acute osteomyelitis in children

The new england journal of medicine

Edward W. Campion, M.D., Editor

Acute Osteomyelitis in Children

Heikki Peltola, M.D., and Markus P??kk?nen, M.D.

From Children’s Hospital, University of

Helsinki, and Helsinki University Central

Hospital, Helsinki (H.P.); and the Divi-

sion of Diseases of the Musculoskeletal

System, University of Turku, and Turku

University Hospital, Turku, Finland (M.P.).

Address reprint requests to Dr. P??kk?nen

at Turku University Hospital, Kiinamyllyn-

katu 4-8, P.O. Box 52, 20521 Turku, Finland,

or at markus.paakkonen@helsinki.fi.

N Engl J Med 2014;370:352-60.

DOI: 10.1056/NEJMra1213956

Copyright ? 2014 Massachusetts Medical Society.acteria may reach bone through direct inoculation from trau-matic wounds, by spreading from adjacent tissue affected by cellulitis or septic arthritis, or through hematogenous seeding. In children, an acute bone infection is most often hematogenous in origin.1In high-income countries, acute osteomyelitis occurs in about 8 of 100,000 children per year,2 but it is considerably more common in low-income countries. Boys are affected twice as often as girls.2,3 Unless acute osteomyelitis is diagnosed promptly and treated appropriately,4 it can be a devastating or even fatal disease with a high rate of sequelae, especially in resource-poor countries where patients present with advanced disease and survivors often have complications that are serious and long-lasting.Staphylococcus aureus is by far the most common causative agent in osteomyelitis,

followed by the respiratory pathogens Streptococcus pyogenes and S. pneumoniae.5-9 For unknown reasons, Haemophilus influenzae type b is more likely to affect joints than bones. Salmonella species are a common cause of osteomyelitis in developing coun-tries and among patients with sickle cell disease.10 Infections due to Kingella kingae are increasing and are most common in children younger than 4 years of age.11B

Common Manifestations

When osteomyelitis is diagnosed, it is classified as acute if the duration of the ill-ness has been less than 2 weeks, subacute for a duration of 2 weeks to 3 months, and chronic for a longer duration.1,2,12 Since any bone can be affected, patients can present with a wide variety of symptoms and signs. Multifocal osteomyelitis may occur at any age but occurs most frequently in neonates.1

Classic clinical manifestations in children are limping or an inability to walk, fever and focal tenderness, and sometimes visible redness and swelling around a long bone, more often in a leg than in an arm (Fig. 1). Often the patient’s condi-tion has deteriorated in the days preceding clinical presentation. Calcaneal osteo-myelitis may proceed insidiously and lead to a delay in seeking treatment. Spinal osteomyelitis is characteristically manifested as back pain, whereas pain on a digital rectal examination suggests sacral osteomyelitis. Acute osteomyelitis should be considered in any patient who presents with a fever of unknown origin. Acute cases occur in all age groups, with a small peak in incidence among prepubertal boys, presumably because of strenuous physical activity and microtrauma.1,9 Chil-dren with methicillin-resistant S. aureus (MRSA) osteomyelitis have a high tem-perature, tachycardia, and a painful limp more often than those with methicillin-susceptible S. aureus (MSSA).13

Diagnosis

The approach to the diagnosis of osteomyelitis in children is shown in Figure 2. If physical examination suggests bone involvement, further tests are performed.

352n engl j med 370;4 nejm.org january 23, 2014

The New England Journal of Medicine

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