OSTEOMYELITIS IN THE NEWBORNBY

JOHN THOMSON and IAN C. LEWISFrom the Department of Child Life and Health, University of Edinburgh

(REcEIV FOR PUBLICATnON FEBRUARY 6, 1950)

The earlier literature on osteomyelitis of veryyoung infants dealt largely with osteomyelitis ofthe jaw and its probable relationship to mastitis inthe nursing mother (Marx, 1920; Bass, 1928;Karplus, 1928; Wilensky, 1932; Poncher andBlayney, 1934).

Metastatic osteomyelitis due to umbilical sepsiswas mentioned by Fraser (1924) who collected some30 cases over a period of four years. He said thata fatal result was almost inevitable. Baumgartner(1920) recorded a case of osteomyelitis of theskull, Madier (1922) one of osteomyelitis ofa vertebra, and Palew (1931) one of gonoccoccalosteomyelitis.

In a study of septicaemia of the newborn infantDunham (1933) found that osteomyelitis occurredin 10-3°h of the cases and that three out of foursuch cases died. Mount (1935) reported a fatal caseof septicaemia with osteomyelitis of the humerus.Green (1935) recorded a case of osteomyelitis ofthe humerus, with recovery, where the originallesion may have been a furuncle of the chin at theage of two weeks. The same author with Shannon(1936) published a series of 23 cases of osteomyelitiswhich occurred before the age of six months. Themortality rate was 45%. They related extra-osseousinfection and trauma to the osteomyelitis and stressedskin infection and omphalitis as primary lesions.They considered that osteomyelitis was not a raredisease in infants and emphasized that the treatmntwas that of the general condition rather than of thelocal one.The poor prognosis given by Fraser and Dunham

was not confirnmd by Diliehunt (1935) among whosecases there were two in the neonatal period. Hesaid:

'The disease is rare in infants. It is relativelybenign, and neglect to treat it in infants is lessharmful than in adults. The prognosis is favour-able. Sequestra do not form. Spontaneous resolu-tion without treatment may occur. Foci ofinfection may become sterile.'

In the three cases recorded by Cass (1940) therewas relatively little systemic disturbance though intwo of them there was pyrexia. Apart fromdeformity, the prognosis was stated to be good inthe absence of infection of the lungs, peritoneum,meninges or skin. Four cases of osteomyelitis allof which recovered were recorded by Stone (1942).He stated that the course of the disease in the new-born was benign and that the treatment of theosseous lesion was of secondary importance. Hegave a good prognosis for life and function.The benign course of the disease was also

mentioned by Einstein and Thomas (1946) who saidthat involvement of a joint was common and wasthe most serious complication. Of their ten casesunder the age of six months one was in the neonatalperiod. A case of osteomyelitis with recovery in a19-day old infant was reported by Shulman (1946).The confusion of opinion in the prognosis of

osteomyelitis was in large measure clarified byGreengard (1946). He recorded ten cases of acutehaematogenous osteomyelitis in infants, one ofwhich was in the neonatal period. He suggestedthat in the newborn infant there were two forms ofthis disease; first, a ' benign ' form in which therewas little or no complaint other than local disabilityand no history of preceding illness, and second, asevere form in which there was systemic evidenceof a violent infection and the local disease made itsappearance as a complication. In this latter groupthe mortality was high. Hutter (1948), recordingthree cases of neonatal osteomyelitis, agreed withGreengard's classification.

Because of the number of cases of osteomyelitisin the neonatal period which have been recordedit may be said that this disease should no longer beconsidered a rare one: yet it has seldom beenreported from a maternity hospital. The four casesnow recorded were prematurely born infants whofrom birth were under the daily care and supervisionof a paediatrician. Thus the earliest clinicalmanifestations of morbidity were observed.

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ARCHIVES OF DISEASE IN CHILDHOODCase Reports

Case No. 1. This immature male infant, the resultof a ninth pregnancy, was born spontaneously ofunrelated parents on July 5, 1943. He weighed 5 lb. 7 oz.at birth. Progress was normal until the ninth day whenonychia of the right middle finger was observed. Despitelocal treatment with gentian violet and fomentations,and chemotherapy with sulphathiazole g. 1 four-hourly,the infammation spread. The finger, and finally thewhole hand, was involved. A discharge of thin puscare to the surface over the dorsal aspect of the distaljoint of the finger which was incised. The pus was notinvestigated bacteriologically. The sinus was healedfour weeks from the appearance of the onychia, when allswelling had disappeared except that affecting the finger.At this stage the finger was examined radiologically(Fig. 1). Almost complete destruction of the bone of

I

FIG. 1.-Radiographs showing pinpoint of bone in themiddle phalanx and considerable destruction of proximal

portion of distal phalanx.

the middle phalanx and most of the proximal part ofthe distal phalanx was seen.The infant was discharged aged 45 days. He weighed

6 lb. 3- oz. No systemic disturbance occurred duringthis acute illness (Fig. 2).The infant has been observed at intervals since

discharge from hospital. A radiograph shows theextent of bone recovery at the age of 5 years and 7months (Fig. 3).

