Management and Outcomes of an Open Distal Femur Fracture in an HIV-Positive Patient: A Case Report From Madina Hospital, Somalia

Introduction

The management of fractures in individuals living with HIV presents unique clinical and ethical challenges, particularly in low-resource settings.¹ HIV infection affects fracture healing through multiple mechanisms, including CD4+ T-cell depletion, altered cytokine signaling, impaired angiogenesis, and antiretroviral therapy (ART)-associated effects on bone metabolism.² These factors raise concerns regarding increased risks of surgical site infection, delayed union, and nonunion following fracture fixation.³ Patients living with HIV may also experience delays in accessing surgical and emergency care due to stigma, additional preoperative requirements, and concerns among healthcare workers regarding occupational exposure, especially in resource-limited settings.⁴ Such barriers may contribute to delayed or suboptimal management, However, several clinical studies have shown that fracture fixation in HIV-positive patients is generally safe and effective.^3,5 For example, Xu et al⁵ reported that fracture healing can occur normally in most HIV-positive patients, although postoperative infections were more common in patients with advanced disease, low CD4+ T-cell counts, and open fractures. Data from Sub-Saharan Africa particularly from fragile and post-conflict health systems such as Somalia remain scarce.⁶

Therefore, this case report aims to describe the successful management and clinical outcome of an open distal femur fracture in an HIV-positive patient treated at Madina Hospital, Mogadishu, and to highlight the feasibility and safety of standard orthopedic management in this setting.

Case Presentation

Patient Information

A 25-year-old male presented with an open distal femur fracture following a gunshot injury (see Figure 1). He was referred to Madina Hospital after refusal of treatment at a private facility due to a newly identified HIV-positive status. The patient was previously unaware of his HIV status but reported a history of intravenous drug use with shared needles approximately 12 months prior. He had no known history of chronic medical conditions such as diabetes mellitus, hypertension, or tuberculosis. There was no history of smoking or alcohol use. These factors were considered important as comorbidities can influence fracture healing and infection risk.

Figure 1 Preoperative X-ray showing a displaced transverse fracture of the distal femoral shaft approximately 8 to 10 cm above the knee joint with cortical disruption and misalignment of bone fragments.

Clinical Findings

On physical examination, the patient was hemodynamically stable. Local examination of the affected limb revealed an open fracture of the distal femur with a wound size greater than 2 cm, mild contamination, and intact distal neurovascular status. The wound showed a small circular entry point consistent with a bullet entry wound, with surrounding soft tissue injury, swelling, deformity, and tenderness. Based on these findings, the injury was classified as a Gustilo-Anderson type II open fracture, characterized by a wound >1 cm with moderate soft tissue damage and contamination but without extensive periosteal stripping.

Diagnostic Assessment

HIV testing was conducted using a WHO-recommended sequential rapid testing algorithm, beginning with the SD Bioline HIV/Syphilis Duo test, followed by confirmatory testing with ABON HIV 1/2/O Tri-Line and STAT-PAK HIV1/2 assays, minimizing the risk of false-positive results. Baseline laboratory investigations revealed mild anemia (hemoglobin 8.7 g/dL) and thrombocytosis (473×10⁹/L). The CD4 count was 400 cells/mm³, indicating moderate immune function.

Radiographs demonstrated a displaced transverse fracture of the distal femoral shaft approximately 8–10 cm proximal to the knee joint, with preserved articular surfaces and surrounding soft tissue injury consistent with an open fracture.

Therapeutic Intervention

Initial Management

Urgent surgical debridement and irrigation were performed on admission. The wound was irrigated with 9 liters of normal saline, devitalized tissue was excised, and a drain was placed for 24 hours. The wound was left open and covered with sterile dressings to allow for repeated assessment and to reduce infection risk. Temporary immobilization with a posterior back slab was applied. Intravenous cefazolin and gentamicin were administered for three days, along with tetanus prophylaxis and analgesia.

Definitive Management

Delayed primary wound closure was achieved on day five post-debridement. The decision to delay closure was based on: The need to monitor for infection in an open fracture, Mild contamination at presentation and Optimization of the wound before closure. This approach aligns with standard open fracture management principles to reduce infection risk.

