Indian Hip Surveillance Guidelines for Children with Cerebral Palsy

Volume 10 | Issue 1 | January-April 2024 | Page: 02-08 | Ashok N Johari, Dhiren Ganjwala, Alaric Aroojis

DOI- https://doi.org/10.13107/ijpo.2024.v10i01.171

Submitted: 12/01/2024; Reviewed: 09/02/2024; Accepted: 18/02/2024; Published: 10/04/2024

Authors: Ashok N Johari MS Ortho [1], Dhiren Ganjwala MS Ortho [2], Alaric Aroojis MS Ortho [3]

[1] Department of Paediatric Orthopaedic & Spine Surgery, Children’s Orthopaedic Centre, Mumbai, Maharashtra, India.
[2] Department of Paediatric Orthopaedic Surgery, Ganjwala Orthopaedic Hospital, Ahmedabad, Gujarat, India.
[3] Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Alaric Aroojis
Hon. Consultant, Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.
E-mail: aaroojis@gmail.com

Guidelines

Preamble:
Hip displacement is the second most common musculoskeletal impairment in children with cerebral palsy (CP). More than one-third of the children are affected by this problem. Hip displacement in children with CP is often asymptomatic until the hip is partially or fully dislocated, resulting in pain, gait disturbances, impaired sitting balance, difficulty in perineal care and pressure sores. The incidence of hip displacement is much higher in non-ambulatory children.

It is now well-known that hip surveillance programmes can effectively detect hip displacement early, leading to earlier proactive management with better outcomes. National and provincial hip surveillance programmes have been developed and adopted in various regions of the world, with evidence supporting the role of surveillance in preventing dislocations and avoiding the need for salvage surgery.

To offer similar benefits to Indian children with CP, a guidelines development project on National Hip Surveillance Program for Cerebral Palsy was initiated in May 2020. Based on the outcome of the one-year guidelines’ development project, this guidelines document was prepared from an Indian practice perspective.

About development of this Indian guideline:
Professional organisations whose members are involved in the care of children with CP were involved in the formation of this guideline. A National Expert Committee was constituted with representatives of these organisations. Advice was sought from international experts on this topic who acted as the Advisory Committee.

In phase 1: The Expert Committee reviewed more than 80 published research articles related to various aspects of hip displacement in CP. Key points from these articles were listed. National guidelines from other countries/regions were also reviewed, discussed and referred.

In phase 2: All important questions related to hip surveillance were listed. These questions were circulated to all the members of the expert committee. The Delphi process was used to develop consensus on these practical questions. When more than 80% of group members agreed to a particular viewpoint, it was considered as a consensus. With two rounds of the Delphi process, the committee reached a consensus on every single question. Consensus statements were listed.

In phase 3: The guideline was drafted based on these consensus statements. The main document was written keeping the from a healthcare professional’s perspective. A simple version of this guideline was also prepared to spread awareness about this important message to the caregivers / family / healthcare aid workers.

NATIONAL GUIDELINES COMMITTEE

STEERING COMMITTEE
Dr. Ashok N. Johari
Paediatric Orthopaedic & Spine Surgeon, Children’s Orthopaedic Centre, Mumbai, India

Dr. Dhiren Ganjwala
Consultant Paediatric Orthopaedic Surgeon, Ganjwala Orthopaedic Hospital, Ahmedabad, India

Dr. Alaric Aroojis
Hon. Consultant, Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India

ADVISORY BOARD
Dr. Kishore Mulpuri
Paediatric Orthopaedic Surgeon, BC Children’s Hospital, Vancouver, Canada

Stacey Miller
Lead Physiotherapist, BC Children’s Hospital, Vancouver, Canada

Dr. Abhay Khot
Paediatric Orthopaedic Surgeon, Royal Children’s Hospital, Melbourne, Australia

Dr. Mohan Belthur
Attending Paediatric Orthopaedic Surgeon, Phoenix Children’s Hospital, Phoenix, Arizona, USA

COMMITTEE MEMBERS
Dr. Sakti Prasad Das
Director, SV NIRTAR, Orissa, India

Dr. Anand Varma
Dept. of Physical Medicine & Rehabilitation, Karnataka Institute of Medical Sciences, Hubballi, India

Asha Chitnis
Consultant Paediatric Therapist, Vedanta Programs, Mumbai, India

Madhavi Kelapure
Paediatric Physiotherapist, Deenanath Mangeshkar Hospital, Pune, India

Trupti Nikharge
Occupational Therapist, B.Y.L.Nair Hospital, Mumbai, India

Dr. Meenakshi Murthy Girish
Professor & Head, Paediatrics, AIIMS, Nagpur, India

Dr. Leena Srivastava
Head, Child Development and Guidance Centre, Bharati Vidyapeeth Medical College and Hospital, Pune, India

Dr. Anaita Udwadia-Hegde
Consultant Paediatric Neurologist, Jaslok Hospital and Research Centre, Mumbai, India.
 
Dr. Surekha Rajadhyaksha
Professor and Chief of Paediatric Neurology and Epilepsy, Bharati Vidyapeeth Hospital, Pune, India

Dr. Mahesh Kamate
Professor of Paediatric Neurology, KAHER’s JN Medical College, Belagavi, India

Dr. Sandeep Patwardhan
Professor of Orthopaedics, Paediatric orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, India

Dr. T.S. Gopakumar
Professor of Orthopaedics, MES Medical College, Perinthalmanna, Malappuram, India

Dr. P N Gupta
Professor, Department of Orthopaedics, Govt. Medical College Hospital, Chandigarh, India

Dr. Jayanth Sampath
Consultant Paediatric Orthopaedic Surgeon, Rainbow Children’s Hospital, Bangalore, India

Dr. Binu Kurian
Consultant Paediatric Orthopaedic Surgeon, St. John’s Medical College Hospital, Bangalore, India

Dr. Abhay Gahukamble
Assistant Professor, Dept of Orthopaedic Surgery at Christian Medical College and Hospital, Vellore, India

Dr. Sanjay Wadhwa
Professor, Dept. of PMR, AIIMS, New Delhi, India

Punita V. Solanki
Occupational Therapist, Mumbai, India

Dr. Rekha MittalAdditional Director (Paediatric Neurology), Madhukar Rainbow Children’s Hospital, New Delhi, India

Aijaaz Ashai
Director & HOD, Adams Wylie Physio Rehab Center, Mumbai, India

 
This guideline is for the medical professionals who are involved in the care of children with cerebral palsy (CP).

Children with cerebral palsy are at increased risk for hip displacement. Hip displacement may occur gradually and may not be painful initially. However, many dislocated hips become painful eventually and lead to reduced function and impaired quality of life. [1]

What is hip surveillance?
Hip surveillance is a process of actively monitoring the child for early identification of hip displacement. It is carried out by clinical and radiographic examinations at regular intervals, so that silent hip impairments are identified. When hip impairments are identified early, they can be managed by less aggressive surgical interventions, thus leading to better structural and functional outcomes. Hip surveillance has been found to be effective in several large population-based studies. [2]

Who should be surveilled?
All children and youth diagnosed with CP and those children not yet diagnosed with CP but for whom there is a clinical suspicion of having CP should be enrolled for surveillance. Besides the spastic variety, dystonic, athetoid, ataxic and hypotonic types of CP are included in hip surveillance.

