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Osteomyelitis in infancy and
childhood: “A clinical and diagnostic overview”
M. Mearadji
International Foundation for Pediatric Imaging Aid
Introduction
Osteomyelitis is a relative common disease in infancy and childhood.
Higher incidence in early life (In USA 1 : 1000 younger than 1 year. 1 : 5000 older).
Clinical symptoms are different depending on location, extension and the type of osteomyelitis.
With exception of neonates fever is a frequent finding.
Other symptoms are pain, soft tissue swelling, tenderness and immobility.
Some laboratory findings could be specific and some non specific.
Classification of osteomyelitis
number of cases studied for this presentation
Pyogenic hematogeneous osteomyelitis: 71
a) Neonatal osteomyelitis: 29
b) Acute osteomyelitis in infancy and childhood: 41
c) Sequelae of infantile meningococcemia: 3
Subacute osteomyelitis (Brodie abscess): 33
Chronic osteomyelitis: 49
a) Sclerosing osteomyelitis: 2
b) Epiphyseal osteomyelitis: 2
Classification of osteomyelitis number of cases studied for this presentation
Exogenous osteomyelitis caused by direct
implantation (surgery, trauma or foreign
bodies): 11
Chronic recurrent multifocal osteomyelitis: 3
Adjacent joint or soft tissue infection: 1
Osteomyelitis resulting from unusual
organisms: 4
Diagnostic priorities of imaging modalities
Plain films are the first step in diagnosis of osteomyelitis.
Ultrasound is useful in recognition of arthritis and soft tissue abscesses.
Nuclear scanning is valuable to search for multifocal location of osteomyelitis.
CT is a proper modality in detection of bone sequestration.
MRI is an adequate modality for early diagnosis and complication of osteomyelitis especially in difficult locations (spine and pelvis).
Pathway of pyogenic hematogenous osteomyelitis.
Hematogeneous osteomyelitis usually involves the
highly vasculated metaphysis.
Organisms lodge mostly in the terminal capillary loops
of metaphysis.
Early initial affection of epiphysis or cortex is rare.
Septic arthritis is frequently an early complication.
Clinical sign and symptoms of acute hematogenous osteomyelitis
Fever (rarely in neonatal period)
Local pain
Soft tissue swelling
Warmth
Sepsis with positive blood cultures
Reluctance to use the limbs
Clinical and radiological data of 29
neonates with hematogenous osteomyelitis
nr %
Age 0 – 4 weeks 29 100
Male
Female
13
16
45
55
Isolated micro organisms
-Staphylococcus aureus
-Streptococcus pneumonia
-Proteus
17
15
1
1
59
52
3,5
3,5
Monolocular affection 16 55
Multilocular afffection 13 45
Septic arthritis 17 59
Clinical and radiological data of 29
neonates with hematogenous osteomyelitis
Affected bone nr %
Femur 20 69
Tibia 9 31
Humerus 6 21
Ulna 2 7
Fibula 1 3
Proximal
phalanx
1 3
Used diagnostic
modalities
nr %
Plain films 29 100
Ultrasound 12 41
CT 0 0
MRI 0 0
Nuclear scanning 2 6
April 2005 May 2005
July 2005
January 2006
A neonate with a multilocular
osteomyelitis of the left femur.
Note the shortening of the femur.
March 2006 May 2006 November 2006
Neonate with monolocular osteomyelitis of tibia.
Neonate with osteo-arthritis
located in distal tibia.
Osteomyelitis of severely affected humerus
with abscess.
Osteomyelitis of proximal humerus
visuable on chest x-ray.
Note the sonographic finding and the
second location in distal femur.
Clinical and radiological data of 41 cases
with postneonatal acute osteomyelitis
nr %
Age 1 – 15 years
Average: 6.2 years
41 100
Male
Female
27
14
62
38
Isolated micro organisms
-Staphylococcus aureus
-Others
12
10
2
29
24
5
Arthritis 9 22
Clinical and radiological data of 41 cases
with postneonatal acute osteomyelitis
Affected bone nr %
Femur 14 34
Tibia 3 7
Fibula 3 7
Humerus 7 17
Radius 1 2
Pelvis 3 7
Sternum 2 5
Spine 1 2
Os frontale 3 7
Foot 4 10
Used diagnostic
modalities
nr %
Plain films 39 95
Ultrasound 17 41
CT 7 37
MRI 6 15
Nuclear scanning 6 15
A case of postneonatal acute
right-sided cox arthritis.
Note the normal x-ray film.
September 2005 October 2005
Acute osteomyelitis of distal
humerus with an abscess
visible on sonogram.
Osteomyelitis of frontal bone with an subdural
abscess (Pott’s Puffy tumor).
Multilocular osteomyelitis
following meningococcal
meningitis.
Note the shortening and
destruction of right femur
and tibia.
Late complication of hemogenous osteomyelitis
Premature and asymmetric epiphyseal plate
closure.
Growth disturbance and limb deformities.
Limb length discrepancy (shortening and
lengthening).
Joint destruction.
Pathologic fracture.
Case A.
Shortening of tibia
following multilocular
osteomyelitis.
