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Emergency Department Management Of Acute Hematogenous Osteomyelitis In Children
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Publication Date

February 2014 (Volume 11, Number 2)

CME

This issue includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP Catgory 1 credits, 4 AAP Prescribed credits, and 4 AOA Category 2A or 2B CME credits

Authors

Hasan S. Merali, MD
Division of Paediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON

Jonathan Reisman, MD
Pediatric Emergency Medicine Services, Massachusetts General Hospital, Boston, MA

Linda T. Wang, MD
Pediatric Emergency Medicine Services, Division of Global Health, Massachusetts General Hospital for Children, Boston, MA

Peer Reviewers

Richard M. Cantor, MD, FAAP, FACEP
Professor of Emergency Medicine and Pediatrics, Director, Pediatric Emergency Department, Medical Director, Central New York Poison Control Center, Golisano Children’s Hospital, Syracuse, NY

Marianne Gausche-Hill, MD, FACEP, FAAP
Professor of Clinical Medicine, David Geffen School of Medicine at the University of California at Los Angeles; Vice Chair and Chief, Division of Pediatric Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA

Abstract

Acute hematogenous osteomyelitis has an annual incidence of approximately 2 to 13 cases per 100,000 persons in developed countries. It can be difficult to diagnose in pediatric patients due to the condition’s often vague presentation. However, it is critical for the emergency clinician to be able to properly identify osteomyelitis, as it can have devastating consequences if left untreated. Because this is a relatively rare condition, there is limited evidence to guide the management, and there is a lack of standardized guidelines. In this issue, a systematic approach to the workup and treatment of a child who presents with possible acute hematogenous osteomyelitis is discussed. The most critical components of the history and physical examination, diagnostic studies, and treatment options are reviewed, including algorithms to guide management. Special populations are given consideration throughout the discussion, and management algorithms are provided.

Excerpt From This Issue

An 8-year-old boy with a history of sickle cell disease presents to the ED on a weekday afternoon because he could no longer keep up with his teammates during soccer practice. His mother is very worried and tells you that he is “not walking right.” She had taken him to his pediatrician earlier in the week because of right leg pain and was told to give him ibuprofen as needed. As the week progressed, he has complained of increasing right leg pain, and later developed a limp. Today, he could not run with his teammates because the pain had worsened. His mother tells you that he felt warm on the way to the ED. The boy denies any trauma. He has not had any chest pain or pain elsewhere in his body, and the rest of his review of systems is negative. His physical examination is notable for a low-grade temperature and mild tachycardia. As he climbs onto the examination bed, you notice that he favors his left leg. He is tender to palpation over the distal aspect of his right femur with some swelling noted, and he begins crying as you palpate. He has full range of motion of his hips, knees, and ankles without any joint swelling or tenderness, and he has normal sensation and reflexes. The rest of his physical examination is normal, as well. You inform the patient and his mother that the differential diagnosis for this presentation is broad and further workup is needed. You tell her you will start with pain medication, x-rays, and blood work. As you think about all of the children you have seen with a limp, you narrow your differential diagnosis, considering the acute onset of this patient’s symptoms and the focal nature of his pain. Aside from plain films and blood work, you consider what else will be helpful for his workup. What specific lab tests might help you to make a diagnosis? In addition to the xray, should you order a CT scan, bone scan, or an MRI? If this is an infectious process, what antibiotics should you choose? Is the fact that he has sickle cell disease related to this presentation?

A previously healthy 2-month-old girl is brought to the ED for “crying all the time” for the past 3 days. Initially, her mother was unsure why her daughter was crying so much, but now she thinks it happens every time she changes her diaper. She feels that the crying is due to some kind of pain. She checked a rectal temperature at home prior to presenting to the ED, and she recalled that it was 38.6°C. On taking further history, you learn that the infant was born vaginally, full-term, and that her mother had no complications during pregnancy or delivery. Of note, her mother is a nurse at your hospital. On physical examination, the patient’s vital signs are notable for a fever to 38.9°C rectally. As you observe her lying on the examining table, you note that she is not moving her left leg. There is minimal swelling over her left calf, and she cries if you try to flex or extend her left knee. She has normal pedal pulses with good capillary refill. Her skin is intact, and the rest of her physical examination is normal. You inform her mother that you would like to perform some x-rays and order laboratory tests. As you think about her constellation of symptoms, you begin to form a differential diagnosis, likely with an infectious cause. What pathogens are likely to have caused this presentation? Is this related to her knee, and should you perform ultrasound on the knee joint? What are some other diagnoses you need to assess and rule out?

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