Determining the severity of injury to the soft tissues is a central component of patient assessment and affects the management of surgical intervention. The reconstructive surgeon can choose from among a variety of techniques for optimal treatment; however, the surgeon needs to know the exact description of the defect as well as distinct patient- and therapy-imminent criteria (Table 12.2). The defect can be differentiated as acute and chronic soft-tissue defects according to its ­etiology. Special forms are the combined soft and osseous tissue defect and the soft-tissue defect resulting from a multiple trauma injury. Furthermore, the surgeon must verify whether a tissue dehiscence is the result of tissue elasticity or edema, or whether it is true soft-tissue loss. To rapidly define the extent of the tissue damage, the defect can be classified as type a (defect reaching the fascia), type b (mixed skin-muscle and other soft tissue defects), and type c (combination of soft-tissue and bony defect). A more detailed determination of the soft-tissue injury in combination with closed or open fractures can be obtained using the classification of Tscherne and Oestern, grouped into four categories according to severity (Table 12.3; [6]).

The proper timing and adequate planning of wound closure in soft-tissue traumas helps to limit further soft-tissue injury and facilitates its rapid recovery. Therefore, the surgeon should also have clear-sighted vision and not pass up a chance for other treatment possibilities if complications arise. The response of soft tissue to injury involves microvascular and inflammatory processes that produce localized tissue hypoxia and acidosis. Incisions placed through such compromised tissue, particularly in blunt soft-tissue injuries, can lead to wound breakdown and deep infection. Therefore, recognizing the signs of soft-tissue injury is the basis for successful management [7].

In any soft-tissue injury, especially of the limbs, an initial radical débridement of damaged and necrotic tissues is necessary within the first 6 h after trauma. The débridement can also be performed in scheduled second- or third look surgeries after 48–72 h. On the one hand, surgical débridement supports the phagocytic activity of the macrophages and reduces the risk of hypoxia and infection within the inflammatory phase of wound healing [8]. On the other hand, it helps to clearly evaluate the extent of injury for the subsequent treatment regimen. The width of the débridement might sometimes be hard to accept by the operating surgeon because of additional tissue loss, but it is necessary to prevent the above-mentioned complications (i.e., zone of injury).

Appropriate timing for soft-tissue reconstruction and wound closure is a matter of controversy. The recommendation of Godina clearly reveals the advantage of aggressive débridement and closure of the wound with vascularized tissue within 72 h. Through adherence to this timeframe, severe complications can be decreased significantly [9]. A special form of a conservative treatment regimen in local wound support can also be obtained from vacuum assisted closure. Because of the optimization of the wound milieu via continuous wound cleaning, spontaneous regeneration processes will be accelerated and definitive wound closure can be reached significantly faster. Furthermore, the flap reconstruction can also be performed beyond the quoted critical time interval of 72 h with results similar to those of immediate reconstruction [10].