Definitive internal fixation using a distal femoral locking plate was performed ten days after injury (see Figure 2), once soft tissue conditions were optimized. Antiretroviral therapy consisting of tenofovir, lamivudine, and dolutegravir was initiated perioperatively following counseling.

Figure 2 Postoperative anteroposterior radiograph of the distal femur demonstrating definitive internal fixation with a distal femoral locking plate and multiple locking screws. The fracture is well reduced with satisfactory alignment and restoration of limb axis. Fixation was performed ten days after injury following optimization of soft tissue condition.

Outcome and Follow-Up

The postoperative course was uneventful. The patient remained hospitalized for four days following fixation and was discharged with outpatient follow-up. Sutures were removed at 15 days. Follow-up radiographs at one month showed early callus formation, while imaging at eight months confirmed complete fracture union with stable fixation. No superficial or deep infections, implant failure, or functional limitations were observed.

Discussion

This case report demonstrates that an HIV-positive patient with an open distal femur fracture can be successfully managed using internal fixation with a locking plate, resulting in favorable clinical and radiological outcomes without postoperative complications.

The importance of this case lies in highlighting that satisfactory fracture healing and infection prevention are achievable in HIV-positive individuals, even in resource-limited settings, when standard orthopedic and infectious disease principles are appropriately applied.

Several key clinical factors likely contributed to the positive outcome. First, the patient was initiated on antiretroviral therapy (ART), which plays a crucial role in immune restoration. Adequate immune function—often assessed by CD4+ T-cell count is a major determinant of wound healing and resistance to infection. Severe immunosuppression has been associated with higher rates of postoperative infection and delayed fracture healing. Second, early and meticulous surgical debridement and irrigation were essential in reducing bacterial load, particularly in the context of an open fracture. Third, the use of a locking plate provided stable fixation, maintaining alignment and promoting fracture union while minimizing mechanical complications.

These findings are consistent with existing literature. A systematic review reported that fracture management in HIV-positive individuals is generally safe and does not significantly increase the risk of delayed union or nonunion compared to HIV-negative patients.⁷ Similarly, a prospective cohort study conducted in South Africa demonstrated comparable fracture healing outcomes regardless of HIV status.⁸ Additionally, a clinical study from Pakistan found that fracture healing can occur normally in most HIV-positive patients, although postoperative wound infections were more common in those with advanced disease, low CD4+ T-cell counts, and open fractures.⁹ Other studies have emphasized the importance of close postoperative follow-up and timely hardware removal after radiological union.¹⁰

Beyond clinical factors, broader systemic challenges must also be considered. Access to HIV care in Sub-Saharan Africa remains limited due to stigma, inadequate healthcare infrastructure, and socioeconomic barriers, which may delay timely surgical intervention and optimal management. This is particularly relevant in fragile health systems such as Somalia. Recent literature highlights persistent inequities in access to HIV services across the region, underscoring the need for integrated and accessible care models.¹¹

This case has several limitations. As a single case report, its findings are not generalizable. Additionally, detailed immunological parameters, including serial CD4 counts and viral load measurements, were not consistently available. Long-term functional outcomes were also limited. Further studies, including case series and cohort studies, are needed to better understand fracture management outcomes in HIV-positive patients, particularly in resource-constrained settings.

Limitations

This report describes a single case, which limits the generalizability of the findings. Long-term functional outcomes and viral load data were not available, which restricts the ability to fully assess recovery and immune status over time. Additionally, the results reflect the experience of a single resource-limited center in Somalia, and caution should be exercised when extrapolating to other settings.

Conclusion

The case demonstrates that open distal femur fractures in patients with well-controlled HIV can be successfully managed with internal fixation, achieving outcomes comparable to HIV-negative individuals when standard surgical principles are followed. Timely debridement, appropriate antibiotic use, delayed wound closure, stable fixation, and early initiation of antiretroviral therapy are key factors contributing to favorable outcomes. Further studies, including case series and cohort studies in Somalia and Sub-Saharan Africa, are needed to strengthen the evidence base and guide clinical practice in resource-limited settings.