Haematogenous pyogenic bone and joint sepsis – reducing avoidable morbidity

Abstract

Background and objectives. Delayed presentation of
haematogenous bone and joint sepsis is common in our
childhood population and leads to a large burden of avoidable
morbidity extending into adult life. We set out to determine
causative factors in these delays.
Design. A prospective study was undertaken over a 1-year
period.
Setting. Ngwelezane Hospital, a regional hospital in Kwa-Zulu-
Natal serving 9 rural district hospitals.
Subjects. Children under 15 years with their first presentation
of bone and joint sepsis, comprising 80 consecutive cases.
Tuberculosis cases were excluded.
Outcome measures. Children were categorised at follow-up into
two groups. The first group had uncomplicated recoveries,
with complete return of function and no clinical or radiological
signs of unresorbed sequestra. The second group had
complications, with evidence of one or more of the following:
chronicity of infection, pathological fracture, deformity, growth
plate disturbance, avascular necrosis or joint stiffness.
Results. Delay in obtaining definitive treatment correlated
strongly with initial misdiagnosis. Only 4/25 septic hips
were correctly diagnosed and referred expediently; 19/50
osteomyelitis cases were initially misdiagnosed and treated as
cellulitis, and a further 19/50 were misdiagnosed as trauma.
Predictably, delayed treatment correlated strongly with a
complicated outcome. No significant associations were found
between delays and distance to nearest primary health care
facility, relative levels of socio-economic deprivation within the
study group, maternal educational attainment, or traditional
healer consultation.
Conclusion. Health care professionals at all levels should be
alerted to the continued high incidence of this disease. We
propose some ‘red flags' to assist primary health care workers
in the diagnosis of this condition.

South African Medical Journal Vol. 97 (6) 2007: pp. 456-460