Wound Botulism Complicating Internal Fixation of a Complex Radial Fracture

Abstract

Botulism developed in a patient following surgical repair of an open radial fracture. Symptoms resolved after treatment with antitoxin and antibiotics, and hardware excision was deferred. Subsequent osteomyelitis necessitated hardware exchange, and wound cultures grew Clostridium argentinense. This case highlights the management of botulism associated with orthopedic hardware. CASE REPORTA 34-year-old man without significant past medical history presented with double vision. Three weeks prior to admission he suffered a compound fracture of his right radius and ulna during a soccer game. He was admitted to the orthopedic service for open reduction and internal fixation with a midulnar and radial plate (see Fig. 1). During the procedure, grass and dirt were noted in the surgical bed. He was treated perioperatively with cefazolin and gentamicin, was discharged, and completed 10 days of cephalexin treatment. Eighteen days following surgical repair he noted both double vision and difficulty opening both eyes. He presented three days later after worsening of symptoms and the development of slurred speech and difficulty swallowing.On admission, he denied fevers or chills, wound breakdown, paresthesias, or any other symptoms and asserted adherence to his postoperative antibiotics. The patient had no significant past medical history, took no other medications, and denied recreational drug use. His speech was dysphonic, and he had bilateral ptosis with notable diplopia. There was severe upper and lower bifacial weakness, and only trace extraocular movement was seen. His pupils were large and minimally reactive to light or accommodation. There was notable tongue and pharyngeal weakness. His right arm showed a healing surgical wound on the volar surface of his forearm. The results of the rest of his examination were unremarkable, as were his laboratory results.A nerve conduction study and electromyogram procedure were conducted, and the interpretation documented "low baseline amplitudes, especially in proximal musculature, with significant facilitation"; the interpreting neurologist noted that in the appropriate clinical context, the features were consistent with wound botulism. The patient was promptly administered a dose of botulinum antitoxin obtained from the CDC (7,500 units of antitoxin A and 5,500 units of antitoxin type B in 100 ml of normal saline solution over 1 h). Infectious disease consultants recommended commencing high-dosage intravenous penicillin G treatment and planning for surgical debridement and removal of the implanted hardware. After receiving botulinum antitoxin, his clinical symptoms improved overnight, and surgical excision was deferred. A blood sample obtained prior to the administration of botulinum antitoxin was negative for Clostridium botulinum toxin when tested by the CDC after trypsinization by use of a mouse bioassay. His symptoms improved, and he was discharged to complete 6 weeks of oral metronidazole and clindamycin treatment.Radiographs obtained 6 weeks after discharge were indicative o...

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Brodie’s Abscess 7 Years after External Fixation of a Displaced Distal Radius Fracture: A Case Report and Review of the Literature

“…Taylor SM et al [17] Wound botulism complicating internal fixation of a complex radial fracture We conclude that pin site discharge, whether sterile or infected, is in general not an indication for early wire removal.…”

“…Osteomyelitis as a rare complication of complex distal radius fractures has been seen if the initial treatment included bone grafting [15,16]. An extremely rare case of osteomyelitis after ORIF of an open radial fracture and wound botulism has been described [17], but not after external fixation.…”