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Neonatal osteomyelitis of the calcaneus: Complication of heel puncture
478
March 1976 The Journal o f P E D I A T R I C S
Neonatal osteomyelitis of the calcaneus: Complication of heel puncture L a w r e n c e D. L i l i e n , M . D . , * V i v i a n J . H a r r i s , M . D . , R a j a m S. R a m a m u r t h y , M . D . , and R o s i t a S. P i l d e s , M . D . , Chicago, Ill.
HEEL PUNCTURES have provided a simple m e t h o d o f obtaining blood from neonates for biochemical determinations. A m i n i m u m of 15,000 h e e l punctures are performed yearly in our neonatal unit which cares for approximately 6,500 neonates per year. W e have seen superficial infection at the puncture sites on rare occasions in small infants who required prolonged respiratory assistance and numerous determinations of blood gases. Osteomyelitis of the underlying os calcis, however, has occurred in only two neonates during a seven-year period. These infants form the basis of this report. CASE REPORTS Case 1. A 2,040 gm infant born at 36 weeks' gestation had approximately six heel punctures during the first five days of life. On the fifth day, a purulent discharge was seen at the puncture site over the left heel; this cleared on the following day. Coagulase-positive Staphylococcus aureus, resistant to penicillin, was cultured from the pus. On the thirteenth day, the heel was blue, swollen, and tender; a purulent discharge was again noted. Oral therapy with oxacillin was begun. Three days later, a large amount of pus was expressed. On the eighteenth day, a roentgenogram revealed erosion of the posterior portion of the left calcaneus compatible with osteomyelitis (Fig. 1). Incision of the abscess revealed a cavity which reached the calcaneus and yielded one milliliter of pus. The cavity was packed with iodoform gauze, and therapy with oxacillin was changed to parenteral methicillin (200 mg/kg/day). Twenty-four hours later, the discharge was no longer present. Clinical improvement continued, and less rarefaction of the calcaneus was seen radioFrom the Division of Neonatology and Pediatric Radiology, Cook County Hospital, University of Health Sciences~The Chicago Medical School and The Abraham Lincoln School of Medicine of the University of Illinois, College of Medicine. *Reprint address: Department of Pediatrics, Cook County Hospital, 700 South Wood St., Chicago, Ill. 60612.
Vol. 88, No. 3, pp. 478-480
graphically on the fifth day of parenteral therapy. Methiciltin was discontinued after 24 days; oral oxacillin (180 mg/kg/day) was given for an additional 17 days. Roentgenograms continued to show reossification of the calcaneus indicative of a heating osteomyelitis (Figs. 2 and 3). The infant remained normothermic throughout his hospital course, took feedings well, and gained weight at a normal rate. He was discharged at eight weeks of age. Case 2. A 1,710 gm infant born at 34 weeks' gestation had 12 heel punctures during the first ten days of life. On tlae tenth day, the left heel became swollen, erythematous, and tender. A small incision yielded pus. A few hours later, the infant developed fever of 38~ with no other clinical evidence of sepsis. Blood and urine cultures were taken an d therapy with intravenous methiciUin and intramuscular kanamycin was started~ The purulent discharge from the heel and the blood culture grew coagulase-positive S. aureus. Roentgenogram of the heel was normal. After nine days of therapy, there was minimal swelling and erythema but no discharge; roentgenogram at this time showed soft tissue swelling and erosion of the posterior aspect of the left os calcis. Kanamycin was discontinued and parenteral methicillin (200 mg/kg/ day) was continued for a total of six weeks. After three weeks of therapy, roentgenograms of the heel showed progressive heating with sclerosis and periosteal reaction. The infant continued to grow normally and was discharged at eight weeks of age. DISCUSSION Osteomyelitis in the neonatal period usually involves the metaphysis of long bones, particularly the humerus and femur? Other bones are occasionally involved, but we were unable to find any reports of osteomyelitis of the os calcis in neonates. In children, osteomyelitis o f the os calcis is also rare; the incidence varies between 3% to 8% in some reviews?, a The portal of entry in the neonates in this report can be ascribed to heel punctures performed nine to 19 days prior to roentgenologic evidence o f osteomyelitis. Three of eight children with calcaneus osteomyelitis reported by
Volume 88 Number 3
Fig. I. Case 1, Day 18: Extensive soft tissue swelling of heel is visible. The entire posterior half of os calcis is radiolucent with poorly defined cortical borders all suggesting destruction of bone.
