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Average 4.2 of 57 Ratings
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?
White blood cell count
Erythrocyte sedimentation rate
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The presence of an abscess in the setting of acute hematogenous osteomyelitis (AHO) is an indication for biopsy, culture, and open debridement. Appropriate treatment of osteomyelitis should lead to a rapid decline in the CRP, which peaks two days post-operatively, then begins to decline and normalizes within a week. Imaging studies will take much longer to show resolution of bone infection.
Unkila-Kallio et al performed a study to compare the clinical value of the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count in diagnosis and follow-up of acute hematogenous osteomyelitis in children. They found that CRP increased and especially decreased significantly faster than ESR, reflecting the effectiveness of the therapy given and predicting recovery more sensitively than ESR or WBC count.
Dormans et al reviewed acute hematogenous osteomyelitis (AHO) and subacute osteomyelitis, including Brodie's abscess, subacute epiphyseal osteomyelitis, and chronic recurrent multifocal osteomyelitis. They recommended various imaging modalities and ultimately biopsy to clarify the diagnosis. The goals of treatment were defined as (1) identification of the organism, (2) proper antibiotic selection, (3) adequate delivery of antibiotics and (4) arrest of tissue destruction.
Unkila-Kallio L, Kallio MJ, Eskola J, Peltola H.
Pediatrics. 1994 Jan;93(1):59-62. PMID: 8265325 (Link to Abstract)
Unkila-Kallio, PEDS 1994
Dormans JP, Drummond DS.
J Am Acad Orthop Surg. 1994 Nov;2(6):333-341. PMID: 10709026 (Link to Abstract)
Dormans, JAAOS 1994
Please rate question.
Average 4.0 of 20 Ratings
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?
Presence of Group A Streptococcus infection
Presence of Coliforms infection
Presence of Haemophilus infection
Presence of Pseudomonas infection
Presence of Group B Streptococcus infection
Calcaneal osteomyelitis in children can occur via hematogenous seeding or direct puncture wounds. There are 2 types of pediatric hematogenous osteomyelitis: acute(AHO) and subacute hematogenous (SHO). The most common organism idenitified is Stapylococcus Aureus according to Blyth et al and is found in 70% of the cases.
The article by Karwowska et al reviewed 146 osteomyelitis cases and noted that tenderness was the most common sign while fever and decreased limb use were the most common symptoms. Miller's review states that Group A streptococcus and Coliforms were less common organisms and with recent immunization programs, Haemophilus influenzae is almost eradicated as an osteomyelitis etiology.
However, the etiology of calcaneal osteomyelitis due to puncture wounds is different. The article by Puffinbarger et al found a 100% incidence of Pseuodomonas infection in their calcaneal osteomyelitis cases caused by puncture wounds, as in this patient's case.
Blyth MJ, Kincaid R, Craigen MA, Bennet GC
J Bone Joint Surg Br. 2001 Jan;83(1):99-102. PMID: 11245548 (Link to Abstract)
Blyth, BJJ 2001
Karwowska A, Davies HD, Jadavji T.
Pediatr Infect Dis J. 1998 Nov;17(11):1021-6. PMID: 9849986 (Link to Abstract)
Puffinbarger WR, Gruel CR, Herndon WA, Sullivan JA.
J Pediatr Orthop. 1996 Mar-Apr;16(2):224-30. PMID: 8742290 (Link to Abstract)
Puffinbarger, JPO 1996
Average 4.0 of 16 Ratings
Sequestrum is defined as which of the following?
reactive bone in acute osteomyelitis
reactive bone in chronic osteomyelitis
necrotic bone providing a nidus for infection in chronic osteomyelitis
healthy bone adjacent to chronic osteomyelitis
healthy bone adjacent to acute osteomyelitis
Sequestrum is the necrotic bone which has become walled off from its blood supply and can present a nidus for chronic osteomyelitis. Involucrum is a layer of new bone growth outside existing bone seen in osteomyelitis. In chronic osteomyelitis, the periosteum is elevated away from the cortical bone by the accumulation of pus leaking from the sequestrum. New bone develops from the periosteum, forming the involucrum.
Illustration A is a diagram demonstrating the sequestrum and involucrum that are found in osteomyelitis. Illustration B is a radiograph of sequestrum
Average 3.0 of 21 Ratings
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?
Surgical treatment of osteomyelitis
CRP > 6
Methicillin-resistant staphylococcus aureus
Fever of greater than 38.5 degrees Celsius
Patient age greater than 8-years-old
Risk factors for the development of a DVT in children with osteomyelitis include surgical treatment, CRP > 6, MRSA, and age > 8 years. A fever of greater than 38.5 has NOT been found to be a risk factor.
