Diagnosis of Pediatric Musculoskeletal Infections: Current Concepts Review

Volume 8 | Issue 1 | January-April 2022 | Page: 14-23 | Neeraj Vij, Jessica Burns, Melissa Esparza, Alexandra Dominianni, Yerin Cho, Mohan V Belthur

DOI-10.13107/ijpo.2022.v08i01.129

Authors: Neeraj Vij BS [1], Jessica Burns MD [2], Melissa Esparza MD [2], Alexandra Dominianni BA [1], Yerin Cho BS [1], Mohan V Belthur MD [1, 2]

[1] Department of Child Health & Orthopaedics, University of Arizona, College of Medicine, Phoenix, Arizona, USA.
[2] Department of Orthopedics, Phoenix Children’s Hospital, Phoenix, Arizona, USA.

Address of Correspondence
Dr. Mohan V. Belthur,
Department of Child Health & Orthopaedics, University of Arizona, College of Medicine, Phoenix, Arizona, USA. Department of Orthopedics, Phoenix Children’s Hospital, Phoenix, Arizona, USA.
E-mail: mbelthur@phoenixchildrens.com

Abstract

Introduction: Pediatric musculoskeletal infections are common and constitute one of the top five conditions contributing to the burden of musculoskeletal disease in childhood. With early accurate diagnosis and appropriate treatment, the clinical course, and outcomes of musculoskeletal infections can be favorable. However, poor outcomes (morbidity/mortality), a wide spectrum of post-infective sequela and significant functional impairment can occur, especially in the setting of delayed diagnosis and inadequate treatment. The purpose of this narrative review is to provide an overview of the standard diagnostic modalities with an emphasis on the recent literature and to summarize the current state of knowledge on the newer diagnostic modalities of the 21rst century.
Materials and Methods: A literature search was performed using the following keywords: “diagnosis”, OR “diagnostic modalities”, OR “diagnostic capability” AND “children” OR “pediatric” AND “musculoskeletal” OR “bony” OR “orthopedic” OR “muscular” AND “infection” OR “bacterial” OR “viral” OR “fungal”. Databases searched included PubMed, EMBASE, Cochrane Library, and SCOPUS. This returned a total of 315 articles. English language articles published between January 1990 and March 2022 regarding traditional or newer diagnostic modalities and pediatric musculoskeletal infection were included in this review.
Results: A total of 62 articles met the inclusion criteria. Our knowledge base regarding the traditional diagnostic modalities has evolved to include several scoring systems with good sensitivities and specificities. Cellular acute phase reactants show promise in the recent literature. There is good literature regarding the evolution of imaging techniques to improve diagnosis. Novel diagnostic modalities in the recent literature include plasma-based acute phase reactants, polymerase chain reaction, and next-generation sequencing.
Conclusion: Continuing to improve our diagnostic accuracy of Pediatric MSKIs can help decrease the worldwide burden of these conditions. As the use of adjunctive biomarkers becomes more common, diagnoses and pathogen identification could be made timelier and antibiotic choices could be individualized leading to improved outcomes. Limited sequence imaging techniques can reduce the associated costs. Polymerase chain reaction and next generation sequencing are important novel technologies that can revolutionize the diagnosis of pediatric musculoskeletal infection.
Keywords:  Paediatric, Musculoskeletal infection, Diagnosis.

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How to Cite this Article:  Vij N, Burns J, Esparza M, Dominianni A, Cho Y, Belthur MV | Septic Arthritis Management: Current Guidelines | International Journal of Paediatric Orthopaedics | January-April 2022; 8(1): 14-23.