Note the premature physial
closure.
Case B.
Shortening of lower limb
following multilocular
osteomyelitis.
Foot amputation complicated
with osteomyelitis of stump.
Low grade osteomyelitis
Subacute osteomyelitis (Brodie abscess) is likely the result of an organism of low virulence contained by a partial host response.
The initial purulent exsudate is replaced by granulation tissue.
Mild clinical manifestation with pain.
Radiological characterised by a variable areas of sclerosis.
Clinical and radiological data of 33 cases
with low grade osteomyelitis
nr %
Age: 2 weeks – 19 years
Average: 6.8 years
33 100
Male
Female
17
16
51
49
Isolated micro organisms 0 0
Biopsy 8 24
Clinical and radiological data of 33 cases
with low grade osteomyelitis
Affected location nr %
Femur 15 45
Tibia 5 15
Pelvis 6 18
Humerus 3 9
Foot 4 12
Radius 1 3
Diagnostic
modalities
nr %
Plain films 33 100
Ultrasound 14 42
CT 2 6
MRI 15 45
Nuclear scanning 4 12
Low grade osteomyelitis located in right-sided
distal metaphysis (Brodie abscess).
Brodie abscess located in the right acetabulum.
The muscle atrophy and persisting joint effusion
shown on sonography were the initial sign of severe
pathology.
Brodie abscess located on the femur
metaphysis. Also visible by ultrasonography.
Clinical signs and symptoms of chronic osteomyelitis
The patient`s history of chronic osteomyelitis is usually
longer than 2 weeks.
Pain is a predominant sign of chronic osteomyelitis.
Fever however is not obligatory in cases with chronic
osteomyelitis.
Immobility and muscle atrophy are a frequent clinical
finding in chronic osteomyelitis.
The laboratory data could be specific or less specific.
In contrast to acute osteomyelitis the less vasculated
diaphysis is affected more frequent by chronic
osteomyelitis.
Clinical and radiological data of 47 cases
with chronic osteomyelitis
nr %
Age 1 – 18 years
Average: 8.4 years
47 100
Male
Female
29
18
62
38
Isolated micro organisms
-Staphylococcus aureus
-Streptococcus epidermis
-Stomatococcus mucilaginosus
11
7
3
1
23,5
15
6
2
Biopsy 17 36
Clinical and radiological data of 47 cases
with chronic osteomyelitis
Affected bone nr %
Femur 12 25
Tibia 10 21
Foot 5 11
Humerus 3 6
Pelvis 2 4
Spine 2 4
Sternum 2 4
Hand 1 2
Rib 1 2
Used diagnostic
modalities
nr %
Plain films 46 98
Ultrasound 15 32
CT 3 6
MRI 6 13
Nuclear scanning 10 21
Right-sided chronic
osteomyelitis of os pubis
Left-sided chronic osteomyelitis of os ilium.
July 2005 December 2005 December 2005
Right-sided chronic
osteomyelitis of diaphysis
of tibia.
Left-sided chronic osteomyelitis of femur with a sequestrum.
Before (A) and after (B) resection.
A
A B
February 2001 June 2002
June 2003
Follow up of sclerosing
osteomyelitis of left clavicle
January 2007 April 2008 April 2007
Right-sided chronic epiphyseal osteomyelitis.
Exogenous osteomyelitis left calcaneus caused
by ulceration (decubitus) of the heel.
Exogenic coccygeal osteomyelitis following
decubitus in a child with spina bifida.
Chronic recurrent multifocal osteomyelitis
The bone lesions are multifocal with a
prolonged course with varying activity of the
disease.
Lack of response to antibiotics.
Typical radiographic lytic regions surrounded
by sclerosis.
No identifiable organism found.
Not complicated with abscesses.
January 2008 February 2008
A case of multifocal recurrent
osteomyelitis affecting the fifth metatarsal
bone of both sides.
Multifocal recurrent
osteomyelitis with a history of
back pain of more than 6
months.
Left ilium affected.
An infant with right-sided primary purulent coxitis
complicated with destruction of the epiphysis later on.
BCG osteomyelitis of right femur.
Salmonella osteomyelitis of distal humerus
with soft tissue abscess.
Conclusion I
The highly vasculated metaphysis is the most
common affected site by hematogenous
osteomyelitis, specially in infancy.
The femur is the most frequently affected bone in
osteomyelitis.
Staphylococcus aureus is the most common
causative organism in all types of osteomyelitis.
A history of osteomyelitis longer than 2 weeks
should be considered as subacute or chronic.
Septic arthritis is an early and limb shortening is a
late complication of osteomyelitis.
Conclusion II
Biopsy is indicated incidentally to confirm the
diagnosis of a subacute or chronic osteomyelitis.
Ultrasound additionally to plain film is a useful
modality in recognition of septic arthritis and soft
tissue abscesses.
Nuclear scanning should be performed when
multifocal involvement is expected.
MRI is a useful method to assess the extention of
inflammatory process as well as in differential
diagnosis with other bone disorders.
CT is the modality of choice in diagnosis of
sequestration by chronic osteomyelitis.
