Epidemiology, Diagnosis, and Treatment of Pericapsular Pyomyositis of the Hip in Children

Objective There are currently no algorithms for early stratification of pediatric musculoskeletal infection (MSKI) severity that are applicable to all types of tissue involvement. In this study, the authors sought to develop a clinical prediction algorithm that accurately stratifies infection severity based on clinical and laboratory data at presentation to the emergency department. Methods An IRB-approved retrospective review was conducted to identify patients aged 0–18 who presented to the pediatric emergency department at a tertiary care children’s hospital with concern for acute MSKI over a five-year period (2008–2013). Qualifying records were reviewed to obtain clinical and laboratory data and to classify in-hospital outcomes using a three-tiered severity stratification system. Ordinal regression was used to estimate risk for each outcome. Candidate predictors included age, temperature, respiratory rate, heart rate, C-reactive protein, and peripheral white blood cell count. We fit fully specified (all predictors) and reduced models (retaining predictors with a p-value ≤ 0.2). Discriminatory power of the models was assessed using the concordance (c)-index. Results Of the 273 identified children, 191 (70%) met inclusion criteria. Median age was 5.8 years. Outcomes included 47 (25%) children with inflammation only, 41 (21%) with local infection, and 103 (54%) with disseminated infection. Both the full and reduced models accurately demonstrated excellent performance (full model c-index 0.83, 95% CI [0.79–0.88]; reduced model 0.83, 95% CI [0.78–0.87]). Model fit was also similar, indicating preference for the reduced model. Variables in this model included C-reactive protein, pulse, temperature, and an interaction term for pulse and temperature. The odds of a more severe outcome increased by 30% for every 10-unit increase in C-reactive protein. Conclusions Clinical and laboratory data obtained in the emergency department may be used to accurately differentiate pediatric MSKI severity. The predictive algorithm in this study stratifies pediatric MSKI severity at presentation irrespective of tissue involvement and anatomic diagnosis. Prospective studies are needed to validate model performance and clinical utility.

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“…Including all types of musculoskeletal infection in the prognostic model reflects clinical practice. 11 …”

Section: Discussionmentioning

confidence: 99%

A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity

Benvenuti

Mignemi³

et al. 2019

Journal of Pediatric Orthopaedics

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“…13 It is also important to differentiate septic arthritis from extra-articular infection. 16 MRI could provide a precise diagnosis enabling debridement of the epicentre of infection and thus preventing a prolonged infectious process as well as avoiding unnecessary debridement of the joint and joint contamination. 16 As we suspected an osteitis on the right side clinically, we started the relevant broad spectrum antibiotics (cloxacillin and cefotaxime).…”

Section: Discussionmentioning

confidence: 99%

“…16 MRI could provide a precise diagnosis enabling debridement of the epicentre of infection and thus preventing a prolonged infectious process as well as avoiding unnecessary debridement of the joint and joint contamination. 16 As we suspected an osteitis on the right side clinically, we started the relevant broad spectrum antibiotics (cloxacillin and cefotaxime). Usually our protocol is to drain the collection as soon as possible -in a similar case we would have opened the hip and knee joint -if these were both negative the femur would have been drilled to decompress any intramedullary pus collection.…”

Section: Discussionmentioning

confidence: 99%

Osteomyelitis in an infant with proximal focal femoral deficiency

2016

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“…3 They found that peri-capsular pyomyositis presented twice as often as septic arthritis (32% vs. 15% respectively). 3 This further illustrates the need to differentiate various hip pathologies other than septic arthritis as reducing the time to commence treatment may be important in avoiding complications of pyomyositis.…”

Section: Dear Editor Early Use Of Mri For Suspected Pyomyositismentioning

confidence: 99%

“…[3][4][5] MRI is superior to ultrasound when imaging the pelvis as it excludes other local pathology.…”

Section: Dear Editor Early Use Of Mri For Suspected Pyomyositismentioning

confidence: 99%

Early use of MRI for suspected pyomyositis

Tharmarajah

Marks

2015

J Paediatrics Child Health

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Your short case on abdominal examination 1 was timely and important. However, the presentation omits two clinical signs that can be useful, and even diagnostic, in children.Carnett's sign 2 was first described in 1926. It is based on the palpation of the abdomen. With the abdomen exposed, the examiner asks the supine patient (child or adult) to relax the abdomen and palpates the abdomen in the normal manner, noting any areas of tenderness or guarding. The examiner then asks the patient to tense his/her abdominal muscles by raising the head and legs from the couch and palpates the abdomen again. If the pain is coming from an intra-abdominal lesion, palpation with tensed muscles will be pain-free. If the pain arises from the muscles or superficial tissues in the abdominal wall, then the tenderness felt with the muscles tensed is the same as, or greater than, the pain with the relaxed muscles. Carnett's sign is positive. This sign is highly reliable in adults.3 I have found that it is a common finding in children with recurrent abdominal pain who do not respond to treatment and where investigations are negative. It is also easy to demonstrate this finding to worried parents and explain that the pain is not due to an undiagnosed intra-abdominal condition, but selfreinforcing cycle of anxiety leading to muscle tension with local tenderness and pain.The second useful technique is auscultatory percussion. This is based on the fact that the sound generated by manual percussion travels well through solid tissue. Some uncooperative children will not relax to allow palpation of the lower edge of the liver. This information can be gained by placing the stethoscope over the known position of the liver, then, starting in the right iliac fossa, tap or stroke the abdominal wall, moving upwards. When the tapping or stroking reaches the lower edge of the liver, there is a sudden change in the quality of sound heard through the stethoscope. 4 It may not be as accurate as standard palpation, but it can give information when palpation is impossible.Carnett's sign can give evidence of intra-/extra-abdominal pathology not available by other clinical methods or by investigations. Auscultatory percussion is useful when conventional methods cannot be used. Both signs are useful in adults. I recommend them to paediatricians for consideration and formal assessment of their value in children. Dear Editor, EARLY USE OF MRI FOR SUSPECTED PYOMYOSITISA 7-year-old boy presents 5 days after a minor fall onto his face with associated dental injury. His presenting complaint includes fevers, left groin pain and progressive difficulty walking with pain on external rotation of the left hip and deep tenderness to the left proximal adductor muscles. The patient was febrile and flushed with a tachycardia and normal blood pressure. The C-reactive protein (CRP) was 62 mg/L and a pelvic X-ray was unremarkable. Based on clinical grounds, initial management included intravenous (IV) hydration and IV cefotaxime and flucloxacillin to cover for a potential iliop...

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Epidemiology, Diagnosis, and Treatment of Pericapsular Pyomyositis of the Hip in Children

Abstract: Level II-"Diagnostic" [Development of diagnostic criteria on the basis of consecutive patients (with universally applied reference "gold" standard)].

Cited by 47 publications

References 16 publications

A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity

A Clinical Prediction Algorithm to Stratify Pediatric Musculoskeletal Infection by Severity

Osteomyelitis in an infant with proximal focal femoral deficiency

Early use of MRI for suspected pyomyositis

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