acute osteomyelitis, septic arthritis and discitis: differences between

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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: [email protected].

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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.


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

Fig. 2. (Continued ).



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Fig. 3. AP pelvis in an infant with septic arthritis and osteomyelitis of the Lhip. Notice the patchy radiolucency and sclerosis of the femoral neck at thesite of osteomyelitis. The left femoral head is irregular, small and fragmentedcompared to the right consistent with an associated septic arthritis (in infants,oa

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tyears for osteomyelitis and 2 years for septic arthritis [2–5].

Compared to older children and adults, there are fewer clini-cal signs and the diagnosis of osteomyelitis and/or arthritis may

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24 A.C. Offiah / European Journa

nfections include tuberculosis, brucellosis, and fungal disease12].

. Anatomical considerations and pathophysiology

The unique vascular anatomy of the epiphyses in neonatesnd infants accounts for the frequency with which osteomyelitisnd septic arthritis co-exist.

The reduced rate of blood flow within vessels at the meta-hysis renders this region more susceptible to haematogenouseeding of infection [13]. Before the appearance of secondaryssification centres, the cartilaginous epiphyses receive theirlood supply directly from metaphyseal blood vessels. Hence,eptic arthritis is a relatively common sequel to osteomyelitis inhe neonate, particularly in joints such as the hip, in which theetaphysis is intracapsular. It is said that in neonatal osteomyeli-

is, infection leads to epiphyseal insult or septic arthritis in 76%f cases [4].

Because of the lax nature of the surrounding muscles, theresence of a joint effusion in neonates may lead to subluxationr dislocation of the affected joint (Fig. 1).

In addition, the accumulation of inflammatory exudate withinhe joint causes vascular compression and may result in avas-ular necrosis of the affected epiphysis. Septic arthritis is alinical emergency, and prevention of significant long-term mor-idity depends on timely diagnosis and relief of pressure; eithery ultrasound guided joint aspiration or more invasive surgicalechniques.

In older children and adults, the epiphyses and metaphysesave a separate blood supply, and spread of infection from boneo joint (or vice versa) is far less common. Furthermore oncepiphyseal fusion has occurred, long-term complications relat-ng to epiphyseal damage and limb length discrepancies are lessf an issue.

Bones and joints of the lower limb are most commonlyffected. Other sites include the upper limbs, and more com-licated locations such as the pelvis and the spine (discitis).

Discitis in the neonate and young child most commonlyffects the lumbar spine. Infection is more likely to reach thepine through the nutrient arteries than via the paravertebralenous system [14]. In a similar way to metaphyseal infec-ion, spinal infection follows arterial septic embolisation. Innfants and young children, the cartilaginous vertebral end platesre traversed by numerous canals through which small bloodessels pass. These vessels terminate adjacent to the inter-ertebral disc thus rendering the disc susceptible to infection.he vascular channels disappear by the third decade of life

15], hence the reduced incidence of discitis in older childrennd adults. The vertebral bodies of infants and small chil-ren have a large network of interosseous collateral arterieshich is not found in adults. This renders the vertebral bod-

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es of infants less susceptible to infarction from septic embolind more able to clear bacteria following septic embolisation.his explains the reduced incidence of vertebral body infection

n infants and young children compared to older children anddults [12].

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steomyelitis of the proximal femoral metaphysis often co-exists with septicrthritis).

. Clinical presentation and laboratory findings

Osteomyelitis and arthritis are commoner in young childrenhan in older children and adults, peaking at around the age of 3

ig. 4. AP right arm. Osteomyelitis of the humerus. There is soft tissue swellingith pockets of gas within the soft tissues. There is permeative destruction of

he entire length of the humerus and associated periosteal reaction.

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herefore be harder to make. This is largely because of the poorlyeveloped immune system of neonates, rendering them less ableo mount an immune response. For this reason, they are at greaterisk of infection by less virulent organisms and may not presentith fever. Furthermore, neonates with osteomyelitis and/or sep-

ic arthritis may have a normal leucocyte count and erythrocyteedimentation rate [2].

Clinical symptoms include poor feeding and/or irritability.here may be a history of swelling or failure to move the affected

imb (pseudoparalysis). An older child with discitis may com-lain of back pain. Younger children will have reduced mobilityr may present with a limp. The young child with discitis maye afebrile. Because of these non-specific clinical symptoms, aigh index of suspicion is required in order to make an earlyiagnosis of osteomyelitis, septic arthritis or discitis.

Risk factors in neonates and young children include prema-

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ure birth, umbilical catheterisation (artery or vein), urinary tractnfections and other pre-existing disease. Risk factors in adultsnclude diabetes mellitus and a compromised immune systemincluding HIV).

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ig. 5. Sequential radiographs in an infant with osteomyelitis of the left humerus. (As better defined than in the patient illustrated in Fig. 4. The soft tissues plains do notadiograph obtained 8 months after that shown in (A). Almost complete return to no


adiology 60 (2006) 221–232 225

. Imaging

The role of imaging is to confirm the presence and site ofnfection, to differentiate unifocal from multifocal disease, toocate and guide aspiration of collections and to identify presentr impending complications such as joint or extradural involve-ent.Radiography is usually the first radiological investigation in

neonate with suspected osteomyelitis/septic arthritis/discitis.ther modalities include ultrasound (US), bone scintigraphy,agnetic resonance imaging (MRI) and computed tomography

CT). These are each discussed separately below.

