Emergency: requires immediate attention
Osteomyelitis in Child
See also in: Cellulitis DDxAlerts and Notices
Synopsis
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.
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
Codes
ICD10CM:M86.9 – Osteomyelitis, unspecified
SNOMEDCT:
60168000 – Osteomyelitis
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Cellulitis
- Abscess
- Chronic trauma
- Septic embolic lesion
- Langerhans cell histiocytosis
- Leukemia
- Ewing sarcoma
- Osteosarcoma
- Chronic nonbacterial osteomyelitis
- Sickle cell acute pain crisis
- Fracture
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Therapy
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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.Subscription Required
References
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Last Reviewed:07/25/2021
Last Updated:11/07/2021
Last Updated:11/07/2021
Emergency: requires immediate attention
Patient Information for Osteomyelitis in ChildOverview
Osteomyelitis is an infection of the bone that often leads to damage of the skin above the infected bone. It can be caused by many different germs including bacteria, fungi, and viruses. The germs can get into the bone in different ways: through the blood, from an infection in the skin or joints, and directly into the bone by a trauma or surgery. Treating this infection depends on several factors such as what type of germ is causing it, what specific bone is involved, what the blood supply is to the bone, whether there is any loss of sensation, recent injury to the area, and whether there are any other diseases involved.Who’s At Risk
Osteomyelitis can occur at any age and can infect any bone of the body. The people most commonly affected by this bone infection are people with diabetes. It most commonly affects the feet. Other people who are at higher risk for osteomyelitis are people who use intravenous (IV) drugs and people with alcohol use disorder, a poor immune system, or who have rheumatoid arthritis (a disease that affects the joints).Signs & Symptoms
Early symptoms of osteomyelitis include dull pain, swelling, redness, and warmth of the area. Fever and chills may also occur.Late symptoms of osteomyelitis (when it has not been looked at or treated by a doctor) include pus drainage from the infected site and deep wounds of the skin called ulcers that do not heal over time.
Self-Care Guidelines
If you notice redness and swelling in your joints and/or bone and have a hard time moving the area – and these are related to a fever and feeling tired – you should consult your doctor. These symptoms can be highly suggestive of osteomyelitis. This is more likely if you have diabetes, have alcohol use disorder, use IV drugs, or have a weakened immune system.When to Seek Medical Care
As described above, if you notice symptoms in the infected area or symptoms related to an infection (like fever), you should go visit your doctor.When at the doctor's office, he/she may do several tests to determine the diagnosis and the right treatment option.
These tests may include:
- A blood sample
- A culture and/or biopsy of the infected area – to find what germ is present
- Pictures of the bone – X-ray and/or MRI
- A test called arthrocentesis that is done to take a sample of liquid from the joint.
Treatments
Treatment usually begins with surgery to remove dead or damaged skin and bone. Often surgeons will use equipment such as screws and plates to support the damaged bone.People who are treated for osteomyelitis must also be given antibiotics to take for at least 6 weeks. The antibiotics will be given directly into the vein through an "intravenous catheter." In the beginning, the antibiotics are given in the hospital. Then, once the doctors believe a person can be switched to an antibiotic taken by mouth, treatment can be given at home with the help of a nurse or in a rehabilitation facility.