case_images: PMC10713250_01
case_images: 33-year-old woman with one month of vague thigh pain presented with pathologic fracture. (a) AP radiograph of the right femur shows a displaced pathologic fracture of the proximal femoral shaft. Smooth periosteal reaction (arrow) surrounds the proximal femoral shaft. Permeative bone destruction is seen at the fracture bone ends. (b) Oblique radiographic view shows additional organized, thick, and dense periosteal reaction or involucrum around the infected cortex (open arrow).
case_images: CRIPA2023-6279174.001.jpg
case_images: PMC10713250_01_CRIPA2023-6279174.001.jpg
case_images: fig1
case_images: Radiographs demonstrated a pathologic fracture of the right femoral shaft, at the site of permeative bone destruction (Figures 1(a) and 2(a)). There was both organized and nonorganized periosteal new bone formation (Figures 1(b), 2(a), and 2(b)).
case_images: CT scan of right femur in the same patient 3 days after fracture. (a) Sagittal reformat of noncontrast CT image shows both organized (open arrow) and disorganized periosteal reactions (white arrow). The permeative bone destruction is best depicted on CT (curved arrow). (b) Coronal reformat of contrast CT image shows a low-density collection/lesion with a thin enhancing rim (arrowhead) around the fracture. The organized thick periosteal bone formation (open arrow) surrounds a very dense spicule that resembles necrotic bone or sequestrum (long thin arrow).
case_images: CRIPA2023-6279174.002.jpg
case_images: PMC10713250_01_CRIPA2023-6279174.002.jpg
case_images: fig2
case_images: There was both organized and nonorganized periosteal new bone formation (Figures 1(b), 2(a), and 2(b)).
case_images: Right femoral bone biopsy demonstrating acute suppurative osteomyelitis, with abundant neutrophils (circles) present alongside a network of reactive woven bone (*) (hematoxylin and eosin; 10x magnification).
case_images: CRIPA2023-6279174.003.jpg
case_images: PMC10713250_01_CRIPA2023-6279174.003.jpg
case_images: fig3
case_images: Acute suppurative osteomyelitis was again evident microscopically (Figure 3).
case_images: (a) Radiograph of right femur status post intramedullary fixation with an antibiotic-coated nail, approximately one month after fracture. There is significant increased bridging bone at the site of the prior pathologic fracture of the proximal right femoral shaft, consistent with fracture healing. (b) Radiograph of right femur status post intramedullary nail exchange and definitive fixation, approximately six months after fracture. Bony callus formation is evident in the region of the fracture with unchanged alignment.
case_images: CRIPA2023-6279174.004.jpg
case_images: PMC10713250_01_CRIPA2023-6279174.004.jpg
case_images: fig4
case_images: Interval radiography showed evidence of callus formation, so she proceeded to undergo an uncomplicated exchange of her antibiotic-coated rod for a definitive implant (Figure 4(a)). After six months of follow-up, the patient was discharged from orthopedics, with radiographic demonstration of fracture healing and resumption of normal, unrestricted activity (Figure 4(b)).