Osteomyelitis in Children Dr. Robert Deane Janeway
Outline <ul><li>Age </li></ul><ul><li>Incidence </li></ul><ul><li>Etiology </li></ul><ul><li>Pathophysiology </li></ul><ul...
Age / Incidence / Etiology <ul><li>1/1000 – 1/ 20 000 </li></ul><ul><li>Male > Female </li></ul><ul><li>Pre antibiotic era...
Age / Incidence / Etiology <ul><li>Advances in treatment </li></ul><ul><ul><li>Earlier dx </li></ul></ul><ul><ul><li>Antib...
Age / Incidence / Etiology <ul><li>Glasgow  incidence decreased </li></ul><ul><li>New Zealand……. Madri > Whites </li></ul>...
Age / Incidence / Etiology <ul><li>H Flu </li></ul><ul><ul><li>Big cause 1970’s </li></ul></ul><ul><ul><li>1-4 yrs </li></...
Pathophysiology <ul><li>Poorly defined </li></ul><ul><ul><li>Direct inoculation </li></ul></ul><ul><ul><li>Hematogenous sp...
Pathophysiology <ul><li>Infection </li></ul><ul><ul><li>Starts in Metaphysis </li></ul></ul><ul><ul><ul><li>Arteriole Loop...
Pathophysiology <ul><li>Few phagocytes in Zone of Hypertrophy </li></ul><ul><ul><li>Highest incidence in fastest growing b...
Pathophysiology <ul><li>Gaps in endothelium metaphyseal vessel </li></ul><ul><li> </li></ul><ul><li>Bacteria pass </li></...
Pathophysiology <ul><li>Spread via Volkman Canal </li></ul><ul><li>     </li></ul><ul><li>Subperiosteal Pus </li></ul><ul...
Pathophysiology <ul><li>Role of Trauma  </li></ul><ul><ul><li>Rabbit experiment </li></ul></ul><ul><ul><li>IV injection of...
Pathophysiology <ul><li>Role of growth plate </li></ul><ul><ul><li>Over 18/12 </li></ul></ul><ul><ul><li>Impermeable to sp...
Pathophysiology
Pathophysiology <ul><li>1 st  osteoblasts die </li></ul><ul><li>Lymphocytes release osteoclast activating factor </li></ul...
Diagnosis <ul><li>Pain </li></ul><ul><ul><li>Neonate peudoparalysis </li></ul></ul><ul><ul><li>NWB </li></ul></ul><ul><ul>...
Pathophysiology <ul><li>Bloodwork </li></ul><ul><ul><li>CBC Diff </li></ul></ul><ul><ul><li>ESR </li></ul></ul><ul><ul><li...
Pathophysiology <ul><li>WBC increased 30-40% </li></ul><ul><li>Left Shift  65% </li></ul><ul><li>ESR increased 91%……….24-3...
Pathophysiology <ul><li>CRP </li></ul><ul><ul><li>More rapid than ESR </li></ul></ul><ul><ul><li>2-4 hrs …..peak 72hrs </l...
Pathophysiology <ul><li>Blood Culture </li></ul><ul><ul><li>+ 30-60% </li></ul></ul><ul><ul><li>Decreased with antibiotic ...
Diagnosis <ul><li>Pus aspiration </li></ul><ul><ul><li>70% bone + cultures </li></ul></ul><ul><ul><li>Septic arthritis  </...
Diagnosis <ul><li>Do blood and joint cultures </li></ul><ul><ul><li>One or other not always +ve in same pt </li></ul></ul>...
Lab Diagnosis <ul><li>WBC not reliable </li></ul><ul><ul><li>False sense of security </li></ul></ul><ul><ul><li>25% increa...
Diagnosis <ul><li>ESR </li></ul><ul><ul><li>Nonspecific acute phase reactant </li></ul></ul><ul><ul><li>Depends on fibrino...
Radiology <ul><li>Plain xray </li></ul><ul><ul><li>Sensitivity 43-75% </li></ul></ul><ul><ul><li>Specificity 75-83% </li><...
Radiology <ul><li>Tc99 </li></ul><ul><ul><li>24-48hrs +ve </li></ul></ul><ul><ul><li>Bone aspiration DOES NOT  give false ...