By whom should the child be surveilled?
All trained clinicians working with children with CP can carry out hip surveillance. These include paediatricians, developmental paediatricians, paediatric neurologists, physical therapists, occupational therapists, physical medicine & rehabilitation experts, orthopaedic surgeons, and paediatric orthopaedic surgeons.

How the child should be surveilled?
Each visit for surveillance consists of two components: a clinical examination and a radiographic examination.

The clinical examination includes determining / re-confirming the Gross Motor Function Classification System (GMFCS) level. Inquiring about hip pain that may be present when moving the hip, changing positions, when looking after personal care.

The passive range of abduction is measured for each hip with maximum possible extension at the hips and knees (Figure 1). Attention is given to the presence of pain while moving the hip. Gait observation should identify cases having Winters, Gage & Hicks (WGH) type 4 gait pattern. They form a subset that deserves special attention.

The examiner also looks for pelvic asymmetry and scoliosis (Figure 2).

The radiographic examination consists of taking an antero-posterior (AP) pelvis radiograph in a supine position with standardized positioning. The pelvis is squared whilst positioning. The hips are kept in neutral abduction/adduction (Figure 3). The patellae should face upwards. For children having flexion deformity at the hips, both lower limbs are flexed at the hips till lumbar lordosis is obliterated. This prevents anterior tilting of the pelvis (Figure 4 & 5).

Migration percentage (MP) is measured on an anteroposterior radiograph. [3] It measures the percentage of the ossified femoral head that lies outside the ossified acetabular roof. To measure the MP, a horizontal line is drawn through each triradiate cartilage (solid horizontal line) and a vertical line is drawn perpendicular to it at the lateral margin of the ossified acetabulum (solid vertical line). Two lines are drawn parallel to this solid vertical line at the medial and lateral border of the ossified femoral head (dotted lines). The distance between these two dotted lines is the width of the ossified femoral head (B). The width of the femoral head which is lateral to the solid vertical line (A) is divided by the width of the ossified femoral head (B). Migration percentage = A/B x 100 (Figure 6).


Migration percentage (MP) is measured for each hip separately.

How frequently should the child be surveilled?
Surveillance should preferably start by the of 2 years for children for whom the diagnosis of CP is made, or even at an earlier age when the diagnosis of CP is suspected. Surveillance frequency depends mainly on the GMFCS level, age of the child, and the age at which hip surveillance is started.
For the sake of easy understanding, the CP population is divided into 3 groups.
• GMFCS level I & II
• GMFCS level III
• GMFCS level IV & V

Children with GMFCS level I & II function should have a clinical and radiographic examination at 2, 6, and 10 years. In addition, they should have clinical examination at age 4 years and 8 years. Children with a Group IV hemiplegic gait pattern should have a clinical exam and x-ray every 2 years after the age 10 years till skeletal maturity.

Children with GMFCS level III function require clinical and radiographical examination every year till the age of 8 years. After 8 years, hip surveillance is carried out every 2 years till skeletal maturity if MP remains less than 30% and MP is stable (stability defined as <10% change in MP over a 12-month period). If a child enters hip surveillance after the age of 8 years, the child should have yearly radiograph for first 2 years and thereafter the frequency is reduced to once in 2 years..

Children with GMFCS level IV and V function should have a clinical and radiographic examinations every 6 months for the first two years. If the MP is less than 30% and MP is stable (stability defined as <10% change in MP over a 12-month period), clinical exams and imaging may be reduced to annual visit. Children at GMFCS level IV and V should have a clinical and radiographic examination every year till skeletal maturity. If a child enters hip surveillance after the age of 4 years, the child should have a radiograph every 6 months for the first 2 years and thereafter the frequency is reduced to annual x-rays.

If in doubt about the GMFCS level, consider the child to have a more severe GMFCS level and accordingly follow guidelines for that GMFCS level.

For quick visual reference please see the figure 7.

Time of discharge from hip surveillance

Children at GMFCS levels I & II are discharged at 10 years if the MP is stable and less than 30%. An exception is a child with Winter & Gage hemiplegic type 4 gait, who should be followed up till skeletal maturity.

Children at GMFCS levels III, IV & V are discharged when they attain skeletal maturity, have MP < 30%, and when pelvic obliquity and scoliosis are not progressive on clinical examinations. Closure of the triradiate cartilage on the AP pelvis x-ray is used to indicate skeletal maturity (Figure 8).

Exception: Child having MP > 30% or progressive pelvic obliquity or scoliosis requires continued surveillance.

What should be the further line of action after hip surveillance?
A child is referred to paediatric orthopaedic surgeons, if
• MP value is 30% or more
• If MP is less than 30% but a child has hip abduction less than 30 degrees
• If MP is less than 30% but a child has hip pain during a clinical exam
• If MP is less than 30% but child / family reports pain at hip during activities
All other children continue to undergo hip surveillance till they are discharged from the surveillance program.

Additional information:
Gross Motor Function Classification System (GMFCS)
The GMFCS is a validated classification system used to describe the gross motor function of children with CP. [4] The expanded and revised version of the GMFCS which is available online is used as a reference. It can be downloaded free of charge from the website https://www.canchild.ca/system/tenon/assets/attachments/000/000/058/original/GMFCS-ER_English.pdf

The GMFCS classifies the children and young adults into five levels on the basis of their self-initiated movement with particular emphasis on sitting, walking, and wheeled mobility. The GMFCS has five levels for describing differences in severity of motor abilities. Distinctions between levels are based on functional limitations, the need for hand-held mobility devices or wheeled mobility. For different age groups, separate descriptions are provided. Generally, it takes only a few minutes to assign a GMFCS level.
The GMFCS is relatively stable but in small children it is likely to change. [5] So, it is important that during each visit, GMFCS level is reconfirmed or re-evaluated.

GMFCS levels I & II suggest a child who is ambulatory without handheld mobility aid. Figure 9 & 10 represent typical GMFCS I & II children in the age group of 6 to 12 years.

GMFCS level III suggests a child who is ambulatory with handheld mobility aid. Figure 11 represents typical GMFCS III children in the age group of 6 to 12 years.

GMFCS level IV represents a child who is a marginal ambulator. For walking, they need the help of a caretaker and the mobility aid (Figure 12). Child at GMFCS level V is considered non-ambulatory (Figure 13).

Winters, Gage and Hicks (WGH) type 4 gait
Winters, Gage and Hicks described four types of gait pattern in hemiplegic children with CP. [6] This classification was based on the sagittal plane kinematics of the ankle, knee, hip and pelvis. The Australian CP group added frontal and transverse planes kinematics to this classification. Child with type 4 gait walks with hip flexed, adducted and internally rotated, knee flexed and ankle in equinus. (Figure 14) Type 4 child can be distinguished easily by gait observation. One does not need computerised gait analysis for identifying this gait pattern.

