What volume of irrigation fluid in liters should be used for an open fracture wound?

Volume of Irrigation Fluid for Open Fractures

Use 3 to 9 liters of normal saline without additives for irrigation of open fracture wounds, with higher volumes (6-9L) reserved for more severely contaminated injuries. 1

Irrigation Solution and Volume Guidelines

Recommended Irrigation Fluid

• Normal saline without any additives is the strongly recommended irrigation solution for open fractures in major extremity trauma. 1
• The 2023 AAOS guidelines provide a "Strong" recommendation for saline irrigation without additives, meaning practitioners should follow this unless a clear and compelling rationale exists for an alternative approach. 1
• Tap water may be acceptable for simple traumatic lacerations in emergency settings, but for open fractures requiring operative management, sterile normal saline is preferred. 1

Volume Recommendations

• Evidence supports using volumes in the range of 3 to 9 liters for open fracture irrigation. 2, 3
• Higher volumes (6-9L) are more effective than lower volumes at removing debris and bacteria, though there is a point of diminishing returns beyond which additional volume provides minimal benefit. 3
• The optimal volume depends on the degree of contamination and soft tissue injury—more severely contaminated wounds (Gustilo Type III) require higher volumes approaching 9 liters. 2, 3
• For less contaminated Type I or II open fractures, 3-6 liters is typically adequate. 2, 3

Irrigation Technique Considerations

Pressure and Delivery Method

• Use low-pressure irrigation rather than high-pressure pulsatile lavage. 4, 5
• While older teaching emphasized high-pressure irrigation, recent evidence suggests low-pressure lavage may decrease reoperation rates for infection and wound complications. 4
• High-pressure irrigation can drive bacteria deeper into tissues and cause bone damage, negating any theoretical benefit of more aggressive mechanical cleansing. 3, 5
• Pulsatile flow has not been demonstrated to increase efficacy over continuous low-pressure irrigation. 3, 5

Timing and Surgical Approach

• Bring patients to the operating room for debridement and irrigation as soon as reasonable, ideally within 24 hours of injury. 1
• Irrigate thoroughly before debridement to remove surface debris and bacteria—this prevents driving organisms deeper into tissue during debridement. 6
• Continue irrigation until there is no obvious debris or foreign matter visible in the wound. 6

What NOT to Use

Avoid Additives

• Do not add soap, castile soap, bacitracin, povidone-iodine, or other antiseptics to the irrigation solution. 1, 4
• A large multicenter trial found no benefit of castile soap solution over normal saline alone for open fracture irrigation. 4
• Antiseptic additives can cause host-tissue toxicity that may impair wound healing despite their antibacterial properties. 3
• The majority of surgeons (70.5%) already favor normal saline alone based on survey data, and this practice is now supported by strong guideline recommendations. 7

Common Pitfalls to Avoid

• Do not use inadequate volumes—less than 3 liters is insufficient for most open fractures and increases infection risk. 2, 3
• Do not delay irrigation to obtain "special" solutions—normal saline is optimal and readily available. 1
• Do not use high-pressure pulsatile lavage thinking it is more effective—it may actually worsen outcomes by damaging bone and driving bacteria deeper. 4, 3, 5
• Do not add antiseptics or antibiotics to irrigation fluid—these additives provide no proven benefit and may cause tissue toxicity. 1, 3