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Osteomyelitis in the Child

- Pathogenesis:
    - osteomyelitis occurs most frequently in the long bones of lower extremities, & to a lesser extent the upper extremities;
    - hematogenous osteomyelitis
    - pediatric bone circulation: tortuous course of nutrient vessels in bone causes bacteria to be trapped in the metaphysis;
    - epiphyseal plate prevents infection from entering the joint space in older children but not in neonates;
    - joint infection secondary to osteomyelitis may occur in shoulder, radial head and the hip as a result of synovial membrane inserting
             distally to epiphysis, allowing bacteria to spread directly from metaphysis to joint space;
             - infecting organism may reach the joint in three ways:
                    - hematogenous seeding of synovial membrane
                    - extension from an adjacent focus of osteomyelitis
                    - direct implantation from a penetrating wound;
    - bacteriology:
          - ages 6 mo to 2 yrs
          - ages over 2 yrs
          - predisposing conditions:
                 - chicken pox: streptococcus
                 - ear infection: h. influenza or streptococcus;
                 - sickle cell: salmonella;
                 - meningitis:
          - references: The changing epidemiology of osteomyelitis in children


- Work Up:
 
    - before aspiration, consider whether an MRI is indicated (you do not want to aspirate and EOG without a prestage MRI);
    - aspiration of site:
         - in order to recover causitive organisms & to determine whether an abscess is present, which wound require surgical drainage;
         - drilling is used to decompress known proximal femoral osteomyelitis that has not already decompressed into the hip joint and to obtain a Gram's stain and culture material in cases of possible primary bone infection with sympathetic hip effusions;
         - in 1974, Kemp and Lloyd-Roberts noted several cases of osteonecrosis after proximal femoral osteomyelitis w/o apparent hip sepsis;
                   - based on this, they recommended drilling all proximal femoral osteomyelitis;
         - reference: Avascular necrosis of the capital epiphysis following osteomyelitis of the proximal femoral metaphysis
- Treatment:
     - antibiotics:
     - surgical debridement and vancomycin Ca sulfate
     - references:
            - Treatment of chronic osteomyelitis in children resistant to previous therapy.

- Complications:
     - deep venous thrombosis
            - Deep Venous Thrombosis Associated with Osteomyelitis in Children
            - Upper-Extremity Deep Venous Thrombosis Associated with Proximal Humeral Osteomyelitis in a Child. A Case Report
            - Deep venous thrombosis associated with acute hematogenous osteomyelitis in children.
            - Venous thrombosis and thromboembolism in children with osteomyelitis.


References:

Pediatric Humeral Osteomyelitis

Osteomyelitis in infants and children. A review of 163 cases

Primary subacute epiphyseal osteomyelitis

Diaphyseal primary subacute osteomyelitis in children

Osteomyelitis of the calcaneus in children.   

Occult epiphyseal bone abscess: lessons for the unwary.

Hematogenous osteomyelitis of the wrist in children.

Osteomyelitis of the pelvis in children.

The three syndromes of iliac osteomyelitis in children.

Chronic Osteomyelitis in Children: Treatment by Intramedullary Reaming and Antibiotic-impregnated Cement Rods

Pathologic Fractures in Children with Acute Staphylococcus aureus Osteomyelitis