Complicated acute haematogenous osteomyelitis with fatal outcome following a closed clavicle fracture-a case report and literature review

Abstract

Among adults, post-traumatic osteomyelitis following a closed fracture is a rarely described entity in the literature, with the involvement of the clavicle bone being particularly uncommon. Early diagnosis and treatment of clavicular osteomyelitis is crucial to prevent serious consequences such as sepsis, mediastinitis and haemorrhage from the great vessels. A 54-year-old male patient presented to the emergency department complaining of fatigue and limited mobility after having fallen and hit his head and right shoulder 10 days previously. No major injury was found during the diagnostic procedure, and the patient was discharged. 2 weeks later, the patient returned with clinical signs of right upper arm cellulitis and probable sepsis. Diagnostic ultrasound imaging and MRI of the right upper arm, as well as re-examination of the X-ray image, confirmed acute complex osteomyelitis of the right clavicle following an overlooked clavicle fracture. Microbiological analysis confirmed clavicular osteomyelitis caused by Escherichia coli septicaemia. Despite prompt treatment with i.v. antibiotics and surgery, the patient's condition rapidly deteriorated and he passed away. Our case demonstrates the critical importance of early diagnosis and appropriate treatment of a closed fracture. Late diagnosis may lead to severe complications, such as complicated osteomyelitis and sepsis, and even a fatal outcome. Furthermore, a brief literature review is presented of previously reported acute osteomyelitis following a closed fracture, including evidence of affected bone and isolated pathogens. Although uncommon, osteomyelitis should be considered a possible cause of a deteriorating clinical condition in patients with a history of recent trauma.

Figure 1.

Ultrasonography of the supraclavicular region. (a) Subcutaneous hyperechoic, complex fluid collection extending above the right clavicle and between the clavicle fragments, with the presence of hyperechoic gas bubbles (white arrows). (b) A free fragment of the clavicle cortical bone (white arrow) surrounded with thick, hyperechoic fluid collection (black arrow).

Figure 2.

X-ray image of the right shoulder. A wide, lucent fracture line without dislocation between the fragments is seen at the distal third of the right clavicle (black arrow). The X-ray was taken during the patient’s first visit to the emergency department and was misinterpreted as normal.

Figure 3.

MRI of the right shoulder. (a) T ₂ fast relaxation fast spin-echo fat-saturated sequence, axial images. Continuation of a large abscess distally encompassing the anterior compartment of the right arm. The fluid collection extended almost to the level of the elbow (white arrows). An additional finding was the moderate right pleural effusion (grey arrow). (b) T ₁ fast spin-echo fat-saturated post-contrast images in the coronal plane. Clavicle fracture and destruction with a markedly diffuse, inflammatory post-contrast enhancement of the clavicle (black arrows). Peripheral ring enhancement of the supraclavicular and brachial abscess formation is evident (white arrows).