Key points
• Hip Surveillance detects hip displacement early and reduces the need for major surgeries.
• Hip surveillance can be carried out by all medical and allied healthcare professionals involved in the care of children with CP.
• Children with all motor types of CP require hip surveillance.
• Surveillance frequency mainly depends on the GMFCS level and the age of the child.
• Migration percentage is used to quantify the severity of hip displacement on standardised AP pelvis radiographs.
• A child is referred to a paediatric orthopaedic / orthopaedic surgeon if MP value is 30% or more, hip abduction is less than 30 degrees, or if hip pain is reported during clinical examination or while performing certain activities.

References

1. Ramstad K, Terjesen T: Hip pain is more frequent in severe hip displacement: A population-based study of 77 children with cerebral palsy. J Pediatr Orthop B 2016;25: 217-221.
2. Hagglund G, Alriksson-Schmidt A, Lauge-Pedersen H, Robdy-Bousquet E, Wagner P, Westbom L: Prevention of dislocation of the hip in children with cerebral palsy: 20 year results of a population-based prevention programme. Bone Joint J 2014;96-B:1546-1552.
3. Reimers, J. The stability of the hip in children. A radiological study of the results of muscle surgery in cerebral palsy. Acta Orthop Scand 1980; 184: S1-100.
4. Wood E, Rosenbaum P. The gross motor function classification system for cerebral palsy: a study of reliability and stability over time. Dev Med Child Neurol 2000; 42: 292– 96.
5. Palisano RJ, Cameron D, Rosenbaum PL, Walter SD, Russell D. Stability of the gross motor function classification system. Dev Med Child Neurol 2006; 48: 424– 28.
6. Winters T, Gage J, Hicks R. Gait patterns in spastic hemiplegia in children and young adults. J Bone Joint Surg Am 1987; 69(3): 437-441.

How to Cite this Article:  Johari AN, Ganjwala D, Aroojis A | Indian Hip Surveillance Guidelines for Children with Cerebral Palsy | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 02-08 . https://doi.org/10.13107/ijpo.2024.v10i01.171

(Article Text HTML)      (Full Text PDF)

Editorial

Volume 10 | Issue 1 | January-April 2024 | Page: 01 | Jayanth S. Sampath

DOI- https://doi.org/10.13107/ijpo.2024.v10.i01.170

Authors: Jayanth S. Sampath FRCSEd (Tr & Orth) [1]

[1] Department of Orthopaedics, Rainbow Children’s Hospital, Bangalore, Karnataka, India.

Address of Correspondence

Dr. Jayanth S. Sampath,
Rainbow Children’s Hospital, Bangalore, Karnataka, India.
E-mail: editor.posi.ijpo@gmail.com

Editorial

The current issue of IJPO is marked by several improvements that have been long overdue. The most important was the constitution of an Editorial Board of ten POSI members, responsible for day-to-day journal affairs. As editor, it is a pleasure to see more hands on deck. Our lead time for the publication of new issues is currently 3 months. The profiles of the new Editorial Committee members are available on the IJPO website. Our social media presence has improved through regular updates on Instagram and Facebook. We thank Dr Easwar T Ramani, POSI Webmaster for the efforts to improve the visibility and accessibility of the POSI journal. We have renewed our efforts to accredit the journal with reputed international indexing bodies.
This issue is dedicated to various aspects of cerebral palsy, an important problem in our practice. The lead article is the Indian hip surveillance guidelines for children with cerebral palsy. The result of over 2 years’ effort by POSI, led by senior members Dr Ashok Johari, Dr Dhiren Ganjwala and Dr Alaric Aroojis, the guidelines provide practical advice to the clinician for the early diagnosis of hip displacement in cerebral palsy. We have followed this with a mini-symposium on lever arm dysfunction. Starting with a basic refresher on biomechanics, subsequent articles provide a detailed account of how lever arm dysfunction affects normal function in a child with cerebral palsy, the importance of clinical examination for accurate diagnosis, the role of various investigations including gait analysis and the management of lever arm dysfunction at different levels from the hip to the foot. The symposium finishes with a flourish, a comprehensive guide to the management of upper limb problems in CP. I am sure every article in this issue will add to your understanding of cerebral palsy. Please do share the articles with your trainees and fellows. IJPO issues are easily downloadable free of charge and in full-text format from our website www.ijpoonline.com
We invite your suggestions and comments for any improvements to the journal. Kindly write to us editor@ijpo.com
It is my pleasure to acknowledge the contributions of authors, reviewers, editors, and the backend team who have been instrumental in bringing out this issue. The cover page artwork acknowledges the importance of hip surveillance in cerebral palsy.

Sincerely

Dr Jayanth S Sampath
Editor,

International Journal of Paediatric Orthopaedics

How to Cite this Article:  Sampat JS | Editorial | International Journal of Paediatric Orthopaedics | January-April 2024; 10(1): 01. https://doi.org/10.13107/ijpo.2024.v10.i01.170

(Article Text HTML)      (Full Text PDF)

Musculoskeletal Tuberculosis in Children

Volume 9 | Issue 3 | September-December 2023 | Page: 28-34 | Santoshini Nemuri, Mandar Agashe

DOI- https://doi.org/10.13107/ijpo.2023.v09.i03.160

Authors: Santoshini Nemuri MS Ortho [1], Mandar Agashe MS Ortho [1]

[1] Department of Orthopaedics, Agashe Paediatric SuperSpeciality Clinic, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Mandar Agashe
Chief consultant, Department of Orthopaedics, Agashe Paediatric SuperSpeciality Clinic, Mumbai, Maharashtra, India.
E-mail: mandarortho@gmail.com

Abstract

Paediatric musculoskeletal tuberculosis is very important to understand as it shares similar clinical, radiological and hematologocal findings with other infectious and non-infectitious conditions . It has become a major health hazard because of its association with immunocompromised states like HIV, Diabetes mellitus and chronic renal and liver diseases. Diagnosis is delayed in paediatric musculoskeletal tuberculosis because of lack of awareness of disease , non-specific clinical and laboratory findings. TB culture is considered as the gold standard in diagnosing tuberculosis and also, detecting drug sensitivity. Because of its potential for multi-drug resistance, there is a dilemma regarding drug of choice and duration of treatment. Surgery is reserved for obtaining samples to establish diagnosis, debridement and sequestrectomy in recalcitrant infections and correction of deformities to restore joint function. This review article briefs about classical clinical presentation, atypical and multifocal musculoskeletal tuberculosis, radiological and laboratory investigations and management of paediatric musculoskeletal tuberculosis.
Musculoskeletal tuberculosis should be kept as a differential diagnosis when managing a case of musculoskeletal infection in children because of its non- specific presentation. Imaging such as MRI and advanced microbiological analysis aids in arriving correct diagnosis. Multidrug chemotherapy is mainstay of treatment. Radical curettage and, antituberculous chemotherapy followed by a period of immobilisation and rehabilitation will give excellent results
Keywords: Paediatric musculoskeletal tuberculosis, multifocal tuberculosis, Tubercular osteomyelitis

