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Key Features

Essentials of Diagnosis

  • Movement of the extremity causes pain, resulting in pseudoparalysis.

  • Soft tissue swelling.

  • Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

  • Surgical drainage of abscess plus antibiotics.

  • Antibiotic therapy for early osteomyelitis without abscess.

General Considerations

  • An infectious process that usually starts in the spongy or medullary bone and extends into compact or cortical bone

  • Commonly preceded by trauma, the lower extremities are more likely to be affected

  • Most commonly caused by hematogenous spread of bacteria from other infected or colonized areas (eg, pyoderma or upper respiratory tract) but it may occur as a result of direct invasion from the outside (exogenous), through a penetrating wound (nail) or open fracture

  • Staphylococcus aureus is the most common infecting organism and has a tendency to infect the metaphyses of growing bones

  • Streptococci (group B Streptococcus in neonates and young infants, Streptococcus pyogenes in older children) are a less common cause of osteomyelitis

  • Pseudomonas aeruginosa is common in cases of nail puncture wounds

  • Children with sickle cell anemia are especially prone to osteomyelitis caused by Salmonella species

Clinical Findings

  • In infants

    • Irritability

    • Diarrhea

    • Failure to feed properly

    • Temperature may be normal or slightly low

    • White blood cell count may be normal or only slightly elevated

    • Pseudoparalysis of the involved limb may be present

  • In older children

    • Severe local tenderness and pain

    • High fever, rapid pulse

    • Knee joints may be affected in age 7–10 years

    • Tenderness is most marked over the metaphysis of the bone where the process has its origin


Laboratory Findings

  • Elevated ESR and CRP

  • Blood cultures are often positive early

  • Important test is the aspiration of pus or biopsy of involved bone

  • It is useful to insert a needle into the bone in the area of suspected infection and aspirate any fluid present

  • Fluid should be stained for organisms and cultured


  • Radiography

    • Findings progress from nonspecific local swelling, to elevation of the periosteum, with formation of new bone from the cambium layer of the periosteum occurring after 3–6 days

    • As infection becomes chronic, areas of cortical bone are isolated by pus spreading down the medullary canal, causing rarefaction and demineralization of the bone

    • Isolated pieces of cortex become ischemic and form sequestra (dead bone fragments)

  • Bone scan is sensitive (before plain radiographic findings are apparent) but nonspecific and should be interpreted in the clinical context

  • MRI

    • Can demonstrate early edema and subperiosteal abscess

    • Can help confirm and localize disease prior to plain film changes



  • Splinting minimizes pain and decreases spread of the infection through lymphatic channels in the soft tissue



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