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FIG. 3.-Radiograph showing extent of bone recovery.

Case No. 2. This female infant was born spontan-eously on January 13, 1943. She weighed just over 5 lb.At 12 days staphylococcal pustules were seen in the rightaxilla and at the right elbow. They were treated with a100 aqueous solution of gentian violet. From thepustule at the elbow inflammation spread rapidly intothe soft tissues. A fluctuating swelling near the proximalend of the ulna and on the dorsal aspect was incised onthe eighteenth day. From the pus thus obtainedStaphylococcus aureus was grown. A diagnosis ofperiostitis or osteomyelitis was made three days later,but was not confirmed. on radiological examination.During the period of clinical inflammation there wasvirtually no general systemic disturbance (Fig. 4). When54 days old a second radiograph of the elbow jointregion confirmed the original diagnosis of osteomyelitis(Fig. 5).The infant made good progress and an uneventful

recovery. Excellent functional use of the arm has beenobtained, so that at 6 years old pronation and supinationwere complete. The only disability was a limitation offlexion at the elbow (Fig. 6).

Case No. 3. Born on January 30, 1947, this spon-taneously delivered immature male infant weighed3 lb. 21 in. There was slight oedema of the legs, butthe general colour was good and breathing was

PERIOD OF ACUTE INFLAMMATION

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FIG. 2.-Chart of Case I showing absence of systemic disturbance during period of acute inflammation.

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OSTEOMYELITIS IN THE NEWBORN

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FIG. 4.--Chart showing only slight halt in weight gain and virtual absence of pyrexia. There was nO generalsystemic disturbance.

G. 6.-Limitation of flexion at

satisfactory. Because there was gastro-enteritis in the unitwhen the infant was born he was given sulphaguanidineas a prophylactic measure. The infant was fed by gavageand made satisfactory progress. On the night of thethirteenth day respirations became rapid and shallowand there was some vomiting. Though on clinical

examination no other abnormality was discovered, arespiratory infection was presumed and penicillin andsulphathiazole were exhibited from the fourteenth dayonwards (Fig. 7). Crepitations were heard in the rightlung on the following day and x-ray examinationsuggested bronchopneumonia.

Swelling over the anterior and superior aspects of theleft shoulder was seen on the sixteenth day. On aspira-tion, blood-stained pus was obtained and from itStaphyiococcus pyogenes albus was grown. It wasinsensitive to penicillin. An identical organism wascultured from the blood on the twentieth day. On thesame day small septic spots appeared on both arms andbecame haemorrhagic. The presence of osteomvelitisof the head of the left humerus was chown radiologicallyon the twenty-second day (Fig. 8). At the same timea localized inflammatory reaction developed in the leftankle and four days later the proximal end of the lefttibia was involved. Osteomyelitis of the tibia wasdemonstrated radiologically (Fig. 9), but the sameclinical diagnosis for the ankle was not confirmed. Theshoulder region, which had been aspirated three times,was opened and drained on the thirty-first day, when theankle was similarly dealt with. On the following dayloose green stools appeared and sulphaguanidinemedication was begun, but stopped in four days whenthese signs had disappeared. There was now littledischarge from the shoulder and none from the ankle.A respiratory infection was still manifest in a nasaldischarge. This became more profuse on the day ofdeath when crepitations were again heard in the rightlung. A severe cyanotic attack occurred and when thisrecurred the infant died, on the thirty-ninth day.Necropsy and histological examination were per-

formed. The findings were as follows:RESPIRATORY SYSTEM. A resolving pneumonia of

haematogenous origin, and minute, apparently quiescent,pyaemic abscesses in both lungs.LOCOMOToR SYSTEM. Osteomyelitis of the head and

neck of left humerus. Left shoulder joint intact, butdistended with pus. Osteomyelitis of the proximal end

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ARCHIVES OF DISEASE IN CHILDHOOD

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right medial malleolus, and

FIG. 8.-Osteomyelitis head of left humerus.

of the left tibia. Puru-lent arthritis of the leftankle joint and lefttarsal joints.Case No. 4. This

male infant was spon-taneously delivered onNovember 11, 1948. He,weighed 5 lb. 21 oz.

