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OSTEOMYELITIS IN CHILDREN

dr. Audi Hidayatullah SpOT

 Introduction
• Musculoskeletal infection remain a common
challenge.
• Even though morbidity & mortality have
dropped, cause by antibiotics.
• Pediatric Orthopaedic infections may be cured
& deformity and disability prevented with:
- Early diagnosis.
- Appropriate antibiotic
therapy.
- Surgical intervention.
Infection should be suspected:

Pain
Fever
Swelling
Tenderness
 OSTEOMYELITIS

• Can be examined from several perspectives:

- Patient age (neonatal, childhood, adult).
- Causative organism (pyogenic or
granulomatous).
- Nature of onset (acute, subacute,
chronic).
- Route of infection (hematogenous, direct,
contiguous spread).
Acute Hematogenous Osteomyelitis (AHO).

• AHO has decreased over resent decades.

• Prompt diagnosis and treatment remains
unchanged.
 Differential diagnosis:
• Rheumatic fever.
• Septic arthritis.
• Cellulitis.
• Malignancy (Ewing’s sarcoma & leukemia).
• Thrombophlebitis.
• Sickle-cell crisis.
• Gaucher’s disease.
• Toxic synovitis.
(Richard, B.S. 1996)
Pathogenesis :
 Bacterial analysis in osteomyelitis:

Neonates : Staphylococcus aureus,

Group B streptococcus,
gram-negative colliform.

Infant & Children : Staphylococcus

aureus.
Diagnosis

• Clinical.
• Laboratory.
• Radiological.
 Clinical:
• Fever and unexplained pain.
• Refused to move the limb.
• Tenderness over the involved bone.
• Decreased ROM in adjacent joint.
• Swelling, erythema, warmth.
 Laboratory:
• WBC not reliable indicator.
• ESR elevated in over 90%.
• C-reactive protein (CRP) over 19mg/l.
• Blood cultures are positive 40 – 50%.
• Aspiration of the affected site.
 Radiological:
• Plain radiographs.
• Bone scan.
• CT-Scan.
• Magnetic resonance imaging (MRI).
• Ultrasound.
 Radiological:
• Plain radiographs may show soft tissue
swelling within 3 days, but bone changes do
not appear for 7 to 14 days.
Bone-scan
May be used to:
- located the area of
involvement in
difficult site.
- Multiple site
involvement.
- In neonate.
• Computed tomography (CT):
- To evaluate bone abscesses.
- To differentiating from other
lucent lesions.
- To identifying extraosseous of
pus.
 MRI:
• Very sensitive, but not
specific.

• It can be used to
differentiated
between the acute
and chronic form.
 Ultrasound:
• Is useful in localizing a subperi-osteal abscess.
• It can show early changes in soft tissue.
• These change were detectable within 24
hours.
 General plan of treatment :

• Bed rest and analgesic.

