Osteomyelitis: A Mother's Perspective
Dec. 16, 2001 began like any other Saturday. About 7 a.m., our 3-year-old son Chandler arose requesting cartoons and cereal. It was not until later that afternoon that I noticed something strange about Chandler's walk. He was favoring his right heel and when I asked him about it, he stated that his foot hurt. I assumed he had stepped on a toy or gotten a rock in his shoe and had bruised his heel. As the week progressed, so did Chandler's limp. I checked with the staff of his daycare center and they reported the same observation. By the following Saturday, the pain in his heel had become so severe that he would cry when the slightest pressure was applied to his foot. A simple task such as putting his shoes on brought tears to his eyes.
I took Chandler to see the on-call pediatrician on Dec. 22. The physician examined his heel and diagnosed it as Sever's disease. I was unfamiliar with this condition. The pediatrician explained that Sever's disease occurs when the growth plate in the heel shifts. He stated it is a self-correcting condition although it may take several months. He suggested I purchase a gel insert for Chandler's shoes to provide some relief when walking. I researched the condition on the Internet and learned Sever's disease is most prominent in pre-pubescent boys ages 12-15 years who are moderately to severely overweight. Chandler is certainly pre-pubescent and weighs 30 pounds.
On Christmas Eve I took Chandler to a local orthopedic physician who agreed that Sever's disease would be a little unusual. He X-rayed Chandler's foot and found no abnormalities. He prescribed a short walking cast to relieve some of the pressure. Finally, I thought, we are making progress. The following week, Chandler stopped bearing weight on his right foot and asked me to carry him everywhere. When I refused to carry him, he would crawl. When I insisted that he walk "like a big boy," he would hop on his left foot. As a nurse, I am all too familiar with the array of possibilities that might be causing him such discomfort. I could feel the fear setting in.
By Jan. 4, 2002, we were back in the orthopedic physician's office. He ordered lab tests (a complete blood count, sedimentation rate and a CRP) and an MRI for the following week. My prayer was simple: please let it be something "fixable." Chandler was sleeping very little at night. He would awake crying and I would find him sitting up in bed, rocking back and forth and holding his foot. "Mommy, my foot hurts," he would sob. We obtained the MRI results the next day. Nothing unusual was found. We were presented with the options of keeping the cast on, or referring us to a pediatric orthopedic surgeon. I opted for the latter, since we knew very little after four weeks.
On Jan. 16, Chandler and I saw the specialist. The physician examined Chandler's foot, reviewed the MRI and lab results and took additional X-rays. He gave me three possibilities: an occult fracture, a malignancy or osteomyelitis. He thought a fracture was highly unlikely. It would be unusual for a 4-week-old fracture to be the source of so much discomfort. He thought a malignancy was unlikely after seeing nothing on the MRI, in the lab results or on the physical exam to support this diagnosis. The only possibility was osteomyelitis. He ordered a bone scan to confirm his suspicions.
Osteomyelitis. How did this happen? There had been no trauma to Chandler's foot. Being certified in infection control, I know osteomyelitis does not just appear; there must be a precipitating factor. The specialist explained it is unusual to see osteomyelitis in a child as young as Chandler; however, he treats one or two cases per year. In every case, osteomyelitis occurred in the heel bone. He explained this was due to the porous nature of the heel at this age. Bacteria that enters the body's circulation tends to get trapped within these cracks and crevices and that's where it reproduces. I recalled that in early December Chandler had fallen at daycare and hit the back of his head. Although it did not require stitches, it was a severe bump requiring part of his hair be shaved. The surgeon agreed this could have been the initial entry point or it could have been something much less significant, like brushing his teeth.
Chandler had surgery Jan. 18. We received good news from the surgeons that the needle aspiration did not reveal pus so an I & D was not indicated. The central line had been placed without difficulty and Chandler had already received his first of many doses of Rocephin. The culture returned negative so we are still uncertain as to the causative organism. Chandler made a miraculous recovery. Within several days, he began to bear minimal weight on the affected foot, and within several weeks his limp was barely noticeable. By the time we switched to oral antibiotics four weeks later, his gait was essentially normal.
Today, Chandler is a normal, active, vivacious little boy who has only a small scar on his right chest marking the insertion site of his central line catheter. The biggest lessons I learned from this experience are to always trust your instincts and always listen to your children. Never ignore that little voice inside ... it could save your child's life.
Pamela Ward, RN, BSN, CIC, is program director of The Wound Center at Carolinas Hospital System in Florence, S.C.