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Osteomyelitis in Children

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Osteomyelitis in Children Dr. Robert Deane Janeway Treatment Previously start IV Follow ESR to guide switch to oral Newer studies Follow CRP Shorter period of tx ... – PowerPoint PPT presentation

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Title: Osteomyelitis in Children


1
Osteomyelitis in Children
  • Dr. Robert Deane
  • Janeway

2
Outline
  • Age
  • Incidence
  • Etiology
  • Pathophysiology
  • Presentation
  • Laboratory investigations
  • Imaging
  • Treatment
  • Surgery
  • Complications
  • Summary
  • Special Groups

3
Age / Incidence / Etiology
  • 1/1000 1/ 20 000
  • Male gt Female
  • Pre antibiotic era 20-50 mortality

4
Age / Incidence / Etiology
  • Advances in treatment
  • Earlier dx
  • Antibiotic tx
  • Surgery less delay
  • Children better nourished

5
Age / Incidence / Etiology
  • Glasgow incidence decreased
  • New Zealand. Madri gt Whites
  • South Africa.. Black gt Whites
  • Changing disease / Changing organism
  • Seasonal Variation
  • Nutritional status, climate, lifestyle

6
Age / Incidence / Etiology
  • H Flu
  • Big cause 1970s
  • 1-4 yrs
  • Now decreased due to vaccinations
  • Kingella Kingae
  • OM in older kids
  • Septic Arthritis 1-3 yrs
  • Neonates separate group

7
Pathophysiology
  • Poorly defined
  • Direct inoculation
  • Hematogenous spread
  • Local invasion

8
Pathophysiology
  • Infection
  • Starts in Metaphysis
  • Arteriole Loop / Venous Lakes
  • Spread via Volkmans canal / Haversian system
  • Endothelium Leaks

9
Pathophysiology
  • Few phagocytes in Zone of Hypertrophy
  • Highest incidence in fastest growing bone
  • Tubular gt Flat bones

10
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)

11
Pathophysiology
  • Spread via Volkman Canal
  • ?
  • Subperiosteal Pus
  • ?
  • Cortex breaks down
  • ?
  • May spread to joint
  • Hip / Shoulder / Fibula / Proximal Humerus

12
Pathophysiology
  • Role of Trauma
  • Rabbit experiment
  • IV injection of bacteria
  • With start in hematoma

13
Pathophysiology
  • Role of growth plate
  • Over 18/12
  • Impermeable to spread
  • Under 18/12 infection crosses growth plate

14
Pathophysiology
15
Pathophysiology
  • 1st osteoblasts die
  • Lymphocytes release osteoclast activating factor
  • Hole in bone

16
Diagnosis
  • Pain
  • Neonate peudoparalysis
  • NWB
  • Failure to use limb
  • Fever
  • Lethargy
  • Anorexia
  • Swelling (neonates / older kids)

17
Pathophysiology
  • Bloodwork
  • CBC Diff
  • ESR
  • CRP
  • Blood Culture

18
Pathophysiology
  • WBC increased 30-40
  • Left Shift 65
  • ESR increased 91.24-36hrs
  • CRP increased 974-6hrs

19
Pathophysiology
  • CRP
  • More rapid than ESR
  • 2-4 hrs ..peak 72hrs
  • 10-30x normal
  • Systemic ds (trauma, tumor)

20
Pathophysiology
  • Blood Culture
  • 30-60
  • Decreased with antibiotic
  • Multiple cultures no significant increase in
    yield
  • 48 hours to get most organisms

21
Diagnosis
  • Pus aspiration
  • 70 bone cultures
  • Septic arthritis
  • Gram stain
  • Lymphocyte count
  • polymorphs
  • gt 80 000 Septic arthritis
  • gt 50 000 in some series
  • 80 000 also in JRA

22
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

23
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

24
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

25
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)

26
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

27
Radiology
  • Gallium
  • 48 hrs to do
  • Non specific
  • Indium
  • I131 leucocytes
  • 24hrs to prepare
  • Monoclonal antibodies
  • Not proven to be better

28
Radiology
  • MRI
  • Sensitivity 83-100
  • Specificity 75-100
  • PPV Tc99
  • Marrow and soft tissue swelling
  • Good in spine and pelvis

29
Radiology
  • T1
  • Best for acute infection
  • Gadolinium helps
  • Changes similar to
  • Infarct
  • Bruise
  • Tumor
  • Post surgical
  • Sympathetic edema

30
Radiology
  • CT
  • Gas
  • sequestrum

31
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

32
Treatment
  • Antibiotic treatment
  • Parenteral / oral combinations
  • Often empirical
  • Serum level more important than route
  • Follow WBC / ESR/ CRP
  • Organism / sensitivity

33
Treatment
  • Treatment Failure
  • High doses
  • Poor oral absorption / compliance
  • Inadequate monitoring of serum levels
  • Delay in Sx

34
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

35
Treatment
  • Neonates
  • No studies, little evidence
  • CRP / ESR not reliable
  • Oral absorption not reliable
  • Therefore IV neonates
  • Cloxacillin

36
Treatment
  • Longer treatment required
  • Pelvis
  • Vertebrae
  • Diskitis
  • Calcaneus

37
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

38
Treatment
  • Surgery Indicated
  • Subperiosteal Abscess
  • Soft Tissue abscess
  • Bone Abscess
  • Failure of clinical response to antibiotic
  • Associated septic arthritis

39
Complications
  • Infection Complications
  • Recurrence
  • Chronic osteo
  • Pathologic fracture
  • Growth plate injury
  • Antibiotic Complications
  • Diarrhea
  • NV
  • Rash
  • Thrombocytopenia
  • Neutropenia
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