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Emergency: requires immediate attention
Osteomyelitis in Child
See also in: Cellulitis DDx
Other Resources UpToDate PubMed
Emergency: requires immediate attention

Osteomyelitis in Child

See also in: Cellulitis DDx
Contributors: David R. Lawton MD, Susan Burgin MD, Sandeep Mannava MD, PhD
Other Resources UpToDate PubMed


Causes / typical injury mechanism: Osteomyelitis is an infection of the bone. In pediatric patients, it is typically caused by the hematogenous spread of bacteria to bone, often involving the metaphyseal region of long bones. Other mechanisms include contiguous spread from an adjacent infection, such as cellulitis, or direct inoculation following trauma or surgery.

Classic history and presentation: Patients may present with fever; however, 40% will be afebrile. Other symptoms include unexplained mild-to-severe bone pain, refusal to bear weight, and reduced range of motion. Although these symptoms may be prominent in an acute infection, subtler and nontoxic presentations could suggest a subacute or chronic infection.

Prevalence: Varies by region, ranging from 1 in 5000-7700 in developed countries. In the United States, an increasing proportion of infections from community-acquired, methicillin-resistant Staphylococcus aureus (MRSA) have been found.
  • Age – The mean age is 6.6 years old, with approximately 40% of cases found in preschool-aged children.
  • Sex / gender – Male-to-female ratio is 1.82:1.
Risk factors: Risk factors include sickle cell disease, diabetes mellitus, immunodeficiency, immunosuppression, indwelling catheters, intravenous (IV) drug abuse, trauma, and prostheses.

Pathophysiology: It is suspected that both the turbulent blood flow and poorly developed reticuloendothelial system inherent to the physis may create an optimal environment for an infection. This can lead to subsequent subperiosteal abscess formation or septic arthritis if originating from within the joint capsule. 

In neonates, predominant pathogens include Group B Streptococcus, S aureus, and gram-negative rods.

Approximately 90% of cases among infants and children are caused by S aureus, with increasing rates of Kingella kingae. In patients with sickle cell disease, Salmonella may cause osteomyelitis but is still less common than S aureus. In IV drug users and in cases of puncture injuries through athletic footwear, Pseudomonas may be suspected.

Grade / classification system: Pediatric osteomyelitis can be further classified by:
  • Patient age: neonatal, childhood
  • Onset: acute, subacute, chronic (longer than 1 month)
  • Causative organism: pyogenic, granulomatous
  • Route of infection: hematogenous, contiguous, direct


M86.9 – Osteomyelitis, unspecified

60168000 – Osteomyelitis

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Cellulitis
  • Skin bacterial abscess
  • Chronic trauma
  • Septic embolic lesion
  • Langerhans cell histiocytosis
  • Leukemia
  • Ewing sarcoma
  • Osteosarcoma
  • Chronic nonbacterial osteomyelitis
  • Sickle cell acute pain crisis
  • Fracture

Best Tests

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Management Pearls

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:07/25/2021
Last Updated:11/07/2021
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Emergency: requires immediate attention
Osteomyelitis in Child
See also in: Cellulitis DDx
Clinical image of Osteomyelitis - imageId=2702877. Click to open in gallery.
Copyright © 2024 VisualDx®. All rights reserved.