• Supportive therapy (IV fluids).
• Local rest for the involved extremity.
• Antibacterial therapy.
• Surgical decompression (if after 24 hours not
improved).
• Antibacterial is continued for 4 – 6 weeks (ESR or
CRP normal).
 Antibiotika :
• Dimulai setelah pengambilan kultur.
• Mulai dgn Antibiotika empirik:
- Anak-anak – S.aureus – Oxacillin.
- Neonatus – H. influenza B (HIB) –
gentamicin.
- Sickle-cell anemia – Salmonella ---
Cefotaxime dan Oxacillin.
 Factors determine the effectiveness of
antibacterial treatment :
• The time interval between the onset of infection and
the institution of treatment.
• The effectiveness of the antibacterial drug against
the specific causative bacteria.
• The dosage of the antibacterial drug.
• The duration of antibacterial therapy.
 Neonatal Osteomyelitis
• Several anatomic features.
• The metaphyseal vessels communicate with
the epiphyseal vessel.
• Septic arthritis and AHO often together.
• The metaphyses of the hip, proximal humerus,
proximal radius and distal lateral tibia are
intra-articular.
• Thrombosis of the vessel may cause ischemia
of epiphyseal growth plate.
• Complete ischemia and lysis of the physis
before ossification of the femoral head, may
result necrosis and reabsorbtion of femoral
head.
• The immune system of neonate is immature,
inflammatory response is compromised.
 Clinical:
• Have only minimal symptoms, malaise, failure
to gain weight.
• There may be no fever.
• Soft tissue swelling and pseudoparalysis.
• Detection of infection is often delayed.
• Multiple site of infection 40%.
 Laboratory
• WBC count and ESR may be normal.
• It is important to aspirate and culture.
• Staphyloccocus aureus the most prevalent
microorganism, but recently group B Strepto-
ccocus.
 Complications:
• Osteonecrosis of epiphysis.
• Joint dislocation.
• Premature physeal arrest.
 Subacute Hematogenous Osteomyelitis
(SHO).
• SHO is the cause of nearly one third of primary bone
infection.
• Insidious onset.
• Mild symptoms.
• Longer duration.
• Inconclusive laboratory data.
• Can cross the growth plate.
• Rarely causes permanent damage.
 Comparison acute and subacute osteomyelitis.
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Subacute Acute
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Pain Mild Severe
Fever Few patients Majority of patients
Loss of function Minimal Marked
Prior Antibiotic therapy Often (30 -40%) Occasionally
Elevated WBC count Few Majority of patient
Elevated ESR Majority of patient Majority of patient
Blood cultures Few positive 50% positive
Bone cultures 60% positive 85% positive
Initial radiographs Frequently abnormal Often normal
Site Any location (may cross Usually metaphysis
physis)
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 Differential diagnosis
• Ewing’s sarcoma.
• Metastatic neuroblastoma.
• Malignant round cell tumor.
• Osteoid osteoma.
Modified classification of the
radiographic :
 Laboratory:
• Cultures are frequently negative.
• Staphylococcus species is the common
microorganism.
• A biopsy is usually required to rule out tumor
and provide a definitive diagnosis.
 Treatment:
• Most patient respond to a single course of
antibiotic.
• A positive culture or failure to respond to
antibiotic indicates for : Curettage, draindage
of abcesses, and sequestrectomy.
 Chronic Osteomyelitis.
• Despite adequate drainage of pus and intensive
antibiotic therapy, with acute osteomyelitis, develop
chronic osteomyelitis.
• With cavities, sequestra, and sinusis.
• S. aureus are the common micro-organism.
 Radiological:
• Plain X-ray and CT.
• To identify the number and extent of infected
cavities and location of sequestra.
Cierny – Mader system
 Subtype by host’s physiologic status :
• A : Healthy.
• Bs : Compromised due to
systemic factors.
• Bl : Compromised due to local
factors.
• Bls : Compromised due to local
& systemic factors.
• C : Treatment worse than the
disease.
 Treatment:
• Antibiotic.

• Local treatment.

• Surgery.
 SEPTIC ARTHRITIS (SA)
• Septic Arthritis (SA) requires urgent
treatment.
• The duration of symptoms prior to treatment
is the most important prognostic factor for
outcome.
 Differential diagnosis:
• Trantient synovitis.
• Rheumatic fever.
• Hemarthrosis.
• Juvenile arthritis.
• Cellulitis.
• Osteomyelitis.
• Hemophilia.
• Leg-Calve-Perthes disease.
 Diagnosis:
• Insidence:
- More common in boys than in
girl.
- Children younger than 2
years.
- The hip, knee, ankle, elbow,
90% of affected joint.
 Diagnosis:
• High temperature (38 – 400 C).
• Asymetric posturing of the extremity.
• Restricted joint motion.
• Tenderness.
• Joint warmth.
• Effusion.
 Laboratory:
• WBC count is elevated in 30% to 60% with a
left shift.
• The ESR usually higher (sensitive test).
• C-reactive protein (CRP).
• Blood cultures are positive in 40% - 50%.
• Needle aspiration.
 Bacterial analysis in septic arthritis.

_______________________________________________
Neonate Group B Streptococcus
species, Stap. aureus,
gram neg. coliform.
Infant – 4 years Stap aureus,
pneumococcus, Group A
strep, Haemophilus
influen B.
Over age 4 years Stap. aureus,
gonococcus.
 Radiology:
• Plain radiography.
• Bone scan (technetium bone scan).
• Ultrasound.
 Treatment:
• The first priority is aspirate the joint and
examine the fluid.
• Plant of treatment:
1. General supportive care.
2. Local rest.
3. Antibiotic.
4. Drainage.
 Antibiotic :
• Children under 4 years: high incidence of
Haemophilus infection --- Ampicillin or
Cephalosporins.
• Older children: Flucloxacillin and Fusidic acid.
 Drainage :
• Aspiration.
• Small incision --- drainage and washed
out. Advisable in :
1. In very young infant.
2. In the hip joint.
3. Pus is very thick.
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