Injury

The “personality” of the fracture (see chapter 2.1) plays both an important role in decision making in the preoperative period and in determining the likelihood of complications. In patients with severe multiple injuries, the high energy transferred to the soft tissues causes swelling and inflammation. This not only places them at risk of developing multiple organ failure which can accompany the systemic inflammatory response syndrome (see chapter 2.9), but also increases the frequency of other local and systemic complications, including compartment syndrome, pulmonary embolus, and infection. The frequency of these local complications also tends to increase with the severity of any isolated injury.

Immobility

Patients who have a prolonged postoperative recovery and reduced mobility are at risk of complications, particularly medical ones, associated with their immobility. These include pneumonia, deep vein thrombosis (DVT), and pressure sores; while in the longer term immobility leads to osteoporosis. These complications rarely require further surgical intervention, and their frequency and severity is reduced by a management strategy which encourages early mobilization and aggressive postoperative rehabilitation. In practice this means early osteosynthesis of any fractures that delay patient mobilization.

Infection

Early acute infection usually occurs in patients who have had a combination of soft-tissue damage and contamination. This may occur at the time of injury or of surgery, or a combination of both. Infection is therefore more likely in patients presenting with high-energy injuries, poor soft tissues, and with open and contaminated wounds. The resulting soft-tissue edema, reduction in blood supply, and loss of an effective epithelial barrier allows for bacterial colonization and wound infection. Systemic factors also play a major role in the frequency of infection. Patients taking steroids, smokers, diabetics, and those who are immunosuppressed have significantly higher rates of postoperative infection.

Operative factors can further increase the risk of infection. Contamination of the wound, the operative field or instruments, rough handling of soft tissues, and excessive surgical time have all been implicated in increasing the rate of postoperative infection.

Blood supply to the affected area is also of profound importance in both tissue healing and infection. Injuries in areas with poor vascular supply, such as the foot and ankle, are more prone to infection. Excessive stripping of soft tissue from fractured bone, depriving it of its blood supply, will make the problem worse. Patients with vascular disease are also much more likely to develop infection and healing problems. Although often stated, there is no evidence that use of self-retaining retractors in limb surgery increases risk of infection. However, like all instruments they must be properly used and not applied to the tissue with excessive tension.

Effective treatment of early deep infection revolves around four principles:

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  Maintenance of stability: A fracture can heal in the presence of infection provided the fracture remains stable. Well fixed metalwork can therefore be retained in the presence of infection. Instability may occur in early deep infection due to failure of fixation. In such cases the fixation needs to be revised or replaced with an alternative fixation method—usually an external fixator. Loose metalwork must be removed.

  
  
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  Debridement and lavage: Any infected collections must be washed out and any necrotic tissue must be excised.

  
  
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  Skin coverage and revascularization: Infection may present with a sinus or ulcer, often with exposed metalwork at the base. Poor blood supply to the soft tissues and skin loss may be addressed through various plastic surgical flap techniques. Improving the blood supply and soft-tissue envelope will help combat infection.

  
  
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  Antibiotics: Appropriate use of antibiotics is essential in the infected wound. Antibiotics should not be started until a culture swab, and preferably also a tissue sample, has been obtained. Samples taken from the skin around a sinus may fail to grow the causative organism of the deep infection. This allows for therapy to be tailored to the organisms’ antibacterial sensitivities.

Decision making in the treatment of early acute infection can be difficult. For patients in whom fracture healing has begun it may be appropriate to debride the wound and suppress their infection with antibiotics until healing has occurred. For those with no evidence of healing or in whom stability is compromised, removal of the loose metalwork and more radical surgery can be considered. Use of intramedullary nails to increase fixation in bone which is already infected carries with it the risk of spreading the infection throughout the medullary cavity of the bone, and should be avoided.