Chronic osteomyelitis due to retained war-time shrapnel after 16 years: Case report

Shrapnel, commonly associated with war-related trauma, is often retained without surgical removal due to its inert nature. However, these retained foreign bodies pose a risk of long-term complications, including chronic osteomyelitis (COM). This case report presents a rare instance of COM caused by retained shrapnel 16 years after a combat injury sustained during the Sri Lankan Civil War. A 55-year-old former soldier presented with fever, right thigh pain, and swelling. He had suffered a right femoral shaft open fracture in a mortar artillery blast in 2008, which was treated with intramedullary nailing. The implant was removed the following year due to infection. Imaging revealed multiple shrapnel fragments and osteomyelitic changes in the right distal femur, with one metal fragment causing erosion of the anterior cortex of the femur. The culture of an abscess of the right anterior thigh yielded methicillin-resistant Staphylococcus aureus, sensitive to vancomycin. The patient underwent abscess drainage, surgical retrieval of some shrapnel, and a 6-week course of oral linezolid. Although retained shrapnel is generally inert, its potential to cause COM necessitates a high index of suspicion. Timely imaging, microbiological cultures, and appropriate surgical and antibiotic management are critical in preventing severe long-term complications.