ESSR 2016 / P-0129
Imaging evaluation and exclusion of sepsis in a child presenting with a limp
Congress: ESSR 2016
Poster No.: P-0129
Type: Educational Poster
Keywords: Infection, Education and training, Diagnostic procedure, Ultrasound, Plain radiographic studies, MR, Paediatric, Musculoskeletal system
Authors: N. Larkman1, A. White1, C. Davies2, K. A. Kingston2; 1Leeds/UK, 2York/UK
DOI:10.1594/essr2016/P-0129

Imaging findings OR Procedure Details

Case 1 (Fig. 3 )

Soft tissue infection - Buttock Abscess

2 year old, non weight bearing on left leg.  Recent chickenpox infection became increasingly irritable and febrile. Reluctant with both active and passive leg movements. CRP 209 (<5), wbc 30.1 (4-11)

 

Fig. 3: Case 1 (A)XR – soft tissue swelling left gluteal region US – No hip joint effusion. MRI – (B) Coronal STIR , (C) Coronal T1 + gad, (D) Axial T1FS + gad Left gluteal abscess with oedema in adjacent muscles and soft tissues. No bone, lower spine, SIJ or hip joint involvement.
References: Radiology, York Hospital, York Hospital - York/UK

Diagnosis - Left gluteal abscess with oedema in adjacent muscles and soft tissues. No bone, lower spine, SIJ or hip joint involvement.

Open surgical drainage. Growth of Beta-Haemolytic Streptococcus.

Treated with Flucloxacillin and Clindamycin.

 

Case 2 (Fig. 4)

Septic Arthritis

5 year old limping after a fall, swollen, painful right knee, fever.

Wbc 12.3 CRP 44. Radiograph – Nothing Abnormal Detected.

US - effusion and aspiration. MRI - to exclude associated osteomyelitis.

 

Fig. 4: Case 2 MRI – (A) cor STIR (B) ax T2 (C-D) sag and ax T1FS+gad;moderate synovial thickening and an effusion, no associated osteomyelitis.
References: Radiology, York Hospital, York Hospital - York/UK

Diagnosis – septic arthritis. Knee aspirate & blood cultures - Beta-Haemolytic Streptococcus (A) & Gram +ve cocci

Underwent arthroscopic washout (x2). Received 3/12 antibiotics.

 

Case 3 (Fig. 5)

Brodies Abscess with Soft Tissue Extension

14 year old; painful swollen right knee for 3/52 on 1 year background. Febrile/night sweats with rigors. Fixed flexion deformity

Pyrexial, Wbc 18.6 CRP 184

Aspiration from knee effusion sterile.

 

Fig. 5: XR (A) – Brodie’s abscess - well defined distal femoral metaphyseal lucency abutting growth plate. Soft tissue swelling posterior to knee. MRI – (B-D) Intraosseous Brodie’s abscess with extension through growth plate into epiphysis. Breach in posterior cortex extending into large, loculated soft tissue abscess in postero-medial distal thigh. Reactive synovitis/joint effusion,
References: Radiology, York Hospital, York Hospital - York/UK

Diagnosis – Brodies abscess with posterior cloaca and extra-articular soft tissue abscess. Blood cultures negative.

 

Underwent incision and drainage of distal femur – grew staph aureus. Had 8/52 post-op flucloxacillin.

 

Case 4  ( Fig. 6)

Sacro-ileitis

2 year old presented with high fever, irritability, anorexia. CRP 147, wbc 23, LP and BC normal.  Given meningococcal prophylaxis. Abdominal and hip US normal. On ward began to refuse to weight bear and pain on sitting.

 

 

Fig. 6: MTWS Sag STIR- normal apart from high signal inflammation around left SIJ MRI pelvis cor & ax STIR - Fluid within the L SIJ with adjacent bone marrow oedema and soft tissue inflammation.
References: Radiology, York Hospital, York Hospital - York/UK

Diagnosis - Sacroileitis - Fluid within left sacroiliac joint with adjacent bone marrow oedema and surrounding soft tissue inflammation.

 

No pathogen identified. Treated with 2/52 IV Ceftriaxone and 2/52 oral Co-Amoxiclav.

 

Case 5 (Fig. 7)

Talar Osteomyelitis

18month old. 1/12 limping & apparent pain in right foot

Afebrile. Normal WBC & CRP.

