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Orthopaedic infections in children

Acute Haematogenous Osteomyelitis

Pathology

1. Inflammation

  • Acute inflammatory reaction with vascular congestion
  • Rise in intra-osseous pressure causing intense pain

2. Suppuration

  • At 2-3 days pus forms within the bone and forces its way down the haversian canals to the surface where it forms a sub-periosteal abscess
  • The pus can spread from here back into the bone, into an adjacent joint or into the soft tissues (Where there is an intra-articular physis)
  • Vertebral infection can spread through the end plate, disc and into the next vertebral body

3. Necrosis

  • At 7 days, rising pressure, vascular stasis, infective thrombosis and periosteal stripping compromise the blood supply to the bone resulting in bone death resulting in a sequestrum

4. New bone formation

  • At 10-14 days this forms from the deep surface of the stripped periosteum forming the involucrum

5. Resolution

  • With release of the pressure and appropriate antibiotics healing can occur
  • There may be permanent deformity
  • Unpublished work (quoted in Dee) shows that experimentally bacteria injected intravenously will settle in the metaphyses of bone preferentially

NB - in 10% of cases there is more than one site of infection.

     

Clinical Features

Children (invariably)

  • Pain, malaise, fever
  • Limp or not weight bearing

Infants

  • Failure to thrive, drowsiness, irritable

Adults

  • The commonest site is the thoracolumbar spine (Batson's venous complex from the pelvis)
  • Other bones involved especially in DM, IVDA, immunosuppressed

 

Examination

  • Local erythema, swelling and tenderness indicates that the pus has broken through the periosteum


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