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Editors

MarkusPääkkönen

Osteomyelitis and Septic Arthritis in Children

Essentials

  • Osteomyelitis or septic arthritis should always be suspected in a febrile child with acute limb symptoms.

Incidence and causes

  • Paediatric acute osteomyelitis and septic arthritis are serious infectious diseases, but both are rare in the industrialised countries.
  • More common in boys than in girls (2:1)
  • In some cases, the infection may be precipitated by trauma (picture 1).
  • In children, the infection is usually caused by a pathogen that travels haematogenously to the bone or joint.
  • The most common causative organisms are Staphylococcus aureus (particularly in osteomyelitis), pneumococci, Group A streptococci and, in unvaccinated children, Haemophilus influenzae type B.

Signs and symptoms

  • An abrupt onset of swelling, redness, heat and tenderness in a limb or joint
  • Fever
  • Particularly in young children, the symptoms may be vague (inability to support weight, irritability, crying, the child looks unwell).

Diagnosis

  • See also Arthritis in children Arthritis in Children.
  • CRP, ESR, complete blood count
  • CRP < 20 mg/l and ESR < 20 mm/h practically rule out a septic infection, provided that symptom onset occurred 24-48 hours previously. In such cases alternative diagnoses must be considered, of which the following require immediate identification and referral to specialist care: leukaemia, epiphysiolysis of the hip Hip Pain in Children and a fracture Upper Limb Injuries in Children. Non-urgent referral is indicated for a child if juvenile arthritis Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis) or enteroarthritis is suspected.
    • Hip synovitis Hip Pain in Children can be managed in primary care provided that there is no doubt about the diagnosis.
  • If a septic infection cannot be excluded, the patient must be sent to a hospital for the collection of a culture sample before antimicrobial therapy is started.

Treatment

  • Diagnostic samples are often obtained under anaesthesia. Performing arthrocentesis in a child patient at an emergency department may also be carried out using nitrous oxide anaesthesia.
  • Intravenous antimicrobial therapy can be started as soon as the necessary samples have been obtained.
  • Clindamycin 40 mg/kg/day or a first-generation cephalosporin 150 mg/kg/day, divided into four doses. It is usually possible to switch to oral treatment after 2-4 days.
  • The duration of treatment is 20 days in osteomyelitis and 10-14 days in septic arthritis.

Prognosis

  • With timely therapeutic intervention the majority of patients recover fully.
  • Feared complications include chronic osteomyelitis, pathological fractures, destruction of the articular cartilage and aseptic necrosis of the femoral head.

    References

    • Pääkkönen M, Peltola H. Management of a child with suspected acute septic arthritis. Arch Dis Child 2012;97: 287-92 [PubMed]
    • Peltola H, Pääkkönen M. Acute osteomyelitis in children. N Engl J Med 2014;370(4):352-60. [PubMed]