Can a Fracture Get Infected? Signs and Treatment

Fractures can and do get infected, and when they do, the consequences are serious. Open fractures, where bone breaks through the skin or the wound reaches the bone, carry the highest risk, but even closed fractures treated with surgical hardware can develop infections weeks or months later. Infection rates vary enormously depending on the severity of the injury, but the biology behind fracture infections, including stubborn bacterial biofilms and disrupted bone healing, makes them harder to treat than a typical wound infection.

How a Fracture Becomes Infected

There are two main routes. The first is direct contamination: when bone is exposed to the outside environment, bacteria from soil, clothing, or the skin surface enter the wound. This is the classic scenario in open fractures, where a high-energy injury like a car crash or a fall tears through skin and muscle, leaving bone open to the elements. The more tissue damage and contamination there is, the higher the infection risk climbs.

The second route involves surgery. Many fractures, both open and closed, need surgical fixation with plates, screws, rods, or nails. Any time hardware is implanted, bacteria can be introduced during the procedure or colonize the implant’s surface afterward. A particularly troublesome feature of these infections is biofilm, a kind of protective slime layer that bacteria build on the surface of metal implants. Once established, a biofilm shelters bacteria from antibiotics and the immune system, encouraging persistent infection that can lead to implant failure and deep bone infection called osteomyelitis.1PubMed Central. The Role of Staphylococcal Biofilm on the Surface of Implants in Orthopedic Infection Staphylococcus aureus is one of the leading culprits in these implant-related infections, partly because of how effectively it forms biofilms on orthopedic hardware.2PubMed Central. Infectious Dose Dictates the Host Response during Staphylococcus aureus Orthopedic-Implant Biofilm Infection

How Common Are Fracture Infections, and What Drives the Risk

The risk of infection after a fracture depends largely on how severe the injury is. Orthopedic surgeons classify open fractures by severity, from relatively minor wounds with little soft-tissue damage (Type I) through catastrophic injuries with massive tissue loss and vascular damage (Type IIIC). A large analysis of over 6,000 open fractures found that surgical site infection rates at 12 months were about 5% for Type I injuries, roughly 10% for Type II, about 14% for Type IIIA, and jumped to around 29% for Type IIIB and 26% for Type IIIC.3PubMed Central. Infection and Nonunion Rates in Open Fractures: Description of 6,042 Fractures from the FLOW and PREP-IT Trials That means the worst open fractures carry nearly a one-in-three chance of becoming infected.

Contamination of the wound makes a bad situation worse. When dirt, debris, or other material becomes embedded in the fracture site, the infection risk climbs by roughly 10 percentage points on top of the baseline rate for that fracture type. A study examining this found that embedded contamination pushed the infection risk for Type I and II fractures to about 16%, and for the most severe Type IIIB and IIIC injuries, up to around 45-46%.4PubMed. Is the Orthopaedic Trauma Association-Open Fracture Classification Better Than the Gustilo-Anderson Classification at Predicting Fracture-Related Infections in the Tibia?

Closed fractures treated surgically carry a much lower infection rate, generally in the low single digits, but patient-level risk factors can push it higher. Research has identified several health conditions that meaningfully increase your risk:

Recognizing the Signs of an Infected Fracture

Fracture infections can show up early, within weeks of the injury or surgery, or they can smolder for months before becoming obvious. Early infections tend to be more dramatic. You may notice increasing redness, warmth, and swelling around the surgical wound or fracture site. Pain that was improving begins to get worse. Fever is possible but not always present, especially in lower-grade infections. Drainage from the wound, particularly if it’s cloudy, discolored, or foul-smelling, is a red flag.

Late or chronic infections are trickier. The hallmark of a chronic bone infection is a draining sinus tract, which is a small opening in the skin that persistently leaks fluid from the infected bone beneath. If you see any wound that will not close, or a spot that keeps draining near a fracture that was surgically repaired, that warrants urgent evaluation. Patients who develop chronic draining sinus tracts from bone and joint infections report significantly worse physical function and quality of life compared to the general population, with pain and limited mobility taking a real toll over time.8PubMed Central. Long-term patient-related quality of life after fracture-related infections of the long bones

A fracture that simply is not healing on schedule can also be a sign of underlying infection. If your surgeon expected bone union by a certain point and X-rays keep showing a gap, infection should be considered, because bacteria actively interfere with the bone-building process.

Why Diagnosis Is Not Straightforward

You might expect a simple blood test to settle the question, but standard inflammatory markers like C-reactive protein (CRP), white blood cell count, and erythrocyte sedimentation rate (ESR) perform poorly for diagnosing fracture-related infections. A large multicenter study found that CRP had only about 38% sensitivity for detecting these infections, meaning it missed more than half of confirmed cases. ESR was somewhat better at 62% sensitivity, but none of these blood tests were reliable enough to rule an infection in or out on their own.9PubMed Central. Limited Predictive Value of Serum Inflammatory Markers for Diagnosing Fracture-Related Infections: results of a large retrospective multicenter cohort study This is a problem because many patients and some clinicians assume that normal blood work means no infection.

