Débridement of extremity war wounds

The extent of surgery appropriate for limb wounds agreed on at the Inter-Allied Surgical Conference in 1917 included excision of the skin margin, generous extension of the wound, exploration through all layers, and excision of damaged muscle--techniques recognizable by all trauma surgeons today. The criteria for muscle viability (the four C's) include contraction on being pinched, consistency (not waxy or "stewed"), capillary bleeding when cut, and color (red, not pale or brown). Skin is excised with a narrow margin, fascia is generously released, all layers of the wound are explored and gross contamination removed, and nonviable muscle is excised. Some low-energy transfer wounds (eg, civilian handgun injury, military shrapnel wounds) involve little tissue damage and can safely be managed nonsurgically, provided that there is confidence in the assessment of wound severity. Questions remain regarding the safest and most effective way to assess wounds and select patients for surgical versus nonsurgical management.