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Bone and joint infections may occur at any age but are more common in children than adults. Optimal management requires early diagnosis and aggressive initial treatment to prevent disabling sequelae. This is usually best achieved with care being provided by a multidisciplinary team of pediatricians and orthopedic surgeons experienced in the specific issues encountered in care of growing children. Soft tissue infections occur more frequently than skeletal infections but they are generally simpler to diagnose and treat with antibiotic therapy. This chapter reviews the approach to diagnosis and management of these disorders in children. Soft tissue infections in children, generally less difficult to diagnose and treat than skeletal infections, remain important because of their greater frequency of occurrence and the need for antibiotic therapy, occasionally in conjunction with hospitalization.

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Acute Hematogenous Osteomyelitis

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Epidemiology

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Acute hematogenous osteomyelitis (AHO) is a disease of young children. The majority of cases occur before 5 years of age with up to one third occurring in children younger than 2 years of age.1,2 There is a male predilection, with males outnumbering females in most published series by approximately 2:1.1-5 However, in a more recently published series, males accounted for 52% of the patients.6 There is frequently a history of some type of minor blunt trauma2,7 or intercurrent illness, such as an upper respiratory tract infection.8 Other risk factors for AHO include immunodeficiency states, sickle cell anemia, and indwelling vascular catheters. In some areas of the United States, the incidence of osteoarticular diseases including AHO has increased with the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).6

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Pathogenesis

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The majority of bone infections in children are of hematogenous origin.2 The vascular anatomy of long bones in children underlies the predilection for localization of blood-borne bacteria. In children, unlike in adults and young infants, the blood supply of the epiphysis is separate from the metaphysis.10 The nutrient artery to the metaphysis empties into a system of venous sinusoids in which sluggish flow presumably facilitates deposition of bacteria. During the cellulitic phase of acute osteomyelitis infection originates on the venous side of the system and then spreads to the nutrient artery, causing thrombosis of the nutrient artery.9 The resultant ischemia prevents host defense mechanisms from reaching the area and allows bacterial proliferation. Formation of an abscess can then occur which can rupture into the subperiosteal space with subsequent elevation of the periosteum, which is loosely adherent in children. If infection is uncontrolled, purulent material may extend up and down the diaphysis and circumferentially around the bone (see Figure 234-1). In areas in which the metaphysis is intra-articular, such as the hip and shoulder, the intraosseous abscess may rupture into the joint resulting in septic arthritis.9 In newborns and young infants, blood vessels connect the metaphysis and epiphysis, and rupture of pus into the adjacent ...

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