Managing Pediatric Bone Infections
February 1, 2025 21 minutes read
Executive Summary
- The incidence of osteoarticular infections in children is estimated to be five to 12 per 100,000, with osteomyelitis being approximately twice as common as septic arthritis. In the United States, septic arthritis has an incidence of four in 100,000 children per year. The larger joints of the lower extremities, such as the hip and knee, are most commonly involved, affecting up to 80% of cases.
- There is an increased risk for osteomyelitis in patients with recent trauma, immunosuppression, sickle cell anemia, or who were born prematurely. Pediatric bone infections may occur in any age group, but they typically are more common in children younger than 5 years of age.
- Historically, a framework called the Kocher criteria was developed to screen for these types of infections and included fever (> 38.5°C), inability to bear weight, white blood cell count > 12,000 cells/mL, and an erythrocyte sedimentation rate of ≥ 40 mm/hour. The Kocher criteria are used to differentiate septic arthritis of the hip with a reported 93% or greater positive predictive value when three or four risk factors are present.
- Magnetic resonance imaging (MRI) has become the gold standard in the diagnosis of osteoarticular infections, rather than ultrasound, bone scan, or computed tomography, since MRI provides more information regarding spread of septic arthritis, subperiosteal abscess, and osteomyelitis and also has no ionizing radiation. The sensitivity of MRI for the diagnosis of osteomyelitis ranged from 81% to 100% in eight studies, and the specificity ranged from 67% to 94% in five studies.
- Timely operative management of septic arthritis can prevent complications, such as osteonecrosis — particularly of the hip. Once a diagnosis of septic arthritis is suspected, it becomes a surgical emergency, and an orthopedics consultation should be obtained to streamline next steps and surgical intervention. Surgical intervention may include drainage, decompression, irrigation, and debridement, depending on the extent of the infection identified on imaging
Pediatric osteoarticular infections may be subtle in their presentation, and clinicians must have a high degree of suspicion to make a timely diagnosis and institute appropriate therapy. The authors provide the essential information clinicians require to understand the presentation, diagnostic evaluation, and management of bone and joint infections in this population.
— Ann M. Dietrich, MD, FAAP, FACEP, Editor
By Brittany Boswell, MD; Mia Karamatsu, MD; Cherrelle Smith, MD, MS; and Guillermo De Angulo, MD, MSCR
Introduction
Pediatric osteoarticular infections vary in presentation and range in severity, with the most severe infections being medical and surgical emergencies. This article will focus on osteomyelitis, or localized bone infection, as well as septic arthritis, an acute infection of the joint. The presentation and ultimate diagnosis may be difficult depending on the age of the child, the ability to communicate concern, nonspecific complaints, localized or disseminated presentation, variety of location (e.g., joint, tendon, muscle, spine), the presence of prior hardware or surgical interventions, or various other comorbidities.1
A comprehensive diagnostic approach may be necessary in pediatric bone infections, including laboratory and radiographic diagnostics, possible procedural interventions, and subspecialty consultation. These infections do pose the risk of joint and bone destruction. Therefore, clinicians must have a high level of suspicion for them, given the variable presentation, for prompt diagnosis and treatment. Treatment includes antimicrobial therapy and may require surgical intervention.
Epidemiology
The incidence of osteoarticular infections in children is estimated to be five to 12 per 100,000, with osteomyelitis being approximately twice as common as septic arthritis.2 In the United States, septic arthritis has an incidence of four in 100,000 children per year.3 The larger joints of the lower extremities, such as the hip and knee, are most commonly involved, affecting up to 80% of cases.4 The incidence of pediatric osteomyelitis is estimated to be between two and eight cases per 100,000 children per year in the United States.5 There is a slight predisposition in males, and it typically presents in otherwise healthy patients.
However, there is an increased risk in those with recent trauma, immunosuppression, sickle cell anemia, or who were born prematurely. Pediatric bone infections may occur in any age group, but they typically are more common in children younger than 5 years of age.6 Osteomyelitis can occur in any bone, but it is more common in long bones, with 75% of cases in the femur and tibia.7
A pediatric patient presenting to the emergency department (ED) with a limp, joint pain, or bone pain is relatively common. However, when these symptoms are accompanied by fever, joint swelling, or erythema, the possibility of an osteoarticular infection must be considered. It is essential for providers to understand the presentation, diagnostic evaluation, and management of bone and joint infections in this population.
