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Osteomyelitis secondary to trauma or infected contiguous soft tissue
L Dubey1, K Krasinski, M Hernanz-Schulman
1Department of Pediatrics, Bellevue Hospital Center, New York, NY.
Insights
Nonhematogenous osteomyelitis (NHO) in children is challenging to diagnose due to its indolent nature. Prompt bone cultures are crucial for confirming NHO and guiding effective antimicrobial therapy.
Area of Science:
- Pediatric Infectious Diseases
- Orthopedic Surgery
- Microbiology
Background:
- Nonhematogenous osteomyelitis (NHO) presents diagnostic challenges, particularly in pediatric patients.
- Predisposing factors include compound fractures, deep decubiti, and foot punctures.
- NHO can affect various long bones and foot bones.
Purpose of the Study:
- To analyze the clinical presentation, diagnosis, and treatment outcomes of pediatric nonhematogenous osteomyelitis.
- To highlight the difficulties in diagnosing NHO, especially following compound fractures.
- To emphasize the importance of bone cultures in guiding therapy.
Main Methods:
- Retrospective review of 24 pediatric patients with NHO admitted between 1980 and 1985.
- Analysis of predisposing factors, clinical symptoms, laboratory findings, radiographic results, and microbiological data.
- Evaluation of treatment strategies, including antibiotic administration and surgical debridement, and recurrence rates.
Main Results:
- Common pathogens included Staphylococcus aureus and Pseudomonas aeruginosa.
- Initial radiographs were nondiagnostic in 42% of cases with compound fractures.
- Bone cultures were positive in 83% of tested patients, while wound cultures were unreliable.
- Recurrence rates were high (42%) despite prolonged antibiotic treatment and debridement.
Conclusions:
- The indolent nature of NHO complicates early diagnosis.
- Prompt bone culture is essential for accurate diagnosis and targeted antimicrobial therapy.
- Wound cultures are not reliable predictors of bone culture results in NHO.
Abstract:
Nonhematogenous osteomyelitis (NHO) occurred in 24 pediatric patients (ages 8 months to 18 years; median, 14 years; 23 male) admitted from 1980 to 1985. Predisposing factors included compound fracture (12), deep decubiti (4) and foot puncture (3). Infection involved tibia (7), foot bones (6), proximal femur (3) and ulna (2). Patients presented with drainage (64%), pain or tenderness (44%) and fever (32%) lasting for 1 to 180 days (median, 10 days). In 24% both white blood cell count and erythrocyte sedimentation rate were normal. Initial radiographs were nondiagnostic in 42% after compound fractures. Bone cultures were positive in 15 of 18 (83%) patients for: Staphylococcus aureus (9), Staphylococcus epidermidis (2), Pseudomonas aeruginosa (4), Escherichia coli (2), Enterobacter sp. (2), Streptococcus faecalis, Serratia sp., Klebsiella pneumoniae, Achromobacter xylosoxidans, Aeromonas hydrophila and Pseudomonas fluorescens (1 each). Wound cultures failed to predict bone culture results in 12 of 16 patients (75%). NHO recurred in 8 of 19 patients (42%) despite intravenously administered antibiotics for greater than 28 days and debridement in 7 of 8 patients. The indolent nature of NHO complicates diagnosis, especially in patients with recent compound fractures. Only prompt bone culture can confirm the presence of NHO and reliably guide antimicrobial therapy.