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Osteomyelitis in Children. Dr. Robert Deane Janeway. Age Incidence Etiology Pathophysiology Presentation Laboratory investigations Imaging. Treatment Surgery Complications Summary Special Groups. Outline. Age / Incidence / Etiology. 1/1000 – 1/ 20 000 Male > Female

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Osteomyelitis in Children


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osteomyelitis in children

Osteomyelitis in Children

Dr. Robert Deane

Janeway

outline
Age

Incidence

Etiology

Pathophysiology

Presentation

Laboratory investigations

Imaging

Treatment

Surgery

Complications

Summary

Special Groups

Outline
age incidence etiology
Age / Incidence / Etiology
  • 1/1000 – 1/ 20 000
  • Male > Female
  • Pre antibiotic era ……20-50% mortality
age incidence etiology4
Age / Incidence / Etiology
  • Advances in treatment
    • Earlier dx
    • Antibiotic tx
    • Surgery less delay
    • Children better nourished
age incidence etiology5
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 etiology6
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
Pathophysiology
  • Poorly defined
    • Direct inoculation
    • Hematogenous spread
    • Local invasion
pathophysiology8
Pathophysiology
  • Infection
    • Starts in Metaphysis
      • Arteriole Loop / Venous Lakes
    • Spread via Volkman’s canal / Haversian system
    • Endothelium Leaks
pathophysiology9
Pathophysiology
  • Few phagocytes in Zone of Hypertrophy
    • Highest incidence in fastest growing bone
    • Tubular > Flat bones
pathophysiology10
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)
pathophysiology11
Pathophysiology
  • Spread via Volkman Canal

  • Subperiosteal Pus

  • Cortex breaks down

  • May spread to joint
    • Hip / Shoulder / Fibula / Proximal Humerus
pathophysiology12
Pathophysiology
  • Role of Trauma
    • Rabbit experiment
    • IV injection of bacteria
    • With # start in hematoma
pathophysiology13
Pathophysiology
  • Role of growth plate
    • Over 18/12
    • Impermeable to spread
    • Under 18/12 infection crosses growth plate
pathophysiology15
Pathophysiology
  • 1st osteoblasts die
  • Lymphocytes release osteoclast activating factor
  • Hole in bone
diagnosis
Diagnosis
  • Pain
    • Neonate peudoparalysis
    • NWB
    • Failure to use limb
  • Fever
  • Lethargy
  • Anorexia
  • Swelling (neonates / older kids)
pathophysiology17
Pathophysiology
  • Bloodwork
    • CBC Diff
    • ESR
    • CRP
    • Blood Culture
pathophysiology18
Pathophysiology
  • WBC increased 30-40%
  • Left Shift 65%
  • ESR increased 91%……….24-36hrs
  • CRP increased 97%…………4-6hrs
pathophysiology19
Pathophysiology
  • CRP
    • More rapid than ESR
    • 2-4 hrs …..peak 72hrs
    • 10-30x normal
    • Systemic ds (trauma, tumor)
pathophysiology20
Pathophysiology
  • Blood Culture
    • + 30-60%
    • Decreased with antibiotic
    • Multiple cultures no significant increase in yield
    • 48 hours to get most organisms
diagnosis21
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
diagnosis22
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
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
diagnosis24
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
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)
radiology26
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
radiology27
Radiology
  • Gallium
    • 48 hrs to do
    • Non specific
  • Indium
    • I131 leucocytes
    • 24hrs to prepare
  • Monoclonal antibodies
    • Not proven to be better
radiology28
Radiology
  • MRI
    • Sensitivity 83-100%
    • Specificity 75-100%
    • PPV = Tc99
  • Marrow and soft tissue swelling
  • Good in spine and pelvis
radiology29
Radiology
  • T1
    • Best for acute infection
    • Gadolinium helps
    • Changes similar to
      • #
      • Infarct
      • Bruise
      • Tumor
      • Post surgical
      • Sympathetic edema
radiology30
Radiology
  • CT
    • Gas
    • sequestrum
treatment
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
treatment32
Treatment
  • Antibiotic treatment
    • Parenteral / oral combinations
    • Often empirical
    • Serum level more important than route
  • Follow WBC / ESR/ CRP
  • Organism / sensitivity
treatment33
Treatment
  • Treatment Failure
    • High doses
    • Poor oral absorption / compliance
    • Inadequate monitoring of serum levels
    • Delay in Sx
treatment34
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
treatment35
Treatment
  • Neonates
    • No studies, little evidence
    • CRP / ESR not reliable
    • Oral absorption not reliable
    • Therefore IV neonates
    • Cloxacillin
treatment36
Treatment
  • Longer treatment required
    • Pelvis
    • Vertebrae
    • Diskitis
    • Calcaneus
treatment37
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
treatment38
Treatment
  • Surgery Indicated
    • Subperiosteal Abscess
    • Soft Tissue abscess
    • Bone Abscess
    • Failure of clinical response to antibiotic
    • Associated septic arthritis
complications
Complications
  • Infection Complications
    • Recurrence
    • Chronic osteo
    • Pathologic fracture
    • Growth plate injury
  • Antibiotic Complications
    • Diarrhea
    • N+V
    • Rash
    • Thrombocytopenia
    • Neutropenia