Wound Excision

Objectives

To provide guidance on the principles of surgical wound management in the deployed setting. This has previously been known as “debridement” but is now described as “wound excision”.

This CGO has been developed as a series of consensus statements agreed by Defence Plastic Surgery and Orthopaedic Surgery Consultants. These are listed below, along with explanatory notes. The objective of this guideline is to act as an aide memoire for the deployed clinician as to what the agreed “best practice” is. These guidelines are to be interpreted with reference to pre-deployment education and training. They are not designed to be an exhaustive manual of how to perform wound excision.

 

Context:

Contextual factors are fundamental to decision-making in the deployed setting. These guidelines have been written with the intention of providing helpful direction while, at all times, emphasising the importance of surgical judgement. Deviation from these consensus statements may be justified by a wide range of contextual factors that include, but are not limited to: tactical situation, timeliness and reliability of patient movement into and out of the facility, equipment and resource supply levels, and volume of cases.

Scope

This guideline applies to the management of combat injured patients within Role 2 and Role 3 settings only (deployed surgical care). Management of combat wounds prior to this is beyond the scope of this guideline. Management of these wounds at Role 4 should adhere to UK standards of practice.

Not all wounds encountered in the deployed setting require surgical care. This guidance applies only to those patients who require surgical management of their wounds as judged by the deployed team.

Audience

Members of deployed surgical teams

Initial Assessment & Management

Initial management of combat injured patients should proceed according to the CGO “Approach to the injured patient” (Link here when linked CGO is live).

Patients with burn injuries should be managed as per the “Burns” CGO (Link here when linked CGO is live).

Administration of Tetanus prophylaxis should be guided by the “Tetanus” CGO (Link here when linked CGO is live).

Clinicians must decide if wounds require formal surgical excision. Factors to include when making this decision include, but are not limited to:

  • Size and Depth: wounds that may be managed non-operatively include abrasions, superficial / extra-fascial wounds, uncomplicated narrow-channel wounds.
  • Complicating Factors: wounds involving underlying fractures, damage to important organs and structures, and infected wounds will require surgical management.
  • Physiological condition of the patient

Wounds that do not require surgical management can be treated under the direction of the Emergency Medicine Consultant with simple wound cleaning, pain relief, suture or steri-strip closure, and dressing as appropriate. Refer to the Deployed Antimicrobial Guidance regarding choice and need for antibiotics in these cases.

 

Record Keeping

At the initial assessment, the following information should be recorded for each wound:

  • Date / Time of injury
  • Mechanism of injury
  • Treatment so far
  • Antibiotic treatment given
  • Is there clinical suspicion of infection
  • Site / Size of the wound
  • General impression (e.g. “heavily contaminated”, “purulent discharge”, “significant necrosis”, “clean”, etc)

 

Photography: See consensus statement 4 below.

Advanced Assessment & Management

Kit and Equipment:

If wound excision is to be undertaken as part of Damage Control Surgery (DCS), the “DCS Set” contains all the required instruments.

If wound excision is to be undertaken in isolation, the “Debridement” set should be used in order to preserve stocks of DCS sets.

 

Additional Equipment:

  • Bowl and swabs for pre-operative decontamination
  • Appropriate fluid for irrigation
  • Suction
  • Diathermy
  • Dressings (see below)

 

Patients undergoing surgical management of combat wounds should receive pre-operative antibiotic prophylaxis, as directed by the Deployed Antimicrobial Guideline (Link here when linked CGO is live).

 

Consensus Statements:

 

  1. Patients with combat wounds should undergo wound excision within the following timelines: As soon as possible for heavily contaminated wounds. Within 12 hours for high energy-transfer injuries. Within 24 hours for all other wounds requiring surgery.

 

  1. Wound excision should be undertaken in a surgical facility.

A “surgical facility” is defined here as wherever the deployed surgical team have designated as their “operating theatre”. This may be in a tented structure, aboard ship, on a suitable vehicle, in a building of opportunity, or any other designated location. Formal surgical wound excision should not take place forward of R2.