Deep venous thrombosis is an uncommon complication in pediatric patients but is rising with the increasing incidence of MRSA. Some studies suggest that S. aureus exotoxins, such as the Panton-Valentine leukocidin, can cause leukocyte lysis and additional injury to endothelial surfaces. These events can cause microthrombosis and deep venous thrombosis.
Hollmig et al. did a retrospective evaluation of 212 pediatric patients hospitalized with osteomyelitis. Patients who were diagnosed with DVT were compared with those who did not develop a DVT. The authors identified risk factors for the development of DVT in pediatric patients with osteomyelitis including age greater than 8 years, CRP >6, methicillin-resistant staph aureus, and surgical treatment of the osteomyelitis.
Gonzalez et al, describes the increasing prevalence of methicillin-resistant staphylococcus aureus osteomyelitis and sepsis at Texas Children's Hospital. They identified 26 patients with staphylococcal sepsis. They were able to use DNA testing to isolate the specific strains responsible for infection noting both community acquired and nosocomial acquired organisms.
Illustration A suggests the possible mechanism by which Panton-Valentine leukocidin secreted by MRSA leads to endothelial cell damage. It suggests tissue necrosis could result from release of reactive oxygen species (ROS) from lysed PMNs rather than a direct necrotic effect on epithelial cells.
Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL
J Bone Joint Surg Am. 2007 Jul;89(7):1517-23. PMID: 17606791 (Link to Abstract)
Hollmig, JBJS 2007
Gonzalez BE, Martinez-Aguilar G, Hulten KG, Hammerman WA, Coss-Bu J, Avalos-Mishaan A, Mason EO Jr, Kaplan SL.
Pediatrics. 2005 Mar;115(3):642-8. PMID: 15741366 (Link to Abstract)
Gonzalez, PEDS 2005
Average 1.0 of 84 Ratings
In which of the following patients with osteomyelitis of the tibia is surgical debridement the next best step in treatment?
A 9-year old girl with new-onset pain and fever
A 7-year-old lethargic boy with a CRP of 20 mg/L that does not decline after a week of nafcillin and vancomycin
A 7-year-old girl with three days of pain, fever, and a WBC of 21,000/mm3 who presents to the ER
An 8-year-old boy whose pain and fever have decreased after 24 hours of ampicillin
An 8-year old lethargic girl with a WBC of 21,000/mm3 and a CRP of 9 after 24 hours of gentamicin
Surgery is indicated in scenario #2 as the patient has failed to respond to appropriate antibiotic treatment for osteomyelitis. Other surgical indications for osteomyelitis are the aspiration of pus from bone and the presence of a subperiosteal abscess.
In the review by Song & Slaboda, the authors note that S. aureus accounts for > 90% of osteomyelitis in children of all age groups. The authors recommend 3-4 weeks of antibiotics, while following the response to therapy with CRP levels.
The patients in scenarios #1 and #3 have not had a trial of antibiotic treatment, thus surgery is not yet indicated. The patient in scenario #4 is clinically improving after 24 hours of antibiotics (presumably a sensitive strain). The patient in scenario #5 has not yet failed appropriate antibiotic treatment, as gentamicin does not effectively treat gram positive organisms such as S. aureus.
Song KM, Sloboda JF
J Am Acad Orthop Surg. 2001 May-Jun;9(3):166-75.PMID: 11421574 (Link to Abstract)
Song, JAAOS 2001
Average 3.0 of 34 Ratings
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?
Repeat aspiration of the left knee
Observation with repeat radiographs in one week
Magnetic resonance imaging (MRI)
Begin intravenous broad-spectrum antibiotics and obtain an infectiouse disease consult
Exploratory surgical arthrotomy
This patient is presenting with signs of infection, but a normal radiograph and knee aspiration. Osteomyelitis should be suspected, and MRI is the most appropriate next step in management. The patient is too ill for observation, and a diagnosis must be made before antibiotics are started. MRI is also useful as it will help evaluate for malignancy which should also be on the differential.
Dormans et al reviews the presentation, diagnosis, and treatment of acute hematogenous osteomyelitis in pediatric patients. The frequency of neonatal osteomyelitis is increasing, presumable due to the greater number of invasive procedures occurring in neonatal ICU's. Definitive diagnosis of osteomyelitis often requires a bone biopsy.
An example of proximal tibial osteomyelitis is demonstrated in Illustrations A and B.
Average 3.0 of 19 Ratings
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?
The clinical scenario and images are consistent with chronic osteomyelitis. The blue arrowheads on the radiograph and computed tomography point out the involucrum of chronic osteomyelitis. The involucrum is new bone growth from the periosteum that walls off the sequestrum from the healthy bone. The sequestrum (white arrows) is the necrotic bone that has become avascular and isolated from the healthy bone.
