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Infection in Closed Fractures: A Case Report and Literature Review
Infection in Closed Fractures: A Case Report and Literature Review
I
nfection after a closed fracture is rare. Whereas open frac- the anesthesiologist noted that the patient had a fever of 39°C.
tures are considered contaminated, closed fractures are as- Intraoperatively, a small amount of purulent liquid was discovered
sumed to be uncontaminated and have an extremely low risk in the medial suprapatellar area. The surrounding soft tissue also
of infection. We report on a previously healthy adult patient who
presented acutely with an infected, closed patellar fracture. The
patient was informed that data concerning her case would be
submitted for publication, and she provided consent.
Our review of the literature has identified several reports
of osteomyelitis in closed fractures1-12. These were generally pe-
diatric cases1,3,5,8,9-11 or cases in immunocompromised adults2,11,12.
Our patient was an immunocompetent adult. We found only five
cases of osteomyelitis after closed fractures in immunocompetent
adults4,6,7,9. In two of the cases, the patients presented with mul-
tiple severe injuries and associated complications that could have
served as a source for hematogenous spread of bacteria4,7. In all
five cases, it took several weeks to months for an infection to
present at the closed fracture site4,6,7,9. Our patient presented
acutely with an isolated closed injury with no apparent source
for infection.
The pathogenesis of an infection after a closed fracture is
an area of interest and research. First, it appears that healthy
tissue and body fluids are not bacteria-free, and that an open
wound is not the only source for a bacterial infection13-17. Second,
mechanisms have been described that allow such indwelling
bacteria to ‘‘home’’ to sites of closed injury16-18. Third, it has been
suggested that local changes after a closed injury can increase
susceptibility to infection13,19. The purpose of this report is to
briefly review these issues and increase awareness of this rare
event.
Case Report
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this
work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.
Nonunion was not uncommon, and the outcome was generally flammatory response and cause an infection. It appears that
poor in these patients. properties of the invading bacteria and local host factors both
The diagnosis of infection at a closed fracture site is often play an important role. n
delayed. It is not unreasonable to suspect infection in patients
who continue to have symptoms of pain and swelling to the
fracture site after several weeks of immobilization. This is es-
pecially true in the pediatric patient with a history of a recent
remote infection, such as a URTI or UTI. In many cases, pa- Christopher Kim, MD
University of Manitoba, AD 420 – 720 McDermot Avenue,
tients are febrile and present with a warm, tender, and fluctuant Winnipeg, Manitoba, R3E 0T3 Canada.
fracture site. The belief that infection does not occur with E-mail address: umkim88@cc.umanitoba.ca
closed fractures may prove too simplified, as perforated skin
may not be the only source for bacterial invasion. Bacteria re- Ted V. Tufescu, MD, FRCSC
side in normal healthy tissue and fluids, including within the Health Sciences Centre, AD4 – 820 Sherbrook Street,
callus of a healing fracture16. We must question what the risk Winnipeg, Manitoba, R3A 1R9 Canada.
factors and mechanisms are for such bacteria to evoke an in- E-mail address: ttufescu@exchange.hsc.mb.ca
References
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