 

  1. Gross contamination should be removed preoperatively by irrigation. Potable water is acceptable for this purpose.

Use enough fluid to remove all loose contamination. Be as thorough as resources allow. Some contamination will inevitably remain embedded in tissues and will require surgical removal.

 

  1. Pre- and Post-excision wound photography is strongly encouraged as part of the patient record.

Seek guidance from the OC and CD regarding the mechanism for capturing, storing, and transmitting these images. Every effort should be made by the deployed command team to facilitate this process.

 

  1. Wound excision should be performed to remove all non-viable tissue. Nerves and blood vessels should be preserved wherever possible.

A systematic and meticulous approach should be used when undertaking wound excision. The aim is to remove all contamination and non-viable tissue. This is not a quick procedure so theatre utilisation and physiological consequences to the patient and must be accounted for.

The surgeon should proceed from superficial to deep, ensuring that all contamination and non-viable tissue are excised at each level: skin, subcutaneous fat, fascia, etc. A “clockface” approach is recommended at each level, whereby the surgeon works from “12 o’clock” around the wound to ensure comprehensive assessment.

If part or all of a limb is clearly beyond salvage, given the contextual factors, it must be excised in the same manner as any other non-viable tissue. It is not considered an “amputation” in the same manner as those performed in firm base-practice. See Consensus Statement 11 below.

Surgeon judgement is required to assess what is and is not viable tissue. Where there is doubt about the viability of tissue there should be an assumption that excision is safer than retention. However, nerves and blood vessels are a special case and should be preserved unless they are clearly beyond salvage.

 

  1. At the primary excision, non-viable skin at the margins of the wound should be carefully excised to leave edges that bleed from the dermis. If the skin edges remain healthy, this does not need to be repeated during subsequent wound excisions.

 

  1. In a mature operational patient care pathway (OPCP), serial marginal wound excision may be an appropriate strategy to avoid excessive removal of viable tissue in evolving complex wounds.

 

This consensus statement reflects the fundamental importance of contextual factors in how combat wounds are managed and is a modification of Consensus Statement

  1. In certain deployed settings, where resources are relatively plentiful relative to patient volume, the surgical decision-making may permit the retention of tissue with intermediate viability, on the assumption that the patient will later be able to return to theatre for review and excision of tissue that has become non-viable.

 

  1. If acute compartment syndrome is suspected, manage according to the Acute Compartment Syndrome & Fasciotomy CGO

 

  1. Where necessary, wound extensions should be along fasciotomy lines if possible.

Wound extensions, and their length, are determined by the size and shape of the wound as well as the need to access deeper structures. The surgeon must access the full extent of the wound cavity and explore tissue planes along which contamination can spread. If the wound is complicated by a fracture, wound extensions are required to allow full delivery of both ends of the bone from the wound for irrigation and removal of contamination.

 

  1. Skin degloving should be avoided. Wound extension should be in the sub-fascial plane.

Do not undermine skin.

 

  1. Do not fashion flaps during primary excision, keep all viable tissue.

Anatomical flaps such as those fashioned for closing amputation residua are not indicated in the deployed setting. All viable tissue, regardless of anatomical pattern, should be retained. This maximises the reconstructive options available upon evacuation to definitive care.

 

  1. Suture tagging of divided nerve and tendons is not required.

 

  1. The status of neurovascular structures encountered during wound excision should be carefully documented.

 

  1. It is not necessary to locate neurovascular structures solely in order to document their status.

The factors that determine the extent of the surgical excision are discussed in Consensus Statement 9. Neurovascular structures that lie outside the required surgical field should not be exposed unnecessarily.

 

  1. Primary repair / reconstruction of tendons and nerves must not be performed at the primary excision. Definitive repair should be considered when the wound is undergoing delayed primary closure at a subsequent episode.