Fig. 2. Case 1, Day 31: There is healing with deformity of posterior surface of the calcaneus. A large rounded calcaneal spur (not present on the opposite heel) is seen.
Feigin and associates ~ had puncture wounds of the heel 12 to 30 days prior to admission. The pathomechanics in our neonates may be direct extension of a soft tissue cellulitis overlying the calcaneus. However, the possibility of direct seeding of the calcaneus by means of long lancet cannot be excluded (Fig. 4). Feigin and associates 3 noted that children with puncture wounds had dissolution of bone on the plantar surface of the calcaneus. On the other hand, those with
Neonatal osteomyelitis o f the calcaneus
479
Fig. 3. Case 1, Day 60: On axial calcaneal view taken 29 days later, there is evidence of abundant new bone formation on lateral aspect of left ealeaneus.
Fig. 4. Postmortem roentgenogram of a 2,000 gm baby showing that the lancet (Becton Dickinson long-point microlance, No. 419, Rutherford, N. J.) tip may reach the periosteum if pressure is exerted on lancet.
hematogenous disease manifested extensive subapophyseal destruction, corresponding to the area of greatest blood supply. This distinction may be difficult in neonates, since the calcaneus apophysis does not appear until four years of age. However, the localized involvement seen radio~aphically in our infants indicates direct extension rather than hematogenous spread. The relatively benign clinical course generally seen in neonatal osteomyelitisI was also evident in these two infants who did not manifest any systemic signs of sepsis. The minimal temperature elevation observed in Case 2
480
Lilien et al
was seen on only one occasion. On the other hand, the site of infection may also be an important factor. Benign clinical courses have been reported in older children who developed osteomyelitis of the calcaneus. 4, ~ Coagulase-positive S. aureus was cultured from the superficial wounds in both infants and is the organism most frequently reported in neonatal osteomyelitisI and calcaneus osteomyelitis in children. 2, ~ The positive blood culture in Case 2 may have been secondary to manipulation of the infected area and development of transient bacteremia. Management of neonatal calcaneus osteomyelitis involves prompt administration of appropriate antibiotics and incision and drainage of forming abscesses. Antibiotic therapy is continued for three to six weeks? With this management, it is unlikely that extensive surgical procedures would be necessary. Although heel puncture is considered a relatively
The Journal of Pediatrics March 1976
benign procedure, aseptic technique must be employed. Roentgenograms are indicated if soft tissue swelling and tenderness of the heel is seen, and if no osseous lesion is apparent should be repeated in seven to ten days, since roentgenologic evidence of osteomyelitis often appears following clinical evidence of disease. REFERENCES
1. Weissberg ED, Smith AL, and Smith DH: Clinical features of neonatal 'osteomyelitis, Pediatrics 53:505, 1974. 2. Antoniou D, and Conner AN: Osteomyelitis of the calcaneus and talus, J Bone Joint Surg 56-A:338, 1974. 3. Feigin RD, McAlister WH, San Joaquin VH, and Middlekamp JN: Osteomyelitis of the calcanus, Am J Dis Child 119:61, 1970. 4. Robertson DE: Primary acute and subacute localized osteomyelitis and osteochondritis in children, Canadian J Surg 10:408, 1967. 5. King DM, and Mayo KM: Subacute haematogenous osteomyelitis, J Bone Joint Surg 51-B:458, 1969.
