ACUTE

OSTEOMYELITIS
IN CHILDREN
International journal of
environmental research and public
health 2016, review : Himatul Mahmudah
“A case of acute osteomyelitis: un 20174011167
update on diagnosis and
treatment”. By Chiapppini, E.,
Mastrangelo, G., Slazzeri, S.
DEFINITION
 The root words Osteon (Bone)
and Myelo (Marrow) are
combined with Itis
(inflammation) to define the
clinical state in which bone is
infected with microorganisms.
 Hippocrates 460-370 BC infection
after fracture
 Nelaton credited with
introducing the term
osteomyelitis in 1844
 CASE PRESENTATION
A previously healthy 18-month-old boy presented
at the emergency department with left hip pain
and a limp following a minor trauma. He had
presented fever for three days, cough and rhinitis
about 15 days before trauma, and had been
treated with ibuprofen, he presented with a
limited and painful range of motion of the left hip
and could not bear weight on that side.
 The examination of other joint was unremarkable,
and no inflammatory signs were evidence.
Case cont……
WBC : 23,000 (H)

Blood Neutrophils: 86% (H)

CRP: 7,2 (H)
Test ESR: 52 (H)

A lytic lesion of the proximal X-

rays
femoral metaphysis

Clinical suspicion of
MRI osteomyelitis of the proximal
femur
INTRODUCTION
 Osteomyelitis is an Inflammation of the bone its
medullary cavity caused by an infecting organism
most commonly by bacteria, usually seen in
children.
 The estimated incidence is about 8 cases per
100,000 children/year.
 Children under 5 years of age are affected in
about 50% of the cases.

 Early detection is crucial given that delay in the

diagnosis is a risk factor for long-term sequelae
Introduction Cont….

Complications

• Possible complications include septic arthritis,

subperiosteal abscess, pyomyositis, deep vein
thrombosis, sepsis, and , multiorgan failure.
CLASSIFICATION
Host
Duration Mechanism response to
the disease
acute
(<2 weeks) exogenous pyogenic

subacute
( 2-6 weeks)

chronic hematogenous nonpyogenic.

(>6 weeks)
Acute VS Sub acute Osteomyelitis
Chronic Osteomyelitis
Organisms Commonly Isolated in
Osteomyelitis Based on Patient Age
 Infants (<1 year)
Group B streptococci, Staphylococcus aureus,
Escherichia coli
 Children (1 to 16 years)
S. aureus, Streptococcus pyogenes, Haemophilus
influenzae
 Adults (>16 years)
Staphylococcus epidermidis, S. aureus,
Pseudomonas aeruginosa, Serratia marcescens
E. coli
Adapted with permission from Dirschl DR, Almekinders LC. Osteomyelitis. Common
causes and treatment recommendations. Drugs 1993;45:29-43
Pathophysiology
 Bacteremia Sluggish flow of
blood in hair pin like loops of
vessels in highly vascular
metaphysis  Bacteria settle
in metaphysis  inflammatory
reaction  a local ischemic
necrosis of bone  abscess
formation  abscess
enlarges  intramedullary
pressure increases  cortical
ischemia  allow purulent
material to escape through
the thin cortex into the
subperiosteal space 
subperiosteal abscess.
 If left untreated  extensive
sequestra formation and
chronic osteomyelitis.
Pathophysiology

 Ifleft untreated
 extensive
sequestra
formation and
chronic
osteomyelitis.
DIAGNOSIS

Anamnesis • The child both a previous upper airway

infection and a previous trauma  may be
(Medical an additional risk factor for acute
osteomyelitis.
History)

• Pain, elevated of inflammatory markers,

functional limitation, fever(+/-), reduced
Physical mobility
Examination • Tenderness over a metaphyseal region of a
long bones, most frequently involves the
metaphysis of long bones
 DIAGNOSIS
• Blood test (Leukocytosis,
increased ESR, elevated
CRP, increased PCT, blood
Additional cultures (+) 50%)
Examination
• X-Ray (an osteolytic lesion)
• MRI
• Biopsy
Diagnosis Cont…
Localization

Multifocal forms are

uncommon, and usually
associated with sepsis, and
occur in about 5%-7% of
pediatric cases, mostly in
newborns 22%
Differential Diagnosis
Update on Therapeutic Management
Supportive
treatment for
pain and
dehydration

Multidisciplinary
challenge and
collaboration
Appropriate (pediatricians, Splintage of
antimicrobial infectious disease the affected
therapy specialists, orthopedic part.
surgeons,
microbiologists and
radiologists)

Surgical
drainage
Nade’s 5 principles of treatment
An appropriate
antibiotic is
effective
before pus
formation

Antibiotics do not
Antibiotics sterilize avascular
should be tissues or abscesses
continued and such areas
after surgery require surgical
removal

If such removal is
effective, antibiotics
Surgery should not
should prevent their
damage already
reformation and
ischaemic bone
primary wound
and soft tissue
closure should be
safe
 Antibiotic
 The choice of specific
antibiotic is based on the
identification of causative
infectious organism and
on local epidemiological
data on resistance
 IV meticillin is the choice
for S.aureus .
 Vancomycin for
methicillin- resistant .
 The length of therapy
depends on :
- Clinical resolation
- Reduction of ESR .
 S.Aureus 14-21 days or
more
 Gonococcal or
meningococcal 7 days of
penicillin
 Surgery
The three main indications for surgery in
acute hematogenous osteomyelitis are:

Subperiosteal and soft tissue

abscesses and intramedullary
purulence should be drained

Suquestra should be reemoved and

contiguous infections foci should
be debrided adequetly and treated
with effective antimicrobial therapy

Failure of the patient to improve

despite appropriate intravenous
antibiotic treatment
 Treatment
In view of the fact that most severe forms
of osteomyelitis are consequent upon
intraosseous hypertension, early surgical
intervention, osteoperforation, acquires
primary importance. An incision, no less
than 10-15 cm in length, is made in the
soft tissues overlying the lesion and the
periosteum is cut longitudinally. Two or
three perforating openings 3-5 mm in
diameter are made at the junction with
the healthy bone. Pus is usually
discharged under pressure in such cases,
while in a disease of a long duration the
contents of the marrow cavity may be
seropurulent for two or three days. The
marrow cavity is irrigated with 1 : 5000
nifrofurazone solution and antibiotics
through the perforation in the bone.
Monitoring tools
History and physical examination

ESR and/or CPR level

White blood cell count

Plain radiographs
Complication
Complications that may occur during treatment include
 recurrent osteomyelitis,
 distant seeding,
 epiphyseal damage and altered bone growth in
neonatus and infant,
 suppurative arthritis,
 metastatic infection,
 pathologic fracture, and
 chronic osteomyelitis.
CONCLUSIONS
Acute osteomyelitis in children is a serious disease
that, when detected and treated early, can heal without
severe sequelae . It is of primary importance to
recognize the signs and symptoms at the onset of the
disease and to properly use the available diagnostic
tools. The role of serum markers as predictive factors
for diagnosis has not been completely established. In
particular, PCT should be further evaluated in larger
studies and a cut-off value has not been univocally
defined. Similarly, recommendations for the duration of
intravenous antimicrobial therapy have not been stated.
Moreover, local different prevalence of antibiotic
resistant strains may justify different therapeutic
approaches. The authors’ opinion is that, at the
moment, every child with acute osteomyelitis should
receive a “tailored therapy”, based on epidemiological
 Nyuwun agunging
pangaksami menawi wonten
klenta – klentunipun …
Matur nuwun …