Radiology <ul><li>Gallium </li></ul><ul><ul><li>48 hrs to do  </li></ul></ul><ul><ul><li>Non specific </li></ul></ul><ul><...
Radiology <ul><li>MRI </li></ul><ul><ul><li>Sensitivity 83-100% </li></ul></ul><ul><ul><li>Specificity 75-100% </li></ul><...
Radiology <ul><li>T1 </li></ul><ul><ul><li>Best for acute infection </li></ul></ul><ul><ul><li>Gadolinium helps </li></ul>...
Radiology <ul><li>CT </li></ul><ul><ul><li>Gas </li></ul></ul><ul><ul><li>sequestrum </li></ul></ul>
Treatment <ul><li>Mostly medical </li></ul><ul><ul><li>Sx to improve local environment </li></ul></ul><ul><ul><li>Remove i...
Treatment <ul><li>Antibiotic treatment </li></ul><ul><ul><li>Parenteral / oral combinations </li></ul></ul><ul><ul><li>Oft...
Treatment <ul><li>Treatment Failure </li></ul><ul><ul><li>High doses </li></ul></ul><ul><ul><li>Poor oral absorption / com...
Treatment <ul><li>Previously start IV  </li></ul><ul><li>Follow ESR  to guide switch to oral </li></ul><ul><li>Newer studi...
Treatment <ul><li>Neonates </li></ul><ul><ul><li>No studies, little evidence </li></ul></ul><ul><ul><li>CRP / ESR not reli...
Treatment <ul><li>Longer treatment required </li></ul><ul><ul><li>Pelvis  </li></ul></ul><ul><ul><li>Vertebrae </li></ul><...
Treatment <ul><li>Surgical intervention </li></ul><ul><ul><li>Controversial indications </li></ul></ul><ul><ul><li>Hole in...
Treatment <ul><li>Surgery Indicated </li></ul><ul><ul><li>Subperiosteal Abscess </li></ul></ul><ul><ul><li>Soft Tissue abs...
Complications <ul><li>Infection Complications </li></ul><ul><ul><li>Recurrence </li></ul></ul><ul><ul><li>Chronic osteo </...
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Osteomyelitis+in+Children

  1. 1. Osteomyelitis in Children Dr. Robert Deane Janeway
  2. 2. Outline <ul><li>Age </li></ul><ul><li>Incidence </li></ul><ul><li>Etiology </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Presentation </li></ul><ul><li>Laboratory investigations </li></ul><ul><li>Imaging </li></ul><ul><li>Treatment </li></ul><ul><li>Surgery </li></ul><ul><li>Complications </li></ul><ul><li>Summary </li></ul><ul><li>Special Groups </li></ul>
  3. 3. Age / Incidence / Etiology <ul><li>1/1000 – 1/ 20 000 </li></ul><ul><li>Male > Female </li></ul><ul><li>Pre antibiotic era ……20-50% mortality </li></ul>
  4. 4. Age / Incidence / Etiology <ul><li>Advances in treatment </li></ul><ul><ul><li>Earlier dx </li></ul></ul><ul><ul><li>Antibiotic tx </li></ul></ul><ul><ul><li>Surgery less delay </li></ul></ul><ul><ul><li>Children better nourished </li></ul></ul>
  5. 5. Age / Incidence / Etiology <ul><li>Glasgow incidence decreased </li></ul><ul><li>New Zealand……. Madri > Whites </li></ul><ul><li>South Africa…….. Black > Whites </li></ul><ul><li>Changing disease / Changing organism </li></ul><ul><li>Seasonal Variation </li></ul><ul><li>Nutritional status, climate, lifestyle </li></ul>
  6. 6. Age / Incidence / Etiology <ul><li>H Flu </li></ul><ul><ul><li>Big cause 1970’s </li></ul></ul><ul><ul><li>1-4 yrs </li></ul></ul><ul><ul><li>Now decreased due to vaccinations </li></ul></ul><ul><ul><li>Kingella Kingae </li></ul></ul><ul><ul><li>OM in older kids </li></ul></ul><ul><ul><li>Septic Arthritis 1-3 yrs </li></ul></ul><ul><ul><li>Neonates separate group </li></ul></ul>
