The Impact of Septic Arthritis and

Osteomyelitis in Paediatrics ANZONA: Racing to the Challenge 2013 Melbourne

Kerry Houghton: CNC Orthopaedics

Nicole Mangion: CNE Orthopaedics

Penny Brown: RN

Incidence Under 13 years

• Osteomyelitis 1: 5000

• Septic Arthritis 1:2500 • Poor outcomes in 27% or 40% if hip affected

Varies country to country (USA)

Zaoutis T, Localio AR, Leckerman K, and others Pediatrics 2009

Number of Episodes

0

20

40

60

80

100

120

2010 2011 2012

Osteomyelitis

Septic Arthritis

Diagnosis Clinical Assessment • Pain

• Fever, unwell

• Range of Motion

• Heat redness

• Swelling

• Weight Bearing Status

Diagnostic Tools • Imaging: Ultrasound, CT,

MRI, Bone Scan, X-ray, PET

• Biopsy: Tissue Culture

• Bloods: WBC, ESR, CRP,

Blood Cultures

Common Organisms • Staphylococcus aureus 70%

• Methicillin-resistant s. aureus (MRSA)

• Streptococcus pyogenes

• Kingella kingae

• Note: Haemophilus influenzae type b was the most

common organism until the introduction of the (Hib)

vaccine

Treatment Osteomyelitis • Hydration

• Pain management

• Intravenous Antibiotics

• Restricted weight bearing

• Late presentation may lead

to surgical intervention,

debridement / drainage /

local antibiotic therapy

Septic arthritis • Hydration

• Pain management

• Intravenous Antibiotics

• ROM exercises

• Aspiration

• Washout joint under G/A

Case Study One

S P : 10 year old boy

• Presented with a 2 day history

of bilateral hip pain no

previous illness (May 11)

• Unable to weight bear

• Fevers

• Rash

• Vomiting

• Respiratory arrest in ED

• Developed multi-organ failure

• MRSA : Sepsis with toxic

shock

• Osteomyelitis right hip

• Thrombus : iliac vein

• Gangrene both lower

extremities

Treatment • PICU stay 34 days with ECMO for 3 weeks

• IV antibiotics (sensitive to MRSA) Vancomycin, Linezolide,

Piperacillin

• Infection Disease consults

• Bloods checks

• Debridement Ischial Tuberosity / Ileum

• Debridement and grafting to feet x 6

• Placement of IVC filter for Thrombus

• Discharged after 184 days on oral Clindamycin

Outcomes Lower Extremities

AVN Femoral head / Joint

Destruction

Outcomes • Application of Hinged hip

distractor right hip (Sept 11)

• Temporary right hip

replacement (Jan 13)

• Now able to weight bear, limited

ROM right hip

• On going physiotherapy

• On going problems with wound

breakdown to grafts (feet)

• Doing well at school

Long Term

• Joint destruction / Osteoarthritis

• Gait

• Potential wound breakdown to grafts on

feet / amputation

• Psychological assessment

Case Study 2

• Transferred from local hospital with 2 day history of fevers, NWB

right leg, unwell, swollen right knee

• Blood cultures received from local hospital: Gram+ve Cocci

Staph

• Imaging: x-ray, ultrasound and bone scan = Fluid collection

anterior lateral thigh, effusion in right knee due to tracking from

distal femur

• K T : 2 and half year old girl

Complications • Respiratory: Septic Showers / Multifocal

pneumonia

• Endocarditis

• PICU stay 2 days

Treatment

• Hydration / pain management

• Washout and debridement x 8

• Regular checks on inflammatory markers / LFT’s / electrolytes

• Insertion of Genta beads

• IV antibiotics: Flucloxacillin, Lincomcin 40 days / Infection Disease

Consults

• Splinting right leg to prevent knee contraction

• Developmental milestones assessed/speech

• Discharged after 42 days on 6 months oral antibiotics (21st March)

Outcomes

Unplanned re-admissions x4

1. Re-admitted with pathological

# distal femur Thomas splint

traction applied for 1 week and

insertion of a flexible nail (23rd

March)

2. Re-admitted with protruding

femoral nail, adjusted in

theatre (12th April)

Outcomes 3. Re-admitted again with

protruding nail, Ilizarov frame

applied. (10th May ). Weekly

hydrotherapy as an outpatient

4. Frame unstable, re-admitted

long leg Hinged POP applied ( 10th Aug)

Long Term • Joint destruction

• Osteoarthritis

• Potential growth disturbance:

angulation deformity leg

length discrepancy

• Cardiac Follow-up

In Summary • Ongoing care transitioning

from a paediatric health care

setting to a adult

• Identification of potential

problems across the child’s

life span

• Education and realistic

expectations