References

1. Agarwal A. Paediatric osteoarticular tuberculosis: A review. Vol. 11, Journal of Clinical Orthopaedics and Trauma. Elsevier B.V.; 2020. p. 202–7.
2. Gupta S, Parihar A, Singh S, Agarwal A, Agarwal S. Pediatric Osteoarticular Tuberculosis as a Diagnostic Dilemma and a Review of Literature. Cureus. 2022 Mar 11;14(3):e23053.doi:10.7759/cureus.23053. PMID: 35308187; PMCID: PMC8926030.
3. Agashe VM, Johari AN, Shah M, Anjum R, Romano C, Drago L, et al. Diagnosis of osteoarticular tuberculosis: Perceptions, protocols, practices, and priorities in the endemic and non-endemic areas of the world—a waiot view. Vol. 8, Microorganisms. MDPI AG; 2020. p. 1–19.
4. Çay U, Alabaz D, Gündeşlioglu OO, Mirioglu A, Pehlivan UA. Skeletal Tuberculosis in Pediatric Population for 15 Years; Twenty Cases from Southern Turkey. Niger J Clin Pract. 2023 Nov 1;26(11):1602–9.
5. Shah I, Dani S, Shetty NS, Mehta R, Nene A. Profile of osteoarticular tuberculosis in children. Indian Journal of Tuberculosis. 2020 Jan 1;67(1):43–5.
6. Kritsaneepaiboon S, Andres MM, Tatco VR, Lim CCQ, Concepcion NDP. Extrapulmonary involvement in pediatric tuberculosis. Vol. 47, Pediatric Radiology. Springer Verlag; 2017. p. 1249–59.
7. Garg RK, Somvanshi DS. Spinal tuberculosis: A review. Vol. 34, Journal of Spinal Cord Medicine. 2011. p. 440–54.
8. Dawani A, Gupta AK, Jana M. Imaging in Pediatric Extra-Pulmonary Tuberculosis. Vol. 86, Indian Journal of Pediatrics. Springer; 2019. p. 459–67.
9. Saraf SK, Tuli SM. Tuberculosis of hip A current concept review. In: Indian Journal of Orthopaedics. Medknow Publications; 2015. p. 1–9.
10. Kant KS, Agarwal A, Suri T, Gupta N, Verma I, Shaharyar A. Tuberculosis of knee region in children: A series of eight cases. Trop Doct. 2014;44(1):29–32.
11. Prakash J, Mehtani A. Hand and wrist tuberculosis in paediatric patients – our experience in 44 patients. Journal of Pediatric Orthopaedics Part B. 2017;26(3):250–60.
12. Shrestha OP, Sitoula P, Hosalkar HS, Banskota AK, Spiegel DA. Bone and Joint Tuberculosis. University of Pennsylvania Orthopaedic Journal. 2010;20:23–28.
13. Mahomed N, Kilborn T, Smit EJ, Chu WCW, Young CYM, Koranteng N, et al. Tuberculosis revisted: classic imaging findings in childhood. Pediatr Radiol. 2023 Aug 1;53(9):1799–828.
14. Dhillon MS, Nagi ON. Tuberculosis of the foot and ankle. Clin Orthop Relat Res. 2002 May;(398):107-13. doi: 10.1097/00003086-200205000- 00015. PMID: 11964638.
15. Mittal R, Gupta V, Rastogi S. Tuberculosis of the foot. Journal of Bone and Joint Surgery – Series B. 1999 Nov;81(6):997–1000.
16. Erol B, Topkar MO, Basar H, Caliskan E, Okay E. Solitary cystic tuberculosis of the distal femur and proximal tibia in children. Journal of Pediatric Orthopaedics Part B. 2015 Jun 19;24(4):315–20.
17. Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. European Spine Journal. 2013 Jun;22(SUPPL.4).
18. Aouraghe H, Benchekroun S, Mahraoui C, Elhafidi N. Multifocal tuberculosis in children: A case of spinal tuberculosis. Int J Mycobacteriol. 2023 Apr 1;12(2):204–6.
19. Syed Zaki A, Bhongade S. Multifocal Skeletal Tuberculosis. Sultan Qaboos Univ Med J. 2012 Nov; 12(4):531-533. doi: 10.12816/0003184 PMID: 23275855
20. Prasad S, Wakhlu A, Misra R, Aggarwal A, Lawrence A, Gupta R, et al. Features of extra-spinal musculoskeletal tuberculosis: A retrospective study from an North Indian Tertiary Care Institute. Indian J Rheumatol. 2017 Sep 1;12(3):146–51.
21. Santos FCF, do Nascimento ALA, Lira LA de S, Lima JF da C, Montenegro R de A, Montenegro LML, et al. Bone tuberculosis: A case report on child. Rev Soc Bras Med Trop. 2013 Mar;46(2):249–51.
22. Paediatric TB Management Guideline 2022 Developed By The National Tuberculosis Elimination Programme Draft.
23. Papavasiliou VA, Petropoulos A V. Bone and joint tuberculosis in childhood. Acta Orthop. 1981;52(1):1–4.

How to Cite this Article:  Nemuri S, Agashe M | Musculoskeletal Tuberculosis in Children | International Journal of Paediatric Orthopaedics | September-December 2023; 9(3): 28-34.| https://doi.org/10.13107/ijpo.2023.v09.i03.160

(Article Text HTML)      (Full Text PDF)

Introduction to Paediatric Musculoskeletal Infections -A Review Article

Volume 9 | Issue 3 | September-December 2023 | Page: 02-08 | Suresh Chand, Bhushan Sagade, Udit Agarwal, Nishant Jagdale, Smit Rajput

DOI- https://doi.org/10.13107/ijpo.2023.v09.i03.156

Authors: Suresh Chand MS Ortho [1], Bhushan Sagade MS Ortho [2], Udit Agarwal MS Ortho [1], Nishant Jagdale DNB Ortho [2], Smit Rajput MD [3]

[1] Department of Paediatric Orthopaedics, King George’s Medical University, Lucknow, India.
[2] Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India.
[3] Department of Internal Medicine, East Carolina University and ECU Health Medical Center, Greenville, North Carolina, USA.

Address of Correspondence

Dr. Nishant Jagdale,
Fellow in Paediatric Orthopaedics, Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, India.
E-mail: nishant93ortho@gmail.com

Abstract

Paediatric Musculoskeletal Infections include osteomyelitis, septic arthritis, pyomyositis, surgical site infections, tuberculosis, and fungal infections with some infrequent manifestations like purpura fulminans, necrotizing fasciitis, soft tissue abscess and septic bursitis. Osteomyelitis and septic arthritis are two common Musculoskeletal Infections. Vertebral tuberculosis is the most common form of skeletal tuberculosis. Staphylococcus aureus is the most frequent cause of Paediatric Musculoskeletal Infections, followed by streptococci. They can be classified on the basis of pathogen, anatomical site, spread, severity etc. Pathogenic organisms may reach a bone or soft tissue location by either of the three means: (a) direct inoculation from penetrating trauma or surgery, (b) contiguous spread from an adjacent soft tissue infection, (c) hematogenous spread from a distant focus of infection with hematogenous spread being the most common cause. It is a complex interplay between the host and the pathogen which plays major role in these infections. Peculiar anatomy of the metaphysis with classical hairpin loop system of the end arterioles and venous sinusoids aids in pathogen entry into the host. After successful invasion of the host, bacteria escapes the host immunity through various mechanisms, complement component pathway being the most common way. Also the various toxins and proteins secreted by bacteria plays an important role in adhesion, invasion, escape form immunity and spread of the infection. This review article helps in understanding this complex interplay between host and pathogen which ultimately results in infection

Keywords: Paediatric Musculoskeletal infections, Osteomyelitis, Pyomyositis, Septic Arthritis.

