Introduction Overview pediatric osteomyelitis is most often the result of hematogenous seeding of bacteria to the metaphyseal region of bone treatment is usually antibiotics with or without surgical drainage Epidemiology incidence 1 in 5000 children younger than 13 years old demographics mean age 6.6 years 2.5 times more common in boys more common in the first decade of life due to the rich metaphyseal blood supply and immature immune system not uncommon in healthy children location typically metaphyseal via hematogenous seeding risk factors diabetes mellitus hemoglobinopathy rheumatoid arthritis chronic renal disease immune compromise varicella infection Pathophysiology mechanism local trauma and bacteremia lead to increased susceptibility to bacterial seeding of the metaphysis history of trauma is reported in 30% of patients microbiology Staph aureus is the most common organism in all children strains of community-acquired (CA) MRSA have genes encoding for Panton-Valentine leukocidin (PVL) cytotoxin PVL-positive strains are more associated with complex infections, multifocal infections, prolonged fever, abscess, DVT, and sepsis MRSA is associated with increased risk of DVT and septic emboli Group B Strep is most common organism in neonates Kingella kingae becoming more common in younger age groups Pseudomonas is associated with direct puncture wounds to the foot H. influenza has become much less common with the advent of the Haemophilus influenza vaccine Mycobacteria tuberculosis children are more likely to have extrapulmonary involvement biopsy with stains and culture for acid-fast bacilli is diagnostic Salmonella more common in sickle cell patients pathoanatomy acute osteomyelitis most cases are hematogenous initial bacteremia may occur from a skin lesion, infection, or even trauma from tooth brushing microscopic activity sluggish blood flow in metaphyseal capillaries due to sharp turns results in venous sinusoids which give bacteria time to lodge in this region the low pH and low oxygen tension around the growth plate assist in the bacterial growth infection occurs after the local bone defenses have been overwhelmed by bacteria spread through bone occurs via Haversian and Volkmann canal systems purulence develops in conjunction with osteoblast necrosis, osteoclast activation, the release of inflammatory mediators, and blood vessel thrombosis macroscopic activity a subperiosteal abscess develops when the purulence breaks through the metaphyseal cortex septic arthritis develops when the purulence breaks through an intra-articular metaphyseal cortex (hip, shoulder, elbow, and ankle) (NOT KNEE) Infants <1 year of age can have infection spread across the growth plate via capillaries causing osteomyelitis in the epiphysis and septic arthritis chronic osteomyelitis periosteal elevation deprives the underlying cortical bone of blood supply leading to necrotic bone (sequestrum) sequestrum the necrotic bone which has become walled off from its blood supply and can present as a nidus for chronic osteomyelitis an outer layer of new bone is formed by the periosteum (involucrum) involucrum a layer of new bone growth outside existing bone seen in osteomyelitis chronic abscesses may become surrounded by sclerotic bone and fibrous tissue leading to a Brodie's abscess Prognosis mortality decreased from 50% to <1% with development of antibiotics Anatomy blood supply the metaphyseal blood capillaries undergo sharp turns prior to entering venous sinusoids leading to turbulent flow and predisposition of bacterial deposition Classification Acute osteomyelitis see pathoanatomy above Subacute osteomyelitis uncommon infection with bone pain and radiographic changes without systemic symptoms increased host resistance, decreased organism virulence, and/or prior antibiotic exposure radiographic classification types IA and IB show lucency type II is a metaphyseal lesion with cortical bone loss type III is a diaphyseal lesion type IV shows onion skinning type V is an epiphyseal lesion type VI is a spinal lesion Chronic osteomyelitis see pathoanatomy above Presentation History limb pain recent local infection or trauma obtain immunization history regarding H. influenza ask about prior antibiotic use, as it may mask symptoms Symptoms limp or refusal to bear weight generally not toxic appearing +/- fever Physical exam inspection & palpation edematous, warm, swollen, tender limb evaluate for point tenderness in pelvis, spine, or limbs range of motion restricted motion due to pain Imaging Radiographs recommended views obtain AP and lateral of the suspected