Nerves and tendon injuries may be managed at a later date, if necessary. They are of secondary importance to achieving a healed wound, and should not dictate the manner and timing of wound closure. Note that the word “considered” does not indicate any degree of compulsion, but permits an attempt at repair if the resources, equipment, and skill-set are available.

 

  1. Bone fragments with a tenuous or no soft tissue attachment should be excised.

There is no role for the retention of devitalised bone fragments, no matter how orthopaedically important, in the deployed setting.

 

  1. Intraoperative irrigation of contaminated wounds should be performed using copious low-pressure sterile saline, where resources allow. If sterile saline is unavailable, potable water may be used as an alternative.

 

  1. Do not use high pressure or pulsed lavage in the management of combat wounds.

 

  1. Following initial wound excision, use a simple dressing as follows: Non-adherent base layer in direct contact with the wound bed and edge. Cover with either an adhesive outer dressing or gauze/wool/crepe depending on size and location. This must be well secured.

Where available, negative pressure dressing systems may be used to manage complex and/or high-exudate wounds. However, these systems are not mandatory in the deployed setting.

Do not underestimate the tendency for dressings to become displaced during patient evacuation. This can have significant negative effects for the patient and transport assets. Secure all dressings to withstand robust handling.

 

  1. Surgeons should perform delayed primary closure at 3-5 days, if the following conditions are met:
    1. No evidence of infection.
    2. Tissues are healthy, with bleeding edges.
    3. No evidence of deterioration since last excision surgery (no new necrotic or infected tissue).
    4. The wound can be closed without excessive tension

If these conditions are not met, the patient requires re-excision surgery. Ensure that record-keeping and photography, as described above, are undertaken at each surgical event.

 

  1. Some low energy-transfer, narrow channel, and superficial wounds do not require full surgical excision.

Refer to the CGO Gunshot Injuries to Extremities for further guidance (Link here when linked CGO is live).

Prolonged Casualty Care

This is covered in the Consensus Statements above.

Paediatric Considerations

This guidance applies equally to children as to adults.

Last reviewed: 09/04/2025

Next review date: 09/04/2026

Version: 1.0

Related resources

Red Cross: WAR WOUNDS: BASIC SURGICAL MANAGEMENT. International Committee of the Red Cross, 1994. Robin Gray. War wounds : basic surgical management

 

The Red Cross Wound Classification: Robin Coupland. The Red Cross Wound Classification | International Committee of the Red Cross