March 1976 The Journal o f P E D I A T R I C S
Neonatal osteomyelitis of the calcaneus: Complication of heel puncture L a w r e n c e D. L i l i e n , M . D . , * V i v i a n J . H a r r i s , M . D . , R a j a m S. R a m a m u r t h y , M . D . , and R o s i t a S. P i l d e s , M . D . , Chicago, Ill.
HEEL PUNCTURES have provided a simple m e t h o d o f obtaining blood from neonates for biochemical determinations. A m i n i m u m of 15,000 h e e l punctures are performed yearly in our neonatal unit which cares for approximately 6,500 neonates per year. W e have seen superficial infection at the puncture sites on rare occasions in small infants who required prolonged respiratory assistance and numerous determinations of blood gases. Osteomyelitis of the underlying os calcis, however, has occurred in only two neonates during a seven-year period. These infants form the basis of this report. CASE REPORTS Case 1. A 2,040 gm infant born at 36 weeks' gestation had approximately six heel punctures during the first five days of life. On the fifth day, a purulent discharge was seen at the puncture site over the left heel; this cleared on the following day. Coagulase-positive Staphylococcus aureus, resistant to penicillin, was cultured from the pus. On the thirteenth day, the heel was blue, swollen, and tender; a purulent discharge was again noted. Oral therapy with oxacillin was begun. Three days later, a large amount of pus was expressed. On the eighteenth day, a roentgenogram revealed erosion of the posterior portion of the left calcaneus compatible with osteomyelitis (Fig. 1). Incision of the abscess revealed a cavity which reached the calcaneus and yielded one milliliter of pus. The cavity was packed with iodoform gauze, and therapy with oxacillin was changed to parenteral methicillin (200 mg/kg/day). Twenty-four hours later, the discharge was no longer present. Clinical improvement continued, and less rarefaction of the calcaneus was seen radioFrom the Division of Neonatology and Pediatric Radiology, Cook County Hospital, University of Health Sciences~The Chicago Medical School and The Abraham Lincoln School of Medicine of the University of Illinois, College of Medicine. *Reprint address: Department of Pediatrics, Cook County Hospital, 700 South Wood St., Chicago, Ill. 60612.
Vol. 88, No. 3, pp. 478-480
graphically on the fifth day of parenteral therapy. Methiciltin was discontinued after 24 days; oral oxacillin (180 mg/kg/day) was given for an additional 17 days. Roentgenograms continued to show reossification of the calcaneus indicative of a heating osteomyelitis (Figs. 2 and 3). The infant remained normothermic throughout his hospital course, took feedings well, and gained weight at a normal rate. He was discharged at eight weeks of age. Case 2. A 1,710 gm infant born at 34 weeks' gestation had 12 heel punctures during the first ten days of life. On tlae tenth day, the left heel became swollen, erythematous, and tender. A small incision yielded pus. A few hours later, the infant developed fever of 38~ with no other clinical evidence of sepsis. Blood and urine cultures were taken an d therapy with intravenous methiciUin and intramuscular kanamycin was started~ The purulent discharge from the heel and the blood culture grew coagulase-positive S. aureus. Roentgenogram of the heel was normal. After nine days of therapy, there was minimal swelling and erythema but no discharge; roentgenogram at this time showed soft tissue swelling and erosion of the posterior aspect of the left os calcis. Kanamycin was discontinued and parenteral methicillin (200 mg/kg/ day) was continued for a total of six weeks. After three weeks of therapy, roentgenograms of the heel showed progressive heating with sclerosis and periosteal reaction. The infant continued to grow normally and was discharged at eight weeks of age. DISCUSSION Osteomyelitis in the neonatal period usually involves the metaphysis of long bones, particularly the humerus and femur? Other bones are occasionally involved, but we were unable to find any reports of osteomyelitis of the os calcis in neonates. In children, osteomyelitis o f the os calcis is also rare; the incidence varies between 3% to 8% in some reviews?, a The portal of entry in the neonates in this report can be ascribed to heel punctures performed nine to 19 days prior to roentgenologic evidence o f osteomyelitis. Three of eight children with calcaneus osteomyelitis reported by
Volume 88 Number 3
Fig. I. Case 1, Day 18: Extensive soft tissue swelling of heel is visible. The entire posterior half of os calcis is radiolucent with poorly defined cortical borders all suggesting destruction of bone.
