A 62-year-old female diabetic patient presented in our outpatient department with complaints of pain in the right shoulder and inability to raise arm of 2 weeks duration.
The medical history revealed generalized malaise and weight loss although no history of fever in the last 3 months. There is no history of trauma.
Local examination revealed rise of temperature, tenderness over right shoulder and proximal arm and restricted range of movements in all plane. There was no external wound, sinus or discharge from any skin sites.
Systemic examination was normal. Neurologically, the patient was normal.
Laboratory tests showed hemoglobin - 10 g/dl, total leukocyte count - 9500/cumm, neutrophils - 65%, lymphocytes - 30%, erythrocyte sedimentation rate (ESR) was raised - 40 mm/h.
Plain radiograph (Fig. 1 and 2) followed by MRI (Fig. 3 and 4) of the right shoulder with humerus showed transverse fracture of proximal shaft of the right humerus, 5 cm distal to surgical neck. Articular surface was not involved.
We suspected tumor or infection and planned computed tomography (CT) chest to look for any pulmonary foci or metastasis. CT chest showed small areas of consolidation in the left upper lobe, pointing toward the infective etiology.
Mantaoux test was negative.
Bronchoalveolar lavage was done and sample sent for culture and sensitivity came out to be negative for acid-fast bacilli.
Considering tumor and tuberculosis as differential diagnosis, J-needle biopsy was done from anterolateral aspect of proximal humerus at the fracture site. The tissue material obtained from biopsy was sent for histopathological examination which confirmed granuloma with epithelioid and Langhan's giant cells.
Culture for acid-fast bacilli of biopsy tissue sample was non-conclusive.
Based on the histopathology report, we concluded this to be tuberculosis osteomyelitis of humerus and our patient was started on category 1 antitubercular drugs, under Revised National Tuberculosis Control Programme (RNTCP) as per revised WHO guidelines.
After 3 days of starting antitubercular drugs, debridement of lesion and fracture fixation using rush nail was done. Standard deltopectoral approach was used to explore the lesion. Both intra- and extra-medullary debridement were done. We used reamers for intramedullary debridement. From the edges of lesion, 1 cm of bone was removed. Debridement was done till all necrotic tissue was removed and bleeding was seen from the edges of bone. Fracture ends were approximated and using greater trochanter as entry point, rush nails were inserted (Fig. 5). We did not use any local antibiotic drug delivery method.
Procedure was uneventful, stitches were removed on day 14th and incision healed well. Post-operatively, our patient was continued on category 1 antitubercular drugs.
Initial follow-up 4 months postoperative and plain radiography after 7 months (Fig. 6) showed overall improvement in general condition of patient, weight gain, and good fracture healing. After 1 year following index surgery, patient complained of pain at nail insertion site at the tip of greater trochanter and shoulder abduction was restricted beyond 40 . The patient did not have pain at fracture site. Rush nails were removed (Fig. 7). Pain subsided following nail removal and shoulder abduction improved with restriction only in terminal 30 .
Fracture healed completely, and patient was pain free. Compared to opposite shoulder, abduction and forward flexion were restricted in terminal 30 . Internal and external rotations and adduction were full.