Open fractures have a increased risk of developing FRI, with rates between 12–52% of all open fractures in low resource setting. Effective initial management is critical in reducing this risk by removing as much primary contamination as possible while at the same time preventing iatrogenic introduction of pathogens. Prompt washout and early administration of antibiotics are vital steps that need to be taken as early as possible.

While generally less at risk than open fractures, closed fractures can also become infected (10–25%). If surgical treatment of these fractures is required, again preventing iatrogenic introduction of pathogens is essential. Minimally invasive surgery techniques, surgical safety checklists, proper operating room hygiene, adequate antibiotic prophylaxis, shorter hospitals stays and operative times all contribute in keeping the infection rate as low as possible. All healthcare workers who treat fractures should be aware of these risk factors to reduce the chances of infection.

To effectively prevent FRI, the clinician must understand how an open fracture can lead to FRI: At the moment of initial injury, microbes are introduced into the zone of injury. While the bodies own immune sytem will try to attack and destroy these microbes, its ability to do so is hampered by the presence of foreign materials and devascularized tisses. In these conditions, microorganisms have the ability to create a biofilm upon these foreign materials and devascularized tissues and help them to survive and thrive. Bacteria in biofilms are difficult to eradicate with only conventional antibiotic therapy. The concentration required to penetrate the microorganisms in a biofilm is simply too high. Therefore, systemic antibiotic therapy is rarely a cure by itself. Surgical debridement is required to remove any tissues or materials that contain or can develop biofilm. Surical debridement can lead to deadspace formation due to bone or tissue loss. It is of vital improtance that this deadspace is managed to prevent recurrent infection. There is increasing evidence that applying local antibiotics in this deadspace have an important additional value in preventing and treating FRI.

Risk factors

The risk of developing FRI is multifactorial and most easily categorized as:

• Injury-related risk factors
• Patient-related risk factors
• Treatment-related risk factors

Injury-related risk factors include the Gustilo Anderson-classification, level and type of wound contamination, and vascular injury.

Patient-related risk factors include smoking,  age, malnutrition, HIV status, and tuberculosis.

Treatment-related risk factors concern the timing and the quality of care provided. Examples include a lack of appropriate antibiotic prophylaxis for an open fracture; a prolonged preoperative hospital stay and prolonged operation time (with increased risk of colonization with a resistant hospital-acquired bacterial strain); inadequate immobilization or fixation techniques; lack of a sterile environment during a surgical procedure; poor initial debridement, increasing the risk of biofilm formation.

Many risk factors are modifiable and avoiding them will lead to better outcomes when treating patients with open fractures.

Preventive measures

Healthcare workers who treat fractures should adhere to guidelines on (open) fractures management. The principles to follow are those of infection prevention and control (IPC). Not only healthcare workers but also patients and caretakers should be informed about the symptoms and signs of FRI to facilitate timely treatment.