References

1. Trapani S. Musculoskeletal infections in childhood: Recognize early to quickly and properly treat. Glob Pediatr. 2024 Mar 1; 7:100108. doi: 10.1016/j.gpeds.2023.100108
2. Hunter, Sarah & Chan, Heidi & Crawford, et al: (2023). Appropriate Antibiotic Duration in Pediatric Bone and Joint Infection: A Systematic Review. Journal of the Pediatric Orthopaedic Society of North America. 5. doi: 10.55275/JPOSNA-2023-736.
3. Hannon M, Lyons T. Pediatric musculoskeletal infections. Curr Opin Pediatr. 2023 Jun 1;35(3):309–15.
4. Radcliffe G. (iii) Osteomyelitis – a historical and basic sciences review. Orthop Trauma. 2015 Aug 1;29(4):243–52.
5. Klenerman L. A history of osteomyelitis from the Journal of Bone and Joint Surgery: 1948 TO 2006. J Bone Joint Surg Br. 2007 May;89(5):667-70. doi: 10.1302/0301-620X.89B5.19170. PMID: 17540756.
6. Nelaton A.: Elements de pathologie chirurgical1844.Germer BailliereParispp. 595-597
7. Schmitt SK. Osteomyelitis. Infect Dis Clin North Am. 2017 Jun;31(2):325-338. doi: 10.1016/j.idc.2017.01.010. PMID: 28483044.
8. Ahmad S, Barik S, Mishra D, et al: Epidemiology of paediatric pyogenic musculoskeletal infections in a developing country. Sudan J Paediatr. 2022;22(1):54-60. doi: 10.24911/SJP.106-1616783478. PMID: 35958066.
9. Jaña FC NETO, Ortega CS, Goiano EO. Epidemiological study of osteoarticular infections in children. Acta Ortop Bras. 2018 May-Jun;26(3):201-205. doi: 10.1590/1413-785220182603145650. PMID: 30038548.
10. Shah I, Dani S, Shetty NS, et al: Profile of osteoarticular tuberculosis in children. Indian J Tuberc. 2020 Jan;67(1):43-45. doi: 10.1016/j.ijtb.2019.08.014. Epub 2019 Aug 22. PMID: 32192616.
11. Jain AK, Jaggi KR, Bhayana H, et al: Drug-resistant Spinal Tuberculosis. Indian J Orthop. 2018 Mar-Apr;52(2):100-107. doi: 10.4103/ortho.IJOrtho_306_17. PMID: 29576636.
12. Mohamad M, Steiger C, Spyropoulou V, et al: Clinical, biological and bacteriological characteristics of osteoarticular infections in infants less than 12 months of age. Future Microbiol. 2021 Apr;16:389-397. doi: 10.2217/fmb-2020-0070. Epub 2021 Apr 13. PMID: 33847142.
13. Shenoy B, Singhal T, Yewale V, et al: Indian Academy of Pediatrics Consensus Statement on Diagnosis and Management of Bone and Joint Infections in Children. INDIAN Pediatr. 2024;61.
14. Agarwal A, Aggarwal AN. Bone and Joint Infections in Children: Septic Arthritis. Indian J Pediatr. 2016 Aug;83(8):825-33. doi: 10.1007/s12098-015-1816-1. Epub 2015 Jul 21. PMID: 26189923.
15. Saavedra-Lozano J, Falup-Pecurariu O, Faust SN, et al: Bone and Joint Infections. Pediatr Infect Dis J. 2017 Aug;36(8):788-799. doi: 10.1097/INF.0000000000001635. PMID: 28708801.
16. Le Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatr Child Health. 2018 Aug;23(5):336-343. doi: 10.1093/pch/pxy049. Epub 2018 Jul 18. PMID: 30653632; PMCID: PMC6054183.
17. Morrey BF, Peterson HA. Hematogenous pyogenic osteomyelitis in children. Orthop Clin North Am. 1975 Oct;6(4):935-51. PMID: 1178165.
18. Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. Am Fam Physician. 2011 Nov 1;84(9):1027-33. PMID: 22046943.
19. Roderick MR, Shah R, Rogers V, et al: Chronic recurrent multifocal osteomyelitis (CRMO) – advancing the diagnosis. Pediatr Rheumatol Online J. 2016 Aug 30;14(1):47. doi: 10.1186/s12969-016-0109-1. PMID: 27576444.
20. Vij N, Ranade AS, Kang P, et al: Primary Bacterial Pyomyositis in Children: A Systematic Review. J Pediatr Orthop. 2021 Oct 1;41(9):e849-e854. doi: 10.1097/BPO.0000000000001944. PMID: 34411048.
21. Taksande A, Vilhekar K, Gupta S. Primary pyomyositis in a child. Int J Infect Dis. 2009 Jul;13(4):e149-51. doi: 10.1016/j.ijid.2008.08.013. Epub 2008 Nov 13. PMID: 19013093.
22. Mignemi ME, Benvenuti MA, An TJ, et al: A Novel Classification System Based on Dissemination of Musculoskeletal Infection is Predictive of Hospital Outcomes. J Pediatr Orthop. 2018 May/Jun;38(5):279-286. doi: 10.1097/BPO.0000000000000811. PMID: 27299780.
23. Hotchen AJ, McNally MA, Sendi P. The Classification of Long Bone Osteomyelitis: A Systemic Review of the Literature. J Bone Jt Infect. 2017 Sep 12;2(4):167-174. doi: 10.7150/jbji.21050. PMID: 29119075.
24. Mader JT, Shirtliff M, Calhoun JH. Staging and staging application in osteomyelitis. Clin Infect Dis. 1997 Dec;25(6):1303-9. doi: 10.1086/516149. PMID: 9431368.
25. Stevenson AJ, Jones HW, Chokotho LC, et al: The Beit CURE Classification of Childhood Chronic Haematogenous Osteomyelitis–a guide to treatment. J Orthop Surg Res. 2015 Sep 17;10:144. doi: 10.1186/s13018-015-0282-9. PMID: 26384208
26. McHenry MC, Alfidi RJ, Wilde AH, Hawk WA. Hematogenous osteomyelitis; a changing disease. Cleve Clin Q. 1975 Spring;42(1):125-53. doi: 10.3949/ccjm.42.1.125. PMID: 1095249.
27. Copley L.A.B., Herring J.A., (2014) Infections of the Musculoskeletal System. In J.A. Herring (Ed). Tachdjian’s Paediatric Orthopaedics (5th ed, Vol-2, pp:1024 -1076e10) Elseweir, Saunders
28. Ciampolini J, Harding KG. Pathophysiology of chronic bacterial osteomyelitis. Why do antibiotics fail so often? Postgrad Med J. 2000;76(898):479–83.
29. Moore-Lotridge, S.N., Schoenecker, J.G. (2022). Pathology of Musculoskeletal Infections. In: Belthur, M.V., Ranade, A.S., Herman, M.J., Fernandes, J.A. (eds) Pediatric Musculoskeletal Infections. Springer, Cham. https://doi.org/10.1007/978-3-030-95794-0_3
30. Scheman L.R., Janota M., & Lewin P. The production of experimental osteomyelitis: Preliminary report. JAMA, Nov 1 1941, 117:18, 1525-1529.
31. Hobo T: Zur Pathogenese der akuten hematogenen Osteomyelitis. Acta Sch Me Kioto 1921;4:1.
32. Trueta J. The three types of acute hematogenous osteomyelitis: A clinical and vascular study. J Bone Joint Surg. 1959, 41-B:4, 671-680.
33. Herring J.A., (2002) Bone and Joint Infections. Tachdjian’s Paediatric Orthopaedics (3rd ed, Vol-3, pp:1841 -1894) W.B. Saunders.
34. Ogden JA, Lister G: The pathology of Neonatal osteomyelitis. Pediatrics 1975;56-A:941
35. Whalen JL,Fitzgerald RH Jr, Morrissy RT: A histological study of acute hematogenous osteomyelitis following physeal injury in rabbits. J Bone Joint Surg 1988;70-A:1383
36. Morrissy RT, Haynes DW: Acute Hematogenous Osteomyelitis: A model with trauma as an etiology. J Pediatr Orthop 1989;9:447.
37. Manche E, Rombouts-Godin V, Rombouts JJ: {Acute Hematogenous Osteomyelitis due to ordinary germs in children with closed injuries: a study of 44 cases}.Acta Orthop Belg 1991;57:91
38. Hofstee MI, Muthukrishnan G, Atkins GJ, Riool M, Thompson K, Morgenstern M, Stoddart MJ, Richards RG, Zaat SAJ, Moriarty TF. Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods. Am J Pathol. 2020 Jun;190(6):1151-1163. doi: 10.1016/j.ajpath.2020.02.007. Epub 2020 Mar 16. PMID: 32194053
39. Rosenfeld S, Bernstein DT, Daram S, Dawson J, Zhang W. Predicting the presence of adjacent infections in septic arthritis in children. J Pediatr Orthop. 2016;36(1):70–4.
40. R. Cunningham, A. Cockayne, H. Humphreys. Clinical and molecular aspects of the pathogenesis of Staphylococcus aureus bone and joint infections. J. Med Microbiol. – Vol. 44 (1996), 157-164
41. Flemming H.C., Wingender J., Szewzyk U., Steinberg P., Rice S.A., Kjelleberg S. Biofilms: an emergent form of bacterial life. Nat Rev Microbiol. 2016; 14: 563-575
42. Garzoni C., Kelley W.L. Staphylococcus aureus: new evidence for intracellular persistence. Trends Microbiol. 2009; 17: 59-65
43. Martinez-Aguilar G, Avalos-Mishaan A, Hulten K, et al: Community-acquired, methicillin-resistant and methicillin susceptible Staphylococcus aureus musculoskeletal infections in children, Pediatr Infect Dis J 23:701, 2004
44. Yang D., Wijenayaka A.R., Solomon L.B., Pederson S.M., Findlay D.M., Kidd S.P., Atkins G.J. Novel insights into Staphylococcus aureus deep bone infections: the involvement of osteocytes. mBio. 2018; 9: e00415-e00418
45. Kwiecinski J., Na M., Jarneborn A., Jacobsson G., Peetermans M., Verhamme P., Jin T. Tissue plasminogen activator coating on implant surfaces reduces Staphylococcus aureus biofilm formation. Appl Environ Microbiol. 2016; 82: 394-401
46. Cicuéndez M, Doadrio JC, Hernández A, Portolés MT, Izquierdo-Barba I, Vallet-Regí M. Multifunctional pH sensitive 3D scaffolds for treatment and prevention of bone infection. Acta Biomater. 2018 Jan;65:450-461. doi: 10.1016/j.actbio.2017.11.009. Epub 2017 Nov 8. PMID: 29127064.