Fig. 2. Case 1, Day 31: There is healing with deformity of posterior surface of the calcaneus. A large rounded calcaneal spur (not present on the opposite heel) is seen.
Feigin and associates ~ had puncture wounds of the heel 12 to 30 days prior to admission. The pathomechanics in our neonates may be direct extension of a soft tissue cellulitis overlying the calcaneus. However, the possibility of direct seeding of the calcaneus by means of long lancet cannot be excluded (Fig. 4). Feigin and associates 3 noted that children with puncture wounds had dissolution of bone on the plantar surface of the calcaneus. On the other hand, those with
Neonatal osteomyelitis o f the calcaneus
479
Fig. 3. Case 1, Day 60: On axial calcaneal view taken 29 days later, there is evidence of abundant new bone formation on lateral aspect of left ealeaneus.
Fig. 4. Postmortem roentgenogram of a 2,000 gm baby showing that the lancet (Becton Dickinson long-point microlance, No. 419, Rutherford, N. J.) tip may reach the periosteum if pressure is exerted on lancet.
hematogenous disease manifested extensive subapophyseal destruction, corresponding to the area of greatest blood supply. This distinction may be difficult in neonates, since the calcaneus apophysis does not appear until four years of age. However, the localized involvement seen radio~aphically in our infants indicates direct extension rather than hematogenous spread. The relatively benign clinical course generally seen in neonatal osteomyelitisI was also evident in these two infants who did not manifest any systemic signs of sepsis. The minimal temperature elevation observed in Case 2
480
Lilien et al
was seen on only one occasion. On the other hand, the site of infection may also be an important factor. Benign clinical courses have been reported in older children who developed osteomyelitis of the calcaneus. 4, ~ Coagulase-positive S. aureus was cultured from the superficial wounds in both infants and is the organism most frequently reported in neonatal osteomyelitisI and calcaneus osteomyelitis in children. 2, ~ The positive blood culture in Case 2 may have been secondary to manipulation of the infected area and development of transient bacteremia. Management of neonatal calcaneus osteomyelitis involves prompt administration of appropriate antibiotics and incision and drainage of forming abscesses. Antibiotic therapy is continued for three to six weeks? With this management, it is unlikely that extensive surgical procedures would be necessary. Although heel puncture is considered a relatively
The Journal of Pediatrics March 1976
benign procedure, aseptic technique must be employed. Roentgenograms are indicated if soft tissue swelling and tenderness of the heel is seen, and if no osseous lesion is apparent should be repeated in seven to ten days, since roentgenologic evidence of osteomyelitis often appears following clinical evidence of disease. REFERENCES
1. Weissberg ED, Smith AL, and Smith DH: Clinical features of neonatal 'osteomyelitis, Pediatrics 53:505, 1974. 2. Antoniou D, and Conner AN: Osteomyelitis of the calcaneus and talus, J Bone Joint Surg 56-A:338, 1974. 3. Feigin RD, McAlister WH, San Joaquin VH, and Middlekamp JN: Osteomyelitis of the calcanus, Am J Dis Child 119:61, 1970. 4. Robertson DE: Primary acute and subacute localized osteomyelitis and osteochondritis in children, Canadian J Surg 10:408, 1967. 5. King DM, and Mayo KM: Subacute haematogenous osteomyelitis, J Bone Joint Surg 51-B:458, 1969.