How To Detect Pediatric Osteomyelitis

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The above X-ray of the right ankle of a 10-year-old boy shows lucency in the tibial metaphysis secondary to acute hematogenous osteomyelitis (AHO).
The above X-ray of the left ankle of a 10-year-old boy shows lucency in the tibial metaphysis secondary to acute hematogenous osteomyelitis (AHO).
This MRI sagittal section shows the same AHO lesions with the right lesion extending into the growth plate.
Here is an X-ray of an AHO lesion extending into the growth plate.
This intraoperative photo shows an AHO lesion within the tibia.
How To Detect Pediatric Osteomyelitis
The lucency in the distal tibial epiphysis is consistent with chronic recurrent multifocal osteomyelitis. It is almost indistinguishable from lesions secondary to AHO.
By Michael Schreck, DPM

   Although both acute hematogenous osteomyelitis (AHO) and chronic recurrent multifocal osteomyelitis (CRMO) are somewhat uncommon, differentiating between the two can be tricky. Having a strong grasp of the etiology and presentation of these conditions can go a long way toward preventing a delayed or inappropriate diagnosis, which could be harmful for pediatric patients.

   Pediatric hematogenous osteomyelitis may occur secondary to a traumatic injury and/or an acquired illness or other immunosuppressive condition. Acute hematogenous osteomyelitis reportedly affects one in 5,000 children in the United States under the age of 13 with half of all cases occurring in children under 5.1-3 The condition can be quite dangerous in prognosis if the diagnosis is delayed. Therefore, it is essential to be able to differentiate between AHO and other conditions.

   Chronic recurrent multifocal osteomyelitis is a separate and rare disorder that affects children and teenagers. The condition is an inflammatory disorder of unknown etiology that involves different osseous sites and has some association with psoriasis and palmoplantar pustulosis. While antibiotic therapy usually works for AHO, one would primarily treat CRMO with antiinflammatories.

   That said, let us take a closer look at each condition.

Understanding The Presentation And Pathophysiology Of AHO

   Acute hematogenous osteomyelitis in children is an uncommon but not rare systemic disease that occurs primarily in the metaphysis of long bones.1 Morbidity mostly occurs via delays in diagnosis that may be due to negative culture results and/or a poor understanding of the pathophysiology of bone infections that can lead to mismanagement of the patient.1 The earliest presentation has no findings other than local tenderness and an elevated erythrocyte sedimentation rate (ESR).4

   Children may acquire osteomyelitis via three sources. The most common sources include contiguous or soft tissue sources (i.e., excoriations, abrasions, insect or animal bites), puncture wounds and hematogenous spread. A history of trauma or other insinuating event to the body can potentiate the infestation of bacteria into the bloodstream.

   Guler, et. al., sought to establish the role of blunt trauma without fracture or obvious wound as a risk factor in children admitted for community-acquired Staph septicemia.5 They showed that skeletal involvement was multifocal and more frequent in traumatized, older patients.5 The period between the symptoms of infection and diagnosis was also shorter in traumatized patients and included 12 (46 percent) of 26 septicemic patients.5

   Viruses or bacterial infections, such as an upper respiratory infection, pharyngitis and otitis media, can also lead to an infection in the bloodstream, and potentially affect the bone and joints. The patient history and physical exam findings may be sensitive but they are rarely specific. Typically, fever, pain and limited use of an affected extremity are the most common symptoms whereas constitutional symptoms are less common. Older children will have even more subtle presentations of symptoms. Arthritic conditions such as juvenile rheumatoid arthritis can make joints more susceptible to invasion by organisms. Accordingly, one should rule out such conditions during a routine screening if a child presents with any joint or limb pain.

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