Working Diagnosis:
Chronic osteomyelitis with subdeltoid abscess as a result of pinning from previous humeral neck fracture

Treatment:
1) Incision and drainage at the bedside and in the operating room with 1.8L of pustular drainage removed. Case Photo #7
2) Operative washout occurred on the day of admission and again 48 hours later. He received cortical drilling of the humerus with placement of vancomycin and tobramycin-impregnated beads in the subdeltoid region and infraspinatus fossa of the left shoulder
3) Antibiotic treatment was de-escalated to cefazolin 2g IV every 8 hours for 6 weeks through a peripherally inserted central catheter in the outpatient setting.

Outcome:
Follow-up in the training room (week 3 of 6 of antibiotics):
- He lost 25 pounds unintentionally since hospitalization. He reported left shoulder tightness but otherwise had no other concerns. On physical exam, he had decreased active range of motion but normal passive range of motion. He was medically cleared to start light/low impact activity and work on strength/range of motion with the athletic trainer. Nutrition was emphasized, with goal of gaining 1-2 pounds per week.

Follow-up 6 months post-injury:
- He was back to playing baseball and pitching, only complaining of a decrease in his pitching velocity from 88 mph to 82 mph. On physical exam, he had full active range of motion with atrophy of the left deltoid Case Photo #8 Case Photo #9 . He continued strengthening the deltoid and scapulothoracic muscles. He had no restrictions in activity.

Outlook:
The patient qualified to play Summer baseball. He pitched well but was not yet back to his baseline. His goal was to play at full capacity in the Spring 2024.

Author's Comments:
Infection after Fracture Fixation (IAFF) does not have a precise definition, and adequate studies describing actual incidence are lacking. Incidence of infection with a closed fracture is 1-2% while incidence of infection with an open fracture is up to 30%. Incidence of infection after pinning is 11%. The timing of pin-track infection is considered early (less than 2 weeks), delayed (2-10 weeks), or late (greater than 10 weeks). This case of infection occurred 15 years later. It is postulated that there is necrotic bone development around the pin that prevents normal fracture healing. This results in non-union, which becomes infected and remains indolent due to the cortex forming around the necrotic bone. Most infections are caused by Staphylococcus aureus secondary to either open trauma or fracture/fixation surgery. The cure-rate of S. aureus orthopedic-implant-associated infections is 100% with ciprofloxacin and rifampin. With cultures returning sensitive to penicillin, cefazolin was deemed to be appropriate and provided a cure for this patient. Of note, an elevated C-reactive protein can be suggestive of infection. An elevated C-reactive protein is expected after surgery, but will normalize within weeks. In the post-operative period, repeated measurements can be informative if there is a secondary increase after it has declined post-surgery. If there is a remote history of surgery and concern for an infection, measuring the C-reactive protein can be a useful test.

Editor's Comments:
This unfortunate elite pitcher developed rapid pain, swelling, and loss of function over the course of 2 weeks after a seemingly innocuous weight-lifting injury. So-called red flag clues of severe pain despite use of opiates, erythema, diffuse swelling, and loss of function triggered hospitalization. With pain out of proportion to the mechanism of injury, the differential diagnoses list correctly prioritized infectious etiologies, although thrombosis would also be an initial consideration. Despite the extent of deep infection and potential for significant morbidity, the patient returned to a high-level of pitching due to prompt recognition of red flag symptoms. Notation of the profound weight loss in this case could also serve as a platform for mental health screening. The coordination of multi-disciplinary care in the inpatient and outpatient settings was essential to an excellent outcome.

References:
1) Waler N, Rupp M, Lang S, et al. The epidemiology of fracture-related infections in Germany. Sci Rep 11, 10443 (2021). https://doi.org/10.1038/s41598-021-90008-w
2) Trampuz A, Zimmerli W. Diagnosis and Treatment of infections associated with fracture-fixation devices. Injury. 2006 May; 37 Suppl 2:S59-66. doi:10.1016/j.injury.2006.04.010
3) Wu H, Yu S, Fu J, Sun D, Wang S, Xie Z, Wang Y. Investigating clinical characteristics and prognostic factors in patients with chronic osteomyelitis of humerus. Burns Trauma. 2019 Dec 5;7:34. https://doi.org/10.1186/s41038-019-0173-0.
4) Steinmetz S, Wernly D, Moerenhout K, Trampuz A, Borens O. Infection after fracture fixation. EFORT Open Rev. 2019 Jul 15; 4(7):468-475. doi:10.1302/2058-5241.4.180093
5) Jardaly AH, LaCoste K, Gilbert SR, Conklin MJ. Late Deep Infections Complicating Percutaneous Pinning of Supracondylar Humerus Fractures. Case Reports in Orthopedics. 2021, 7915516, 5 pages, 2021. https://doi.org/10.1155/2021/7915516

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