area findings early films may be normal or show loss of soft tissue planes and soft tissue edema new periosteal bone formation (5-7 days) osteolysis (10-14 days) late films (1-2 weeks) show metaphyseal rarefaction (reduction in metaphyseal bone density) or possible abscess CT indication more helpful later in the disease course to demonstrate bone changes or abscesses MRI detects abscesses and early marrow and soft tissue edema indications can assist with decision making when a poor clinical response to antibiotics or surgical drainage considered views T1 signal decreased T1 with gadolinium signal increased T2 signal increased 88% to 100% sensitivity, sensitivity increased by Gadolinium contrast Bone scan indications nondiagnostic x-ray need to localize pathology in infant or toddler with non-focal exam technetium-99m can localize the focus of infection and show a multifocal infection 92% sensitivity a cold bone scan may be associated with more aggressive infections Studies Serum labs WBC count elevated in 25% of patients and correlates poorly with treatment response C-reactive protein elevated in 98% of patients with acute hematogenous osteomyelitis becomes elevated within 6 hours most sensitive to monitor therapeutic response declines rapidly as the clinical picture improves CRP is the best indicator of early treatment success and normalizes within a week failure of the C-reactive protein to decline after 48 to 72 hours of treatment should indicate that treatment may need to be altered ESR elevated in 90% of patients with osteomyelitis rises rapidly and peaks in three to five days, but declines too slowly to guide treatment less reliable in neonates and sickle cell patients plasma procalcitonin new serologic test that rises rapidly with a bacterial infection, but remains low in viral infections and other inflammatory situations elevated in 58% of pediatric osteomyelitis cases bone aspiration helps establish a definitive diagnosis 50% to 70% of affected patients have positive cultures blood culture is positive only 30% to 50% of the time and will likely be negative soon after antibiotics are administered, even if treatment is not progressing satisfactorily Aspiration assists in diagnosis and management helps guide antibiotic selection when organism identified (50% of the time) proceed with surgical drainage if pus is aspirated technique large bore needle utilized to aspirate the subperiosteal and intraosseous spaces under fluoroscopic or CT-guidance start antibiotics after aspiration Biopsy and culture consider when diagnosis not clear (i.e. subacute osteomyelitis) and need to rule out malignancy Treatment Nonoperative treatment antibiotic therapy alone indications early disease with no subperiosteal abscess or abscess within the bone surgery is not indicated if clinical improvement obtained within 48 hours modalities antibiotics begin with empiric therapy generally, nafcillin or oxacillin, unless high local prevalence of MRSA (then use clindamycin or vancomycin) mechanism of action for vancomycin involves binding to the D-Ala D-Ala moiety in bacterial cell walls if gram stain shows gram-negative bacilli - add a third generation cephalosporin convert to organism-specific antibiotics if organism identified mycobacterium tuberculosis treatment for initial 1 year is multiagent antibiotics and rarely surgical debridement due to risk of chronic sinus formation duration typically treat with IV antibiotics for four to six weeks controversial duration intravenous versus oral often a case by case decision with input from infectious disease consultation Operative treatment surgical drainage, debridement, and antibiotic therapy indications deep or subperiosteal abscess failure to respond to antibiotics chronic infection contraindications hemodynamic instability, as patients should be stabilized first - however sometimes operative treatment of the underlying infection helps stabilize the patient example of institution algorithm treatment pathway Technique Surgical drainage, debridement, and antibiotic therapy soft tissue evacuate all purulence, debride devitalized tissue, and drill as needed into intraosseous collections send tissue for culture and pathology to rule out neoplasm close wound over drains or pack and return to OR in two to three days bone work remove the sequestrum in chronic cases Complications DVT incidence is an infrequent complication in children risk factors CRP > 6 surgical treatment age > 8-years-old MRSA treatment therapeutic anticoagulation Meningitis Septic arthritis risk factors bones with intra-articular metaphysis are at risk (hip, shoulder, elbow, ankle) neonates treatment irrigation and debridement Growth disturbances and limb-length discrepancies from growth plate involvement treatment observation and possible corrective surgery depending on severity or projected severity Pathologic fractures
