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 login to view 3 more bullets biofilm formation login to view 1 more bullet 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 login to view 1 more bullet sub-acute and chronic infections login to view 5 more bullets 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) login to view 1 more bullet 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 login to view 3 more bullets technique login to view 1 more bullet outcomes login to view 1 more bullet Operative surgical debridement indications login to view 1 more bullet technique login to view 4 more bullets outcomes login to view 2 more bullets