Wound irrigation in musculoskeletal injury

Wound irrigation to remove debris and lessen bacterial contamination is an essential component of open fracture care. However, considerable practice variation exists in the details of technique. Volume is an important factor; increased volume improves wound cleansing to a point, but the optimal volume is unknown. High-pressure flow has been shown to remove more bacteria and debris and to lower the rate of wound infection compared with low-pressure irrigation, although recent in vitro and animal studies suggest that it may also damage bone. Pulsatile flow has not been demonstrated to increase efficacy. Antiseptic additives can kill bacteria in the wound, but host-tissue toxicities limit their use. Animal and clinical studies of the use of antiseptics in contaminated wounds have yielded conflicting outcomes. Antibiotic irrigation has been effective in experimental studies in some types of animal wounds, but human clinical data are unconvincing due to poor study design. There are few animal or clinical studies of musculoskeletal wounds. Detergent irrigation aims to remove, rather than kill, bacteria and has shown promise in animal models of the complex contaminated musculoskeletal wound.