**3. Gender, age, type, and site of infection**

Several trends can be derived from the reported cases in a descriptive manner. Children with DVT were noted to be male 34 times out of the 46 cases in which gender was identified

Deep Venous Thrombosis in Children with Musculoskeletal Infection 71

Findings Features

SPE CVC

MRSA R femoral SPE CVC

MSSA L popliteal SPE CVC

C. Tropicalis L popliteal Unknown CVC

MRSA IVC and SVC Unknown CVC

S aureus R femoral Bilateral infiltrates ICU; PVL

S aureus Unkown SPE PVL

Clear

pneumonia

Unknown ICU; PVL

SPE PVL

SPE PVL

SPE ICU

transverse sinues

Hip MRSA Unkown Necrotizing

MSSA L femoral; bilateral IJs; R brachial

femoral; iliac

MRSA L superficial/common femoral

MRSA R subclavian; brachial; cephalic

MRSA R femoral; external iliac; saphenous

Source Year Series DVT Age (y) Sex Type Location Organism DVT Site Pulmonary

femur

tibia

femur

tibia

L distal femur

Dohin8 2007 39 3 U U U Unknown S aureus Unkown Unknown PVL

femur

femur

femur

humerus

MRSA-Methicillin Resistant Staph Aureus; S-staphyloccocus; GABHS-Group A beta hemolytic

SPE-Septic pulmonary emboli; PneumoT-Pneumothorax; ICU-Intensive care unit; Comp. sy.-

CVC-Central venous catheters; Sep. Art.- Septic Arthritis; Strep.- Streptoccocus; IJ-Internal jugular Table 1. Summary of Published Cases of DVT in Patients with Musculoskeletal Infection

(73.9%).1-19 The average age of the children with DVT in the reviewed studies was 9 years with only six children under the age of 4 years among the 49 children with a recorded age (12.2%).1- 19 The type of infection was found to be osteomyelitis in 51 out of the 55 cases (92.7%) in which the musculoskeletal infection type was delineated. 1-19 However, two cases of septic arthritis and two cases of pyomyositis were also noted.2,7,9 The location of the infection was reported in 46 out of the 54 children with osteomyelitis and noted to be unifocal in 40 children and multifocal in the remaining six (see table 2). The site of osteomyelitis was most commonly reported in the femur (26 occurrences), and specifically reported in the proximal femur on 7 occasions and the distal femur on 6 occasions. The tibia was the second most common location of osteomyelitis (13 occurrences) with the proximal tibia specified in 5 cases and the distal tibia specified in one case. Overall, the location of the musculoskeletal infection was found to be in the pelvis (ilium, ischium, pubis, or sacrum) or lower extremities in 48 out of the 51 cases in which the site of infection was reported (94.1%), with the three remaining cases identified in

DVT-Deep vein thrombosis; y-years; m-Male; f-Female; U-Unknown; Osteo.-Osteomyelitis; R-Right; L-

 6 U Osteo. L femur EnterococcusUnkown Unknown 13 U Osteo. L femur S aureus Unkown Unknown

Gite12 2008 3 8 U Osteo. R femur No growth Unkown Unknown

and tibia

8 f Pyom. L calf Strep. MilleriL posterior tibial Clear

L hip GABHS R IJ; Sigmoid;

 U U U Unknown S aureus Unkown Unknown PVL U U U Unknown S aureus Unkown Unknown PVL

10 m Osteo. R proximal

6 f Osteo. L distal tibia,

Art.

Art.

Nourse11 2007 2 1 m Osteo. L femur MRSA L superficial/common

9 m Osteo. R proximal

13 m Osteo. L proximal

Compartment syndrome; PVL-Panton-Valentine Leukocidin; C. Candida;

the upper extremities (humerus in two children) and thoracic spine.

13 m Osteo. R femur

2 m Osteo. R proximal

4 m Osteo. L proximal

Mitchell10 2007 3 9 m Osteo. R proximal

McDonald13 2010 1 5 m Osteo. R proximal

Left; MSSA-Methicillin Senstive Staph Aureus; Bil.-Bilateral;

streptoccocci; IVC-Inferior vena cava; SVC-Superior vena cava;

14 m Osteo. L distal

6 f Sep.

