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Introduction
  • 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
Presentation
  • 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
Imaging
  • 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
Studies
  • 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
Treatment
  • 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
      • outcomes
        • 71% success seen with debridement and antibiotics for early acute postoperative infection 
          • Risk factors for failure include intramedullary nail and open fracture
 

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