Imaging helps, but has its own limitations. Standard X-rays can show bone changes consistent with chronic infection but are useless in the early stages. MRI is more sensitive but can be distorted by metal hardware. Nuclear medicine scans that combine a bone scan with a white-blood-cell scan can help detect osteomyelitis at fracture sites by distinguishing bone infection from the soft-tissue inflammation that inevitably accompanies healing fractures.10PubMed. Detection of osteomyelitis at fracture nonunion sites: comparison of two scintigraphic methods

The gold standard for diagnosis is obtaining tissue from the fracture site and culturing it in a lab to identify the responsible bacteria. This is far more reliable than swabbing the surface of a wound. In deep or complex wounds, surface swabs agreed with the bacteria found in deep tissue samples only about 22% of the time in one study.11Clinical Microbiology and Infection. Diagnostic evaluation of superficial ulcer swab culture in spinal cord injury patients with advanced-stage pressure ulcers Swabs tend to miss important bacteria, especially certain gram-negative organisms, and sometimes grow bacteria from the skin surface that are not actually causing the deep infection.12PubMed Central. A Comparison of Tissue versus Swab Culturing of Infected Diabetic Foot Wounds If your doctor suspects a fracture infection, surgical sampling of the tissue around the bone is typically needed for accurate diagnosis.

Treatment Typically Involves Both Surgery and Antibiotics

Treating an infected fracture is not like treating a skin infection with a course of pills. Nearly every case requires surgery, and most patients need a prolonged course of antibiotics as well. The specific approach depends on whether the fracture has healed, whether the hardware is stable, and how severe the infection has become.

When hardware is still needed to hold the fracture in place and the infection is caught relatively early, surgeons often use a strategy called DAIR: debridement, antibiotics, irrigation, and implant retention. The surgeon reopens the wound, cuts away infected and dead tissue, thoroughly washes the area, and leaves the hardware in place while antibiotic treatment is started. This approach can work well in otherwise healthy patients when the bone is healing and the implant remains stable.13Journal of Musculoskeletal Surgery and Research. Debridement, antibiotics, and implant retention in a fracture-related infection with flexible forearm nail in situ: A case report of a successful outcome in an adolescent Animal research has shown that thorough cleaning of the inside of the bone canal during DAIR can help reduce the bacterial load in areas that systemic antibiotics struggle to reach.14Orthopaedic Proceedings. DEBRIDEMENT, ANTIBIOTICS, IRRIGATION, AND IMPLANT RETENTION IN A SHEEP FRACTURE-RELATED INFECTION MODEL

In more severe or chronic infections, the hardware may need to be removed entirely. If the fracture has not yet healed, the surgeon faces a difficult balancing act: the infection needs aggressive debridement, but the bone still needs stabilization. This sometimes means removing one type of fixation and replacing it with another, such as swapping a plate for an external frame that holds the bone from outside the body. Dead bone must be removed as well, which can leave gaps that need to be filled later with bone grafts.

Antibiotic therapy after debridement surgery usually starts with intravenous drugs for about two weeks, often followed by several more weeks of oral antibiotics.15PubMed Central. Antibiotic treatment regimens for bone infection after debridement: a study of 902 cases When hardware stays in place, one key finding is that extending antibiotics beyond 12 weeks does not appear to lower the risk of relapse.16PubMed Central. Evaluating the duration of antimicrobial therapy for the treatment of orthopedic hardware infections That matters because prolonged antibiotic courses carry their own risks, from side effects to antibiotic resistance, so knowing when you can safely stop is valuable.

Local Antibiotic Delivery

Because bone has relatively poor blood supply compared to soft tissue, getting enough antibiotic to the infection site through an IV alone can be challenging. This is where local antibiotic delivery comes in. Surgeons can place antibiotic-loaded beads or cement directly into the infected cavity after debridement. The most established method uses gentamicin mixed into a type of bone cement. The drug concentrations achieved right at the infection site are far higher than what systemic antibiotics alone can deliver, well above the threshold needed to kill most common bone-infecting bacteria.17PubMed. The use of antibiotic-containing bead chains in the treatment of chronic bone infections Non-biodegradable cement spacers have been the standard for this approach for decades, offering both high antibiotic release and structural support for the bone.18PubMed Central. Local antibiotic therapy in osteomyelitis The downside is that non-biodegradable spacers need a second surgery for removal once they’ve done their job, which has pushed research toward biodegradable alternatives that dissolve on their own.

