Osteomyelitis and Other Bone and Joint Infections

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88 Osteomyelitis and Other Bone and Joint Infections


Osteomyelitis is inflammation of bone caused by bacterial or, less often, fungal infection. Osteomyelitis is categorized both by the mechanism of pathogen transmission to the bone (hematogenous, direct extension) and by the clinical presentation (acute, subacute, or chronic). In children, hematogenous spread of bacteria to the bone is the most common mode of transmission (Figure 88-1). Less often, osteomyelitis is the result of contiguous spread from a soft tissue infection or direct inoculation by penetration, such as after trauma or surgery. Vascular insufficiency is a rare cause of osteomyelitis in children. Eighty-five percent of cases of osteomyelitis occur in children younger than 16 years of age (50% in children younger than 5 years of age), with a male-to-female ratio of 2 : 1, except within the first year of life, when both genders are affected equally. Long bones (femur, tibia, humerus, in that order of frequency) followed by bones of the hands and feet and pelvis are the most common sites involved (see Figure 88-1). Approximately 5% of patients have multiple foci.


Isolation of a bacterial source of osteomyelitis occurs in 50% to 80% of patients when both blood and bone are cultured. The bacteria responsible for osteomyelitis in children vary by age and underlying condition (see Figure 88-1). Staphylococcus aureus is the most common pathogen in any age group (70%-90% of cases), with community-acquired methicillin-resistant S. aureus (CA-MRSA) becoming more prevalent in recent years. In infants younger than 2 months of age, group B streptococci and gram-negative enteric bacteria are seen in addition to S. aureus. In children younger than 5 years of age, S. aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Kingella kingae are leading causes of osteomyelitis. Children older than 5 years of age are most commonly infected by S. aureus or S. pyogenes. Neisseria gonorrhoeae may be the etiologic agent in sexually active adolescents.

Approximately 10% of cases of acute hematogenous osteomyelitis are caused by S. pyogenes, a pathogen that tends to cause higher fever and white blood cell (WBC) count than S. aureus. An upper respiratory tract infection often precedes osteomyelitis with K. kingae, and this organism has been associated with outbreaks at daycare centers. Joint involvement is more common with S. pneumoniae than with S. aureus and S. pyogenes, perhaps because children with osteomyelitis caused by S. pneumoniae tend to be younger.

After introduction of the Haemophilus influenzae type b (Hib) conjugate vaccine, the frequency of osteomyelitis caused by this organism has significantly decreased. Actinomyces spp. have been isolated in facial and cervical osteomyelitis. Mixed flora, including Pseudomonas spp., S. aureus, and anaerobes, are seen in osteomyelitis that occurs after a puncture wound to the foot through sneakers. Salmonella spp. are an important cause of osteomyelitis in patients with sickle cell disease. Mycobacterium tuberculosis causes skeletal lesions in 1% of children with tuberculosis, typically manifested by lower thoracic vertebral osteomyelitis (Pott’s disease).

Clinical Presentation

Patients with acute hematogenous osteomyelitis describe localized bone pain that worsens over a brief period of time; the majority of these patients present to medical attention within 2 weeks of symptom onset. Pain precludes use of an affected extremity (pseudoparalysis). Fever is often present. Less common associated signs include malaise, anorexia, and vomiting. On physical examination of a patient with acute hematogenous osteomyelitis, swelling, erythema, warmth, and point tenderness that is out of proportion to the soft tissue findings may be present over the affected bone.

Ten percent of hematogenous osteomyelitis is categorized as subacute based on a slower progression of mild to moderate pain over the site of infection and the absence of systemic symptoms. Chronic osteomyelitis is characterized by waxing and waning pain and swelling that does not respond to prolonged antibiotics.

The clinical presentation of pelvic osteomyelitis includes pain in the hip, buttock, groin, lower back, or abdomen; gait abnormality; and, in some cases, fever. There is point tenderness over the affected bone and pain with manipulation of the hip. Distinguishing pelvic osteomyelitis and septic arthritis of the hip can be difficult, although range of motion of the hip joint is typically preserved in pelvic osteomyelitis.

Vertebral osteomyelitis can present with back, abdominal, chest, or leg pain; low grade–fever; and tenderness over the affected vertebrae. Fewer than 25% of patients demonstrate neurologic abnormalities. Symptoms can be subtle and slowly progressive, making diagnosis difficult. Vertebral osteomyelitis can be similar in presentation to diskitis but tends to affect older children and adolescents.

Chronic recurrent multifocal osteomyelitis is a distinct autoinflammatory disorder that is characterized by episodes of pain, swelling, and low-grade fever that recur over several years, radiographic findings of multiple lesions that have the appearance of osteomyelitis, an inability to isolate an infectious etiology, and a lack of clinical response to antimicrobial therapy. Girls are more commonly affected than boys, with symptom onset around 10 years of age.


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