References
  1. Guthrie HC, Clasper JC, Kay AR, Parker PJ, Limb Trauma and Wounds Working Groups A. Initial extremity war wound debridement: a multidisciplinary consensus. Journal of the Royal Army Medical Corps. 2011 Jun;157(2):170–5.
  2. Lurin I, Burianov O, Yarmolyuk Y, Klapchuk Y, Derkach S, Gorobeiko M, et al. Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war. Injury. 2024 Feb;55(2):111280.
  3. Kazmirchuk A, Yarmoliuk Y, Lurin I, Gybalo R, Burianov O, Derkach S, et al. Ukraine’s Experience with Management of Combat Casualties Using NATO’s Four-Tier “Changing as Needed” Healthcare System. World journal of surgery. 2022 Dec;46(12):2858–62.
  4. Schoenfeld AJ, Dunn JC, Bader JO, Belmont PJ. The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003-2011. The journal of trauma and acute care surgery. 2013 Aug;75(2):287–91.
  5. Masini BD, Waterman SM, Wenke JC, Owens BD, Hsu JR, Ficke JR. Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. Journal of orthopaedic trauma. 2009 Apr;23(4):261–6.
  6. Belmont PJ, McCriskin BJ, Hsiao MS, Burks R, Nelson KJ, Schoenfeld AJ. The nature and incidence of musculoskeletal combat wounds in Iraq and Afghanistan (2005-2009). Journal of orthopaedic trauma. 2013 May;27(5):e107-13.
  7. Eccles S, Handley B, Khan U, Nanchahal J, Nayagam S, McFadyen I, editors. Standards for the Management of Open Fractures. Oxford University PressOxford; 2020.
  8. Chan JKK, Aquilina AL, Lewis SR, Rodrigues JN, Griffin XL, Nanchahal J. Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs. The Cochrane database of systematic reviews. 2022 Apr 1;4(4):CD013555.
  9. Brouwers MC, Kerkvliet K, Spithoff K, AGREE Next Steps Consortium. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ (Clinical research ed). 2016 Mar 8;352:i1152.
  10. NICE: National Institute for Clinical Excellence. 2023 [cited 2024 Dec 18]. Fractures (complex): assessment and management. Available from: https://www.nice.org.uk/guidance/ng37
  11. NATO, Ministry of Defence. Allied Joint Publication-4.10 Allied Joint Doctrine for Medical Support. Edition C, Version 1. 2019.
  12. Rozell JC, Connolly KP, Mehta S. Timing of Operative Debridement in Open Fractures. Orthopedic Clinics of North America. 2017 Jan;48(1):25–34.
  13. Duyos OA, Beaton-Comulada D, Davila-Parrilla A, Perez-Lopez JC, Ortiz K, Foy-Parrilla C, et al. Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes? Journal of the American Academy of Orthopaedic Surgeons. 2017 Mar;25(3):230–8.
  14. Owens BD, Wenke JC. Early Wound Irrigation Improves the Ability to Remove Bacteria. The Journal of Bone & Joint Surgery. 2007 Aug;89(8):1723–6.
  15. Malhotra AK, Goldberg S, Graham J, Malhotra NR, Willis MC, Mounasamy V, et al. Open extremity fractures: impact of delay in operative debridement and irrigation. The journal of trauma and acute care surgery. 2014 May;76(5):1201–7.
  16. Anonymous A. Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel 15 December 2021. Journal of special operations medicine : a peer reviewed journal for SOF medical professionals. 2022;22(1):11–7.
  17. Fernandez R, Green HL, Griffiths R, Atkinson RA, Ellwood LJ. Water for wound cleansing. Cochrane Database of Systematic Reviews. 2022 Sep 14;2022(9).
  18. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. New England Journal of Medicine. 2015 Dec 31;373(27):2629–41.
  19. FLOW Investigators, Petrisor B, Sun X, Bhandari M, Guyatt G, Jeray KJ, et al. Fluid lavage of open wounds (FLOW): a multicenter, blinded, factorial pilot trial comparing alternative irrigating solutions and pressures in patients with open fractures. The Journal of trauma. 2011 Sep;71(3):596–606.
  20. Anglen J, Gainor B, Simpson W, Christensen G. The use of detergent irrigation for musculoskeletal wounds. International Orthopaedics. 2003 Feb;27(1):40–6.
  21. Baechler MF, Groth AT, Nesti LJ, Martin BD. Soft tissue management of war wounds to the foot and ankle. Foot and ankle clinics. 2010 Mar;15(1):113–38.
  22. Arnez ZM, Khan U, Tyler MPH. Classification of soft-tissue degloving in limb trauma. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2010 Nov;63(11):1865–9.