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Septic Arthritis Management: Current Guidelines

Volume 8 | Issue 1 | January-April 2022 | Page: 08-13 | Gaurav Gupta, Easwar T. Ramani, Gaurav Garg, Maulin Shah
DOI-10.13107/ijpo.2022.v08i01.128

Authors: Gaurav Gupta MS Ortho. [1, 2], Easwar T. Ramani MS Ortho. [3, 4 ], Gaurav Garg MS Ortho. [5], Maulin Shah MS Ortho. [6]

[1] Department of Paediatric Orthopaedics, Asian Hospital, Faridabad, UP, India.
[2] Department of Orthopaedics, Child Ortho Clinic, Faridabad & Delhi, India.
[3] Department of Paediatric Orthopaedics, Baby Memorial Hospital, Kozhikode, Kerala, India.
[4] Department of Paediatric Orthopaedics and Spine Surgery, Palakkad District Cooperative & Research Centre, Palakkad, Kerala, India.
[5] Department of Paediatric Orthopaedics, Excelcare Hospital, Jaipur, India.
[6] Department of Paediatric Orthopaedics, Orthokid Clinic, Ahmedabad, Gujarat, India.

Address of Correspondence
Dr. Maulin Shah,
Consultant Paediatric Orthopaedic Surgeon, Orthokid Clinic, Ahmedabad, Gujarat, India.
E-mail: maulinmshah@gmail.com

Abstract

Septic arthritis is an orthopaedic emergency that is more commonly seen in infants and young children. Release of proteolytic enzymes leads to permanent destruction of intra-articular cartilage and subchondral bone as early as 72 hours after onset. Hip and knee are the most commonly involved joints. Staphylococcus aureus is the most common causative organism across all paediatric age groups. Recently, there is a significant increase in incidence of Klebsiella and Pseudomonas, especially in neonates. Sensitivity patterns of causative organisms are also changing with increasing resistance to empirical antibiotics, requiring the use of higher antibiotics.
The detection of septic arthritis in neonates is challenging. The physician has to rely on indirect signs and maintain a high index of suspicion. C-reactive protein (CRP) along with difficulty in weight bearing have a better predictive value in diagnosis. Ultrasonography (USG) is a useful tool for quick screening of a joint and to detect effusion. Many recent studies have suggested percutaneous drainage/aspiration as an equally effective modality to manage septic joints, thus avoiding the morbidity of open arthrotomy and the risks of general anaesthesia. Lack of response to minimally invasive methods warrant an open approach. Antero-lateral arthrotomy is preferred over the posterior approach to avoid iatrogenic damage to the blood supply of the femoral head. Arthroscopic lavage of the septic joint is also becoming popular. The choice of empiric antibiotic treatment should be based on age, vaccination status and underlying co-morbidities. There is growing evidence in literature for short-course intravenous (IV) therapy. Delayed diagnosis, sickle cell disease, and infection caused by certain strains of methicillin-resistant staphylococcus aureus (MRSA) are predispose to orthopaedic sequelae.
Keywords:  Septic Arthritis, Arthrotomy, Osteomyelitis.

