Delayed Complications from Retained Shrapnel: A Case of Chronic Osteomyelitis

A recent case report published in Surgery Case Reports details a rare instance of chronic osteomyelitis (COM) – a long-term bacterial infection of the bone – developing 16 years after a combat injury. The case highlights the potential for retained shrapnel fragments to cause delayed complications, even decades after the initial trauma.

The Case: A Soldier’s Delayed Pain

A 55-year-old former soldier presented at the National Hospital Kandy in Sri Lanka with fever, right thigh pain, and swelling that had persisted for seven days. His medical history revealed a right femoral shaft fracture sustained in 2008 during the Sri Lankan Civil War, caused by a mortar artillery blast. The initial fracture was treated with intramedullary nailing, but the implant was removed the following year due to infection.

Diagnosis and Findings

Imaging revealed multiple shrapnel fragments embedded in the patient’s right distal femur, alongside signs of osteomyelitis. One metal fragment was causing erosion of the anterior cortex of the femur. A culture of an abscess on the patient’s right anterior thigh identified methicillin-resistant Staphylococcus aureus (MRSA), a bacteria resistant to many common antibiotics.

Treatment and Outcome

The patient underwent drainage of the abscess and surgical removal of accessible shrapnel fragments. He was then treated with a six-week course of oral linezolid, an antibiotic used to combat resistant bacterial infections. Following treatment and outpatient care, the patient was discharged.

The Risks of Retained Shrapnel

Whereas often considered inert, retained shrapnel can pose a long-term risk of complications, particularly chronic osteomyelitis. Medical staff noted that Staphylococcus aureus is capable of surviving within biofilms and remaining dormant for extended periods, potentially contributing to delayed infections.

The case underscores the importance of thorough removal of shrapnel during initial surgical intervention following explosive injuries. Although complete removal isn’t always possible, the medical team emphasizes the need for long-term monitoring of patients with embedded metal fragments to detect and address potential complications.

Expert Perspective

“When fragments hit the body in an explosion, surgery to remove as many fragments as possible is essential,” the medical staff stated in their report. “Remaining fragments are generally harmless, but the possibility of causing chronic infection, especially if they are near the bones, should not be overlooked.”

The National Hospital Kandy, the second largest medical institution in Sri Lanka , played a key role in the patient’s treatment and the publication of this case report. The Centre for Research at the National Hospital Kandy continues to contribute to medical advancements in the region.