Matzkin et al review 55 cases of chronic osteomyelitis in pediatric patients from the Pacific islands. Staph aureus was the most frequent organism (43% were MRSA). An average of 1.3 surgical debridements were required per patient, and nearly half of cases had a sequestrum excised.
Matzkin EG, Dabbs DN, Fillman RR, Kyono WT, Yandow SM.
J Pediatr Orthop B. 2005 Sep;14(5):362-6. PMID: 16093948 (Link to Abstract)
Matzkin, JPOBR 2005
Hevroni A, Koplewitz BZ.
N Engl J Med. 2007 Feb 22;356(8):e7. PMID: 17314333 (Link to Abstract)
Hevroni, NEJM 2007
Average 4.0 of 27 Ratings
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?
MRI of the knee
Observation with follow-up ESR, CRP, and repeat aspiration in 1-2 days
Oral cephalosporin and follow-up in 10 days
Surgical arthrotomy, debridement, and irrigation procedure
Chest, abdomen, and pelvis CT
The child's clinical presentation is consistent with an acute infection. However, results from the aspiration are not consistent with septic arthritis of the knee. The child most likely has acute osteomyelitis. Therefore, MRI will confirm diagnosis and assist in planning a bone biopsy and culture to guide antibiotic management.
McCarthy et al. reviewed the current evaluation, diagnosis, and management of pediatric osteomyelitis. They emphasized prompt and accurate diagnosis, timely medical and/or surgical intervention, and long-term follow-up as paramount to achieving clinical success.
Peltola & Pääkkönen reviewed the diagnosis and management of acute osteomyelitis in children and note that there is a predilection for osteomyelitis in the long bones (i.e., femur). They present an algorithm for the diagnosis and management of osteomyelitis (Illustration A).
Figure A and B are unremarkable AP and lateral radiographs of the knee. Radiographs in patients with osteomyelitis may show deep soft tissue swelling, but are unlikely to show osseous changes during an acute episode. Illustration A depicts the recommendations from Peltola & Pääkkönen regarding the diagnosis and management of osteomyelitis.
Answer 2: Observation with repeat ESR and CRP would be appropriate if suspicion for infection was low and ESR and CRP were not already elevated.
Answer 3: Oral cephalosporins for 10 days would not be indicated at this time. First a diagnosis of osteomyelitis is required and if confirmed intravenous, not oral, antibiotic therapy should be initiated.
Answer 4: Surgical arthrotomy, debridement and irrigation would be more appropriate if the results from the aspiration confirmed a septic arthritis.
Answer 5: Chest, abdomen and pelvis CT would be more appropriate if there was a clinical suspicion for malignancy.
McCarthy JJ, Dormans JP, Kozin SH, Pizzutillo PD.
Instr Course Lect. 2005;54:515-28. PMID: 15948476 (Link to Abstract)
McCarthy, JBJS 2005
Peltola H, Pääkkönen M.
N Engl J Med. 2014 Jan 23;370(4):352-60. PMID: 24450893 (Link to Abstract)
Peltola, NEJM 2014
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?
Casting of the ankle and observation
CT of the tibia
Oral antibiotic therapy, with outpatient follow-up in 6 weeks
Biopsy and culture of the tibial lesion
Urgent ankle arthrotomy
The patient's presentation is consistent with subacute osteomyelitis, with the development of a Brodie's abscess as shown in Figures B-D.
McCarthy et al in their ICL on pediatric musculoskeletal infections state that initially, the most important aspect of treating children and adolescents with subacute hematogenous osteomyelitis is ruling out tumors. Therefore, in addition to cultures of involved tissue, a biopsy is needed. They also state that if infection is confirmed, treatment consists of administration of appropriate antibiotics and, when the osteomyelitis is chronic (with symptoms for more than one month), débridement and removal of any sequestrum may be required. Patients with this condition usually do not have any constitutional symptoms, and lab work-up may be normal.
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?
Multicentric giant cell tumor
Polyostotic mycobacterial infection
Tuberculosis has become more prevalent in developed countries over the past 30 years because of immunocompromised patients and the emergence of multidrug-resistant strains. Children are more likely to have extrapulmonary involvement. The most common sites of musculoskeletal involvement are the spine (50%), large joints (25%), and long bones (11%). Involved joints have diffuse osteopenia and subchondral erosions as seen in Figures C and D. Patients can present with constitutional symptoms of fever, night sweats, weight loss, and pain. The WBC is usually normal and the ESR is often elevated. The purified protein derivative test (PPD) is positive.
The biopsy specimen in Figure E shows multiple giant cells with caseous necrosis. The special stain is a Ziehl-Neelsen stain that displays the mycobacterium as "red snappers" against a blue background. Culture for acid-fast bacilli on Lowenstein-Jensen medium is diagnostic. Treatment is usually medical with multi-agent antbiotics for at least 1 year but surgical débridement of long-bone lesions facilitate resolution of constitutional symptoms.
