Module 37, Pediatric Orthopaedist Level

1,2,3,4,5,

A 9 month old male child with history of normal pregnancy, delivery and growth presented to the emergency room. The mother reported a 2 day fever of unknown origin with vague abdominal pain and diarrhea. Initial work up revealed: temperature of 40.1, WBC 16,800 with left shift, x-rays of Chest Abdomen, Pelvis, and Hips were normal. A bone scan was negative, spinal tap was normal. The child was admitted with a diagnosis of viral infection vs. mycoplasma pneumonia. He was started on erythromycin.(images 1 & 2) On hospital day 2 the right hip was noted to be flexed and the child appeared to have pain with any movement of the hip. The hip was aspirated and the Gram stain identified gram positive cocci and the child was started on Nafcillin 150mg IV q4. Daily hip aspirations were performed for decompression. Final culture: coag (+) Staph aureus resistant to penicillin. On hospital day 6 the child's temperature spiked to 103.4. The right hip x-ray showed a defect in proximal medial metaphysis. On post-operative day 18 a right hip x-ray shows subluxation of right hip, possibly with metaphyseal lucency consistent with osteomyelitis. The child was again taken to operating room for repeat incision and drainage this time via the posterior approach with Penrose drains and hip spica cast (15cc seropurulent fluid was drained). Antibiotics changed to Oxacillin 225mg IV q4. (images 3, 4 & 5)

Question 37A

This subluxation should be treated by placing the child in a spica cast.

Question 37B

The primary cause of the changes in the proximal femur are due to chronic osteomyelitis.

Question 37C

The long-term prognosis for this hip is very guarded and the parents should be informed of the severity of this problem.

Question 37D

By age six the child was developing severe hip subluxation . Maintaining reduction of the hip should be the main priority.

Question 37E

By age 15 he was having severe pain. A valgus osteotomy would provide substantial period of functional pain relieve.