Wound & Hardware Infection

Topic updated on 07/07/15 9:46am
  • Overview
    • wound and hardware infection can be a critical development in determining patient outcome
  • Epidemiology
    • incidence
      • up to16% infection rate following traumatic fracture
    • risk factors
      • host immunocompetency
      • extremes of age
      • diabetes
      • obesity
      • alcohol or tobacco abuse
      • steroid use
      • malnutrition
      • medications
      • previous radiation
      • vascular insufficiency
  • Pathophysiology
    • mechanisms
      • seeding
        • disruption of soft tissue envelope, blood vessels, and periosteum allow bacteria to avoid host defenses
        • direct seeding of implant and/or anatomical structure
        • hematogenous seeding
      • biofilm formation
        • dependent on exopolysaccharide glycocalyx
  • History
    • history of trauma must be detailed
      • extent of soft tissue injury
      • extent of bony injury
      • previous or current hardware
      • previous or current surgery at the same site
      • history of previous skin or deep infections
  • Symptoms
    • pain at previous fracture site
      • may indicate infected non-union
    • fevers, chills, and night sweats may be present
  • Physical exam
    • inspection
      • erythema, drainage, or purulence
      • tenderness
    • motion
      • gross motion at fracture site is suggestive of non-union
  • Radiographs
    • recommended views
      • biplanar images of afflicted area
      • 45 degree orthogonal views can also be obtained to evaluate for union
    • findings
      • acute infection
        • radiographs may be normal
      • sub-acute and chronic infections
        • peri-implant lucency can be seen
        • involucrum
          • reactive bone surrounding active infection
        • sequestrum
          • retained nidus of infected necrotic bone
  • CT
    • indications
      • pre-operative planning
  • MRI
    • indications
      • useful adjunct for diagnosis and delineating extent of disease
      • to assess soft-tissue masses and fluid collections
    • sensitivity and specificity
      • 98% sensitive
      • 78% specific
  • WBC-labeled scans
    • can help determine infection from other similar appearing etiologies
  • Labs
    • WBC
      • may be normal in chronic or indolent infections
    • erythrocyte sedimentation rate
      • may remain elevated for months following initial injury or surgery in absence of infection
    • C-reactive protein
      • most predictive for postoperative infection in the first week after fracture fixation 
      • should decrease from a plateau after postoperative day 2 (after fixation of fractures)
        • will increase further or fail to decrease if a hematoma or infection is present
  • Cultures
    • in-office cultures swabs or aspirations of wounds or sinus tracts are unreliable
    • intraoperative deep cultures are most reliable method of isolated causative organisms
      • multiple specimens from varying locations should be obtained
  • Nonoperative
    • chronic suppression with antibiotics
      • indications
        • risk of surgical treatment outweighs the benefit to the host
          • immunosuppressed, elderly, etc.
        • presence of an infected but incompletely healed fracture following internal fixation
      • technique
        • ESR and CRP levels used to assess adequacy of treatment
      • outcomes
        • 32% rate of chronic infected nonunion persisting or worsening despite suppression
  • Operative
    • surgical debridement
      • indications
        • any active infection
      • technique
        • hardware should be maintained if stability at risk with removal
        • low-pressure irrigation with normal saline may be superior to other methods of irrigation
        • thorough identification and debridement of infection key to success
        • deep bony specimens should be obtained for culture as well as biopsy


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Qbank (3 Questions)

(OBQ13.5) Which of the following processes relies on an exopolysaccharide glycocalyx? Topic Review Topic

1. Osteoclast differentiation
2. Biofilm creation
3. Metastatic bone disease
4. Endochondral bone formation
5. Intramembranous bone formation

(OBQ05.133) After open reduction and internal fixation of long bone fractures, at what time period should C-reactive protein start to decrease? Topic Review Topic

1. 24 hours
2. 48 hours
3. 96 hours
4. 7 days
5. 12 days

(OBQ04.122) Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery? Topic Review Topic

1. Patient temperature
2. WBC count
3. Erythrocyte sedimentation rate
4. C-reactive protein
5. Rheumatoid Factor


Cases chest.jpg iwre chest ct.jpg in chest.jpg
HPI - patient was reffered by the general physician patient had come to the physcian...
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Nguyen LL, Nelson CL, Saccente M, Smeltzer MS, Wassell DL, McLaren SG
Clin. Orthop. Relat. Res.. 2002 Oct;(403):29-37. PMID: 12360004 (Link to Pubmed)
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Mok JM, Pekmezci M, Piper SL, Boyd E, Berven SH, Burch S, Deviren V, Tay B, Hu SS
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Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA, Bosse M; Southeast Fracture Consortium.
J Bone Joint Surg Am. 2010 Apr;92(4):823-8.[PMID] 20360504[/PMID]
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J Am Acad Orthop Surg. 8(5):285-91. PMID: 11029556 (Link to Pubmed)
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Takahashi J, Ebara S, Kamimura M, Kinoshita T, Itoh H, Yuzawa Y, Sheena Y, Takaoka K
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