Bone Abstracts

Background: Meningococcal septicaemia in childhood has a high mortality rate in the acute stage, often requiring intensive care support. Survivors are well known to have long-term sequelae in the form of neuropathy, renal scarring, loss of limbs and necrotic tissue damage. We describe here a case where a survivor of this disease developed growth plate arrest and consequent severe bowing of both tibias which now require surgical correction. Relevant literature is also reviewed.

Presenting problem: A 14-month-old boy with severe meningococcal septicaemia and wide spread necrotic skin lesions over buttocks and knees had required ventilation, inotrope support, and renal replacement therapy in the acute stage; but recovered well in 3 weeks with none of the well recognised complications. Three months later he developed progressive bowing of both legs (more noticeable on walking) and a waddling gait but no other clinical or biochemical features of rickets. X-ray of lower limbs revealed abnormal metaphyseal changes at the distal femoral and proximal tibial ends with linear lucencies, sclerosis and irregular widened growth plates. MR scans confirmed growth plate abnormalities secondary to septicaemic illness.

Clinical management: Over the next few months, his bowing became further pronounced. Though he was initially managed conservatively, he will need corrective osteotomies on the medial side. In addition to optimising calcium and vitamin D intake as well as active physiotherapy, he remains under close follow up for growth, limb length and deformity monitoring.

Discussion: Few studies in the literature (Canavese 2010, Monsell 2011, Park 2011) have described similar experiences with larger cohorts of children, and recognised need for monitoring for late bone sequelae, as well as role for corrective osteotomies in this group. Likely aetiologies include ischemia secondary to endotoxin induced microvascular damage to the physes, peripheral growth plate injury due to tethering under areas of skin necrosis, and high metabolic rate with differential perfusion of different areas of the growth plate.

Conclusion: Orthopaedic abnormalities though not very common, can have significant impact on growth and development of children surviving severe meningococcal disease. Increased awareness and prompt recognition as well as early orthopaedic intervention is required to optimise long-term growth potential of the long bones and restoration of limb length as well as mechanical axis in this group.