QUESTIONS 1 of 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Previous Next (OBQ12.95) A 9-year-old boy was placed in a short leg splint in an emergency department after twisting his ankle during recess. He presents 10 days later with increasing pain and fevers up to 39 degrees C over the last 3 days. The splint is removed revealing intact skin integrity with notable swelling and erythema overlying the distal fibula. Lab results include a C-reactive protein level of 12mg/L (normal 0-3.2 mg/L), erythrocyte sedimentation rate of 38mm/h (normal 0-20mm/h) and a white blood cell count of 12.3 K/mm3(normal 4.3 -11.4 K/mm3). Radiographs are included in Figures A and B. MRI images include T1, T2 and post-contrast in Figures C-E, respectively. What is next step in management? Review Topic QID: 4455 FIGURES: A B C D E 1 Irrigation and debridement of distal fibular osteomyelitis 89% (4024/4526) 2 Place in short leg walking cast for 3 weeks 2% (104/4526) 3 Begin oral antibiotics and follow up in 2 weeks 6% (265/4526) 4 Perform stress radiographs to assess integrity of the syndesmosis 1% (60/4526) 5 Transition to lace up ankle brace and begin functional rehab 1% (32/4526) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07PE.36) A 6-year-old boy with acute hematogenous osteomyelitis of the distal femur is being treated with intravenous antibiotics. The most expeditious method to determine the early success or failure of treatment is by serial evaluations of which of the following studies? Review Topic QID: 6096 1 CBC count with differential 2% (2/124) 2 MRI 0% (0/124) 3 CT 0% (0/124) 4 Radiographs 0% (0/124) 5 C-reactive protein (CRP) 97% (120/124) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07PE.28) An 8-year-old boy has had pain and swelling around the right knee for the past 4 weeks. He recalls bumping it about 4 weeks ago. He has no pain in other joints, and denies any fevers, chills, or other symptoms. A radiograph is shown in Figure 13. Laboratory studies show a WBC count of 9,700/mmP3P, an erythrocyte sedimentation rate of 18 mm/h, and a C-reactive protein level of 3.7 mg/L. What is the next most appropriate step in management? Review Topic QID: 6088 FIGURES: A 1 Chemotherapy and radiation therapy 2% (1/59) 2 Intravenous antibiotics, protected weight bearing, and a repeat C-reactive protein after improvement 12% (7/59) 3 Open biopsy and debridement of the site, followed by intravenous antibiotics 58% (34/59) 4 Technetium Tc 99m bone scan 19% (11/59) 5 Empiric oral antibiotics and repeat laboratory studies in 1 week 10% (6/59) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07PE.14) A 2-year-old girl has had a 2-day history of fever and refuses to move her left shoulder following varicella. Laboratory studies show an erythrocyte sedimentation rate of 75 mm/h and a peripheral WBC count of 18,000/mmP3P. What is the most common organism in this scenario? Review Topic QID: 6074 1 Kingella kingae 3% (4/120) 2 Group A beta-hemolytic streptococcus 24% (29/120) 3 Group B streptococcus 8% (9/120) 4 Staphylococcus epidermidis 2% (2/120) 5 Staphylococcus aureus 60% (72/120) N/A Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ06.167) A 7-year-old boy presents with right elbow and left wrist swelling for the past 3 months. Clinical photos of the elbow and wrist are shown in Figures A and B, and radiographs in Figures C and D. His parents report that he has had night sweats and a loss of appetite, and physical examination is notable for bilateral axillary lymphadenopathy. Leukocyte count is normal but the ESR is elevated. The child undergoes a diagnostic biopsy shown in Figure E. What is the most likely diagnosis? Review Topic QID: 353 FIGURES: A B C D E 1 Multicentric giant cell tumor 9% (163/1851) 2 Letterer-Siwe disease 7% (122/1851) 3 Polyostotic mycobacterial infection 70% (1296/1851) 4 Hand-Schuller-Christian disease 12% (217/1851) 5 Metastatic rhabdomyosarcoma 2% (41/1851) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.50) Sequestrum is defined as which of the following? Review Topic QID: 436 1 reactive bone in acute osteomyelitis 1% (32/2164) 2 reactive bone in chronic osteomyelitis 8% (172/2164) 3 necrotic bone providing a nidus for infection in chronic osteomyelitis 89% (1917/2164) 4 healthy bone adjacent to chronic osteomyelitis 