THE ORTHOPAEDIC MANAGEMENT OF PERIPHERAL ISCHAEMIA IN CHILDHOOD MENINGOCOCCAL SEPTICAEMIA

Abstract

Aims: Evaluate the outcome of orthopaedic intervention in children who sustained peripheral ischaemia resulting from meningococcal septicaemia and to assess the benefit of fasciotomies within this group.

Introduction: There have been only two published series on the orthopaedic management of meningococcal septicaemia in children. We carried out a retrospective review of all patients who had undergone this intervention in RHSC.

Methods: Between 1994 and 2004 there were 190 admissions to paediatric intensive care unit (PICU) with meningococcal septicaemia. 12 had significant Orthopaedic/Plastic Surgical input. Case notes were examined to establish admission patterns, limb progress, subsequent operative intervention and eventual outcomes.

All presented with vague viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 children were admitted from A& E and 4 were transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).

We were able to follow up 8 of the survivors clinically.

Results: All children had some form of surgical treatment. 9 children had one or more amputations. Two children did not require amputations. Seven of the 12 children had fasciotomies performed (mean 34 hours after admission, range 2–96 hours). The child who died from overwhelming sepsis had multiple fasciotomies at 9 hours post admission. The remaining children had varying amputations. The other five children did not have fasciotomies. Of these one child did not require any amputations, three children had partial amputation of a single limb and one child had partial amputations of two limbs. All five within this group required additional split-skin grafts.

8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).

Conclusion: There is no evidence from our study that early fasciotomies are detrimental to survival, limb function or subsequent wound healing after definitive amputation. In other published series fasciotomy has been advocated within 24hours.

In our study 2 of our 7 patients who underwent fasciotomy the demarcation level receded distally post decompression leading to more distal amputation levels.