Heterotopic Ossification- Induced Osteomyelitis 3 Years after a Closed Both-Bone Forearm Fracture in a Pediatric Patient: A Case Study


Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children, while the feet, spine, and hips are most commonly involved in adults. Microorganism seeding of the bone occurs via: hematogenous spread from bacteremia, direct inoculation from penetrating trauma, or contiguous spread from local infection. Hematogenous spread is the predominant underlying pathogenesis in the pediatric (children<18-years-old) population, because of the rich vascular supply associated with developing skeletal tissue. Staphylococcus aureus, gram-positive cocci, is the most commonly isolated organism in children and adults with Osteomyelitis. Treatment modalities typically involve both surgical intervention and long-term antibiotic therapy. Untreated, the infection can progress to a chronic stage and is associated with complications including: pathologic fractures, growth arrest, septic arthritis, and sepsis. Treatment of osteomyelitis typically requires a multidisciplinary approach, including long term oral and/or intravenous antibiotic therapy and surgical intervention. Osteomyelitis as a secondary complication of closed fractures is a rare occurrence with less than 50 document cases reported in literature to the extent of the author’s knowledge. We report an atypical case of acute osteomyelitis originating from a localized bony spicule in a paediatric patient, more than 3 years after a surgically treated closed distal forearm both-bone (radius and ulna) fracture. The patient in this report exhibited an atraumatic nine-month course of recurrent abscess formation and localized inflammation, despite surgical debridement and multiple rounds of antibiotic therapy. A bony spicule noted on x-ray, which the authors believe formed from early consolidation of heterotopic ossification fragments, was surgically excised, after which the patient ceased to develop recurrent abscesses. Histological analysis of the spicule revealed findings consistent with a definitive diagnosis of S. aureus (MSSA) acute osteomyelitis. In conclusion, the initial injury was addressed with surgical intervention and the patient exhibited appropriate healing clinically and on radiographs with an uncomplicated postoperative period. The patient was evaluated over a nine-month period, during which he exhibited recurrent abscess formation overlying the left radial styloid alongside localized inflammatory symptoms, in spite of multiple rounds of antibiotics and a surgical debridement. Additionally, the patient did not exhibit clinical or radiographic signs or findings on bone biopsy consistent with osteomyelitis, further delaying an appropriate diagnosis in the presence of an already low index of suspicion. Complete resolution was achieved with a second surgical intervention to excise the bony spicule which was noted on x-ray. A diagnosis of acute osteomyelitis was confirmed with histological analysis of the excised bone fragment and the patient did not experience additional recurrences of inflammatory abscess formation.