Etiology/Pathophysiology
Most osteoarticular infections occur via hematogenous spread or via direct inoculation. Secondary septic arthritis may occur because of direct spread from osteomyelitis. The most commonly identified organism is Staphylococcus aureus, but the causative agent varies based on the age of the patient.8-10 (See Table 1.)
Table 1. Causative Agents of Bone Infection | |
| Patient Trait | Bacterial Etiology |
Neonates |
|
Preschool age |
|
Adolescent |
|
Sickle cell anemia |
|
Penetrating foot wound |
|
Animal bite |
|
Prosthetic joint |
|
These infections most commonly affect children younger than 5 years of age, but patients of all ages may be affected. Risk factors in the neonatal group include premature birth, history of umbilical vessel catheterization, indwelling central lines, or history of material infection.11 Older children may have an increased risk if there is a history of immunodeficiency, joint surgery, hemoglobinopathy, underlying arthritis, or diabetes.
Risk factors for pediatric bone infections such as osteomyelitis are well-documented in peer-reviewed literature. A notable source, the Pediatrics in Review article by Dennis R. Roy, provides insights into the pathogenesis and risk factors for osteomyelitis in children, including associations with trauma and immune compromise.12
Key risk factors include:
- Trauma: Recent injury to a bone can facilitate bacterial entry and infection.
- Bacteremia: Bloodstream infections often seed bacteria in bone, especially in the metaphysis.
- Medical conditions: Immunocompromised states, chronic illnesses (e.g., diabetes), and recent viral infections like chickenpox increase susceptibility.
- Surgical history: Previous surgical procedures involving bones or joints elevate the risk of infection.
- Social and environmental factors: Poor hygiene, malnutrition, and low socioeconomic status also may contribute to higher risk.
Hematogenous spread is the most common underlying mechanism for osteoarticular infections. The synovial membrane has high blood flow and lacks a basement membrane, making it susceptible to bacterial spread. Direct inoculation can occur with microtrauma, which introduces contamination into the joint space, or secondary to recent surgical instrumentation. Once bacteria enter the synovium, the release of endotoxins and cytotoxins creates an inflammatory response, which can destroy the synovium and lead to swelling and pain. Increased swelling then leads to diminished blood flow, which can cause avascular necrosis and joint damage. A recent study created a clinical prediction rule to aid in the assessment of children being evaluated for possible musculoskeletal infection who are at high risk for acute hematogenous osteomyelitis.5,13,14
Clinical Presentation
Children with osteoarticular infections may present with fever, localized bone pain, inability to bear weight, a limp, or localized swelling, erythema, or warmth. The history of presentation and physical findings may vary by the underlying etiology and will be discussed separately.
Septic Arthritis
Patients with septic arthritis often present with fever, inability to move the affected joint, swelling, erythema, or warmth. On a physical exam, they often will resist both passive and active range of motion and may refuse to ambulate if the lower extremities are involved. There may be an obvious joint effusion, warmth, or erythema. Patients may show signs of systemic illness with fever, vomiting, or diarrhea. The most commonly affected joint is the hip, followed by the knee. When the hip is affected, the patient may try to lie in a position of comfort, with the hip flexed, abducted, and externally rotated. An example of posture concerning for septic arthritis can be found at https://bit.ly/40HSoIf.15
Osteomyelitis
Children with osteomyelitis most commonly present with localized bone pain and may have a fever.2,4 This often develops over about a week of symptoms, rather than an acute presentation.7 Overall, acute osteomyelitis is defined by fewer than four weeks of symptoms, subacute osteomyelitis has one to three months of symptoms, and chronic osteomyelitis is classified as having symptoms for three months or longer.