Progress was satis-factory until thefifteenth day whenirritability and anorexiawere observed. Onclinical examinationonly mild paronychiaof the left fifth toe wasobserved. Oral peni-cillin, 30,000 units four-hourly, was prescribed.Pyrexia and loss ofweight occurred in thenext 24 hours (Fig. 10).The infant appearedgrey and toxic. Theeyes were sunken.There was localizedinflammation over the

movement of the anklecaused the infant to cry. On the third day of theillness pus was aspirated from the ankle and aculture of penicillin-resistant Staphylococcus aureuswas obtained. At the same time the left wrist wasinflamied. Oral penicillin was changed to intramuscularinjections of 100,000 units three-hourly. On the fifthday of illness a swelling on the anterolateral aspect ofthe upper third of the right thigh was aspirated andthick pus obtained. By this time the inflammation of theleft wrist subsided, but the right ankle remained swollenand fluctuating. Oral penicillin, 200,000 units three-hourly, was given again. Some clinical improvement inthe child's condition was apparent at this time, anddespite the persistence of pyrexia the improvement wasmaintained. He lost the grey appearance of a desperatelyill infant. On the ninth day the localized swelling at theright ankle was incised, and from the pus a culture ofStaphylococcus aureus, resistant to over 100 units ofpenicillin per ml. but sensitive to 2 units of streptomycinper ml., was obtained. The discharge from the ankle waspersistent. A probe could be passed into the ankle joint.X-ray examination on the fifteenth day showed

destruction and dislocation of the head of the rightfemur (Fig. I1). An unsuspected lesion of the fourthright costochondral joint was also disclosed. Theright leg was kept abducted and externally rotatedwith a Putti mattress splint. On the nineteenth day ofthe illness streptomycin nmeication was begun, and100 mg. were given daily for nine days. All inflammationsubsided rapidly and the infant made good clinicalprogress. A radiograph on the fortieth day of illnessshowed regeneration of bone (Fig. 12). The infant wasdischarged when 93 days old, and weighed 8 lb. 71 oz.

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OSTEOMYELITIS IN THE NEWBORN27

disease of the fourth rightcostochondral joint. There wascomplete destruction of the headof the right femur, some mal-formation of the proximial end ofthe shaft, and some upward dis-placement. The acetabulum washealthy (Fig. 13).

DiscusionT'he consensus of opinion

concerning the aetiology ofneonatal osteomyelitis is infavour of an antecedent infec-tion. This may be omphalitis,as emphasized by Fraser, or arespiratory infection as in CaseNo. 3, or, most commonly, askin lesion. Skin lesions arevciy pIcVd.tmm II LIC IImWUU1Hperiod and are invariably

1IG. 9.-Osteomvelitis of proximal staphylococcal in type. Over,nd of tibia. 'No bone lesion a three-year period in a

demonstrated in ankle. maternity hospital Henderson(1943) recorded 550 cases, an

The child's progress has been supervised at the infant incidence of 6 .8o0. He reported no complicationswelfare clinic during the first year of life, and he has also other than conjunctivitis, and there were no deaths.attended the orthopaedic department. There have been These lesions are usually small, few in number, andno illnesses. At one year old he weighed 19 lb. 4 oz., transient. The relative infrequency with whichhad five teeth, and was an alert, happy child who on the copiaonaperadthesewhwihteslightest provocation exhibited a strong desire to stand caompictyothseionsapparladthe esempwitherwh uichhon his feet. maot fteelsosyiltosmethrpuc

Radiological examination at this age showed that the measures,. largely obscures the potential dangerright ankle joint had healed completely and had about which exists in all such cases.20 degrees of movement. There was no evidence of It is significant that all our four cases were

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FIG. IO.--Clinical chart showing grossly abnormal temperature and weight loss at beginning of illness.

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ARCHIVES OF DISEASE IN CHILDHOOD

immature infants. Such infants are immuno-logically immature, and not only much more

susceptible to bacterial invasion than full-terminfants, but also much less able to combat an

established infection.These four cases are divisible into two clinical

groups. Cases 1 and 2 showed no systemic

FIG. 12.-Radiograph illustrating rgeneration of boneon the fortieth day of the illness.

disturbance and ran a relatively mildor 'benign ' course, whereas Cases 3and 4 showed a gross systemicdisturbance which ended fatally for oneof them. This division of cases tendsto confirm Greengard's clinicalclassification (1946), which is supportedby Hutter (1948).

It can hardly be doubted that inCases 3 and 4 the multiple osteomyelitiswas a complication ansing from ablood-borne infection. This may havebeen of respiratory origin in Case 3,and have arisen from skin infection inCase 4.