  7. 7. Pathophysiology <ul><li>Poorly defined </li></ul><ul><ul><li>Direct inoculation </li></ul></ul><ul><ul><li>Hematogenous spread </li></ul></ul><ul><ul><li>Local invasion </li></ul></ul>
  8. 8. Pathophysiology <ul><li>Infection </li></ul><ul><ul><li>Starts in Metaphysis </li></ul></ul><ul><ul><ul><li>Arteriole Loop / Venous Lakes </li></ul></ul></ul><ul><ul><li>Spread via Volkman’s canal / Haversian system </li></ul></ul><ul><ul><li>Endothelium Leaks </li></ul></ul>
  9. 9. Pathophysiology <ul><li>Few phagocytes in Zone of Hypertrophy </li></ul><ul><ul><li>Highest incidence in fastest growing bone </li></ul></ul><ul><ul><li>Tubular > Flat bones </li></ul></ul>
  10. 10. Pathophysiology <ul><li>Gaps in endothelium metaphyseal vessel </li></ul><ul><li> </li></ul><ul><li>Bacteria pass </li></ul><ul><li>  </li></ul><ul><li>Adhere to Type 1 collagen </li></ul><ul><li>  </li></ul><ul><li>Increase pressure in bone/ decrease blood flow </li></ul><ul><li>  </li></ul><ul><li>Bone infarction / Dead Bone (sequestrum) </li></ul>
  11. 11. Pathophysiology <ul><li>Spread via Volkman Canal </li></ul><ul><li>  </li></ul><ul><li>Subperiosteal Pus </li></ul><ul><li>  </li></ul><ul><li>Cortex breaks down </li></ul><ul><li>  </li></ul><ul><li>May spread to joint </li></ul><ul><ul><li>Hip / Shoulder / Fibula / Proximal Humerus </li></ul></ul>
  12. 12. Pathophysiology <ul><li>Role of Trauma </li></ul><ul><ul><li>Rabbit experiment </li></ul></ul><ul><ul><li>IV injection of bacteria </li></ul></ul><ul><ul><li>With # start in hematoma </li></ul></ul>
  13. 13. Pathophysiology <ul><li>Role of growth plate </li></ul><ul><ul><li>Over 18/12 </li></ul></ul><ul><ul><li>Impermeable to spread </li></ul></ul><ul><ul><li>Under 18/12 infection crosses growth plate </li></ul></ul>
  14. 14. Pathophysiology
  15. 15. Pathophysiology <ul><li>1 st osteoblasts die </li></ul><ul><li>Lymphocytes release osteoclast activating factor </li></ul><ul><li>Hole in bone </li></ul>
  16. 16. Diagnosis <ul><li>Pain </li></ul><ul><ul><li>Neonate peudoparalysis </li></ul></ul><ul><ul><li>NWB </li></ul></ul><ul><ul><li>Failure to use limb </li></ul></ul><ul><li>Fever </li></ul><ul><li>Lethargy </li></ul><ul><li>Anorexia </li></ul><ul><li>Swelling (neonates / older kids) </li></ul>
  17. 17. Pathophysiology <ul><li>Bloodwork </li></ul><ul><ul><li>CBC Diff </li></ul></ul><ul><ul><li>ESR </li></ul></ul><ul><ul><li>CRP </li></ul></ul><ul><ul><li>Blood Culture </li></ul></ul>
  18. 18. Pathophysiology <ul><li>WBC increased 30-40% </li></ul><ul><li>Left Shift 65% </li></ul><ul><li>ESR increased 91%……….24-36hrs </li></ul><ul><li>CRP increased 97%…………4-6hrs </li></ul>
  19. 19. Pathophysiology <ul><li>CRP </li></ul><ul><ul><li>More rapid than ESR </li></ul></ul><ul><ul><li>2-4 hrs …..peak 72hrs </li></ul></ul><ul><ul><li>10-30x normal </li></ul></ul><ul><ul><li>Systemic ds (trauma, tumor) </li></ul></ul>
