Ankle Pain In A Street Hockey Player - Page #4
 

Working Diagnosis:
Osteomyelitis of the right distal fibula with multiple unusual pathogens including: Escherichia Coli, Klebsiella oxytoca, Klebsiella pneumoniae, and Shigella sonnei (subgroup D).

Treatment:
She was treated outpatient with a four week course of Ciprofloxacin 750mg PO BID.

Outcome:
She was back to floor hockey within 10 weeks of diagnosis and is currently doing well. Follow-up X-Rays were performed including, B/L hip AP/Lat, and right ankle. Her hip revealed no focal lesion and the ankle showed healing changes of osteomyelitis in the distal fibula Case Photo #10. We plan to see her back in the office for follow-up in 6 months.

Author's Comments:
Teaching points:

Case history including her initial injury did not match the previous working diagnosis of a fracture.

Bone scan revealed uptake in proximal femur which she never displayed any symptoms and follow up XR was negative.

Biopsy yielded unusual pathogens, but due to her clinical picture, imaging, and sterile biopsy they could not be disregarded.

Highly unlikely extensive contamination with four different organisms would occur from a sterile IR bone biopsy.

It’s unusual for osteomyelitis to cross the physis.

The choice to use a fluoroquinolone - benefit outweighed risk.

Editor's Comments:
The most common cause of osteomyelitis in children is hematologic spread, but preceeding blunt trauma to bone infections is quite common. Staphylococcus species continues to be the most common pathogen for osteomyelitis.1

References:
1. Kaplan, SL. "Osteomyelitis in Children". Infect Dis Clin N Am. 19 (2005) 787–797.

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