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