Consensus guidelines on the management of musculoskeletal infection affecting children in the UK

Abstract

AimsThe aim of this study was to determine the consensus best practice approach for the investigation and management of children (aged 0 to 15 years) in the UK with musculoskeletal infection (including septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis). This consensus can then be used to ensure consistent, safe care for children in UK hospitals and those elsewhere with similar healthcare systems.MethodsA Delphi approach was used to determine consensus in three core aspects of care: 1) assessment, investigation, and diagnosis; 2) treatment; and 3) service, pathways, and networks. A steering group of paediatric orthopaedic surgeons created statements which were then evaluated through a two-round Delphi survey sent to all members of the British Society for Children’s Orthopaedic Surgery (BSCOS). Statements were only included (‘consensus in’) in the final agreed consensus if at least 75% of respondents scored the statement as critical for inclusion. Statements were discarded (‘consensus out’) if at least 75% of respondents scored them as not important for inclusion. Reporting these results followed the Appraisal Guidelines for Research and Evaluation.ResultsA total of 133 children’s orthopaedic surgeons completed the first survey, and 109 the second. Out of 43 proposed statements included in the initial Delphi, 32 reached ‘consensus in’, 0 ‘consensus out’, and 11 ‘no consensus’. These 11 statements were then reworded, amalgamated, or deleted before the second Delphi round of eight statements. All eight were accepted as ‘consensus in’, resulting in a total of 40 approved statements.ConclusionIn the many aspects of medicine where relevant evidence is not available for clinicians to base their practice, a Delphi consensus can provide a strong body of opinion that acts as a benchmark for good quality clinical care. We would recommend clinicians managing children with musculoskeletal infection follow the guidance in the consensus statements in this article, to ensure care in all medical settings is consistent and safe.Cite this article: Bone Joint J 2023;105-B(7):815–820.

Investigation and Management of Lower Limb Septic Arthritis in Children: An Update Using the Latest British Orthopaedic Association Standard for Trauma (BOAST) Guidelines

“…If the child is stable and surgery is planned, antibiotics may be delayed until synovial fluid sampling is completed [6]. Osteomyelitis in adjacent bones must be considered in all cases of septic arthritis [19]. Definitive management comprises urgent surgical drainage and lavage of the joint [2], ideally within 24 hours.…”

“…As well as this, any child with suspected septic arthritis should also have an examination of their spine and a full systemic assessment to exclude alternative infection sources [ 6 ]. This should include upper respiratory tract and ears [ 19 ]. Generally, the limb will be held in a position where the joint capsule is most lax for comfort.…”

“…Figure 2 shows an MRI of a patient with septic arthritis of the knee. Ultrasound may be an alternative when MRI is not possible [ 19 ] and may be more sensitive than MRI at detecting early joint effusions [ 20 ]. An ultrasound image showing an effusion of the hip joint is shown in Figure 3 .…”

“…If a child has acute symptoms and initial investigations reveal elevated inflammatory markers or joint effusion on imaging, they should be kept nil by mouth and urgently referred to orthopedics. It is important to note that normal inflammatory markers do not exclude septic arthritis early in the disease course [ 19 ]. If the child is clinically stable and not displaying signs of hemodynamic compromise from sepsis, antibiotic therapy may be delayed allowing joint aspiration first to obtain a sample for microscopy and culture [ 21 ].…”

Children’s orthopaedics

“…Guidelines on care can be helpful to eliminate variation in practice, and this work from the British Society for Children’s Orthopaedic Surgery (BSCOS) group working in various institutions in the UK aimed to establish a consensus on the best practices for investigating and managing musculoskeletal infections. 4 Their guidelines are aimed for use in children aged zero to 15 years in the UK. This includes all infective conditions, such as septic arthritis, osteomyelitis, pyomyositis, tenosynovitis, fasciitis, and discitis.…”