In addition to localized pain, many patients also present with impaired function, such as a limp or the inability to move the affected limb, and some will have associated skin changes, such as erythema, swelling, or warmth. A physical exam may be notable for fever, bony tenderness to palpation, limited range of motion of the affected extremity, or skin changes. Neonates may present in a more nonspecific fashion with irritability, fussiness, or poor feeding, which makes diagnosis more difficult.
Vertebral Osteomyelitis
Vertebral osteomyelitis, or osteomyelitis of the vertebral bodies, is less common in children, but it may present with nonspecific back pain, tenderness to palpation, or fever. In the event of ongoing infection that progresses to abscess or spinal involvement, patients may experience neurological symptoms, such as numbness, tingling, motor disturbance, or bowel and bladder dysfunction. In addition to spinal tenderness, a physical examination may reveal neurological abnormalities, such as sensory disturbance, decreased strength, or altered reflexes.
Discitis
Discitis, an infection of the intervertebral discs of the spine, may present in a nonspecific fashion with malaise, back pain, limited mobility caused by pain, a limp or antalgic gait, and with or without a fever. A physical exam also is nonspecific, but patients may have back pain on palpation.
Tenosynovitis
Tenosynovitis, infection of the tendon sheath, presents with digit pain, swelling, redness, and decreased movement, with or without fever. This is less common in healthy children but typically occurs in the setting of penetrating injury, such as animal bites. A physical examination is notable for symmetrical/uniform swelling of the affected finger, which is held in a flexed position, pain on any attempt of passive finger extension, and tenderness along the course of flexor tendon sheath.16
An example of pyogenic flexor tenosynovitis and physical exam with Kanavel signs can be found at https://bit.ly/4jnRtnk.17 Kanavel signs should prompt the emergency physician to consider this diagnosis.
Pyomyositis
Pyomyositis is defined as a purulent collection within skeletal muscle and occurs most commonly in otherwise healthy children older than 2 years of age into adolescence. It typically presents with localized muscular pain, difficulty with ambulation, and fever, but it also can present with vague and nonspecific complaints, which make the diagnosis more difficult.17 A physical exam may be notable for localized swelling. The early stages of this disease may lack infectious symptoms and may be misdiagnosed as a muscular strain, contusion, deep vein thrombosis, or another noninfectious entity. The iliopsoas, internal obturator, and quadricep muscles most commonly are involved.
Differential Diagnosis
In any case of acute joint pain, swelling, warmth, or diminished mobility in a joint with or without infectious symptoms, the emergency provider must consider osteoarticular infections. Clinicians must have a high index of suspicion for septic arthritis, osteomyelitis, pyomyositis, or discitis. Viral infections also can present with arthritis and lead to transient synovitis. It also is important to consider alternative diagnoses, such as causes of noninfectious arthritis (e.g., Legg-Calve-Perthes [LCP] disease, slipped capital femoral epiphysis [SCFE], traumatic fracture, oncologic conditions, crystal-induced arthritis, rheumatologic arthritis, and reactive arthritis).18
Diagnostic Studies
The diagnosis of osteoarticular infections can be made by clinical findings supported by various laboratory and radiologic studies, as well as fluid analysis from joint aspiration. This article will focus on the workup of septic arthritis and osteomyelitis. As mentioned, clinically, patients who present with localized bone pain, inability to ambulate, and localized warmth or swelling with or without fever must be assessed for osteoarticular infections. The diagnostic algorithm for septic arthritis is depicted in Figures 1a and 1b and can guide workup and management in suspected cases.19
Figure 1a. Diagnostic Algorithm of Septic Arthritis |
 |
SF: synovial fluid; MRI: magnetic resonance imaging; LDH: lactate dehydrogenase Reprinted with permission from Benito N, Martínez-Pastor JC, Lora-Tamayo J, et al. Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP, and SECOT. Enferm Infecc Microbiol Clin (Engl Ed). 2024:42(4):208-214. |
Figure 1b. Diagnostic Algorithm of Septic Arthritis |
 |
*Leukocyte count usually > 20,000/μL; > 100,000/μL highly suggestive of septic arthritis **Septic and crystalline arthritis may occur simultaneously ***Diagnosis of septic arthritis ****Assessment by a rheumatologist and/or orthopedic surgeon is suggested LDH: lactate dehydrogenase; SF: synovial fluid; PMN: polymorphonuclear neutrophils Reprinted with permission from Benito N, Martínez-Pastor JC, Lora-Tamayo J, et al. Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP, and SECOT. Enferm Infecc Microbiol Clin (Engl Ed). 2024:42(4):208-214. |
Blood work is a common adjunct used to further investigate the clinical picture and diagnosis of septic arthritis in children, given that differentiating septic arthritis from other pathologies sometimes can be difficult. Historically, a framework called the Kocher criteria was developed to screen for these types of infections and included fever (> 38.5°C), inability to bear weight, white blood cell (WBC) count > 12,000 cells/mL, and an erythrocyte sedimentation rate (ESR) of ≥ 40 mm/hour.20 The Kocher criteria are used to differentiate septic arthritis of the hip with a reported 93% or greater positive predictive value when three or four risk factors are present.
