Limb Loss: A Complication of Septicemia in Children
JOY WINDORSKI, R.N
Prosthetic clinic teams throughout North America are challenged with providing care for children who have lost limbs following acute septicemia. A literature search found seven studies related to this specific subject citing 41 cases.1,2,5,6,9,10,12 There are also a number of individual case reports described. 7,13
This paper will discuss six cases. It will restate the definition of septicemia, and will summarize common concerns found in treating these children.
Septicemia may be accompanied by septic shock, or purpura fulminans. It is a process in which organisms from a relatively benign infectious disease invade multiple body systems. The onset is abrupt and symptoms are often flu-like, but are soon followed by a petechial rash and a generalized inflammatory response. Intravascular coagulation may cause tissue death to any organ or body system, including the skeleton. Lesions of the skin often involve underlying tissue and bone (Fig. 1 ). The skeletal system, however does not always sustain enough damage to require amputation. Sometimes the child is left with angular deformities of the bone, limb length discrepancies, septic arthritis, or osteomyelitis rather than loss of the limb. Surviving children have been treated with steroids, heparin, and immune mediating agents. All medical approaches have had "unpredictable" benefits.
Six cases with limb loss resulting from septicemia are tabulated in Table 1 . These children were each treated at other facilities during the acute phase of illness, and transferred to Gillette Children's Hospital during rehabilitation phases. The ages of disease onset ranged from five months to five years-two months. There are four males and two females. Meningococcus was the most frequent invading organism, and was present in four of these cases. All of the cases had problems with hypertrophic scarring. Limb loss varied from one to four limbs, and three of the cases had serious insult to other body systems which complicated their rehabilitation. Physical medicine played a significant role in the management of four of these cases. Orthotic and prosthetic devises were fitted according to individual case needs. The common goal in treating each child was to maximize independence, functional skills, and self esteem. Families of all the cases reviewed here had difficult emotional transitions; first with the enormity of the disease, and later with grieving the limb loss.
This series of cases was compared with seven other studies found in literature between 1982 and 1991. Five studies were reported in the United States, one in Ireland, and one in the United Kingdom. Six individual case reports were also reviewed. Meningococcus is reported more frequently than other causative organisms. There is no pattern with respect to sex or male or age distribution. Pediatric patients reported varied in age from one month to 14 years. Estimated mortality rates vary from 10-50%. Survival rates may be affected by timely amputations and growing knowledge of the disease process. Skin necrosis or scar tissue were frequently cited as complicating rehabilitation.
Clinic teams will be increasingly challenged to rehabilitate children with limb loss secondary to septicemia due to improved survival rates. The disease is devastating physically and emotionally for children and their families. Careful evaluation of these patients may assist teams in establishing realistic goals for future patients. Medical/surgical management, return of mobility and physical skills, and the restoration of self esteem are essential for the transition back into society.
Gillette Children's Hospital, 200 East University Avenue, St. Paul, Minnesota 55101, (612) 229-3894
- Askin, SR, Sullivan, G, David, K, Zubrow, A, Razi, N: Limb Gangrene Secondary to Thromboembolic Disease of the Newborn, Orthopaedic Review, XXI, 1:49-51, January, 1992.
- Canale, ST, Ikard, ST: The Orthopaedic Implications of Purpura Fulminans. J. Bone and Joint Surgery, 661:764769, June, 1984.
- Carson, JWK: Gangrene Requiring Amputation in Meningocele Infection. Irish Medical Journal, 78:14-16, 1985.
- Dobashi, Carol: Disseminated Intravascular Coagulation Resulting in Amputation: A Case Report. Physical Therapy, 63:1283-1286, 1983.
- Duncan, JS, Ramsay, LE: Widespread Bone Infarction Complicating Meningococcas Septicemia and Disseminated Intravascular Coagulation. British Medical Journal, 288:111-112, 1984.
- Grogan, DP, Love, SM, Ogden, JA, Miller, EA, Johnson, LO: Chonro-Osseous Growth Abnormalities After Meningococcemia. A Clinical and Histopathological Study. Journal of Bone and Joint Surgery-American Volume, 71(6):9211`928, July, 1989.
- Jacobsen, ST, Crawford, AH: Amputation Following Meminingocemia. A Sequela to Purpura Fulminans. Clinical Orthopaedics, 185:214-219, 1984.
- Kahn, A, Blum, D: Factors For Poor Prognosis in Fulminating Meningococcemia. Conclusions from observations of 67 childhood cases. Clinic Pediatrics, 17:680-687, 1978.
- Kruse, RW, Tassanawipas, A, Bowen, JR: Orthopaedic Sequalae of Meningococ cemia. Orthopedics, 14(2) 174178, February, 1991.
- Landham, TL, Datta, D, Nirula, HC: Amputation for Gangrene of the Limbs Following Severe Meningococcal Infection. Journal of the Royal College of Surgeons in Edinburgh, 36(1):11-2, February 1991.
- Robinow, M, Johnson, GF, Nanagas, MT, Mesghali, H: Skeletal Lesions Following Meningococcemia and Disseminated Intravascular Coagulation, American Journal of Diseases of Children, 137, March 1983.
- Silbert, Steven, Oppenheim, William: Purpura Fulimans. Medical, Surgical and Re habilitative Considerations. Clinical Orthopaedics, 193:206-213, 1985.
- Tochen, ML: Bone Lesions in a Child with Meningococcal Meningitis and Dissem inated Intravascular Coagulation. Journal of Pediatrics, 91:342-343, 1977.