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Hematogenous Osteomyelitis

- Discussion:
    - general features:
           - pediatric bone circulation
    - age of patient:
           - osteomyelitis in the newborn
                   - in infants below the ages of 1 year, some metaphyseal vessels may transverse epiphyseal plate and permit spread of infection to epiphysis and adjacent joint;
                   - this is most common in the hip, and occurs less often in the shoulder, and rarely in the elbow;
           - osteomyelitis in the child
                   - bones of children are enveloped in a tough periosteal sleeve;
                   - this sleeve is lifted away from the bone by dissecting pus;
                   - periosteal sleeve is firmly attached to the bone in the region of epiphyseal plate and forms a barrier to prevent spread of infection to the adjacent joint;
    - bacteriology:
           - most common organism is staphylococcus aureus;
           - streptococcal & haemophilus influenzae bone infections are seen in young children, and sickle cell patients are prone to bone infection by salmonella;
           - in older adults and in patients with compromised immune systems, bone infection by gram-negative organisms is common;
           - tubercle bacilli and fungi may also cause hematogenous osteomyelitis;
           - ref: Microbiological culture methods for pediatric musculoskeletal infection: a guideline for optimal use.
    - diff dx:
           - leukemia and EOG
    - associated conditions:
           - septic arthritis
                   - occurs most often in young children (12 to 18 months) due to the epiphyseal circulation;
                   - in older children, associatted septic arthritis can occur w/ involvement of the proximal femur (most common), and less often in
                           the proximal humerus, distal lateral tibia, and the radial head;
           - multiple sites of involvement:
                   - in neonates with hematogenous osteomyelitis, 40% will have multiple sites of involvement;

- Clincial Findings:
    - high fever and WBC are variable findings;
    - metaphyseal tenderness is often present (joint motion should be unhindered unless septic arthritis is present);
           - bone aspiration is performed at site of maximal tenderness using a 16 or 18 gauge spinal needle;

- Radiographic Findings
    - radiological features can mimic various benign or malignant bone tumours and non-pyogenic infections;

- Radioisotope Scanning
    - useful for identifying multiple sites of involvement (neonates);


- Surgical Debridement:
    - some argue that surgical debridement is indicated if pus is aspirated;
    - surgical drainage is effected by opening the periosteum and cortical drilling;

- Subacute Haematogenous Osteomyelitis:
    - may be an uncommon cause of limp in children;
    - dx can be difficult since signs, symptoms, and labs for osteomyelitis are often unremarkable;
    - look for sublte extremity swelling and/or subtle loss of range of motion;
    - elevated temperature is uncommon;
    - radiographs may show a well circumscribed subchondral lesion w/ well defined trabecular margins;
    - bone scan is often positive;
    - treatment often consists of surgical evacuation both as a therapeutic measure and a diagnostic measure (in order to rule out malignancy);
    - in the report by Rascol MN (2001), the author followed 21 children (1990-1998) with primary subacute haematogenous osteomyelitis;
           - pain, swelling and a limp had been present for two to 12 weeks with little functional impairment;
           - laboratory tests were non-contributory;
           - lesions were classified radiologically into metaphyseal, diaphyseal, epiphyseal and vertebral;
           - 24 sites involved, with most (20) being in the tibia; 17 lesions were in the diaphysis, 5 in the metaphysis and two in the epiphysis;
           - diagnosis was confirmed histologically in all cases;
           - staphylococcus aureus was cultured in six patients;
           - healing occurred in all patients after treatment with antibiotics for 6 weeks and radiological improvement was seen after three to six months;
           - subacute osteomyelitis develops as a result of increased host resistance and decreased bacterial virulence;
           - histological confirmation is necessary to avoid a delay in diagnosis;
    - references:
           - Primary subacute haematogenous osteomyelitis of the tarsal bones in children
           - Subacute osteomyelitis presenting as bone tumors.
           - Primary subacute haematogenous osteomyelitis in children.

Acute and chronic osteomyelitis in children. Ferguson AB:  Clin Orthop 1973;96:51.

Acute osteomyelitis in children: a review of 116 cases.   

Pediatric Acute Hematogenous Osteomyelitis

The treatment of chronic hematogenous osteomyelitis.

Acute hematogenous osteomyelitis in children.  DR Dirschl.  Orthop Rev. Vol 23. 1988. p 61-66.

Primary subacute epiphyseal and metaepiphyseal osteomyelitis in children. diagnosis and treatment guided by MRI.

Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature.