Fracture-related and metalwork infection — Rapid

Synopsis

Recognise confirmatory and suggestive infection around fracture fixation, protect diagnostic yield, integrate union, stability, biofilm and soft-tissue decisions, and coordinate debridement, implant strategy and culture-directed therapy.

A sinus, fistula or wound breakdown communicating with the fracture or implant, or purulence at surgery, is confirmatory evidence of fracture-related infection.
Suggestive features include persistent drainage, redness, swelling, fever, increasing pain, radiographic loosening, lysis, non-union and new effusion; they trigger investigation rather than proving infection alone.
Septic patients receive immediate assessment, blood cultures and parenteral antibiotics. Stable patients should have consultant review within 48 hours and no empirical antibiotics before that review.
Assess union, fixation stability, deformity, perfusion, soft-tissue cover, previous cultures and antibiotics and host factors before choosing retention or removal.
Use plain radiographs first for union, loosening, periosteal reaction and lysis; add CT for union and sequestra and MRI or nuclear imaging for a specific extent question.
When debridement is indicated, take five deep microbiology specimens with separate instruments and two histology samples in chronic or uncertain infection.
In stable non-acute infection, discuss an antibiotic-free interval with microbiology; BOASt gives a minimum two weeks before sampling when safe.
After samples, start broad treatment, review at 48 hours, and link definitive antibiotics to debridement, fracture stability, implant strategy and vascularised cover.

Key red flags

Shock, spreading erythema, rapidly increasing drainage or deep fluctuance requires immediate medical and surgical source-control assessment and antibiotics after blood cultures.

New deformity, abnormal movement, broken hardware or inability to load suggests fixation failure or infected non-union and requires protection and urgent imaging.

Exposed metalwork, skin necrosis, threatened flap or absent arterial signals indicates a combined infection, perfusion and coverage emergency.

Persistent wound leakage after fixation needs prompt consultant-led investigation; repeated community antibiotic courses can suppress cultures while biofilm and non-union progress.

Investigation priorities

Initial plain radiographsFirst step

Assess union, alignment, lysis and implant integrity.

Management branches

SepticTreat systemic danger and drain

Organ dysfunction, bacteraemia or rapidly progressive fracture-site infection is present.

Obtain blood cultures, start parenteral therapy and call orthopaedic, anaesthetic and infection teams immediately.
Protect unstable fixation and assess perfusion, soft tissue and deep collections urgently.
Debride and drain without avoidable delay, obtaining five deep samples and histology where feasible.
Review blood-culture clearance and plan stability and coverage after physiological rescue.

StablePreserve diagnosis and plan reconstruction

Drainage, pain, loosening or non-union suggests infection without systemic illness.

Withhold antibiotics and arrange consultant review within 48 hours, documenting prior agents and wound chronology.
Discuss at least a two-week antibiotic-free interval for non-acute sampling with microbiology when safe.
Define union, fixation, perfusion and cover with radiographs and targeted cross-sectional imaging.
Plan debridement, five cultures, two histology samples, implant strategy and reconstruction through the infection MDT.

Key medicines

Post-sampling broad-spectrum therapyAfter five deep cultures and indicated histology, give the full adult fracture-related-infection protocol regimen and review it at 48 hours with preliminary results; in sepsis, give parenteral therapy after rapid blood cultures even if deep sampling must follow.Choice depends on allergy, renal and hepatic function, local resistance and prior isolates; avoid empirical treatment of a stable leaking wound before consultant review, and never substitute breadth for stability, perfusion or cover.

Directed implant-associated regimenUse the narrowest organism-active regimen with exact dose, route, monitoring and duration agreed by the infection specialist after culture review, adding any biofilm-active component only for a susceptible organism and a deliberate retained-implant strategy.Check all interactions, renal, hepatic and marrow toxicity and oral absorption; suppression until union requires written failure criteria and an implant-removal plan rather than open-ended unreviewed prescribing.

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