However, multiple systematic reviews have noted a diminishing positive predictive value of the criteria. A recent study found that the Kocher criteria alone would have missed contiguous osteomyelitis in 43.2% of children with septic arthritis and that children with three or four Kocher criteria, regardless of the presence of a hip effusion, had a high incidence of osteomyelitis. Hence, the Kocher criteria may be less specific for septic arthritis with contiguous osteomyelitis.3,21
The combination of a complete blood count (CBC), including a WBC count, C-reactive protein (CRP), and the ESR are nonspecific and cannot diagnose septic arthritis. However, they can increase suspicion when used in conjunction with clinical presentation, imaging, and joint fluid analysis.19 Although the CBC alone is nonspecific, it can be helpful when evaluating for other entities, such as an oncologic process. Blood cultures should be obtained in cases of suspected septic arthritis or osteomyelitis. The rate of positivity in blood cultures in osteoarticular infections is variable, but multiple studies estimate about one-third of cases to be positive. With organisms that are known to cause endocarditis, blood culture positivity should prompt the provider to evaluate for endocarditis with echocardiography.22
While the Kocher criteria may be a useful adjunct in evaluating a child for suspected septic arthritis, a recent multicenter matched case-control study was performed to define clinical and laboratory factors associated with acute hematogenous osteomyelitis in children undergoing evaluation for a suspected musculoskeletal (MSK) infection (e.g., osteomyelitis, septic arthritis, or pyomyositis) in the pediatric ED. Unlike septic arthritis, osteomyelitis can be more variable and mimic other entities. In this 23-site study, a four-point risk score was derived by assigning points to the top performing independent predictor variables from the multivariable model. The top-performing predictors were duration of illness > three days, history of fever or highest ED temperature ≥ 38°C, CRP > 2.0 mg/dL, and ESR > 25 mm/hour. Patients with a risk score of 0 would have an absolute risk of 0.2% to 0.3%, and those with a risk score of 4 would have an absolute risk of 37.9% to 49.1%.5 While this score does not differentiate osteomyelitis from the other MSK infections, it easily can be applied in the ED setting to inform the decision to pursue or forego definitive diagnostic imaging and/or invasive testing (e.g., magnetic resonance imaging [MRI]), joint aspiration, or bony cultures) in children for whom the diagnosis of osteomyelitis is being considered.
In addition to inflammatory markers, imaging is a useful adjunct in making the diagnosis. Plain radiographs are suggested as first-line imaging to evaluate for signs of joint damage, and soft markers of osteomyelitis and to evaluate for other diagnostic entities such as fractures, SCFE, LCP, and bony tumors.22 It is important to note the plain radiographs have low sensitivity and may appear normal in cases of osteoarticular infection. However, cases of more subacute duration may show widening of the joint or bony lesions.7
In children, an ultrasound is helpful in detecting effusions that may not be obvious on the physical exam. Bilateral hip effusions detected on ultrasound may be more suggestive of transient synovitis. Ultrasound also can be useful in guiding fluid aspiration. Children more commonly have a spread of septic arthritis with abscess or osteomyelitis, in which case MRI is indicated for further evaluation.