Average 3.0 of 33 Ratings
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?
Bones with an intra-articular metaphyses are the proximal humerus, proximal radius, proximal femur, and distal fibula/tibia. This makes the shoulder, elbow, hip, and ankle potential sources of septic arthritis secondary to direct metaphyseal spead of osteomyelitis. The metaphysis of the knee is extra-articular and as such proximal tibial or distal femur osteomyelitis does not routinely spread to the knee. As can be seen in Illustration A, intra-articular metaphyses can spread infection directly to the joint. Song and Sloboda review pediatric osteomyelitis and discuss the most common organisms and protocols used for treatment. Sucato et al review pediatric septic arthritis of the hip and discuss the diagnostic tests used to confirm the diagnosis such as ESR, CRP, and intra-articular aspiration. They also discuss current protocols for the emergent treatment of septic arthritis.
Illustration B and C demonstrate the intra vs extrarticular location of the metaphyses at the knee and hip joint and the different paths that osteomyelitis can travel from the richly vascularized metaphysis.
Sucato DJ, Schwend RM, Gillespie R.
J Am Acad Orthop Surg. 1997 Oct;5(5):249-260. PMID: 10795061 (Link to Abstract)
Sucato, JAAOS 1997
Average 4.0 of 31 Ratings
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?
Long leg cast and continued non-weightbearing to the extremity
Chest CT scan and referral to an orthopaedic oncologist
Neoadjuvant chemotherapy followed by surgical resection
Percutaneous biopsy with culture and antibiotics
Percutaneous pinning of the physeal fracture and long leg cast placement
The clinical presentation is highly suspicious of acute hematogenous osteomyelitis as demonstrated by the history and imaging findings. The most appropriate next step in management is a percutaneous biopsy with culture and antibiotics.
Percutaneous or open biopsy is required for obtaining specimen for culturing and susceptibility testing so organism directed antibiotics can be administered. Identification of the infecting organism is the essential step in confirming diagnosis and selecting the appropriate antibiotic. Yield of positive cultures from bone range from 51 – 73% when performed before antibiotic administration.
A patient with acute hematogenous osteomyelitis will present with pain, disuse, with or without concomitant infection. Examination will reveal irritability or malaise, swelling and erythema of subcutaneous bones, tenderness or pain with ROM of adjacent joints. Laboratory evaluation should include CBC with differential, ESR, CRP, and blood cultures. WBC and ESR may be normal. Plain radiographs in AHO often reveal overlying soft tissue swelling, obliteration of normal fat pads and muscle layers, resorption of bone with or without periosteal new bone formation. Some surgeons may prefer to obtain a MRI before the culture is performed, especially if the labs and exam do not fit with infection.
Average 3.0 of 26 Ratings
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?
Discharge home on non-steroidal anti-inflammatory drug (NSAID) and short leg non-weightbearing cast
Discharge home on oral antibiotics with serial ESR and CRP in an outpatient setting
Admit to hospital for percutaneous aspiration for culture and intravenous antibiotics with serial ESR and CRP
Admit to hospital for percutaneous biopsy and referral to orthopaedic oncologist
Admit to hospital for percutaneous screw fixation of distal tibia fracture
This patient's history, physical examination, and imaging is consistent with acute hematogenous osteomyelitis (AHO) following minor trauma to the ankle.
Song et al present Level 5 evidence stating that sequential parenteral-oral antibiotic regimens are the mainstay of AHO treatment. ESR and CRP are positive in AHO cases up to 91% and 97%, respectively. Failure of the CRP level to fall rapidly after initiation of antibiotic treatment has been predictive of long-term sequelae. Aspiration of bone to be sent for culture can identify the offending organism and offer organism-directed antibiotic therapy but can often have false negative culture results. Blood cultures (results pending in this case) are only positive 30-60% of the time and in many cases treatment of presumed infections is empirical, based on clinical and radiographic criteria. Empirical antibiotic coverage should always include coverage for Staphylococcus aureus, since it is the most common pathogen in all age groups. The presence of a soft-tissue or intra-osseous abcess, concomitant septic arthritis, failure to respond to antibiotic therapy are generally recognized indications for surgical intervention.
Average 3.0 of 23 Ratings
Boy 12 year old, with patological fracture distal third of right femur.Scar...
HPI - -Multiple discharging sinuses from distal thigh 1 year ago, healed after debridement and dressings.
- Presently has deformity of the knee with painful gait
How would you manage this patient?
HPI - septic arthritis ankle 2 years ago, since then bulking intermittent pain for 6 months.
Would you obtain any additional imaging studies prior to deciding treatment?
HPI - h/o trauma 6 months back ..treated by non-medical professional(quacks in village)
h/o low grade fever..
treatment plan and X ray findings