T Nunn1, P Rollinson. 1. Department of Trauma and Orthopaedics, Ngwelezane Hospital, Empangeni, Kwa-Zulu-Natal.
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.
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.