Infection of the fracture hematoma from skeletal traction in an asymptomatic HIV-positive patient

Open Access-This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. In June, 2011, a 27-year-old man was walking home in the dark, in Lilongwe, Malawi, when he fell several meters into an open septic tank that was under construction. He was brought to Kamuzu Central Hospital (KCH), the main government referral hospital for the central region of Malawi, in considerable pain and was found to have sustained a left closed subtrochanteric spiral fracture (Figure 1). He also sustained a brachial plexus injury on his left side with complete loss of function of the shoulder and elbow, but with some hand function preserved. Hemoglobin test was not done on admission due to the full blood count (FBC) machine in the laboratory having broken down. As would be the case for femoral fractures in most hospitals in the region, proximal tibial skeletal traction was applied. The brachial plexus injury was treated with a sling only. The patient was HIV-positive and had started antiretroviral treatment (ART) only a few weeks before the accident. A CD4 count result was not available to us, but in Malawi ART is started only when the CD4 count is below 350. He had no AIDS-defining conditions, had not lost weight, had no symptoms or complaints from his HIV infection, and as such was probably WHO clinical stage 1 (WHO 2007) and CDC class A2 (CDC 1992). He was admitted to the male orthopedic ward on traction. This ward is designed for 40 beds, but at any time has between 60 and 90 inpatients, and most of the time there is only one qualified nurse on duty. KCH has surgeons who are trained to do locked intramedullary (IM) nailing of fractures, and it has the equipment. A successful operation with an IM nail would have led to this patient being out of bed in a few days, but because of a heavy workload, a severe lack of staff and theater time, and the fact that this fracture was considered by the treating clinicians to have good potential for of healing, it was decided to continue treatment with traction until union. We saw the patient 3 months later. He had spent the entire 3 months on traction in bed without physiotherapy or exercises. A new radiograph showed increased angulation …