1% (30/2164) 5 healthy bone adjacent to acute osteomyelitis 0% (7/2164) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ05.149) An 8-year-old boy twists his right leg while playing soccer 6 days ago. Initial radiographs on the day of injury were negative, and the patient was placed into a knee immobilizer by his pediatrician. Despite being non-weightbearing on crutches, his pain has continued to worsen, and he presented to the ER with a low grade fever and irratibility. A current bone scan and MRI is shown in Figure A and B. Examination shows no knee effusion but there is tenderness to palpation over the proximal tibia. Current WBC and ESR is normal and CRP is elevated. What is the next most appropriate initial step in management? Review Topic QID: 1035 FIGURES: A B 1 Long leg cast and continued non-weightbearing to the extremity 8% (56/725) 2 Chest CT scan and referral to an orthopaedic oncologist 19% (139/725) 3 Neoadjuvant chemotherapy followed by surgical resection 2% (11/725) 4 Percutaneous biopsy with culture and antibiotics 69% (500/725) 5 Percutaneous pinning of the physeal fracture and long leg cast placement 2% (16/725) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ08.97) A pediatric patient has just been diagnosed with osteomyelitis of the femur. All of the following are risk factors for the development of deep venous thrombosis EXCEPT? Review Topic QID: 483 1 Surgical treatment of osteomyelitis 10% (130/1354) 2 CRP > 6 9% (118/1354) 3 Methicillin-resistant staphylococcus aureus 17% (232/1354) 4 Fever of greater than 38.5 degrees Celsius 44% (590/1354) 5 Patient age greater than 8-years-old 21% (278/1354) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.80) A 10-year-old boy complains of two days of worsening right knee pain. He has been unable to ambulate on the leg since waking up this morning. He denies any recent trauma to the leg. Physical exam is notable for focal tenderness over the distal femur without a palpable fluid collection. His ESR is 68 mm/hr (normal <15) and CRP is 14 mg/dL (normal <1). His temperature is currently 101.2 degrees F. Radiographs are provided in Figures A and B. An aspiration of the knee yielding 7 mL of straw colored fluid reveals 1700 nucleated cells per mL, and no organisms on gram stain. Which of the following is the most appropriate next step? Review Topic QID: 191 FIGURES: A B 1 MRI of the knee 72% (1039/1446) 2 Observation with follow-up ESR, CRP, and repeat aspiration in 1-2 days 10% (143/1446) 3 Oral cephalosporin and follow-up in 10 days 2% (22/1446) 4 Surgical arthrotomy, debridement, and irrigation procedure 15% (219/1446) 5 Chest, abdomen, and pelvis CT 1% (9/1446) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ07.232) An afebrile 8-year-old Ethiopian girl presented with a limp. Two years earlier, she had had mild trauma followed by a “bone infection” and had received short courses of oral antibiotics. Examination revealed a small, pus-secreting wound on the anterior aspect of her left thigh. Her blood count was normal, but her erythrocyte sedimentation rate was 48 mm. A radiograph and computed tomographic scan are shown in Figure A and B respectively. What do the blue arrowheads identify in both of these imaging studies? Review Topic QID: 893 FIGURES: A B 1 Bone infarct 1% (8/1250) 2 Sequestrum 23% (291/1250) 3 Involucrum 75% (939/1250) 4 Osteosarcoma 0% (4/1250) 5 Hematoma 0% (2/1250) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ07.151) In which of the following patients with osteomyelitis of the tibia is surgical debridement the next best step in treatment? Review Topic QID: 812 1 A 9-year old girl with new-onset pain and fever 0% (0/744) 2 A 7-year-old lethargic boy with a CRP of 20 mg/L that does not decline after a week of nafcillin and vancomycin 90% (666/744) 3 A 7-year-old girl with three days of pain, fever, and a WBC of 21,000/mm3 who presents to the ER 3% (24/744) 4 An 8-year-old boy whose pain and fever have decreased after 24 hours of ampicillin 0% (3/744) 5 An 8-year old lethargic girl with a WBC of 21,000/mm3 and a CRP of 9 after 24 hours of gentamicin 6% (48/744) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ11.29) A 9-year-old boy is being treated for acute hematogenous osteomyelitis of the distal tibia with appropriate IV antibiotic therapy. After three days of treatment, he fails to show any clinical improvement. Advanced imaging is obtained and reveals a 1.5x1.5cm abscess in the distal tibia. The patient subsequently undergoes formal open surgical debridement, without complications. Following surgery, serial evaluations