How to Cite this Article:  Chand S, Sagade B, Agarwa U, Jagdale N, Rajput S | Introduction to Paediatric Musculoskeletal Infections- A Review Article | International Journal of Paediatric Orthopaedics | September- December 2023; 9(3): 02-08.| https://doi.org/10.13107/ijpo.2023.v09.i03.156

(Article Text HTML)      (Full Text PDF)

Paediatric Musculoskeletal Infection– A Review

Volume 9 | Issue 3 | September-December 2023 | Page: 09-15 | Ashish Upadhyay, Varun Garg, Anil Agarwal, Kishmita Sachdeva, Ankitha KS, Jainam Salot

DOI- https://doi.org/10.13107/ijpo.2023.v09.i03.157

Authors: Ashish Upadhyay MS Ortho [1], Varun Garg MS Ortho [1], Anil Agarwal MS Ortho [1], Kishmita Sachdeva MS Ortho [1], Ankitha KS MS Ortho [1], Jainam Salot MS Ortho [1]

[1] Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, Delhi, India.

Address of Correspondence

Dr. Anil Agarwal,
Department of Orthopedics, Chacha Nehru Bal Chikitsalya, New Delhi, India
E-mail: anilrachna@gmail.com

Abstract

Acute paediatric musculoskeletal infections (MSKI) include septic arthritis, acute osteomyelitis and pyomyositis. Prompt treatment is necessary to prevent long term disabilities in children. Explore medical topics like blood flow, natural remedies, and pill effects. Discover how pharmaceutical companies innovate treatments, impacting health. Learn about blood pressure influences and timing medication efficacy. In this review, we discuss the etiopathogenesis, clinical features and management of MSKI. We also discuss about the role of new markers of inflammation and MRI in MSKI. The clinical presentation is variable, depending upon the age group, and difficult to distinguish from other pathologies. Diagnosis is therefore based on not only clinical presentation but also laboratory and radiological investigations. The mainstay of treatment includes antibiotic therapy, and surgical decompression.