Computed tomography (CT) can be used as an alternative if MRI is not readily available, but the risks and benefits of CT in children should be discussed. MRI has become the gold standard in the diagnosis of osteoarticular infections, rather than ultrasound, bone scan, or CT, since MRI provides more information regarding spread of septic arthritis, subperiosteal abscess, and osteomyelitis and also has no ionizing radiation. The sensitivity of MRI for the diagnosis of osteomyelitis ranged from 81% to 100% in eight studies, and the specificity ranged from 67% to 94% in five studies.22
However, it comes with limitations in the pediatric population. Younger children may require sedation to tolerate MRI, which often takes at least 30 minutes to complete. This can lead to delays in diagnosis and treatment, and sedation carries its own risks. Table 2 summarizes the diagnostic imaging modalities for pediatric bone infections, based on current evidence and guidelines. Table 3 outlines the best use cases for each imaging modality.
Table 2. Diagnostic Imaging Modalities for Pediatric Bone Infections22-24 | |||
| Imaging Modality | Key Features | Advantages | Limitations |
Magnetic resonance imaging |
|
|
|
Computed tomography |
|
|
|
X-ray |
|
|
|
Bone scintigraphy |
|
|
|
Ultrasound |
|
|
|
Table 3. Best Use Cases by Diagnostic Imaging Modality for Pediatric Bone Infections22-24 | |
| Imaging Modality | Best Use Cases |
Magnetic resonance imaging | Detecting early infections, pelvic or spinal osteomyelitis, surgical planning |
Computed tomography | Detecting cortical destruction, abscess, or sequestra in chronic cases |
X-ray | Screening for fractures, excluding malignancy, or late-stage infections |
Bone scintigraphy | Screening when magnetic resonance imaging is unavailable, detecting multifocal osteomyelitis |
Ultrasound | Detecting abscesses or superficial infections |
Synovial fluid should be collected in cases of suspected septic arthritis where an effusion is present and available for sampling. Synovial fluid should be sent for Gram stain, WBC and polymorphonuclear neutrophils (PMN) percentage cell counts, and cultures. A WBC count of > 100,000/μL or 50,000-100,000/μL with > 90% PMN are suggestive of a bacterial infection.19
Synovial fluid should be cultured aerobically and anaerobically to identify an organism. False negatives may occur with difficult organisms, such as Kingella or Neisseria. Polymerase chain reaction (PCR) is very helpful in identifying a causative organism in these situations. Clinicians also can consider particular cultures for tuberculosis or other fungal infection, depending on the history.
In combination with the clinical presentation, the laboratory values, imaging, and synovial fluid results can help guide the emergent approach to the management of osteoarticular infections. More difficult cases with high suspicions of infection require consultation with pediatric orthopedics, infectious disease, or rheumatology.
Emergency Approach to Management
Treatment of osteoarticular infections includes a combination of antimicrobials, joint aspiration, surgical management, and long-term subspecialty follow-up with orthopedic and infectious disease specialists. With prompt diagnosis and treatment, many children have favorable outcomes.
Septic Arthritis
Timely operative management of septic arthritis can prevent complications, such as osteonecrosis — particularly of the hip. Once a diagnosis of septic arthritis is suspected, it becomes a surgical emergency, and an orthopedics consultation should be obtained to streamline next steps and surgical intervention. Surgical intervention may include drainage, decompression, irrigation, and debridement, depending on the extent of the infection identified on imaging.4
Antimicrobial therapy should be initiated empirically based on the most likely organism for the child’s age group and other comorbidities. Coverage may start out broadly and can be narrowed based on aspirate and culture results while the patient is inpatient. In hemodynamically stable patients, orthopedic surgeons may request to delay antibiotics until debridement and cultures can be obtained. This decision should be a multidisciplinary decision based on the patient presentation, patient stability, and timing to further intervention.