of which of the following studies is the most expeditious method to determine the early success of treatment? Review Topic QID: 3452 1 White blood cell count 2% (50/2765) 2 MRI 1% (15/2765) 3 Erythrocyte sedimentation rate 3% (74/2765) 4 C-reactive protein 94% (2602/2765) 5 Radiographs 1% (14/2765) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.131) A 14-year-old boy presents 6 months after spraining his right ankle. Radiographs obtained at the time of injury are shown in Figure A. He returns to clinic with persistent right ankle pain. The patient denies fevers, and has an ESR of 35 mm/h (nl 0-20). CRP and WBC are normal. Current radiographs and MRI images are shown in Figures B, C, and D. What is the next most appropriate step in management? Review Topic QID: 317 FIGURES: A B C D 1 Casting of the ankle and observation 5% (63/1305) 2 CT of the tibia 2% (30/1305) 3 Oral antibiotic therapy, with outpatient follow-up in 6 weeks 2% (21/1305) 4 Biopsy and culture of the tibial lesion 89% (1162/1305) 5 Urgent ankle arthrotomy 2% (22/1305) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ05.177) A 13-year-old girl reported left ankle pain after falling while playing soccer 3 weeks ago. The pain initially improved, but for the past 10 days she has had increased pain. She reports a decreased appetite. Her temperature is 38.9 degrees celsius and her white blood cell count is normal. The ESR and CRP are elevated and blood cultures have been drawn and are pending. Current ankle radiographs are normal and T1 and T2 MRI images are shown in Figures A and B, respectively. What is the most appropriate next step in treatment? Review Topic QID: 1063 FIGURES: A B 1 Discharge home on non-steroidal anti-inflammatory drug (NSAID) and short leg non-weightbearing cast 5% (30/638) 2 Discharge home on oral antibiotics with serial ESR and CRP in an outpatient setting 2% (11/638) 3 Admit to hospital for percutaneous aspiration for culture and intravenous antibiotics with serial ESR and CRP 84% (539/638) 4 Admit to hospital for percutaneous biopsy and referral to orthopaedic oncologist 5% (33/638) 5 Admit to hospital for percutaneous screw fixation of distal tibia fracture 4% (23/638) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ07.184) A 7-year-old boy complains of worsening left knee pain over the last 2 weeks. He has been unable to bear weight through the left lower extremity for the past 24 hours. The knee and lower leg are warm and tender to palpation. Current temperature is 100.9 degrees Fahrenheit, and CRP is 11 mg/dL (nml <1). A radiograph is provided in Figure A. A joint aspiration yields 2 mL's of synovial fluid demonstrating a cell count of 2,500 and no organisms on gram stain. Which of the following is the most appropriate next step in management? Review Topic QID: 845 FIGURES: A 1 Repeat aspiration of the left knee 8% (142/1808) 2 Observation with repeat radiographs in one week 10% (172/1808) 3 Magnetic resonance imaging (MRI) 70% (1274/1808) 4 Begin intravenous broad-spectrum antibiotics and obtain an infectiouse disease consult 7% (130/1808) 5 Exploratory surgical arthrotomy 5% (84/1808) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ06.216) Septic arthritis in pediatric patients may occur secondary to direct intra-articular spread from metaphyseal osteomyelitis. This can occur in all the following joints EXCEPT? Review Topic QID: 227 1 Hip 8% (126/1615) 2 Ankle 16% (256/1615) 3 Shoulder 9% (153/1615) 4 Elbow 15% (239/1615) 5 Knee 52% (833/1615) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ09.161) A 6 year-old boy develops tenderness at the right heel and avoids putting weight on the right extremity after stepping on a nail 2 weeks ago while wearing tennis shoes. His mother notes that he has had a fever of 39.0. Calcaneal osteomyelitis caused by a puncture wound has an increased rate of which of the following compared to hematogenous osteomyelitis? Review Topic QID: 2974 1 Presence of Group A Streptococcus infection 4% (107/3054) 2 Presence of Coliforms infection 2% (57/3054) 3 Presence of Haemophilus infection 1% (17/3054) 4 Presence of Pseudomonas infection 91% (2793/3054) 5 Presence of Group B Streptococcus infection 2% (69/3054) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Post-septic arthritis of the knee sequelae in an 8 year old patient (C2854) Ajay Alex Pediatrics - Osteomyelitis - Pediatric 8/24/2017 124 2 9 Chronic osteomyelitis (C1734) raul mena Pediatrics - Osteomyelitis - Pediatric 1/1/2014 287 1 8 Cronic Osteomyelitis (C1369) nishant pandey Pediatrics - Osteomyelitis - Pediatric 1/2/2013 226 2 18