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23. Thompson RM, Gourineni P. Arthroscopic Treatment of Septic Arthritis in Very Young Children. J Pediatr Orthop. 2017 Jan;37(1):e53-e57. doi: 10.1097/BPO.0000000000000659
24. Eric W Edmonds 1 2, Christina Lin 1, Christine L Farnsworth 2, James D Bomar 2, Vidyadhar V Upasani 1 2 . A Medial Portal for Hip Arthroscopy in Children With Septic Arthritis: A Safety Study. J Pediatr Orthop Nov/Dec 2018;38(10):527-531. doi: 10.1097/BPO.0000000000000861.
25. Scott Rosenfeld 1, Derek T Bernstein, Shiva Daram, John Dawson, Wei Zhang. Predicting the Presence of Adjacent Infections in Septic Arthritis in Children. J Pediatr Orthop 2016 Jan;36(1):70-4. doi: 10.1097/BPO.0000000000000389.
26. Corey O Montgomery 1, Eric Siegel, Robert D Blasier, Larry J Suva. Concurrent septic arthritis and osteomyelitis in children. J Pediatr Orthop , 2013 Jun;33(4):464-7. doi: 10.1097/BPO.0b013e318278484f.
27. Jedidiah E Schlung 1, Tracey P Bastrom 2, Joanna H Roocroft 2, Peter O Newton 2, Scott J Mubarak 1 2, Vidyadhar V Upasani. Femoral Neck Aspiration Aids in the Diagnosis of Osteomyelitis In Children With Septic Hip. J Pediatr Orthop ,Nov/Dec 2018;38(10):532-536. doi: 10.1097/BPO.0000000000000868.
28.Clinical Practice Guideline by PIDS and IDSA • JPIDS 2021
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30. Liu C, Bayer A, Cosgrove SE, et al; Infectious Diseases Society of America. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18–e55
31. No authors listed. British Society for Antimicrobial Chemotherapy.http://www.bsac.org.uk/pyxis/Bone%20and%20joint/Septic%20arthritis/Septic%20arthritis.htm(date last accessed 28 February 2009).
32. Vinod MB, Matussek J, Curtis N, Graham HK, Carapetis JR. Duration of antibiotics in children with osteomyelitis and septic arthritis. J Paediatr Child Health 2002;38:363-7
33. Peltola H, Paakkonen M, Kallio P, Kallio MJ; OM-SA Study Group. Clindamycin vs. first-generation cephalosporins for acute osteoarticular infections of childhood – a prospective quasi-randomized controlled trial. Clin Microbiol Infect. 2012;18(6):582–589.
34. Peltola H, Paakkonen M, Kallio P, Kallio MJ; Osteomyelitis-Septic Arthritis (OM-SA) Study Group. Prospective, randomized trial of 10 days versus 30 days of antimicrobial treatment, including a short-term course of parenteral therapy, for childhood septic arthritis. Clin Infect Dis. 2009;48(9):1201–1210

How to Cite this Article:  Gupta G, Ramani ET, Garg G, Shah M | Septic Arthritis Management: Current Guidelines | International Journal of Paediatric Orthopaedics | January-April 2022; 8(1): 08-13.

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Pelvic Pyomyositis in Children: Current Concepts Review

Volume 8 | Issue 1 | January-April 2022 | Page: 02-07 | Archan Desai, Ashish Ranade, Mohan V. Belthur, Sandeep Patwardhan, Gauri A. Oka
DOI-10.13107/ijpo.2022.v08i01.127

Authors: Archan Desai [1], Ashish Ranade [1, 2], Mohan V. Belthur [3], Sandeep Patwardhan [4], Gauri A. Oka [1]

[1] Department of Orthopaedics, Bharati Hospital and Research Centre, Pune, Maharashtra, India.
[2] Department of Orthopaedics, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India.
[3] Department of Child Health & Orthopaedics, University of Arizona College of Medicine-Phoenix, USA.
[4] Department of Orthopaedics, Sancheti Hospital, Pune, Maharashtra, India.

Address of Correspondence
Dr. Ashish Ranade,
Consultant Paediatric Orthopaedic Surgeon, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India. Visiting Pediatric Orthopaedic Surgeon, Bharati Vidyapeeth Medical College Hospital, Pune, Maharashtra, India
E-mail: ranadea2@gmail.com

Abstract

Pyomyositis in children is an uncommon bacterial infection of skeletal muscles which has more frequently been described in tropical areas, but it is becoming increasingly recognized in temperate climates too. Any muscle group in the body can be involved, but it commonly affects the large muscle groups which are located around the pelvic girdle and lower extremities. Clinical presentation is very similar to septic arthritis of the hip and needs to be diagnosed early. MRI is the investigation of choice. Depending on the severity this condition, it can be treated conservatively with antibiotics in its early stage and with percutaneous or formal incision and drainage in later stages. Generally, if it is diagnosed early, good outcomes can be expected.
Keywords: Pelvic Pyomyositis, Septic arthritis, Infection, Magnetic resonance imaging

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How to Cite this Article:  Desai A, Ranade A, Belthur MV, Patwardhan S, Oka GA | Pelvic Pyomyositis in Children: Current Concepts Review | International Journal of Paediatric Orthopaedics | January-April 2022; 8(1): 02-07.