Initial antibiotic selection usually includes coverage for Streptococcus and Staphylococcus, with consideration of methicillin-resistant Staphylococcus aureus (MRSA) coverage based on community prevalence. This usually includes intravenous cefazolin with the addition of clindamycin or vancomycin, depending on the local antibiogram and susceptibilities. If Kingella, Lyme, or Neisseria gonorrhoeae is of concern, then a third-generation cephalosporin, such as ceftriaxone, should be selected as the initial antibiotic of choice.
Intravenous antibiotics are continued inpatient until clinical improvement and/or susceptibilities allow for narrowing and a targeted transition to oral antibiotics. The total duration of antimicrobial treatment usually is two to three weeks in uncomplicated cases of septic arthritis and three to four weeks in cases of septic arthritis with concomitant osteomyelitis. Longer courses of therapy may be required in other atypical organisms, newborns, or immunocompromised patients.19
In cases of septic arthritis, a few studies have investigated the utility of a short course of steroids in affecting outcomes. One randomized control trial performed in Costa Rica measured patients one year after receiving a course of dexamethasone as part of their treatment for septic arthritis. The study found that only 2% of patients demonstrated limping, joint pain, and difficulty with movement, compared to 26% of patients who received placebo.25
A Cochrane systematic review included two randomized controlled trials with patients aged 2 months to 18 years who received a diagnosis of septic arthritis and were prescribed steroids in addition to antibiotics or as an adjunct to surgical drainage. This review found that, at the one-year follow up, patients who received steroids had improved mobility, less pain, and required a shorter antibiotic course. However, given there were only two studies with low-quality evidence, no conclusion currently can be made, and more studies are required to understand the true effects of steroids (risks and benefits) as adjunctive treatment.26
Uncomplicated cases of septic arthritis with prompt diagnosis and treatment can lead to quick resolution and return to baseline activity. Complications can arise in 10% to 25% of patients. Complications include osteonecrosis and joint destruction with loss of mobility, septic emboli, deep vein thrombosis, sepsis with multiorgan failure, and even death.13
Osteomyelitis
In children with acute hematogenous osteomyelitis, treatment is focused on antimicrobials as well as possible further diagnostic and therapeutic procedures.
In children with ill appearance or instability, empiric antibiotics should be started immediately rather than withholding until invasive diagnostics are performed. The decision to withhold antibiotics in advance of a planned procedure in an otherwise stable child with osteomyelitis should be done in conjunction with orthopedics. Procedures such as bone biopsy and aspiration or washout may be performed at the discretion of the pediatric orthopedic specialist. In one systematic review of patients with osteomyelitis, blood cultures identified a pathogen in 32% of cases, while the combination of bone or tissue culture with blood culture increased the yield in identifying a pathogen to 55% of cases.22
Regardless, the yield of positive cultures collected even 24 to 48 hours after initiation of antibiotic therapy is similar to the yield obtained prior to the administration of antibiotics. Another systematic review by Dartnell, however, found that the trend that medical management without drainage or debridement was increasing and that this rarely led to treatment failure.27 At present, invasive therapeutic procedures, such as washout, should occur in cases of rapid progression and abscess development.
Similar to the empiric treatment of septic arthritis, in children with suspected osteomyelitis, empiric antibiotic therapy should have activity against S. aureus (usually cefazolin or nafcillin) with consideration of addition of MRSA coverage (clindamycin or vancomycin) based on community prevalence. The selection of definitive therapy then is narrowed based on the identified pathogen and susceptibilities. In cases of culture-negative osteomyelitis, the antibiotic regimen should be based on the most likely organism with demonstrated patient improvement.