  20. 20. Pathophysiology <ul><li>Blood Culture </li></ul><ul><ul><li>+ 30-60% </li></ul></ul><ul><ul><li>Decreased with antibiotic </li></ul></ul><ul><ul><li>Multiple cultures no significant increase in yield </li></ul></ul><ul><ul><li>48 hours to get most organisms </li></ul></ul>
  21. 21. Diagnosis <ul><li>Pus aspiration </li></ul><ul><ul><li>70% bone + cultures </li></ul></ul><ul><ul><li>Septic arthritis </li></ul></ul><ul><ul><ul><li>Gram stain </li></ul></ul></ul><ul><ul><ul><li>Lymphocyte count </li></ul></ul></ul><ul><ul><ul><li>% polymorphs </li></ul></ul></ul><ul><ul><li>> 80 000 = Septic arthritis </li></ul></ul><ul><ul><li>> 50 000 in some series </li></ul></ul><ul><ul><li>80 000 also in JRA </li></ul></ul>
  22. 22. Diagnosis <ul><li>Do blood and joint cultures </li></ul><ul><ul><li>One or other not always +ve in same pt </li></ul></ul><ul><ul><li>Gram stain +ve 1/3 bone and joint aspirations </li></ul></ul><ul><li>Future looking for bacteria DNA / RNA </li></ul>
  23. 23. Lab Diagnosis <ul><li>WBC not reliable </li></ul><ul><ul><li>False sense of security </li></ul></ul><ul><ul><li>25% increased Mayo clinic </li></ul></ul><ul><ul><li>65% diff abnormal </li></ul></ul><ul><li>Acute phase reactants </li></ul><ul><ul><li>Change in plasma proteins d/t cytokines </li></ul></ul>
  24. 24. Diagnosis <ul><li>ESR </li></ul><ul><ul><li>Nonspecific acute phase reactant </li></ul></ul><ul><ul><li>Depends on fibrinogen concentration </li></ul></ul><ul><ul><li>Increased 48-72 hrs </li></ul></ul><ul><ul><li>Increased in 90% of cases </li></ul></ul><ul><ul><li>Not affected by antibiotic tx </li></ul></ul><ul><li>CRP </li></ul><ul><ul><li>Increased in 98% of cases </li></ul></ul>
  25. 25. Radiology <ul><li>Plain xray </li></ul><ul><ul><li>Sensitivity 43-75% </li></ul></ul><ul><ul><li>Specificity 75-83% </li></ul></ul><ul><li>Soft tissue swelling 48hrs </li></ul><ul><li>Periosteal reaction 5-7d </li></ul><ul><li>Osteolysis 10d to 2 wks </li></ul><ul><ul><li>(need 50% bone loss) </li></ul></ul>
  26. 26. Radiology <ul><li>Tc99 </li></ul><ul><ul><li>24-48hrs +ve </li></ul></ul><ul><ul><li>Bone aspiration DOES NOT give false +ve </li></ul></ul><ul><ul><li>Decreased uptake in early phase d/t increased pressure </li></ul></ul><ul><ul><li>“ cold” scan up to 100% PPV </li></ul></ul>
  27. 27. Radiology <ul><li>Gallium </li></ul><ul><ul><li>48 hrs to do </li></ul></ul><ul><ul><li>Non specific </li></ul></ul><ul><li>Indium </li></ul><ul><ul><li>I 131 leucocytes </li></ul></ul><ul><ul><li>24hrs to prepare </li></ul></ul><ul><li>Monoclonal antibodies </li></ul><ul><ul><li>Not proven to be better </li></ul></ul>
  28. 28. Radiology <ul><li>MRI </li></ul><ul><ul><li>Sensitivity 83-100% </li></ul></ul><ul><ul><li>Specificity 75-100% </li></ul></ul><ul><ul><li>PPV = Tc99 </li></ul></ul><ul><li>Marrow and soft tissue swelling </li></ul><ul><li>Good in spine and pelvis </li></ul>
  29. 29. Radiology <ul><li>T1 </li></ul><ul><ul><li>Best for acute infection </li></ul></ul><ul><ul><li>Gadolinium helps </li></ul></ul><ul><ul><li>Changes similar to </li></ul></ul><ul><ul><ul><li># </li></ul></ul></ul><ul><ul><ul><li>Infarct </li></ul></ul></ul><ul><ul><ul><li>Bruise </li></ul></ul></ul><ul><ul><ul><li>Tumor </li></ul></ul></ul><ul><ul><ul><li>Post surgical </li></ul></ul></ul><ul><ul><ul><li>Sympathetic edema </li></ul></ul></ul>