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Bruck Syndrome (Bone Fragility with Congenital Joint Contractures): A Case Report

Volume 7 | Issue 3 | September-December 2021 | Page: 29-34 | Gaurav Gupta, Qaisur Rabbi, Maulin Shah, Vikas Bohra
DOI-10.13107/ijpo.2021.v07i03.120

Authors: Deepika A. Pinto MS DNB Orth. [1], Sandeep V. Vaidya MS DNB Orth. [1]

[1] Department of Paediatric Orthopaedics, Pinnacle Ortho Center, LBS Road, Thane West, Maharashtra, India.

Address of Correspondence
Dr. Deepika A. Pinto,
Clinical Associate in Paediatric Orthopaedics, Pinnacle Ortho Center, LBS Road, Thane West, Maharashtra, India.
E-mail: deepupinto@gmail.com

Abstract

Background: Bruck syndrome is a disorder in which features of osteogenesis imperfecta and arthrogryposis multiplex congenita coexist. It is an extremely rare condition with less than 40 cases reported worldwide.
Case presentation: We describe the case of a girl child, born of a consanguineous marriage, who, at birth, was noted to have flexion contractures of both knees and elbows as well as right clubfoot. Post-natally, she developed repetitive fractures of both femurs occurring with trivial trauma. She presented to us at the age 8.5 years, with short stature and inability to stand due to the severe knee flexion contractures. She also had flexion contractures at bilateral elbows. Intelligence and fine motor skills were normal. Sclerae, teeth and hearing were also normal. Radiographs revealed osteoporosis, severely deformed femora and vertebral body flattening. A diagnosis of Bruck syndrome was made on the basis of clinical findings. Genetic testing was offered, but declined by the child’s parents. She has since undergone osteotomies and rodding for both femurs, and bilateral distal femoral anterior hemi-epiphysiodesis for gradual correction of knee contractures. She is on cyclical pamidronate therapy to address bone fragility.
Conclusion: In this report, we describe the diagnostic features and management of this rare syndrome, and provide a summary of the existing literature on the disorder.
Keywords: Bruck syndrome, Osteogenesis imperfecta, Arthrogryposis, Congenital joint contractures, Bone fragility

References

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5. Ha-Vinh R, Alanay Y, Bank RA, Campos-Xavier AB, Zankl A, Superti-Furga A, et al. Phenotypic and molecular characterization of Bruck syndrome (osteogenesis imperfecta with contractures of the large joints) caused by a recessive mutation in PLOD2. Am J Med Genet Part A. 2004;131A(2):115–20.
6. van der Slot AJ, Zuurmond A-M, Bardoel AFJ, Wijmenga C, Pruijs HEH, Sillence DO, et al. Identification of PLOD2 as Telopeptide Lysyl Hydroxylase, an Important Enzyme in Fibrosis. J Biol Chem. 2003;278(42):40967–72.
7. Shaheen R, Al-Owain M, Faqeih E, Al-Hashmi N, Awaji A, Al-Zayed Z, et al. Mutations in FKBP10 cause both Bruck syndrome and isolated osteogenesis imperfecta in humans. Am J Med Genet Part A. 2011;155(6):1448–52.
8. Bank RA, Robins SP, Wijmenga C, Breslau-Siderius LJ, Bardoel AFJ, Van der Sluijs HA, et al. Defective collagen crosslinking in bone, but not in ligament or cartilage, in Bruck syndrome: Indications for a bone-specific telopeptide lysyl hydroxylase on chromosome 17. Proc Natl Acad Sci. 1999;96(3):1054–8.
9. Mokete L, Robertson A, Viljoen D, Beighton P. Bruck syndrome: congenital joint contractures with bone fragility. J Orthop Sci. 2005;10(6):641–6.
10. Breslau-Siderius EJ, Engelbert RHB, Pals G, van der Sluijs JA. Bruck syndrome: a rare combination of bone fragility and multiple congenital joint contractures. J Pediatr Orthop B. 1998;7(1):35–8.
11. Moravej H, Karamifar H, Karamizadeh Z, Amirhakimi G, Atashi S, Nasirabadi S. Bruck syndrome – a rare syndrome of bone fragility and joint contracture and novel homozygous FKBP10 mutation. Endokrynol Pol. 2015;66(2):170–4.
12. Luce L, Casale M, Waldron S. A Rare Case of Bruck Syndrome Type 2 in Siblings With Broad Phenotypic Variability. Ochsner J. 2020;20(2):204–8.
13. Puig-Hervás MT, Temtamy S, Aglan M, Valencia M, Martínez-Glez V, Ballesta-Martínez MJ, et al. Mutations in PLOD2 cause autosomal-recessive connective tissue disorders within the Bruck syndrome-Osteogenesis imperfecta phenotypic spectrum. Hum Mutat. 2012;33(10):1444–9.
14. Boyce AM, Gafni RI. Approach to the Child with Fractures. J Clin Endocrinol Metab. 2011;96(7):1943–52.
15. Alman B, Goldberg MJ. Syndromes of Orthopaedic Importance. In: Lowell and Winter’s Pediatric Orthopaedics. 7th ed. Lippincott Williams & Wilkins; 2014. p. 266.
16. Otaify GA, Aglan MS, Ibrahim MM, Elnashar M, El Banna RAS, Temtamy SA. Zoledronic acid in children with osteogenesis imperfecta and Bruck syndrome: a 2-year prospective observational study. Osteoporos Int. 2016;27(1):81–92.
17. Santana A, Oleas-Santillán G, Franzone JM, Nichols LR, Bowen JR, Kruse RW. Orthopedic Manifestations of Bruck Syndrome: A Case Series with Intermediate to Long-term Follow-Up. Case Rep Orthop. 2019;2019:8014038.

