Dec.16, 2001 began like any other Saturday. About 7 a.m., our 3-year-old sonChandler arose requesting cartoons and cereal. It was not until later thatafternoon that I noticed something strange about Chandler's walk. He wasfavoring his right heel and when I asked him about it, he stated that his foothurt. I assumed he had stepped on a toy or gotten a rock in his shoe and hadbruised his heel. As the week progressed, so did Chandler's limp. I checked withthe staff of his daycare center and they reported the same observation. By thefollowing Saturday, the pain in his heel had become so severe that he would crywhen the slightest pressure was applied to his foot. A simple task such asputting his shoes on brought tears to his eyes.
I took Chandler to see the on-call pediatrician on Dec. 22. The physicianexamined his heel and diagnosed it as Sever's disease. I was unfamiliar withthis condition. The pediatrician explained that Sever's disease occurs when thegrowth plate in the heel shifts. He stated it is a self-correcting conditionalthough it may take several months. He suggested I purchase a gel insert forChandler's shoes to provide some relief when walking. I researched the conditionon the Internet and learned Sever's disease is most prominent in pre-pubescentboys ages 12-15 years who are moderately to severely overweight. Chandler iscertainly pre-pubescent and weighs 30 pounds.
On Christmas Eve I took Chandler to a local orthopedic physician who agreedthat Sever's disease would be a little unusual. He X-rayed Chandler's foot andfound no abnormalities. He prescribed a short walking cast to relieve some ofthe pressure. Finally, I thought, we are making progress. The following week,Chandler stopped bearing weight on his right foot and asked me to carry himeverywhere. When I refused to carry him, he would crawl. When I insisted that hewalk "like a big boy," he would hop on his left foot. As a nurse, I amall too familiar with the array of possibilities that might be causing him suchdiscomfort. I could feel the fear setting in.
By Jan. 4, 2002, we were back in the orthopedic physician's office. Heordered lab tests (a complete blood count, sedimentation rate and a CRP) and anMRI for the following week. My prayer was simple: please let it be something"fixable." Chandler was sleeping very little at night. He would awakecrying and I would find him sitting up in bed, rocking back and forth andholding his foot. "Mommy, my foot hurts," he would sob. We obtainedthe MRI results the next day. Nothing unusual was found. We were presented withthe options of keeping the cast on, or referring us to a pediatric orthopedicsurgeon. I opted for the latter, since we knew very little after four weeks.
On Jan. 16, Chandler and I saw the specialist. The physician examinedChandler's foot, reviewed the MRI and lab results and took additional X-rays. Hegave 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-oldfracture to be the source of so much discomfort. He thought a malignancy wasunlikely after seeing nothing on the MRI, in the lab results or on the physicalexam to support this diagnosis. The only possibility was osteomyelitis. Heordered a bone scan to confirm his suspicions.
Osteomyelitis. How did this happen? There had been no trauma to Chandler'sfoot. Being certified in infection control, I know osteomyelitis does not justappear; there must be a precipitating factor. The specialist explained it isunusual to see osteomyelitis in a child as young as Chandler; however, he treatsone or two cases per year. In every case, osteomyelitis occurred in the heelbone. 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 thesecracks and crevices and that's where it reproduces. I recalled that in earlyDecember Chandler had fallen at daycare and hit the back of his head. Althoughit did not require stitches, it was a severe bump requiring part of his hair beshaved. The surgeon agreed this could have been the initial entry point or itcould have been something much less significant, like brushing his teeth.
Chandler had surgery Jan. 18. We received good news from the surgeons thatthe needle aspiration did not reveal pus so an I & D was not indicated. Thecentral line had been placed without difficulty and Chandler had alreadyreceived his first of many doses of Rocephin. The culture returned negative sowe are still uncertain as to the causative organism. Chandler made a miraculousrecovery. Within several days, he began to bear minimal weight on the affectedfoot, and within several weeks his limp was barely noticeable. By the time weswitched to oral antibiotics four weeks later, his gait was essentially normal.
Today, Chandler is a normal, active, vivacious little boy who has only asmall scar on his right chest marking the insertion site of his central linecatheter. The biggest lessons I learned from this experience are to always trustyour instincts and always listen to your children. Never ignore that littlevoice inside ... it could save your child's life.
Pamela Ward, RN, BSN, CIC, is program director of The Wound Center atCarolinas Hospital System in Florence, S.C.