Castaldo7 2007 1 U U Sep.


MSSA R femoral; popliteal L lower lobe

MSSA L femoral; popliteal Diffuse infiltrates

MSSA L femoral Pneumatoceles Death

MSSA R femoral Multiple lung

MSSA L femoral Pneumonia,

S aureus L iliac Multiple

MSSA L femoral; popliteal Bil. patchy

S aureus R external iliac Bil. Densities;

external iliac

popliteal

MRSA SVC; L internal jugular; subclavian

external iliac

R atrium

S aureus IVC; L common femoral

 2.5 f Osteo. L ilium S aureus IVC; common iliac Pneumonia ICU 6 f Pyom. L soleus GABHS L popliteal; peroneal Unknown Comp. sy.

 14 m Osteo. L tibia MRSA L popliteal; saphenous SPE PVL 11 m Osteo. L femur MRSA L femoral vein SPE PVL; CVC

2004 59 5 U U Osteo. Unkown MRSA Unkown Unknown PVL U U Osteo. Unkown MRSA Unkown Unknown PVL U U Osteo. Unkown MRSA Unkown Unknown PVL U U Osteo. Unkown MRSA Unkown Unknown PVL U U Osteo. Unkown MSSA Unkown Unknown PVL

Findings Features

PneumoT.

ICU

infiltrate

infiltrates

emboli

empyema

infiltrates

infiltrates

cavities

MRSA L common iliac Bilateral infiltrates PVL; CVC

MRSA R femoral; popliteal SPE PVL; CVC

MRSA L saphenous Pleural effusions PVL; CVC

MRSA SVC Clear CVC

MRSA R femoral; popliteal Clear CVC

MRSA R femoral; popliteal SPE CVC

MRSA L femoral; popliteal SPE CVC

MSSA R femoral; popliteal Unknown CVC

MRSA Azygous; IVC SPE CVC

Clear PVL

SPE PVL; CVC

Clear CVC

CVC

Bil. opacities; effusions

patchy infiltrates Death

R middle lobe SPE

Source Year Series DVT Age (y) Sex Type Location Organism DVT Site Pulmonary

tibia

R tibia

femur

femur

head

neck

fibula

R tibia

fibula

pubis & ilium

and tibia

and tibia

femur

fibula

tibia

femur

tibia

femur

spine

10 f Osteo. L sacrum MRSA L common iliac; L

14 m Osteo. R femur MRSA R common femoral;

3 m Osteo. R femur MRSA R common femoral;

3 m Osteo. R tibia MSSA R femoral; popliteal Clear

Gonzalez6 2006 116 9 12 m Osteo. R ilium MSSA R deep pelvic Clear

Newgard1 2002 1 12 m Osteo. Sacroiliac MSSA R common iliac SPE

Letts18 1999 1 11.5 m Osteo. Sacrum MSSA R popliteal; R femoral;

Smith17 1997 2 4 f Osteo. L femur S aureus IVC and femoral Pneumatoceles Death

2.5 f Osteo. L ilium S aureus IVC and common iliac Pneumonia

Jupiter15 1982 2 12 m Osteo. L humerus MSSA L arm deep Multiple

12 f Osteo. L femur,

10 m Osteo. L femoral

10 m Osteo. L femoral

4 f Osteo. L femur,

14 m Osteo. R femur

13 m Osteo. L femur

13 m Osteo. R proximal

9 m Osteo. R proximal

12 m Osteo. R proximal

11 f Osteo. L distal

13 m Osteo. R distal

7 m Osteo. Thoracic

2006/7 352 15 13 m Osteo. R distal

Horvath14 1971 1 9 m Osteo. R proximal

Muhlendahl16 1988 1 12 f Osteo. R distal

Gorenstein19 2000 3 11 m Osteo. L proximal

Walsh2 2002 4 11 m Osteo. L distal

Yuksel4 2004 1 3 m Osteo. R distal

10 m Osteo. L ischium,

Martinez-Aguilar3

Crary5; Hollmig9


DVT-Deep vein thrombosis; y-years; m-Male; f-Female; U-Unknown; Osteo.-Osteomyelitis; R-Right; L-Left; MSSA-Methicillin Senstive Staph Aureus; Bil.-Bilateral;

