Working Diagnosis:
Brodie's abscess

Treatment:
Debridement of tibial abscess at time of biopsy. PICC placed for 4 weeks of IV Clindamycin (based on culture sensitivities and infectious disease consultation).

Outcome:
Postoperative course was uncomplicated. After completing physical therapy he gradually returned to full, pain-free activity. He was followed clinically without issue, and following a subsequent ankle injury 18 months later his radiographs showed a well-healed tibia.

Author's Comments:
With Brodie's abscess the clinical course is generally insidious, with persistent pain as the most common presenting complaint. Patients are typically afebrile, and inflammatory markers are normal. Staph aureus is the most common pathogen. It typically affects the metaphysis of long bones, most commonly the tibia. The lesion on radiograph classically has central lucency, with surrounding sclerotic margin. Plain films often heighten suspician, but further imaging can be helpful to characterize the lesion. Brodie's abscess is commonly misdiagnosed in favor of a variety of neoplasms on imaging, so biopsy is often necessary for definitive diagnosis. Treatment involves surgical debridement followed by antibiotics. Antimicrobial course is generally 4-6 weeks and based on susceptibilities if available.

Editor's Comments:
Brodie’s abscess is a form of subacute osteomyelitis. Presentation is usually insidious with mild symptoms and no systemic reaction. The most common age at presentation is 2-15 years old. Staph aureus is the cause of half the cases in of osteomyelitis in infants and children. Group A streptococcus is the second most common cause in older children and adolescents. 28% occur in the tibia and fibula, while 25% occur in the femur. The metaphysis is the most commonly affected area, because the cortex is the thinnest. Radiographs usually show an area of lucency with sclerotic margin. It may be confused with a bone tumor.
Work-up can include CBC, ESR, and CRP (often normal). Blood cultures are usually negative. Radiographs are the initial imaging test of choice, but often a MRI or CT is needed for further characterization. Open drainage and culture tend to have a better diagnostic rate than fine needle aspiration. Biopsy can help to differentiate from bone tumor.
Treatment usually requires surgical debridement and antibiotics for 4-6 weeks. Most reoccurrences are within 6 months. Clinical healing usually precedes radiographic healing which can take 3-12 months.

Krogstad, Paul. Epidemiology, pathogenesis, and microbiology of hematogenous osteomyelitis in children. UptoDate online. Accessed 7/5/2013.
Khoshaa, Khalid. Subacute Osteomyelitis (Brodie Abscess) Medscape. http://emedicine.medscape.com/article/1248682-overview. Accessed 7/5/2013

References:
1. Ezra E, et al. Primary Subacute Epiphyseal Osteomyelitis. J of Ped Ortho, 22:333-337, 2002.

2. Soto, R et al. Chronic osteomyelitis of the tibia resembling benign bone lesion. Pediatrics International. 49, 663-667, 2007.

3. Alter SA, Sprinkle RW. Brodie’s Abscess: A Case Report. J Foot Ankle Surg, Vol 34 2:208-214, 1995.

4. Edmundson SP, Hirpara KM, Ryan RS, O’Grady P. Brodie’s abscess presenting in a young soccer player following ankle injury. Ir J Med Sci, 180:783-784, 2011.

5. Harris NH, Kirkaldy-Willis WH. Primary subacute pyogenic osteomyelitis. J Bone Joint Surg, 47-B:526-532, 1965.

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