summary Wound & Hardware Infection is the most common complication following orthopedic trauma surgery and is a significant source of patient morbidity. Diagnosis can be made clinically with the presence of incisional erythema, dehiscence, purulent drainage and/or persistent fracture nonunion or hardware loosening on radiographs Intraoperative deep cultures are the most reliable method to isolate causative organisms Treatment is usually surgical irrigation and debridement followed by culture-directed antibiotics. Hardware removal may be performed acutely or in a delayed fashion depending on fracture healing. Epidemiology Incidence up to 16% infection rate following traumatic fracture Risk factors host immunodeficiency extremes of age diabetes obesity alcohol or tobacco abuse steroid use malnutrition medications previous radiation vascular insufficiency Etiology 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 helpful to detect bony infection in the setting of hardware hardware can cause metal artifact in an MRI making it difficult to assess for infection Studies Labs WBC may be normal in chronic or indolent infections erythrocyte sedimentation rate (ESR) may remain elevated for months following initial injury or surgery in absence of infection C-reactive protein (CRP) 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
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.5) Which of the following processes relies on an exopolysaccharide glycocalyx? QID: 4640 Type & Select Correct Answer 1 Osteoclast differentiation 1% (29/5473) 2 Biofilm creation 96% (5239/5473) 3 Metastatic bone disease 1% (38/5473) 4 Endochondral bone formation 2% (100/5473) 5 Intramembranous bone formation 1% (37/5473) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12FA.2) A 22-year-old male presents 4 weeks following open reduction and internal fixation of his unstable ankle fracture. He has had three days of increasing pain, swelling and the new onset of purulent drainage from the mid-portion of the lateral incision. Laboratory values, including white blood cell count, sedimentation rate, and C-reactive protein are elevated. Current radiographs are seen in Figures A and B. On examination the wound probes deep and likely involves the lateral plate. What is the best step in management at this time? QID: 3809 FIGURES: A B Type & Select Correct Answer 1 Suppression with broad spectrum oral antibiotics until fracture healing 1% (35/3637) 2 Suppression with broad spectrum intravenous antibiotics until fracture healing 1% (43/3637) 3 Surgical debridement, removal of internal fixation, culture specific antibiotics, casting until fracture healing 25% (900/3637) 4 Surgical debridement, maintenance of internal fixation, culture specific antibiotics until fracture healing 71% (2599/3637) 5 Wound culture in the office and suppression with culture specific antibiotics until fracture healing 1% (32/3637) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.133) After open reduction and internal fixation of long bone fractures, at what time period should C-reactive protein start to decrease? QID: 1019 Type & Select Correct Answer 1 24 hours 4% (79/1809) 2 48 hours 65% (1177/1809) 3 96 hours 18% (331/1809) 4 7 days 10% (184/1809) 5 12 days 2% (35/1809) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
All Videos (2) Podcasts (1) Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine Infection - James Carey, MD ( 4.11, 2018 Winter SKS) Trauma - Wound & Hardware Infection B 8/15/2018 628 views 3.5 (4) Login to View Community Videos Login to View Community Videos 2016 Current Solutions in Orthopaedic Trauma The Infected Nonunion - Paul Tornetta III, MD (CSOT #10, 2016) Paul Tornetta Trauma - Wound & Hardware Infection B 2/21/2017 1799 views 4.3 (12) Trauma⎪Wound & Hardware Infection Orthobullets Team Trauma - Wound & Hardware Infection Listen Now 12:16 min 12/11/2019 463 plays 5.0 (6)
Open tibia pilon fracture (IIIa) with gross contamination (farmward injury) (C101067) Panagiotis Poulios Trauma - Wound & Hardware Infection E 5/1/2018 493 8 7 wire in chest (C1310) Surendra Shetty Trauma - Wound & Hardware Infection E 11/4/2012 82 3 5