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Osteomyelitis in Children

Dr. Robert Deane


Janeway
Outline
Age Treatment
Incidence Surgery
Etiology Complications
Pathophysiology Summary
Presentation Special Groups
Laboratory
investigations
Imaging
Age / Incidence / Etiology
1/1000 – 1/ 20 000

Male > Female

Pre antibiotic era ……20-50% mortality


Age / Incidence / Etiology
Advances in treatment
Earlier dx
Antibiotic tx
Surgery less delay
Children better nourished
Age / Incidence / Etiology
Glasgow incidence decreased
New Zealand……. Madri > Whites
South Africa…….. Black > Whites

Changing disease / Changing organism


Seasonal Variation
Nutritional status, climate, lifestyle
Age / Incidence / Etiology
H Flu

Big cause 1970’s


1-4 yrs
Now decreased due to vaccinations
Kingella Kingae
OM in older kids
Septic Arthritis 1-3 yrs
Neonates separate group
Pathophysiology

Poorly defined

Direct inoculation
Hematogenous spread
Local invasion
Pathophysiology
Infection
Starts in Metaphysis
• Arteriole Loop / Venous Lakes
Spread via Volkman’s canal / Haversian system
Endothelium Leaks
Pathophysiology
Few phagocytes in Zone of
Hypertrophy

Highest incidence in fastest


growing bone

Tubular > Flat bones


Pathophysiology
Gaps in endothelium metaphyseal vessel

Bacteria pass

Adhere to Type 1 collagen

Increase pressure in bone/ decrease blood flow

Bone infarction / Dead Bone (sequestrum)
Pathophysiology
Spread via Volkman Canal

Subperiosteal Pus

Cortex breaks down

May spread to joint
Hip / Shoulder / Fibula / Proximal Humerus
Pathophysiology
Role of Trauma

Rabbit experiment
IV injection of bacteria
With # start in hematoma
Pathophysiology
Role of growth plate
Over 18/12
Impermeable to spread
Under 18/12 infection crosses growth plate
Pathophysiology
Pathophysiology
1st osteoblasts die
Lymphocytes release osteoclast activating
factor
Hole in bone
Diagnosis
Pain
Neonate peudoparalysis
NWB
Failure to use limb
Fever

Lethargy

Anorexia

Swelling (neonates / older kids)


Pathophysiology
Bloodwork

CBC Diff
ESR
CRP
Blood Culture
Pathophysiology
WBC increased 30-40%

Left Shift 65%

ESR increased 91%……….24-36hrs

CRP increased 97%…………4-6hrs


Pathophysiology
CRP
More rapid
than ESR
2-4 hrs
…..peak 72hrs
10-30x normal
Systemic ds
(trauma, tumor)
Pathophysiology
Blood Culture

+ 30-60%
Decreased with antibiotic
Multiple cultures no significant increase in
yield
48 hours to get most organisms
Diagnosis
Pus aspiration
70% bone + cultures
Septic arthritis
• Gram stain
• Lymphocyte count
• % polymorphs
> 80 000 = Septic arthritis
> 50 000 in some series
80 000 also in JRA
Diagnosis
Do blood and joint cultures

One or other not always +ve in same pt


Gram stain +ve 1/3 bone and joint aspirations

Future looking for bacteria DNA / RNA


Lab Diagnosis
WBC not reliable
False sense of security
25% increased Mayo clinic
65% diff abnormal

Acute phase reactants


Change in plasma proteins d/t cytokines
Diagnosis
ESR
Nonspecific acute phase reactant
Depends on fibrinogen concentration

Increased 48-72 hrs


Increased in 90% of cases
Not affected by antibiotic tx
CRP
Increased in 98% of cases
Radiology
Plain xray
Sensitivity 43-75%
Specificity 75-83%

Soft tissue swelling 48hrs


Periosteal reaction 5-7d
Osteolysis 10d to 2 wks
(need 50% bone loss)
Radiology
Tc99
24-48hrs +ve
Bone aspiration
DOES NOT give
false +ve
Decreased uptake
in early phase d/t
increased pressure
“cold” scan up to
100% PPV
Radiology
Gallium
48 hrs to do
Non specific

Indium
I131 leucocytes
24hrs to prepare

Monoclonal antibodies
Not proven to be better
Radiology
MRI
Sensitivity 83-100%
Specificity 75-100%
PPV = Tc99

Marrow and soft tissue swelling


Good in spine and pelvis
Radiology
T1
Best for acute infection
Gadolinium helps
Changes similar to
• #
• Infarct
• Bruise
• Tumor
• Post surgical
• Sympathetic edema
Radiology
CT
Gas
sequestrum
Treatment
Mostly medical
Sx to improve local environment
Remove infected devitalized bone
Decompress abscess cavity

Timing !!
Early antibiotic before necrosis / pus then sx
less likely to be needed
Treatment
Antibiotic treatment
Parenteral / oral combinations
Often empirical
Serum level more important than route

Follow WBC / ESR/ CRP


Organism / sensitivity
Treatment
Treatment Failure
High doses
Poor oral absorption / compliance
Inadequate monitoring of serum levels
Delay in Sx
Treatment
Previously start IV
Follow ESR to guide switch to oral

Newer studies
Follow CRP
Shorter period of tx needed
IV 5d / total 23 d tx
Cephalosporin 150mg/kd/day
Treatment
Neonates
No studies, little evidence
CRP / ESR not reliable
Oral absorption not reliable
Therefore IV neonates
Cloxacillin
Treatment
Longer treatment required
Pelvis
Vertebrae
Diskitis
Calcaneus
Treatment
Surgical intervention
Controversial indications
Hole in bone not always Sx
If purulent aspirate Sx necessary

Sx less frequent with newer antibiotic


22-83% earlier studies
8-43% recent studies
Treatment
Surgery Indicated

Subperiosteal Abscess
Soft Tissue abscess
Bone Abscess
Failure of clinical response to antibiotic
Associated septic arthritis
Complications
Infection Complications
Recurrence
Chronic osteo
Pathologic fracture
Growth plate injury

Antibiotic Complications
Diarrhea
N+V
Rash
Thrombocytopenia
Neutropenia