Thread by @DhananjayaSabat

Dear all postgraduate orthopedic residents...
1st lesson of Orthopedics from my teacher I learnt....
There is nothing called cellulitis in an infant unless there is a wound.
It is osteomyelitis, unless proven otherwise.
#orthotwitter

Pt from NICU with swelling and tenderness below knee. Diagnosed as cellulitis and some oral antibiotics given.
Xray was not informative.
The baby was home with a pus point formed in upper tibia, got an I & D by a local doc.

At 1 mo, the pt has a recent onset distal tibial swelling and redness, impending to burst. No fever. TLC 24000. ESR 110. CRP 26.

The Xray shows what was missed - acute osteomyelitis of proximal tibia; inadequately treated with contiguous involvement of distal tibia now; prominent tubular sequestrum formation with attempts of involucrum formation.

I & D at distal tibia done with pus evacuation; IV antibiotics started with AK slab. All parameters improved gradually - at 10 day; TLC 12000, ESR 22, CRP 1.2.

Pearls of diagnosis of acute osteomyelitis:
1. High risk neonate ( premature/ neonatal sepsis/ NICU admission)
2. Not taking feed
3. Pseudoparalysis (any movement is painful)
4.Metaphuseal swelling
5. Point tenderness "match stick tenderness".

6. TLC ESR CRP - significantly high.
Note that
Fever : rare in immunocompromised.
Redness or palpable pus : already late as pus has come out to soft tissue.
Xray: normal, metaphyseal lucency is the first sign in bone.
USG: normal, periosteal abscess may be detected later

MRI can detect early changes in marrow. Blood culture can identify the organism, so as the local pus culture.

Most important point to note: clinical suspicion is the most important key to diagnosis.

Differential diagnosis for a nenonate not moving a limb:
1. Paralytic: obstretic palsy in upper limb, cerebral hemorrhage
2. Pseudoparalysis
A. Fracture: birth injury, child abuse
B. Septic arthritis
C. Acute osteomyelitis
D. Injection site abcess
#orthotwitter