particles are carefully removed from the wound, which is then cleaned with the hand brush to remove any impurities. Any minor bleeding at this stage is irrelevant, because this helps to clean the wound from the inside (O Fig. 9.10).

After rinsing the extremity with saline solution again to remove any residual soap, the extremity is dried with sterile compresses.

The extremity is then rubbed with an alcoholic disinfectant around the area of the wound together with the wound itself (O Fig. 9.11). Another swab can be taken from the wound at this point in time, with a third following after the operation has begun (O Fig. 9.17).

The wound is now covered with sterile compresses and the injured extremity is wrapped in a sterile disposable towel. The patient is now transferred from the transporter to the operating table using a roll board (O Figs. 9.12-9.14).

Fig. 9.14. Removing the roll board
Fig. 9.15. Permanent stabilisation of the fractured extremity

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