Journal of pediatric orthopedics
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Case Reports
Orthopaedic manifestations of invasive group A streptococcal infections complicating primary varicella.
The incidence of invasive group A streptococcal (GAS) infections in primary varicella appears to be increasing. GAS infections complicating varicella range from cellulitis, abscess, and septic arthritis to life-threatening necrotizing fasciitis and pyomyositis in association with GAS toxic shock syndrome (TSS). Four patients admitted in 1 year to the Children's Hospital and Medical Center in Seattle, whose care included evaluation and treatment by the Orthopaedic service, are presented to illustrate this spectrum. ⋯ These patients required aggressive fluid resuscitation and prolonged intensive care unit support. Diagnostic imaging studies were obtained in one patient with necrotizing pyomyositis but may have served only to delay definitive treatment. Recognition of the potential for secondary GAS infections and a high index of suspicion for the presence of necrotizing soft-tissue infection are essential in the evaluation of any child with fever and localized extremity pain with varicella.
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Thoracic outlet syndrome, although uncommon in children, may be precipitated during rapid growth in adolescence, especially in association with a cervical rib. Four children exhibited the aching, tiredness in the limb, and occasional paresthesia in adolescence. Two had a cervical rib requiring removal, after which the symptoms disappeared. ⋯ It is proposed that in a child, the anatomy of the thoracic outlet is constantly changing with growth and development of the structures that form the thoracic outlet, as well as those that traverse the outlet itself. A conservative approach to these symptoms is warranted in the first instance to allow further growth and remodeling of the thoracic outlet, which may be sufficient to accommodate the nerve roots and brachial plexus and alleviate the symptoms. Excision of the cervical rib in the presence of increasing and chronic symptoms can be quit beneficial.