Some fracture wound infections present more than 2 weeks after fracture surgery. Often, there are atypical systemic or local symptoms (mild fever, or less erythema). Ultimately, increasing pain, redness and swelling, etc., become evident. Sometimes, late onset of wound breakdown, or drainage (formation of a sinus tract), is the first indication that an indolent infection is present. An infection that presents more than 2 weeks after fracture surgery should be considered differently, with need for more aggressive treatment.
The microorganisms that cause delayed infection are usually of lower virulence (e.g., coagulase-negative staphylococci). Infecting bacteria have often been present long enough to have become adherent to metallic implant and dead bone, and are thus more resistant to antibiotics. Thorough surgical debridement is required, and provides an important opportunity for fracture-wound evaluation. Nonviable bone and soft tissue may require debridement. Hardware may need to be removed, although if it still provides stable fixation, an attempt may be made to leave it, and suppress the infection until the fracture has healed. This requires debridement, wound closure (perhaps staged) and appropriate antibiotics. If more extensive debridement, including substantial bone removal, is required, or internal fixation needs to be removed, treatment may require external fixation with more involved bone and/or soft-tissue reconstruction.