  23. Sassoon A, Riehl J, Rich A, Langford J, Haidukewych G, Pearl G, et al. Muscle Viability Revisited. Journal of Orthopaedic Trauma. 2016 Jan;30(1):17–21.
  24. Penn-Barwell JG, Sargeant ID, Penn-Barwell JG, Bennett PM, Fries CA, Kendrew JM, et al. Gun-shot injuries in UK military casualties – Features associated with wound severity. Injury. 2016 May;47(5):1067–71.
  25. Ritenour AE, Dorlac WC, Fang R, Woods T, Jenkins DH, Flaherty SF, et al. Complications After Fasciotomy Revision and Delayed Compartment Release in Combat Patients. Journal of Trauma: Injury, Infection & Critical Care. 2008 Feb;64(2):S153–62.
  26. Gordon WT, Talbot M, Shero JC, Osier CJ, Johnson AE, Balsamo LH, et al. Acute Extremity Compartment Syndrome and the Role of Fasciotomy in Extremity War Wounds. Military Medicine. 2018 Sep 1;183(suppl_2):108–11.
  27. Clasper J, Standley D, Heppell S, Jeffrey S, Parker P. Limb Compartment Syndrome And Fasciotomy. Journal of the Royal Army Medical Corps. 2009 Dec;155(4):298–301.
  28. Arnez ZM, Tyler MPH, Khan U. Describing severe limb trauma. British Journal of Plastic Surgery. 1999 Jun;52(4):280–5.
  29. Bage T, Power DM. Iatrogenic peripheral nerve injury: a guide to management for the orthopaedic limb surgeon. EFORT Open Reviews. 2021 Aug;6(8):607–17.
  30. Al-Hourani K, Pearce O, Stoddart M, Riddick A, Khan U, Kelly MB. Orthoplastic Reconstruction of Type IIIB Open Tibial Shaft Fractures Using Debrided, Devitalized Cortical Segments: Health-Related Quality-of-Life Outcomes. Journal of Orthopaedic Trauma. 2022 Jul;36(7):332–8.
  31. Al-Hourani K, Stoddart M, Khan U, Riddick A, Kelly M. Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments. The Bone & Joint Journal. 2019 Aug;101-B(8):1002–8.
  32. FLOW Investigators. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. New England Journal of Medicine. 2015 Dec 31;373(27):2629–41.
  33. Gupta R, Sharma AR, Singhal A, Shail S, Masih GD. Concepts in wound irrigation of open fractures: ’Where we came from, and where are we now? Journal of clinical orthopaedics and trauma. 2021 Dec;23:101638.
  34. Gardezi M, Roque D, Barber D, Spake CSL, Glasser J, Berns E, et al. Wound Irrigation in Orthopedic Open Fractures: A Review. Surgical infections. 2021 Apr;22(3):245–52.
  35. Johal H, Axelrod D, Sprague S, Petrisor B, Jeray KJ, Heels-Ansdell D, et al. The effect of time to irrigation and debridement on the rate of reoperation in open fractures. The Bone & Joint Journal. 2021 Jun 1;103-B(6):1055–62.
  36. Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model. The Journal of bone and joint surgery American volume. 2009 Jan;91(1):92–8.
  37. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. Journal of orthopaedic trauma. 1999 Nov;13(8):526–33.
  38. Hassinger SM, Harding G, Wongworawat MD. High-pressure pulsatile lavage propagates bacteria into soft tissue. Clinical orthopaedics and related research. 2005 Oct;439:27–31.
  39. Boyd JI, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clinical orthopaedics and related research. 2004 Oct;(427):13–7.
  40. Maurya S, Bhandari PS. Negative Pressure Wound Therapy in the Management of Combat Wounds: A Critical Review. Advances in wound care. 2016 Sep 1;5(9):379–89.
  41. Liu X, Zhang H, Cen S, Huang F. Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: A systematic review and meta-analysis. International journal of surgery (London, England). 2018 May;53:72–9.
  42. Costa ML, Achten J, Bruce J, Tutton E, Petrou S, Lamb SE, et al. Effect of Negative Pressure Wound Therapy vs Standard Wound Management on 12-Month Disability Among Adults With Severe Open Fracture of the Lower Limb: The WOLLF Randomized Clinical Trial. JAMA. 2018 Jun 12;319(22):2280–8.
  43. Iheozor-Ejiofor Z, Newton K, Dumville JC, Costa ML, Norman G, Bruce J. Negative pressure wound therapy for open traumatic wounds. The Cochrane database of systematic reviews. 2018 Jul 3;7(7):CD012522.

Zeiderman MR, Pu LLQ. Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma. Burns & trauma. 2021;9:024.

Evidence method

The literature supporting the historic consensus statement paper was reviewed and new literature was discovered via literature review for each consensus statement.