Fracture related infection after low-energy gunshot injuries

Civilian firearm violence is a significant healthcare burden and particularly fractures after gunshot injuries are at risk for fracture related infection (FRI). This risk has been reported between 3.6 and 22 % in different retrospective case series. A central question is how to prevent this complication after ballistic injuries. Antibiotic prophylaxis - or better preemptive antibiotic therapy - should be applied early and recent data do not show benefits for long duration. A recent paper demonstrated that prophylactic antibiotic administration for ≥48 h is unwarranted for patients with ballistic fractures to the extremities and may even be associated with a higher infection risk. Three days of preemptive antibiotic therapy or even 24 h was not inferior compared to longer-duration therapy in the development of infectious sequelae after gunshot fractures to the pelvis. The microbiological profile of FRIs following gunshot injuries is diverse, though Gram-positive pathogens dominate but also polymicrobial infections are of significance. Narrow-spectrum agents, such as cefazolin or clindamycin, showed comparable effectiveness compared to extended gram-negative coverage in uncomplicated case in the absence of visceral involvement or gross contamination. However, in cases with bowel injuries or other high-risk features, broader-spectrum therapy may still be justified. A further important question is whether or not retained bullied fragments should be removed. Recent data showed a statistically significant increased risk of FRI when retained bullied fragments are not removed at the time of internal fracture fixation. Treatment of FRI after gunshot injuries should be based on the recently developed diagnostic, classification and treatment principles of FRI in general. This includes a straight forward diagnostic approach using suggestive and confirmatory criteria. Treatment strategy should rely on a multidisciplinary approach, including all relevant disciplines, e.g. plastic surgery, microbiology, infectious disease etc. Treatment goal is the infection free consolidation of the fracture with good function of the limb with restoration of quality of life, including psycho-social health of the patient.