Patient presentation should be considered on an individualized basis based on underlying conditions, such as hemoglobinopathies, certain exposures, and immunization status, which would warrant broader coverage to include Salmonella, Brucella, and/or Haemophilus. This is further demonstrated in Table 4. In uncomplicated cases and patient improvement on initial intravenous therapy, clinicians can transition to oral therapy for a three- to four-week course. In cases of relapse or non-responsiveness, emergency physicians should consider adequacy of the current regimen, consider broadening therapy, and consider repeat imaging or surgical intervention.22
Table 4. Empiric Antibiotic Selection for Osteomyelitis Based on Likely Pathogen |
|
| Pathogen | Empiric Intravenous Antibiotic |
|
|
|
|
|
|
|
|
|
|
Adapted from Woods CR, Bradley JS, Chatterjee A, et al. Clinical practice guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc. 2021;10(8):801-844. |
|
In any patient with an osteoarticular infection, the first step in management is the stabilization of hemodynamic status. Patients who present with signs of sepsis must have fluid resuscitation and prompt initiation of antibiotics. Those who are hemodynamically stable can undergo further workup as previously outlined, followed by antibiotics and admission for further management. Short-term complications of osteoarticular infections include sepsis, septic shock, deep vein thrombosis, and septic pulmonary emboli. Long-term complications include avascular necrosis, joint laxity, limited range of motion, leg length discordance if the growth plate is involved, pathologic fractures, and premature osteoarthritis.13
Emergency Department Disposition
Children with confirmed or suspected osteoarticular infections should be admitted to the hospital for intravenous antibiotics, possible surgical intervention, and monitoring for transition to oral antibiotics. These patients will have interval laboratory monitoring to include the complete blood count, inflammatory markers, blood cultures (if positive), as well as monitoring of the fever curve to guide transition to oral antibiotics and discharge readiness. Patients with persistent concerns, such as prolonged symptoms prior to treatment, persistent fever despite effective therapy or debridement, persistently elevated CRP, multifocal infection, surgery required for source control, hip involvement, or imaging concerning for risk of pathologic fracture should have long-term follow-up.
Outpatient follow-up should include the primary pediatrician, pediatric orthopedic team, and infectious disease specialists in intervals at one to two weeks, four to six weeks, and three months after discharge. Patients with the previously mentioned risk factors are considered high risk for complications and should have follow-up for at least one year after discharge. In addition, those with chronic osteomyelitis more likely will have pathologic fractures and recurrent surgeries, so they may warrant longer follow-up.28
Conclusion
Pediatric osteoarticular infections can vary in presentation, given the sometimes nonspecific complaints, difficulty with history depending on the age of the patient, and the overlap with other osteoarticular conditions. The emergency clinician should have a high level of suspicion and appropriate timely diagnostic workup to avoid delays in diagnosis and to prevent risk of sequelae of these infections.
The comprehensive workup includes laboratory, radiographic, and possible subspecialty procedural and/or surgical intervention. The treatment of osteoarticular infections focuses on empiric followed by directive antibiotic therapy and possible surgical source control by pediatric orthopedics specialists. It requires admission and long-term follow-up with subspecialists.
Brittany Boswell, MD, is Assistant Professor of Emergency Medicine and Pediatrics, Stanford University, Stanford, CA
Mia L. Karamatsu, MD, is Assistant Professor of Emergency Medicine and Pediatrics, Stanford University School of Medicine, Stanford, CA
Cherrelle Smith, MD, MS, Assistant Professor of Emergency Medicine and Pediatrics, Stanford University, Stanford, CA.
Guillermo De Angulo, MD, MSCR, is Assistant Professor of Emergency Medicine and Pediatrics, Stanford University, Stanford, CA
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- Benito N, Martínez-Pastor JC, Lora-Tamayo J, et al. Executive summary: Guidelines for the diagnosis and treatment of septic arthritis in adults and children, developed by the GEIO (SEIMC), SEIP, and SECOT. Enferm Infecc Microbiol Clin (Engl Ed). 2024:42(4):208-214.
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- Qi H, Zhu Z, Zhu D. Erythrocyte sedimentation rate for assisted diagnosis of pediatric osteomyelitis: A meta-analysis. Ther Clin Risk Manag. 2023;19:1039-1049.
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- Disch K, Hill DA, Snow H, Dehority W. Clinical outcomes of pediatric osteomyelitis. BMC Pediatr. 2023;23(1). doi:https://doi.org/10.1186/s12887-023-03863-z
Pediatric osteoarticular infections may be subtle in their presentation, and clinicians must have a high degree of suspicion to make a timely diagnosis and institute appropriate therapy. The authors provide the essential information clinicians require to understand the presentation, diagnostic evaluation, and management of bone and joint infections in this population.
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