Keywords: Septic arthritis, Musculoskeletal infections, Osteomyelitis, Pyomyositis

References

1. Saavedra-Lozano J, Falup-Pecurariu O, Faust SN, Girschick H, Hartwig N, Kaplan S, et al. Bone and joint infections. Pediatr Infect Dis J. 2017;36:788–99.
2. Agarwal A, Aggarwal AN. Bone and joint infections in children: acute hematogenous osteomyelitis. Indian J Pediatr. 2016;83:817–24.
3. Calvo C, Núñez E, Camacho M, Clemente D, Fernández-Cooke E, Alcobendas R, et al. Epidemiology and management of acute, uncomplicated septic arthritis and osteomyelitis: Spanish multicenter study. Pediatr Infect Dis J. 2016;35:1288–93.
4. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br. 2012;94:584–95.
5. Samara E, Spyropoulou V, Tabard-Fougère A, Merlini L, Valaikaite R, Dhouib A, et al. Kingella Kingae and osteoarticular infections. Pediatrics. 2019;144:e20191509.
6. Kang SN, Sanghera T, Mangwani J, Paterson JMH, Ramachandran M. The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br. 2009;91:1127–33.
7. Gigante A, Coppa V, Marinelli M, Giampaolini N, Falcioni D, Specchia N. Acute osteomyelitis and septic arthritis in children: a systematic review of systematic reviews. Eur Rev Med Pharmacol Sci. 2019 ;23(2 Suppl):145–58.
8. Comegna L, Guidone PI, Prezioso G, Franchini S, Petrosino MI, Di Filippo P, et al. Pyomyositis is not only a tropical pathology: a case series. J Med Case Reports. 2016;10:372.
9. Momodu II, Savaliya V. Septic Arthritis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 May 1]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK538176/
10. Stephen RF, Benson MKD, Nade S. Misconceptions about childhood acute osteomyelitis. J Child Orthop. 2012;6:353–6.
11. Morrissy RT, Haynes DW. Acute hematogenous osteomyelitis: a model with trauma as an etiology. J Pediatr Orthop. 1989;9:447–56.
12. Rosenfeld S, Bernstein DT, Daram S, Dawson J, Zhang W. Predicting the presence of adjacent infections in septic arthritis in children. J Pediatr Orthop. 2016;36:70–4.
13. Benvenuti M, An T, Amaro E, Lovejoy S, Mencio G, Martus J, et al. Double-edged sword: musculoskeletal infection provoked acute phase response in children. Orthop Clin North Am. 2017;48:181–97.
14. Li Y, Zhou Q, Liu Y, Chen W, Li J, Yuan Z, et al. Delayed treatment of septic arthritis in the neonate: A review of 52 cases. Medicine (Baltimore). 2016;95:e5682.
15. Deshpande SS, Taral N, Modi N, Singrakhia M. Changing epidemiology of neonatal septic arthritis. J Orthop Surg Hong Kong. 2004;12:10–3.
16. Narang A, Mukhopadhyay K, Kumar P, Bhakoo ON. Bone and joint infection in neonates. Indian J Pediatr. 1998;65:461–4.
17. Moore-Lotridge SN, Gibson BH, Duvernay MT, Martus JE, Thomsen IP, Schoenecker JG. Pediatric musculoskeletal infection: an update through the four pillars of clinical care and immunothrombotic similarities with COVID-19. J Pediatr Orthop Soc N Am [Internet]. 2020 [cited 2024 May 1];2(2). Available from: https://www.jposna.org/index.php/jposna/article/view/124
18. Mitchell PD, Abraham A, Carpenter C, Henman PD, Mavrotas J, McCaul J, et al. Consensus guidelines on the management of musculoskeletal infection affecting children in the UK. Bone Jt J. 2023;105-B:815–20.
19. Moore-Lotridge SN, Daryoush JR, Wollenman CC, Gibian JT, Johnson SR, Thomsen IP, et al. CRP predicts the need to escalate care after initial debridement for musculoskeletal infection. J Pediatr Orthop. 2024;44:188–96.
20. Benvenuti MA, An TJ, Mignemi ME, Martus JE, Mencio GA, Lovejoy SA, et al. A clinical prediction algorithm to stratify pediatric musculoskeletal infection by severity. J Pediatr Orthop. 2019;39:153–7.
21. Sox HC, Liang MH. The erythrocyte sedimentation rate. Guidelines for rational use. Ann Intern Med. 1986;104:515–23.
22. Böttiger LE, Svedberg CA. Normal erythrocyte sedimentation rate and age. Br Med J. 1967;2(5544):85–7.
23. Wirtz DC, Heller KD, Miltner O, Zilkens KW, Wolff JM. Interleukin-6: a potential inflammatory marker after total joint replacement. Int Orthop. 2000;24:194–6.
24. Whicher J, Bienvenu J, Monneret G. Procalcitonin as an acute phase marker. Ann Clin Biochem. 2001;38:483–93.
25. Oppert M, Reinicke A, Müller C, Barckow D, Frei U, Eckardt KU. Elevations in procalcitonin but not C-reactive protein are associated with pneumonia after cardiopulmonary resuscitation. Resuscitation. 2002;53:167–70.
26. Li H, Luo YF, Blackwell TS, Xie CM. Meta-analysis and systematic review of procalcitonin-guided therapy in respiratory tract infections. Antimicrob Agents Chemother. 2011;55:5900.
27. Lowsby R, Gomes C, Jarman I, Lisboa P, Nee PA, Vardhan M, et al. Neutrophil to lymphocyte count ratio as an early indicator of blood stream infection in the emergency department. Emerg Med J. 2015;32:531–4.
28. Gafter-Gvili A, Mansur N, Bivas A, Zemer-Wassercug N, Bishara J, Leibovici L, et al. Thrombocytopenia in Staphylococcus aureus bacteremia: risk factors and prognostic importance. Mayo Clin Proc. 2011;86:389–96.
29. Malpani R, Haynes MS, Clark MG, Galivanche AR, Bovonratwet P, Grauer JN. Abnormally high, as well as low, preoperative platelet counts correlate with adverse outcomes and readmissions after elective total knee arthroplasty. J Arthroplasty. 2019;34:1670–6.
30. Higgins E, Suh GA, Tande AJ. Enhancing diagnostics in orthopedic infections. J Clin Microbiol. 2022;60:e0219621.
31. Li SF, Cassidy C, Chang C, Gharib S, Torres J. Diagnostic utility of laboratory tests in septic arthritis. Emerg Med J. 2007;24:75–7.
32. Kelly EG, Cashman JP. Leucocyte esterase in the rapid diagnosis of paediatric septic arthritis. Med Hypotheses. 2013;80:191–3.
33. Deshpande PG, Wagle SU, Mehta SD, Bharucha BA, Irani SF. Neonatal osteomyelitis and septic arthritis. Indian Pediatr. 1990;27:453–7.
34. Kothari NA, Pelchovitz DJ, Meyer JS. Imaging of musculoskeletal infections. Radiol Clin North Am. 2001;39:653–71.
35. Volberg FM, Sumner TE, Abramson JS, Winchester PH. Unreliability of radiographic diagnosis of septic hip in children. Pediatrics. 1984;74:118–20.
36. Chau CLF, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol. 2005;60:149–59.
37. Shenoy B, Singhal T, Yewale V, Choudhury J, Kumar A P, Agashe MV, et al. Indian Academy of Pediatrics consensus statement on diagnosis and management of bone and joint infections in children. Indian Pediatr. 2024;61:209–18.
38. Castellazzi L, Mantero M, Esposito S. Update on the management of pediatric acute osteomyelitis and septic arthritis. Int J Mol Sci. 2016;17:855.
39. Bhaskar AR, Johari AN. Musculoskeletal infections in the neonate. In: Belthur MV, Ranade AS, Herman MJ, Fernandes JA (eds), Pediatric Musculoskeletal Infections. Springer, Cham. 2022.
40. Swarup I, Meza BC, Weltsch D, Jina AA, Lawrence JT, Baldwin KD. Septic arthritis of the knee in children: a critical analysis review. JBJS Rev. 2020;8:e0069.
41. Peters W, Irving J, Letts M. Long-term effects of neonatal bone and joint infection on adjacent growth plates. J Pediatr Orthop. 1992;12:806–10.
42. Kaye JJ, Winchester PH, Freiberger RH. Neonatal septic “dislocation” of the hip: true dislocation or pathological epiphyseal separation? Radiology. 1975 ;114:671–4.
43. Zhang Z, Li H, Li H, et al. Clinical experience of debridement combined with resorbable bone graft substitute mixed with antibiotic in the treatment for infants with osteomyelitis. J Orthop Surg Res. 2018;13:218.

