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Bone and Joint Infections

We are talking about septic arthritis and acute osteomyelitis, how does it present? In younger kids it can present as limping, refusal to bear weight on a limb and irritability bone infection, joint infection, osteomyelitis, osteomielitis, osteomylitis, septic arthritis. It the early states, the patient may be walking and just limping a little bit, and this is common in two-year-old kids when they can’t give you a good story.

You don’t know whether it’s coming from the foot, the knee, the hip, but they will usually present with some sort of a subtle problem to the parents. The difference between an injury, is you would expect some sort of fever or systemic signs. Fevers are helpful, usually the symptoms are going to be a day or two, usually less than seven days. If they preexisting conditions such as cancer or something else, of course, then we already know we have to be really diligent in those situations.

The history of recent trauma is interesting because the differential diagnosis in most of these situations is going to be infection versus fracture. At least half the time there is the story of, "he fell off the slide two days ago and we thought he was just guarding it from that." Well it may be that had something to do with the infection starting also, so it doesn’t prove one way or the other whether it’s an infection or a fracture. Other recent infections are important, particularly in the septic joints, like an ear infection can end up becoming a septic joint a couple of days later.

Treatment for infections. There are a lot of situations where we aspirate joints in order to drain them, both for diagnosis and for treatment. Joints that are superficial and easy to get at, such as the knee, that works pretty well, and we don’t usually take a patient to the operating room that has a septic knee joint will do aspirations on a daily basis for a couple of days, and if the patient gets better, then we don’t take them to the operating room, and if they don’t get better, then we take them to the operating room.

In joints that are easy to examine, and specifically the hip joint, we don’t wait that time because you can’t examine it very well, you can’t be sure if you’re in the joint easily without using x-ray imaging and the consequences are too dire, so in septic hip joints, it’s an almost automatic operation if you can identify that they septic, and our radiologists, if they tap the hip and get pus, we just take the kids to the operating room and drain the hips, if it’s the knee, it’s a different issue, elbows can be drained, ankles can be drained as long as you are comfortable doing that. If the patient’s don’t get better clinically, then washing them out is the gold standard. The antibiotics have to be able to get to the location. There are circumstances where there is so much pressure, no much pus under pressure that the antibiotics aren’t going to get there, in that case you have to surgically decompress it just like you would with any other abscess.

Emergency situations. These we consider emergencies and we take to the operating room essentially right away, the first situation is something that leads to law suits when there is a delay in diagnosis. Whenever the child presents limping, the first thing you want to think of is hip arthritis or septic arthritis. The hips are tough because they are harder to examine, you can cause severe damage to the hip joint very early in the situation before it is obvious what the problem is, and it has worse sequelae than any other joint. This is a child that had bilateral septic hips and suffered growth arrest on both of the hip. You see here, there is no epiphysis at all on this hip on the left side, all there is is a femoral neck, and on the other side, the growth plate was damaged, it’s still present and there is still a femoral head, but look at how short the neck is on this side.

All the growth that would have occurred at the top of the hip joints is gone, so the patient is going to be short and hip joints aren’t going to be shaped properly, and there is no way to fully recovery from this problem. The other situation is a cold bone scan. That means you are doing a bone scan, the technetium material can’t get to the bone because the pressure is too high in the bone. If that occurs, then you’re not going to get any antibiotics in the bone either, therefore you have to drain it. This side, if you compare the two shoulders here, you can see that there is less uptake here than there is on the other side. This was the case where the patient had an abscess in that area. We ended up having to drain this, put holes in the bone to let the pus come out and let the antibiotics get in, and then she did pretty well on that. This situation needs surgery and can’t be treated with antibiotics.