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3Débridement

Next, all dead, or questionably viable, tissue is excised systematically from each tissue layer:

  • subcutaneous tissues
  • deep fascia
  • muscle
  • bone

At each level, leave only obviously viable tissue.
Any bony fragments devoid of soft-tissue attachment should be removed. Contaminated, or non-viable, bone surfaces will also need excision with hand instruments, such as chisels and rongeurs.
Copious irrigation with a balanced salt solution (such as Ringer-lactate) helps to remove bacteria, bits of dead tissue and blood clot, and improves the surgeon’s ability to examine the wound.
The use of pulsed pressure-lavage systems risks driving contamination into the hidden depths of the wound, and is of questionable value. 

See also:
Bhandari, M.et al. (1999) High and Low Pressure Pulsatile Lavage of Contaminated Tibial Fractures: An In Vitro Study of Bacterial Adherence and Bone Damage.  J Ortho Trauma: 13: 526-533.
Hassinger, S.M. et al. (2005) High-Pressure Pulsatile Lavage Propagates Bacteria into Soft Tissue Clin Ortho Rel Res 439; 27-31.
D. J. Crowley et al. (1989) Irrigation of the wounds in open fractures J Bone and Joint SurgB - 89, 580-585.