What Happens When an Infection Is Not Controlled

A fracture infection that goes untreated or fails to respond to treatment can spiral into serious complications. The most feared is infected nonunion, where the bone simply refuses to heal because the infection creates a hostile environment for bone growth. Staphylococcus aureus, the most common offender, kills the bone-building cells (osteoblasts) by secreting toxins that destroy cell membranes. The loss of these cells directly cripples the bone’s ability to repair itself.19PubMed Central. The Role of Persistent Inflammation in the Pathogenesis of Infected Nonunion: A Narrative Review

Infection also throws off the normal immune response that drives bone healing. Healthy bone repair requires the body’s immune cells to shift from an initial inflammatory state to a repair-promoting state. Infection locks the immune system into the inflammatory phase, which keeps dissolving bone instead of building it.20PubMed Central. From macrophage polarization to clinical translation: immunomodulatory hydrogels for infection-associated bone regeneration The result is a vicious cycle: infection prevents healing, and the unhealed bone provides a continuing haven for bacteria. Breaking that cycle often requires multiple surgeries, sometimes with months of external fixation and staged reconstruction.

Preventing Infection After an Open Fracture

The most critical preventive step for open fractures is getting antibiotics started as quickly as possible. Guidelines generally call for intravenous antibiotics within an hour of hospital arrival, but meeting that target in practice has been an ongoing struggle. One study found that only about 48% of open-fracture patients received antibiotics within the first hour.21PubMed Central. State of the Union: Timeliness to Antibiotics in Open Fractures A dedicated performance improvement program at one trauma center managed to push that rate from 50% to 78% within the first hour, demonstrating that institutional focus on the problem makes a real difference.22PubMed. Substantial improvement in prophylactic antibiotic administration for open fracture patients: results of a performance improvement program

Beyond antibiotics, thorough wound irrigation during surgery washes out bacteria and debris. Surgical technique matters too: gentle handling of soft tissue, good wound coverage, and appropriate timing of definitive fixation all play a role. For patients, the modifiable risk factors discussed earlier, particularly smoking and blood sugar control, are worth addressing. If you are a smoker facing fracture surgery, quitting before the procedure may reduce your infection risk. If you have diabetes, working with your doctor to tighten glycemic control before elective surgery is a practical step you can take.

The Toll on Quality of Life and Finances

Fracture-related infections extract a cost that goes well beyond the medical bills. Patients who develop these infections report significantly worse physical function and more pain compared to the general population, even years after treatment. One study of long-bone fracture infections found that, on average four years after their last surgery, patients scored well below population norms on measures of physical health and overall quality of life.8PubMed Central. Long-term patient-related quality of life after fracture-related infections of the long bones A separate analysis confirmed that patients with fracture-related infections scored markedly worse on both physical function and pain scales compared to reference populations.23PubMed. Fracture-related infection in long bone fractures: A comprehensive analysis of the economic impact and influence on quality of life

The financial impact is steep. Treating an infected fracture costs roughly 1.5 to 8 times more than treating the same fracture without infection, with the wide range reflecting differences in severity and health-care settings.24PubMed Central. The economic impact of infection and/or nonunion on long-bone shaft fractures: a systematic review The biggest cost drivers are the additional surgeries, extended hospital stays, and prolonged antibiotic therapy that infection demands.25PubMed. Fracture-related infections of the lower extremity – Analysis of costs and their drivers For a patient who expected to have a fracture fixed and move on with life, the reality of repeated operations and months of treatment is devastating both physically and financially.

Emerging Approaches to Diagnosis and Treatment

One frustrating reality of fracture infections is that standard cultures sometimes come back negative even when infection is clearly present. The bacteria may be hiding inside biofilm, present in low numbers, or simply not growing well under standard lab conditions. Next-generation sequencing (NGS), which reads the genetic material of any bacteria in a tissue sample without needing them to grow in a dish, offers a way around this problem. In culture-negative infections, NGS has detected unusual organisms that standard methods missed entirely, allowing doctors to choose targeted antibiotics for pathogens they would not otherwise have known about.26PubMed Central. Next-Generation Sequencing Supports Targeted Antibiotic Treatment for Culture Negative Orthopedic Infections In at least one case, NGS detected high bacterial diversity in a biopsy sample that cultures called negative, and the patient went on to develop a severe infection within a week, suggesting that the sequencing result was the accurate one.27PubMed Central. Enhancing diabetic foot osteomyelitis diagnosis with metagenomics next-generation sequencing, proof of concept

On the treatment side, bacteriophage therapy is one of the more intriguing developments. Bacteriophages are viruses that infect and kill specific bacteria without harming human cells. In a canine model of acute fracture-related infection, seven days of bacteriophage therapy performed at least as well as six weeks of antibiotics for clearing the infection, and it was actually better at breaking down biofilm and promoting new bone formation at the fracture site.28PubMed. Bacteriophage Therapy for Acute Fracture-Related Infections: An Effective Treatment When Compared With Antibiotics in a Canine Model This is still early-stage research, and human trials will need to confirm the results, but the potential to shorten treatment times and overcome antibiotic-resistant biofilms makes phage therapy a space worth watching.