How to Cite this Article:  Upadhyay A, Garg V, Agarwal A, Sachdeva K, Ankitha KS, Salot J. | Paediatric Musculoskeletal Infection– A Review | International Journal of Paediatric Orthopaedics | September-December 2023; 9(3): 09-15. | https://doi.org/10.13107/ijpo.2023.v09.i03.157

(Article Text HTML)      (Full Text PDF)

Mimics of Paediatric Musculoskeletal Infections and their Management

Volume 9 | Issue 3 | September-December 2023 | Page: 16-21 | Vivek Singh, Cury Sharma, Aditya K S, Danish Vayoli, Sitanshu Barik 

DOI- https://doi.org/10.13107/ijpo.2023.v09.i03.158

Authors: Vivek Singh MS Ortho [1], Cury Sharma MS Ortho [1], Aditya K S MS Ortho [1], Danish Vayoli MS Ortho [1], Sitanshu Barik MS Ortho [2]

[1] Department of Orthopedics, Paediatric Orthopaedic Unit, AIIMS, Rishikesh, Uttarakhand, India,
[2]  Department of Orthopedics, Paediatric Orthopaedic Unit, AIIMS, Nagpur, Maharashtra, India.

Address of Correspondence

Dr. Vivek Singh,
Additional Professor, In-charge Paediatric Orthopaedics, Shoulder & Hand Surgery Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
E-mail: singhvr27@gmail.com

Abstract

Musculoskeletal infections in pediatric and adolescent populations pose challenges due to heightened pathogen virulence and emerging antimicrobial resistance. Prompt diagnosis is hindered by conditions mimicking these infections, necessitating multidisciplinary approaches. Recent advancements in diagnostics facilitate accurate differentiation. Common mimickers include cellulitis, neoplasms, hematological disorders, inflammatory conditions and stress fractures. Overlapping symptoms demand thorough history-taking and clinical assessment. Laboratory investigations, including CRP and procalcitonin, aid diagnosis, alongside imaging modalities like MRI. Management involves collaborative efforts, emphasizing early recognition, antibiotic therapy, and surgical intervention as needed. Adherence to guidelines and vigilant monitoring optimize outcomes and mitigate risks. This article describes the common mimickers of MSK infection in children and the approach to reaching a correct diagnosis by thorough history taking, clinical examination, relevant laboratory investigations, and appropriate radiological investigations.

Keywords: Infection mimickers, Pediatric infections, MSKI,  Blood markers, Multidisciplinary approach

References

1. Kasalak Ö, Overbosch J, Adams HJ et al . Diagnostic value of MRI signs in differentiating Ewing sarcoma from osteomyelitis. Acta Radiol. 2019 Feb;60(2):204-212.
2. Arkader A, Brusalis C, Warner WC, et al. Update in Pediatric Musculoskeletal Infections: When It Is, When It Isn’t, and What to Do. J Am Acad Orthop Surg 2016; 24: e112-121.
3. Forgie SE, Robinson JL. Pediatric malignancies presenting as a possible infectious disease. BMC Infect Dis 2007; 7: 44.
4. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81: 1662–1670
5. Yeo A, Ramachandran M. Acute hematogenous osteomyelitis in children. BMJ 2014; 348: g66.
6. Nijsten MW, Olinga P, The TH,et al. Procalcitonin behaves as a fast responding acute phase protein in vivo and in vitro. Crit Care Med. 2000 Feb;28(2):458-61.
7. Naess A, Nilssen SS, Mo R, Eide GE, Sjursen H. Role of neutrophil to lymphocyte and monocyte to lymphocyte ratios in the diagnosis of bacterial infection in patients with fever. Infection. 2017 Jun;45(3
8. Wagh Y, Reddy R, Gundavda M, et al. Tuberculosis (T.B.) masquerading as tumor. An 8-year study on 25 cases of long bone tuberculosis presenting as tumors. SICOT-J 2020; 6: 14.
9. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999; 81: 1662–1670.
10. Henninger B, Glodny B, Rudisch A, Trieb T, Loizides A, Putzer D, Judmaier W, Schocke MF. Ewing sarcoma versus osteomyelitis: differential diagnosis with magnetic resonance imaging. Skeletal Radiol. 2013 Aug;42(8):1097-104.
11. Sykes MC, Ahluwalia AK, Hay D, Dalrymple J, Firth GB. Acute musculoskeletal infection in children: assessment and management. Br J Hosp Med (Lond). 2023 Jun 2;84(6):1-6.
12. Castellazzi L, Mantero M, Esposito S. Update on the Management of Pediatric Acute Osteomyelitis and Septic Arthritis. Int J Mol Sci. 2016 Jun 1;17(6):855. doi: 10.3390/ijms17060855. PMID: 27258258; PMCID: PMC4926389.
13. Harik NS, Smeltzer MS. Management of acute hematogenous osteomyelitis in children. Expert Rev Anti Infect Ther. 2010 Feb;8(2):175-81. doi: 10.1586/eri.09.130. PMID: 20109047; PMCID: PMC2836799.
14. Afghani B., Kong V., Wu F.L. What would pediatric infectious disease consultants recommend for management of culture-negative acute hematogenous osteomyelitis? J. Pediatr. Orthop. 2007;27:805–809.
15. Pääkkönen M, Peltola H. Management of a child with suspected acute septic arthritis. Arch Dis Child. 2012 Mar;97(3):287-92. doi: 10.1136/archdischild-2011-300462. Epub 2011 Sep 27. PMID: 21953417.
16. Gornitzky AL, Kim AE, O’Donnell JM, Swarup I. Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review. JBJS Rev. 2020 Jun;8(6):e1900202. doi: 10.2106/JBJS.RVW.19.00202. PMID: 33006465.

How to Cite this Article:  Singh V, Sharma C, Aditya KS, Vayoli D, Barik S. | Mimics of Paediatric Musculoskeletal Infections and their Management | International Journal of Paediatric Orthopaedics | September-December 2023; 9(3): 16-21. | https://doi.org/10.13107/ijpo.2023.v09.i03.158

(Article Text HTML)      (Full Text PDF)