How to Cite this Article:  Pinto AD, Vaidya SV | Bruck Syndrome (Bone Fragility with Congenital Joint Contractures): A Case Report. | September-December 2021; 7(3): 29-34.

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Introducing and Treating a Pediatric Monteggia Intermediate-Type 3 and 4 Fracture: A Case Report

Volume 7 | Issue 3 | September-December 2021 | Page: 50-52 | Pavan Soni, Tushar Agrawal

DOI-10.13107/ijpo.2021.v07i03.125

Authors: Pavan Soni  D Ortho. [1], Tushar Agrawal DNB Ortho. [1]

[1] Department of Orthopaedic, Aastha Hospital, Kandivali (W), Mumbai, Maharashtra, India.

Address of Correspondence
Dr Pavan Soni
Department of Orthopaedics, Aastha Hospital, Kandivali (W), Mumbai, Maharashtra, India.
E-mail: pavan.soni22@gmail.com

Abstract

Bado based his classification of Monteggia fractures on the direction of the radial head dislocation. We present a case of a Monteggia fracture that is an intermediary between Bado type 3 and 4 occurring in a 4-year-old Indian girl. It is a fracture of the proximal ulna and radial shaft, along with a lateral dislocation of the radial head that was treated with retrograde elastic nailing of the radius fist, then the ulna. Our case report is unique because this fracture pattern has not been presented earlier in literature. Interestingly, what presented as a both bone forearm fracture, on careful examination, was a Monteggia fracture. Our report aims to help other surgeons identify and treat this complex injury, in addition, increase awareness of this rare Monteggia variant.
Keywords: Monteggia, Paediatric forearm fractures, Elbow injuries

References

[1] Olney BW, Menelaus MB. Monteggia and equivalent lesions in childhood. Journal of pediatric orthopedics. 1989 Mar 1;9(2):219-23.
[2] Bado JL. 7 The Monteggia Lesion. Clinical Orthopaedics and Related Research (1976-2007). 1967 Jan 1;50:71-86.
[3] Ravessoud FA. Lateral condylar fracture and ipsilateral ulnar shaft fracture: Monteggia equivalent lesions?. Journal of pediatric orthopedics. 1985 May 1;5(3):364-6.
[4] Arazi M, Ögün TC, Kapicioglu MS. The Monteggia lesion and ipsilateral supracondylar humerus and distal radius fractures. Journal of orthopaedic trauma. 1999 Jan 1;13(1):60-3.
[5] Bhandari N, Jindal P. Monteggia lesion in a child: Variant of a Bado Type-IV lesion. A case report. JBJS. 1996 Aug 1;78(8):1252
[6] Rang, M., Pring, M. E., & Wenger, D. R. (2005). Rang’s children’s fractures.
[7] Gleeson AP, Beattie TF. Monteggia fracture-dislocation in children. Emergency Medicine Journal. 1994 Sep 1;11(3):192-4.

