Acute hematogenous osteomyelitis and septic arthritis in children: clinical characteristics and outcomes study.

OBJECTIVE: To evaluate the clinical features, causative pathogens and outcomes-related to acute hematogenous osteomyelitis and septic arthritis in pediatric patients. MATERIAL AND METHOD: The authors conducted a retrospective cohort study of patients under 15 years of age with diagnosis of acute hematogenous osteomyelitis (AHO) and/or septic arthritis (SA), treated at Queen Sirikit National Institute of Child Health from 1996 to 2006. Demographic data, clinical characteristics, bacterial spectrum, and outcomes were collected. Potential risk factors for osteoarticular sequelae in the patients who had more than 2 years of follow-up were analyzed. RESULTS: One hundred and twenty-nine patients met the diagnostic criteria which included 51 cases with SA, 35 cases with AHO and 37 cases with both SA and AHO. The patient's age ranged between 1 day and 13 years 4 months, comprising 37 (28.6%) of newborns, 28 (21.7%) of > 1-12 months, 18 (14%) of > 1-3 years and 46 (35.7%) of > 3-15 years. Causative bacteria were found in 103 of 129 patients (80%), the two most common pathogens were methicillin-sensitive Staphylococcus aureus (MSSA) in 48 (46.6%) and methicillin-resistant Staphylococcus aureus (MRSA) in 18 (17.5%) cases. The initial temperature on admission day was high (> 37.5 degrees C) in only one-third of newborns, one-half of infants and two-thirds of the older group. The duration of antibiotic administration ranged between 21 and 56 days (mean 42 days). Arthrotomy or drainage and bone or joint aspiration underwent in 62% and 17% of cases respectively. Outcomes of 79 patients who had more than 2 years of follow-up identified osteoarticular sequelae in 23 patients (29%) that consisted of avascular necrosis of epiphysis, limb-length discrepancy and pathologic fractures. Univariate analysis for potential risk factors compared between sequelae and without sequelae groups demonstrated significant association with more than 1 week duration of presenting symptoms, newborn age group, hip joint infection, infection with MRSA and more than 3 days delayed treatment with appropriate antibiotics. CONCLUSION: MSSA was the most common bacterial pathogen causing pediatric osteoarticular infections in all age groups but was second to MRSA in the newborn group. Osteoarticular sequelae were avascular necrosis of epiphysis, limb length discrepancy, and pathologic fracture which were significantly related to longer duration of presenting symptoms, newborn age group, hip joint involvement, MRSA infection and delayed administration of appropriate antibiotics.

Bilateral asynchronous humeral shaft fractures in a patient with autosomal dominant osteopetrosis type II (Albers-Schonberg disease).

Osteopetrosis is a rare metabolic disease which presents with fragile osteosclerotic bone. A thirteen-year-old girl with an underlying autosomal dominant osteopetrosis (ADO) type II who sustained a left oblique humeral shaft fracture after trivial trauma is presented. Radiographic results showed many characteristic features of osteopetrosis, including incomplete remodeling of a previous fracture of the contralateral humeral shaft. The authors obtained good healing and alignment of the left humeral shaft fracture by sugar tong slab.

Scurvy in pediatric patients: a review of 28 cases.

OBJECTIVE: To study the dietary factors, clinical findings, plasma vitamin C level and post-treatment outcome of scurvy in pediatric patients at Queen Sirikit National Institute of Child Health. STUDY DESIGN: A retrospective study. METHOD: The medical and radiographic records of pediatric patients, diagnosed with scurvy at Queen Sirikit National Institute of Child Health from 1995 to 2002 were reviewed. RESULTS: Twenty-eight pediatric patients were diagnosed with scurvy. Their ages ranged between 10 months-9 years 7 months (median age of 29 months). 93 per cent of the cases were between 1-4 years of age. All were fed with well-cooked foods and small amounts or no vegetables and fruits. Supplementation with ultra heat temperature (UHT) milk was found in 89 per cent, average 5.8 boxes/day and 14.3 months in duration. Eighty-six per cent of cases were misdiagnosed previously. Clinical manifestations involved limp or inability to walk (96%), tenderness of lower limbs (86%), bleeding per gum (36%), fever (18%), and petechial hemorrhage (3.6%). All cases had abnormal radiographic findings compatible with scurvy and 2 cases had epiphyseal separation. All had clinical improvement within the first week after vitamin C supplementation. CONCLUSION: Vitamin C deficiency was found in the children's intake of small amounts or no vegetables and fruits together with UHT-milk. Frequent manifestations were limping and inability to walk and pain in the lower limbs. Response to vitamin C treatment was dramatic.

Causes of femoral shaft fracture in children under five years of age.

OBJECTIVE: To study the causes of femoral shaft fracture in children younger than 5 years of age. STUDY DESIGN: Retrospective, descriptive study. PATIENTS AND METHOD: Medical records and radiographs of 39 children younger than 5 years of age with femoral shaft fractures treated in Queen Sirikit National Institute of Child Health during the years 1996-2001 were reviewed. The responsible causes for the femoral shaft fracture given by caretakers by interview were collected. RESULTS: The most common history was falling or jumping from a height (36%) followed by traffic accidents (26%) and object or person falling on top of them (23%) respectively. Only one case presented with a history of abuse. Nine cases were suspected of abuse, but, without further investigations it was not possible to identify the exact cause of fracture. CONCLUSION: Histories given by caretakers for the cause of femoral shaft fracture in children younger than 5 years of age are varied. The orthopedists should find out the exact cause of fracture to prevent missed or delayed diagnosis of abuse that may have occurred.

Intramedullary pin fixation in clavicular fractures: A study comparing the use of small and large pins.

The S-shaped clavicle poses a problem for intramedullary pin fixation. Stability of fracture fixation is closely related to the length of intramedullary pin engagement. This study was carried out to determine the engagement length of intramedullary pins into clavicular fractures using a small and a large pin. Seven pairs of fresh cadaveric clavicles were prepared and arranged into Group 1 and Group 2 for paired study. A mid-third clavicular fracture was created at the junction of the two curves of the clavicle. In Group 1, a 3.2 mm diameter threaded Steinman pin was introduced into the medullary canal of the clavicle by retrograde technique and the medial fragment of the fracture was drilled until the pin perforated the bone cortex. In Group 2, a 4 mm diameter threaded Steinman pin was used in the same manner. The results showed that Group 1 had an average engagement of pin into the clavicle of 9.11 cm with a ratio to total length of the clavicle of 0.59. In Group 2, the average engagement length into the clavicle was 7.17 cm with a ratio of 0.47. The difference was significant, with the smaller pin providing better fixation. The pins in both groups perforated the lateral fragment at the posterosuperior aspect and the medial fragment at the anterior aspect of the clavicle. The angle that the pin made with the long axis of the clavicle in Group 1 was 22.43 degrees and in Group 2, 26.57 degrees. Although the 3.2 mm diameter pin was more aligned to the long axis of the clavicle than the 4 mm diameter pin, the difference was not significant.