  30. 30. Radiology <ul><li>CT </li></ul><ul><ul><li>Gas </li></ul></ul><ul><ul><li>sequestrum </li></ul></ul>
  31. 31. Treatment <ul><li>Mostly medical </li></ul><ul><ul><li>Sx to improve local environment </li></ul></ul><ul><ul><li>Remove infected devitalized bone </li></ul></ul><ul><ul><li>Decompress abscess cavity </li></ul></ul><ul><li>Timing !! </li></ul><ul><ul><li>Early antibiotic before necrosis / pus then sx less likely to be needed </li></ul></ul>
  32. 32. Treatment <ul><li>Antibiotic treatment </li></ul><ul><ul><li>Parenteral / oral combinations </li></ul></ul><ul><ul><li>Often empirical </li></ul></ul><ul><ul><li>Serum level more important than route </li></ul></ul><ul><li>Follow WBC / ESR/ CRP </li></ul><ul><li>Organism / sensitivity </li></ul>
  33. 33. Treatment <ul><li>Treatment Failure </li></ul><ul><ul><li>High doses </li></ul></ul><ul><ul><li>Poor oral absorption / compliance </li></ul></ul><ul><ul><li>Inadequate monitoring of serum levels </li></ul></ul><ul><ul><li>Delay in Sx </li></ul></ul>
  34. 34. Treatment <ul><li>Previously start IV </li></ul><ul><li>Follow ESR to guide switch to oral </li></ul><ul><li>Newer studies </li></ul><ul><li>Follow CRP </li></ul><ul><ul><li>Shorter period of tx needed </li></ul></ul><ul><ul><li>IV 5d / total 23 d tx </li></ul></ul><ul><ul><li>Cephalosporin 150mg/kd/day </li></ul></ul>
  35. 35. Treatment <ul><li>Neonates </li></ul><ul><ul><li>No studies, little evidence </li></ul></ul><ul><ul><li>CRP / ESR not reliable </li></ul></ul><ul><ul><li>Oral absorption not reliable </li></ul></ul><ul><ul><li>Therefore IV neonates </li></ul></ul><ul><ul><li>Cloxacillin </li></ul></ul>
  36. 36. Treatment <ul><li>Longer treatment required </li></ul><ul><ul><li>Pelvis </li></ul></ul><ul><ul><li>Vertebrae </li></ul></ul><ul><ul><li>Diskitis </li></ul></ul><ul><ul><li>Calcaneus </li></ul></ul>
  37. 37. Treatment <ul><li>Surgical intervention </li></ul><ul><ul><li>Controversial indications </li></ul></ul><ul><ul><li>Hole in bone not always Sx </li></ul></ul><ul><ul><li>If purulent aspirate Sx necessary </li></ul></ul><ul><li>Sx less frequent with newer antibiotic </li></ul><ul><ul><li>22-83% earlier studies </li></ul></ul><ul><ul><li>8-43% recent studies </li></ul></ul>
  38. 38. Treatment <ul><li>Surgery Indicated </li></ul><ul><ul><li>Subperiosteal Abscess </li></ul></ul><ul><ul><li>Soft Tissue abscess </li></ul></ul><ul><ul><li>Bone Abscess </li></ul></ul><ul><ul><li>Failure of clinical response to antibiotic </li></ul></ul><ul><ul><li>Associated septic arthritis </li></ul></ul>
  39. 39. Complications <ul><li>Infection Complications </li></ul><ul><ul><li>Recurrence </li></ul></ul><ul><ul><li>Chronic osteo </li></ul></ul><ul><ul><li>Pathologic fracture </li></ul></ul><ul><ul><li>Growth plate injury </li></ul></ul><ul><li>Antibiotic Complications </li></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>N+V </li></ul></ul><ul><ul><li>Rash </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Neutropenia </li></ul></ul>
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