Fracture Infection
When a broken bone becomes infected, recovery can become prolonged and complicated, requiring specialized medical care and sometimes multiple surgeries to heal properly.
Table of contents
- What Is Fracture Infection?
- How Fracture Infections Happen
- Who Is at Higher Risk?
- Recognizing the Signs of Infection
- How Doctors Diagnose Fracture Infections
- Treatment Options
- Recovery and Treatment Success
What Is Fracture Infection?
Most broken bones do not lead to infections. However, when infections do occur after fractures, they represent a serious complication that can significantly impact healing and recovery.[1] A fracture-related infection (FRI) is an infection that develops in or around a broken bone, either at the time of injury or during the healing process.[6]
Fracture-related infections are debilitating complications that can result in permanent functional loss or, in severe cases, even amputation.[2] These infections disrupt bone healing, may lead to chronic bone infection called osteomyelitis, and often require repeat surgical procedures to resolve.[13]
How Fracture Infections Happen
Infections typically occur after fractures because bacteria enter the body during the traumatic event or during medical treatment.[1]
Open Fractures
The highest risk for infection occurs with open fractures, also called compound fractures. This type of injury happens when a bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the bone.[1] Fracture-related infection occurs more frequently in open fractures when the fractured bone protrudes from the skin.[6]
The skin normally acts as a natural barrier to outside contaminants, including bacteria. When the skin is broken, bacteria can easily travel down to the broken bone, potentially leading to an infection.[6] Direct exposure to environmental pathogens during injury significantly elevates the likelihood of contamination and subsequent infection.[13]
Surgical Procedures
During surgery to fix a fracture, the surgeon cuts through skin and other tissues to reach the broken bone. The risk for developing an infection in this setting is quite low, usually less than 2 to 3% in healthy individuals, although this varies depending on the injury and the operation performed.[1] Some sources report even lower rates, suggesting less than 1% in healthy individuals when proper preventive measures are taken.[3]
Preventive antibiotics are given before surgery to lower the risk of infection, and high standards of care in the operating theater help prevent infection.[3] Less commonly, an infection can occur at the surgical site even long after the injury has healed. This occurs when bacteria enter the body during another procedure, such as a tooth extraction or root canal, and make their way through the bloodstream to the implants used to treat the fracture.[1]
Who Is at Higher Risk?
In general, the greater the damage to the surrounding skin, muscles, arteries, and veins near the fracture site, the higher the risk for infection.[3]
Medical Conditions
Chronic diseases that lower your immune system may put you at greater risk for infection after fracture.[1] These conditions include:
- Diabetes mellitus (a chronic disease affecting how your body processes blood sugar)[1]
- Immune deficiencies such as HIV[1]
- Rheumatoid arthritis (an autoimmune disease causing joint inflammation)[1]
- Hemodialysis[6]
Lifestyle Factors
Certain lifestyle choices can increase your risk of developing an infection after a fracture. The most significant factor is smoking and using nicotine products.[1] Other risk factors include:
Treatment-Related Factors
Research has identified specific factors related to treatment that increase the risk of treatment failure. These include obesity, certain severe types of open fractures (specifically Gustilo Anderson type 3c), and keeping the surgical implant in place rather than removing it during treatment.[2]
Recognizing the Signs of Infection
An infection after fracture will usually cause symptoms that are more severe than what is considered normal during healing.[1] Recognizing the symptoms of an infection early can make a difference in treatment outcomes.[6]
Common symptoms include:
- Increased pain around the affected area[1]
- Warmth, redness, and swelling beyond normal healing[1]
- Persistent pain that does not improve when you rest and elevate the injured limb[1]
- Formation of a pus pocket; if it bursts, pus will drain from the injury[1]
- Fever, chills, and night sweats[1]
- Persistent, increasing, or new drainage around the wound[6]
If the infection is near a joint, such as your knee or shoulder, the joint may become difficult to move.[3] Usually, drainage occurs when a fracture has been previously fixed with hardware and is the most common symptom that patients recognize.[6]
Symptoms like numbness, stinging, or burning are not normal signs of a broken bone and should be examined by a medical professional immediately.[6]
How Doctors Diagnose Fracture Infections
Distinguishing between normal post-surgical inflammation and true infection can be challenging, requiring a combination of tests and clinical judgment for accurate diagnosis.[13]
Initial Testing
Even if an infection appears obvious, your orthopedic surgeon will probably order an X-ray. Blood tests may also help identify the infection.[3] Blood tests can provide important information about whether infection is present in your body.[1]
Advanced Testing
If these initial tests do not confirm an infection, your orthopedic surgeon may order additional tests, although this is rare.[3] These may include:
- Computed tomography (CT) scan[3]
- Tagged white blood cell scan[3]
- Magnetic resonance imaging (MRI) scan[3]
Treatment Options
Having a fracture-related infection is a significant complication that takes teamwork and effort to overcome.[6] Treating infections after a fracture often involves a combination of surgical and medical interventions.[6]
Emergency Treatment for Open Fractures
An open fracture is a surgical emergency. Antibiotics are started as soon as possible in the emergency room.[3] The next critical steps in controlling the risk for infection are to cleanse the wound and remove as much contamination as possible from the skin, soft tissues, and bone.[3]
This procedure is called debridement (removal of damaged tissue and foreign material) and irrigation, and is typically performed in an operating room. Depending on the severity of your injury, you may require several debridement and irrigation procedures.[3]
Treatment After Surgery
If your orthopedic surgeon suspects an infection after surgery, he or she may initially treat it with antibiotics alone, but you will likely require additional surgery to clean out the infection.[3] The mainstay of treatment is surgical debridement, which involves removal of the hardware and non-living tissue or bone.[6]
Comprehensive Treatment Approaches
Treatments for fracture-related infections may include:[6]
- Removal of fracture hardware
- Surgical debridement of bone
- Local delivery of antimicrobial agents
- Phage therapy
- Repair of fracture nonunion (when a fracture fails to heal)
- Bone transport
- Bone grafting (various techniques)
- Ilizarov external fixation
Often, treatment teams work with plastic surgeons, infectious disease providers, and other specialists to promote the best outcomes for patients.[6] A multidisciplinary team approach is essential to optimize treatment and address risk factors such as diabetes and obesity.[2]
Antibiotic Treatment
Most patients will have to take antibiotics for 6 to 12 weeks. A bone infection can be complicated to eliminate and may require long-term treatment and several surgeries. In extreme cases, some patients have to take antibiotics for the rest of their life.[22]
Recovery and Treatment Success
The treatment and recovery from fracture-related infections can be prolonged and complicated.[1] Standard treatment typically involves surgical debridement and prolonged antibiotic therapy; however, complete eradication of the infection is not always achieved, and high recurrence rates remain a significant concern.[13]
In one major trauma center study, fracture-related infection treatment failure occurred in 24 out of 102 patients, representing 23.5% of cases.[2] Treatment failure was defined as infection recurrence or amputation.[2]
In the most severe cases, amputation of the infected limb may be performed. This is only considered during a life-saving situation when a severe infection is uncontrollable.[22] In approximately 3% of fracture-related infection cases, amputation becomes necessary.[14]
If an infection is successfully treated, most patients will recover without ongoing problems.[22] Fracture-related infections are a serious concern, but with proper treatment and attention, they can be managed effectively.[6]
