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.