In Cases I and 2 a feature was theintimate relationship of the site of theosteomyelitis to the site of the initialinflammatory lesion in the soft tissues.The circumscribed nature of the lesionthroughout the illness and the absenceof any gross systemic disturbance mighthave suggested that one was dealingwith a direct extension of a localinflammatory process. From this pointof view it is unfortunate that no bloodcultures were attempted in Cases 1 and2. Moreover, any consideration ofsuch a suggestion must be tempered bythe knowledge that Hutter obtainedpositive blood cultures from a case of

'benign' neonatal osteomyelitis.

FIG. 13.-Radiograph Showing condition of rght hipjoint at one year after illness.

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OSTEOMYELITIS IN THE NEWBORN 279

The three surviving cases each show some degreeof permanent disablement. The extent of thedisability in Cases 1 and 2 is slight and the functionalresult is very good. These two cases resemble thosedescribed by Cass (1940), who pointed out the riskof deformity in mild cases, and those described byEinstein and Thomas (1946) who said that involve-ment of a joint was a common and serious complica-tion in ' benign ' cases.The degree of loss of function sustained from

neonatal osteomyelitis is not determined by the' benignity ' or otherwise of the course of the diseasein the acute phase, but rather by the extent to whichnatural healing takes place and by the functionalnature of the affected bone and joint. This isillustrated in Case 4 which shows the greatest degreeof permanent disability of the three surviving cases.The much greater degree of disablement is caused bythe destruction of a joint which should provide ahigh degree of stability. It is not possible in thiscase to assess the ultimate extent of the functionaldisability. It is hoped that much may be accom-plished by orthopaedic means.

Because of the residual disability so often presentin 'benign ' or mild cases, one feels that the term'benign' is a misnomer whose use should bediscontinued. With this suggestion Greengard andHutter are in agreement.The high mortality rate hitherto recorded in

neonatal osteomyelitis is not likely to continue, forthe advent of chemotherapy and antibiotic treat-ment is exerting an ameliorating influence on theprognosis of this disease. This is well illustrated byHutter, who records that during 1934-43 in theChildren's Hospital, Los Angeles, there were 12cases of haemolytic staphylococcal osteomyelitisin children under the age of six months. Themortality rate was 580o. In the subsequent periodfrom 194347 there were six similar cases in the sameage period. They were all treated with penicillinand chemotherapy, with no deaths.The increase in the survival rate may result in the

sequelae of neonatal osteomyelitis being seen morefrequently in orthopaedic hospitals and clinics.

This premise cannot be based on the small numberof cases now recorded, but the two groups mentionedby Hutter offer highly suggestive evidence. In the1934-43 groups none of the survivors showedresidual deformity, but in the 1943-47 groupstwo-thirds ofthe survivors showed residual deformityinvolving one or more joints.

Four cases of neonatal osteomyelitis occurring inimmature infants are recorded.They are divisible into two clinical groups; one

relatively mild, the other severe and carryingconsiderable risk to life.The potential danger existing from staphylococcal

skin lesions in the neonatal period is stressed andthe particular susceptibility of the immature infant.

Attention is drawn to a probable increase in thenumber of cases of disability following neonatalosteomyelitis which may be seen in orthopaedicclinics.The adjective term 'benign' which has been

applied to the mild group of cases is a misnomer.

RiEFERENCESBass, M. H. (1928). Amer. J. Dis. Child., 35, 65.Baumgartner, J. (1920). Rev. med. Suisse rom., 40, 816.Cass, J. M. (1940). Arch. Dis. Childh., 15, 55.Dillehunt, R. B. (1935). Surg. Gynec. Obstet., 61, 96.Dunham, E. C. (1933). Amer. J. Dis. Child., 45, 229.Einstein, R. A. J., and Thomas, C. G. (1946). Amer. J.

Roentgenol., 55, 299.Fraser, J. (1924). Brit. med. J., 2, 605.Green, W. T. (1935). J. Amer. med. Ass., 105, 1835.

and Shannon, J. G. (1936). Arch. Surg., Chicago,32, 462.

Greengard, J. (1946). Med. Clin. N. Amer., 30, 135.Henderson, J. L. (1943). Edinb. med. J., 50, 535.Hutter, C. G. (1948). 1. Pediat., 32, 522.Karplus, D. (1928). Z. Kinderheilk, 45, 732.Madier, J. (1922). Nourrison, 10, 168.Marx, E. (1920). Nederl. Tijdschr. Geneesk., 2, 294.Mount, W. B. (1935). Amer. J. Obstet. Gvnec.. 29, 126.Palew, P. (1931). Amer. J. Surg., 13, 246.Poncher, H. G., and Blayney, J. R. (1934). Armer. J.

Dis. Child., 48, 730.Shulman, B. H. (1946). J. Aner. med. Ass., 130, 854.Stone, S. (1942). Aner. J. Dis. Child., 64, 680.Wilensky, A. 0. (1932). Ibid., 43, 431.

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