MRSA-Methicillin Resistant Staph Aureus; S-staphyloccocus; GABHS-Group A beta hemolytic

streptoccocci; IVC-Inferior vena cava; SVC-Superior vena cava;

SPE-Septic pulmonary emboli; PneumoT-Pneumothorax; ICU-Intensive care unit; Comp. sy.-

Compartment syndrome; PVL-Panton-Valentine Leukocidin; C. Candida;

CVC-Central venous catheters; Sep. Art.- Septic Arthritis; Strep.- Streptoccocus; IJ-Internal jugular

Table 1. Summary of Published Cases of DVT in Patients with Musculoskeletal Infection

(73.9%).1-19 The average age of the children with DVT in the reviewed studies was 9 years with only six children under the age of 4 years among the 49 children with a recorded age (12.2%).1- 19 The type of infection was found to be osteomyelitis in 51 out of the 55 cases (92.7%) in which the musculoskeletal infection type was delineated. 1-19 However, two cases of septic arthritis and two cases of pyomyositis were also noted.2,7,9 The location of the infection was reported in 46 out of the 54 children with osteomyelitis and noted to be unifocal in 40 children and multifocal in the remaining six (see table 2). The site of osteomyelitis was most commonly reported in the femur (26 occurrences), and specifically reported in the proximal femur on 7 occasions and the distal femur on 6 occasions. The tibia was the second most common location of osteomyelitis (13 occurrences) with the proximal tibia specified in 5 cases and the distal tibia specified in one case. Overall, the location of the musculoskeletal infection was found to be in the pelvis (ilium, ischium, pubis, or sacrum) or lower extremities in 48 out of the 51 cases in which the site of infection was reported (94.1%), with the three remaining cases identified in the upper extremities (humerus in two children) and thoracic spine.

Deep Venous Thrombosis in Children with Musculoskeletal Infection 73

Among the 58 children with DVT, the location of occurrence of the DVT was recorded in 45 cases and was noted to be multi-focal in 22 (48.9%) children (see table 3). 79 specific locations of the DVT were recorded with the most common being femoral (25 or 32%); popliteal (14 or 18%); iliac (12 or 15%); and inferior vena cava (6 or 8%). Overall, the reported incidence of DVT involving a location inclusive of the inferior vena cava, pelvis, or

> Sigmoid Sinus 1 1% Transverse Sinus 1 1% Internal Jugular 4 5% Superior Vena Cava 3 4% Subclavian 2 3% Arm 4 5% Atrium 1 1% Azygous 1 1% Inferior Vena Cava 6 8% Iliac 12 15% Femoral 25 32% Popliteal 14 18% Posterior Tibial 1 1% Peroneal 1 1% Saphenous 3 4% Total 79 100% Multiple locations reported 22

Location of DVT Occurrence

Location not reported 13

Several studies have suggested that children with DVT- associated osteomyelitis demonstrate a more severe clinical course when compared to children who do not have deep venous thrombosis.3,5,6,8,9,10,11 Specifically, children with DVT are more likely to be admitted to the intensive care unit (ICU), require more surgical procedures, and have a longer hospitalization than their counterparts who do not have DVT but who do have similar forms of musculoskeletal infection.2,5,9,10,13,17,19 One study found that children with DVT required an average of 2.6 surgical procedures per child and had a mean duration of hospitalization of 30.6 days, compared to children without DVT who underwent an average of 0.9 surgical procedures per child and were hospitalized an average of 9.5 days.9 The same study determined that children with DVT presented with higher inflammatory indices in comparison to children who did not have DVT.9 The mean C-reactive protein (CRP) in children with DVT was 16.9 mg/dL , compared with only 6.8 mg/dL in children without DVT.9 While intuitively it might be thought that children with DVT would have a delay in clinical presentation to a healthcare facility, the authors found that there was in fact a

**6. Location of DVT** 

lower extremities was 62 of the 79 occurrences (78.5%).

Table 3. Frequency Distribution of DVT Location

**7. Clinical features** 


Table 2. Frequency Distribution of Osteomyelitis Site