 

Fig. 7: XR (A) – bony erosion lateral talus USS - fluctuance at posteromedial subtalar joint MRI – (B) coronal STIR (C) axial T2 (D) axial STIR; oedema throughout talus with more fluid component lateral aspect. Generalised post-contrast enhancement.
References: Radiology, York Hospital, York Hospital - York/UK

Diagnosis – osteomyelitis. Blood cultures negative

Treated with IV ceftriaxone then PO cefalexin

 

Case 6 (Fig. 8)

Discitis

3 year old presented with low back/buttock pain and reluctance to walk

ESR 76 (1-15), CRP 15, wbc normal, negative blood cultures.

XR – normal

 

 

Fig. 8: MRI (A) sag T1, (B) sag T1 + gad, (C) sag STIR, (E) axial T1, (F) ax T1 + gad L4/5 discitis. Pocket of fluid in disc space extending into adjacent vertebral bodies. Oedematous bone marrow. Small extradural collection. Avid enhancement after contrast.
References: Radiology, York Hospital, York Hospital - York/UK

Diagnosis - discitis.

No pathogen identified. Improved with 6/52 Flucloxacillin.

 

Case 7 (Fig. 9)

Septic Arthritis/Osteomyelitis

13 year old presented with painful, swollen left knee. Joint effusion on XR. Aspirate grew staph aureus, started on flucloxacillin. Remained pyrexial and symptoms worsened. Raised inflammatory markers. MRI - confirmed bone, joint and soft tissue involvement.

 

Fig. 9: MRI (A) Sag T1, (B) ax T2, (C) Cor T2, (D) Cor T1FS + gad. Enhancing sepiginous cavities in distal femur with posteromedial subperiosteal abscess . Large soft tissue abscess and joint effusion/synovitis.
References: Scarborough Hospital, York Hospitals, UK
 

Diagnosis - septic athritis and osteomyelitis with intra-osseous and soft tissue abscesses.

Multiple washouts and open debridements. Several courses of intravenous and oral antibiotics.

 

 

Differential Diagnoses to consider:

 

 

Developmental Dysplasia of the Hip (Fig. 10)

Perthes (Fig. 11)

Transient Synovitis (Fig. 12)

Slipped Upper Femoral Epiphysis (Fig. 13)

 

 

Case A (Fig. 14)

Osteoid osteoma

3 year old presented with painful limp.  CRP, wbc normal. Aypyrexial.

 

Fig. 14: (A) US – left hip effusion. Initially treated as transient synovitis but symptoms continued. (B) GA MRI with US guided aspiration – sterile effusion. Coronal STIR shows left hip effusion and diffuse femoral neck oedema. Some medial cortical thickening so (C) multiplanar CT obtained which confirmed osteoid osteoma (arrow), later readmitted for (D) ablation therapy by CT guided thermocoagulation,
References: Radiology, York Hospital, York Hospital - York/UK

 

Case B (Fig. 15)

Chronic Relapsing Multifocal Osteomyelitis

10 year old boy presented with left hip pain and limp. Mildly raised inflammatory markers.

 

Fig. 15: (A)2008 Normal FLL XR for left hip pain(B)MRI cor STIR in 2009 3/12 left hip pain , abnormal oedematous marrow signal in roof of left acetabulum, right greater trochanter and both ischia. Opinion and biopsy from Birmingham Bone Tumour Unit. Diagnosed CRMO. ESR 16, CRP 21. No pathogen. Treated with non steroidals and occasional antibiotics.(C)2011 cortical thickening and sclerosis right subtrochanteric region. (D)2013 thickening and sclerosis medial 2/3 right clavicle, typical for CRMO
References: Radiology, York Hospital, York Hospital - York/UK

 

Case C (Fig. 16)

Idiopathic Chondrolysis

14 year old girl presented with an acutely painful, stiff left hip and limp. Rapidly developed a flexion deformity. Inflammatory markers and wbc normal.

 

Fig. 16: Idiopathic chondrolysis XR 2013 - joint space narrowing and flexion deformity. US - Left hip joint effusion, aspirated and found to be sterile. MRI - Left hip joint effusion and synovitis with widespread cartilage loss. Bone marrow oedema in the femur and acetabulum, with characteristic band of high signal in the central weight bearing portion of the epiphysis. Diagnosed as idiopathic chondrolysis. XR at 1year follow up showed no significant improvement in degree of cartilage loss.
References: Radiology, York Hospital, York Hospital - York/UK

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