How to Cite this Article:  Soni P, Agrawal T | Introducing and Treating a Pediatric Monteggia Intermediate-Type 3 and 4 Fracture: A Case Report | International Journal of Paediatric Orthopaedics | September- December 2021; 7(3): 50-52.

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Temporary Transphyseal Medial Malleolar Screw Hemiepiphysiodesis for Acquired Ankle Valgus Following Fibular Graft Harvest in Children: A Series of 15 Patients

Volume 7 | Issue 3 | September-December 2021 | Page: 17-22 | Ankit Jain, Anil Agarwal, Nitish Bikram Deo, Ankur, Jatin Raj Sareen

DOI-10.13107/ijpo.2021.v07i03.117

Authors: Ankit Jain D. Ortho. [1], Anil Agarwal MS Ortho. [1], Nitish Bikram Deo MS Ortho. [1], Ankur MS Ortho. [1], Jatin Raj Sareen MS Ortho. [1]

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

Address of Correspondence
Dr Anil Agarwal
Specialist, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Delhi, India.
E-mail: anilrachna@gmail.com

Abstract

Purpose: To assess the role of temporary transphyseal medial malleolar screw hemiepiphysiodesis in cases of acquired ankle valgus following non-vascularized fibular harvest.
Methods: This retrospective chart review included 15 children (18 ankles). Exclusion criteria were inadequate records or additional procedures besides screw hemiepiphysiodesis. Radiological evaluations included lateral distal tibial angle (LDTA) and fibular station (Malhotra grade).
Results : The average patient age was 8.6 years at surgery. The overall duration of treatment was 18.2 months and post removal follow-up (5 ankles) was 16.6 months. The average correction rate was 0.48 degrees/ month. LDTA changed significantly following hemiepiphysiodesis (Pre-op 077.3 degrees/ in situ follow-up 85.9 degrees). The Malhotra grade did not change significantly during the same period. The average recurrence rate [noted in 4/5 patients] was 0.52 degrees per month. However, LDTA and Malhotra grade did not change significantly post removal.
Conclusions : We report the results of temporary transphyseal medial malleolar screw hemiepiphysiodesis for post fibular harvest acquired ankle valgus in children. Temporary hemiepiphysiodesis is a viable option for the correction of acquired ankle valgus in children. The fibular station is however not restored following the procedure. Recurrence of deformity following screw removal remains a worrying complication in some patients.
Keywords: Hemiepiphysiodesis, Ankle valgus, Growth modulation, Fibula, Harvest

References

1. Davids JR, Valadie AL, Ferguson RL, Bray EW 3rd, Allen BL Jr. Surgical management of ankle valgus in children: use of a transphyseal medial malleolar screw. J Pediatr Orthop. 1997;17:3-8.
2. Stevens PM, Belle RM. Screw epiphysiodesis for ankle valgus. J Pediatr Orthop. 1997;17:9-12.
3. Stevens PM, Kennedy JM, Hung M. Guided growth for ankle valgus. J Pediatr Orthop. 2011;31:878-83.
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How to Cite this Article:  Jain A, Agarwal A, Deo NB, Ankur, Sareen JR | Temporary Transphyseal Medial Malleolar Screw Hemiepiphysiodesis for Acquired Ankle Valgus following Fibular Graft Harvest in Children: A Series of 15 Patients | International Journal of Paediatric Orthopaedics | September-December 2021; 7(3): 17-22.

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