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European Journal of Radiology 60 (2006) 221–232

Review

Acute osteomyelitis, septic arthritis and discitis:Differences between neonates and older children

A.C. Offiah ∗Department of Radiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK

Received 22 June 2006; accepted 13 July 2006

bstract

There are aetiological, clinical, radiological and therapeutic differences between musculoskeletal infection in the neonate (and infant) andn older children and adults. Due to the anatomy and blood supply in neonates, osteomyelitis often co-exists with septic arthritis. Discitis is

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ore common in infants whereas vertebral body infection is more common in adults. This review article discusses the important clinical andadiological differences that in the past have led many authors to consider neonatal osteomyelitis a separate entity from osteomyelitis in thelder child.

2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Neonate; Infection; Osteomyelitis; Arthritis; Discitis; Imaging

Contents

1. Nomenclature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2212. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2223. Anatomical considerations and pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2244. Clinical presentation and laboratory findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2245. Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

5.1. Radiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2255.2. Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2265.3. Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2275.4. Magnetic resonance imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

5.5. Computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

6. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2327. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

. .

The term osteomyelitis refers to infection of bone and/or bonearrow. Depending on both the virulence of the organism and

he immune response mounted by the host, osteomyelitis may becute, subacute or chronic. Acute osteomyelitis is not common

∗ Tel.: +44 20 7405 9200x5269; fax: +44 20 7829 8665.E-mail address: offiaa@gosh.nhs.uk.

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720-048X/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.ejrad.2006.07.016

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

n adults [1]. Conversely, in neonates osteomyelitis is usuallycute [2].

Septic arthritis refers to infection of a joint. While this mayccur in isolation, in neonates it is much more likely to occurs a consequence of bony infection (osteomyelitis) with spreadnto the adjacent joint.

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Nomenclature

Discitis refers to infection of a disc space and adjacent ver-ebral end plates.

Vertebral infection indicates infection of the vertebral body.ecause of the differences in vascular supply (see below), ver-

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222 A.C. Offiah / European Journal of Radiology 60 (2006) 221–232

Fig. 1. AP chest of an infant with septic arthritis of the right shoulder. NoticeSm

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alter Harris I injury of the shoulder (compare the relationship of epiphysis andetaphysis with the normal left side) as a result of a large joint effusion.

ebral infection is less commonly seen in infants and younghildren than in teenagers and adults.

. Pathogenesis

Infection may reach the bone (or joint) via three main routes:

The bloodstream, i.e. haematogenous spread. This is the com-monest route of infection in the neonate.Direct contamination, e.g. penetrating or puncture wounds,surgery. This route of infection is commoner in older childrenand adults.Indirect contamination from a nearby infection, e.g. cellulitis.

The causative organism depends on the age of the patient, andn the neonate is most commonly Staphylococcus aureus. Otherrganisms include Escherichia coli, Group-B Streptococci, otherram-negative rods and Candida albicans [6–8].Since the introduction of the HiB vaccine, the incidence of

aemophilus influenza infection in infants and older childrens much reduced [9], with S. aureus and Group-A Streptococcieing the more common causative organisms.

Infection with Neisseria gonorrhoeae occurs in adolescents.almonella should be considered in children with sickle cell dis-ase. Fungal, parasitic and mycobacterial infection may occur,articularly in the immunocompromised host and in endemic

egions [10].

In childhood discitis, a causative organism is not com-only isolated [11] and biopsy should be reserved for those

ailing to respond to anti staphylococcal therapy. Atypical

ig. 2. Sequential radiographs in a neonate with osteomyelitis of the left femur.A) Lateral of both knees on day of presentation. Note significant swellingf the left knee compared to the right. There is early periosteal reaction ofhe distal femoral shaft (arrow). There is possibly increased metaphyseal andpiphyseal radiolucency compared to the normal side. (B) AP radiograph leftnee on day of presentation. Periosteal reaction of the distal femur (arrows) isetter appreciated on this radiograph. (C) AP and lateral radiographs left kneedays following initial radiographs. Metaphyseal irregularity and radiolucency

nd periosteal reaction of the distal femur are well demonstrated. (D) AP andateral radiographs left knee 16 days following initial radiographs. The soft tissuewelling has resolved. Periosteal reaction has consolidated. (E) AP radiographeft knee 2.5 months after initial radiographs. There is almost complete resolutionf changes following adequate antibiotic therapy.

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A.C. Offiah / European Journal of Radiology 60 (2006) 221–232 223

Fig. 2. (Continued ).

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