.1. Radiography

Radiographic features in osteomyelitis and/or septic arthritis


nclude deep soft tissue swelling, widening of the joint spaceith or without subluxation (Fig. 1) or frank dislocation, osteo-orosis, periosteal new bone formation and bony destructionFigs. 2–5). Deep soft tissue swelling may be difficult to recog-

) Radiograph obtained at time of referral to tertiary center. Bony destructionappear obliterated (however see MRI obtained at the same time, Fig. 11). (B)

rmal following adequate therapy.



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ig. 6. AP and lateral spine in a child with discitis. Note narrowing of the affecarticularly anteriorly (B).

ise in the neonate because of the poor definition of fascial planesnd relative lack of subcutaneous fat present at this age [2].t should be noted that radiographs have a low sensitivity foretecting the presence of a joint effusion [16]—suspicious fea-ures include widening of the joint space and bulging of the softissues. Radiography allows the exclusion of other conditionsuch as fractures and is useful for the long-term follow up ofomplications.

Soft tissue swelling can be detected as early as 48 h after onsetf infection [17]. However, bony destruction is not detectableadiologically until at least a third of the matrix has been involved18]. This accounts for the low prevalence of abnormal radio-
raphs at presentation, e.g. Capitanio and Kirkpatrick reportedhat only 20% of radiographs were abnormal at 10–14 days [19].
high index of suspicion and further imaging with other modal-ties will often be required.

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isc space and irregularity and sclerosis of the vertebral end plates at that level,

Initial findings in the spine may be limited to a loss of the nor-al lumbar lordosis. Subsequently disc space narrowing (Fig. 6)ith end plate erosions will develop. Long standing infectionay lead to pressure erosion of the superior and inferior mar-

ins of the adjacent vertebral body. Although contiguous diseases recognised, infection is more commonly seen to affect a singleevel.

.2. Ultrasound

Although non-invasive, ultrasound is an operator dependantechnique. In able hands, changes of acute osteomyelitis may be
etected as early as 48 h after onset of infection [20]. Ultrasoundllows the detection of subperiosteal collections [21] and jointffusions and therefore is extremely useful in neonates suspectedf having a septic arthritis. It should be emphasised however,

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hat neither the size nor the echogenicity allows the radiologisto firmly conclude whether the detected effusion is infected ortherwise [22]. Conversely, the same authors showed that septicrthritis of the hip was extremely unlikely in the absence ofn effusion [22]. Note that a normal ultrasound scan does notxclude osteomyelitis [23].

Mah et al. documented the chronology of ultrasound find-ngs in acute osteomyelitis. The earliest finding was deep softissue swelling, followed by elevation of the periosteum by

thin layer of fluid (Fig. 7), a definite subperiosteal collec-ion (Fig. 8) and finally cortical erosion. The prevalence ofhese findings depended on the duration of clinical signs; thusoft tissue swelling was at a maximum prevalence in patientsith symptoms of 1–3 days duration while cortical erosionsere commonest at 2–4 weeks. Concurrent septic arthritis wasiagnosed in just under a third of patients. All ultrasoundcans had returned to normal by 4 weeks after clinical cure24].

In addition to allowing the confirmation of a joint effusion,


ltrasound serves to guide needle aspiration of the affectedoint(s).

ig. 7. Ultrasound left femur in a 14-day neonate. There is increased echogenic-ty of the deep soft tissues around the distal femur. This is associated with

inimal elevation of the periosteum by a small amount of subperiosteal fluidarrow).

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ig. 8. Ultrasound left femur in a 16-day neonate. There is a 2 mm subperiostealollection in the lateral aspect of the left distal femur.

.3. Scintigraphy

Bone scintigraphy is more sensitive than radiography forhe detection of osteomyelitis in the early stages of disease;
or example, in one study it was found that in the first weekf disease, radiography and technetium (99mTc)-labelled bonecans were positive in 42% and 87% of cases, respectively [25].cintigraphy is useful for detecting multiple foci of infection.
ig. 9. Triple phase 99mTc-labelled isotope bone scan (same patient as Fig. 7).igures illustrate increased uptake in the distal left femur in the blood poolA) and delayed phases (B). Note the physiological increased uptake of theetaphyses (B)—this may obscure subtle pathological increased uptake in less

bvious cases than that illustrated.



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ultifocal disease is more commonly seen in neonates than inlder children in whom either monoarticular septic arthritis ornifocal osteomyelitis is the norm [5,26].

Because of the increased vascularity of the metaphysealegion in neonates and children, high quality images, magni-cation and pin-hole collimation are required to differentiatehysiological from pathological increased uptake [1]. Single
hoton emission computed tomography (SPECT) and positronmission tomography with 18F-labelled FDG further increasehe spatial resolution, allowing improved visualisation of abnor-
al sites [27].

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Various isotopes may be employed. Typically bone scans areerformed using a 99mTc-labelled phosphonate complex. Whennfection is suspected then a triple phase bone scan is performed.n the past, the use of gallium-67 citrate (Ga) has been advo-ated; it should be noted that Ga does not differentiate softissue from bony uptake, and for this, as well as radiation doseonsiderations, is increasingly being replaced by 99mTc hexam-
thylpropylene amineoxamine (99mTcHMPAO) labelled whitelood cells [1].
Diagnostic (but non-specific) features on scintigraphic stud-es include evidence of hyperperfusion (Fig. 9) with increased


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ptake in all three phases (perfusion, blood pool activity andone metabolism) of the triple phase bone scan. In contrast todults, infection in children rarely involves the entire length ofhe diaphysis [1]. The radiologist should beware of cold spotsphotopaenic areas), which in neonates may lead to a false neg-tive scan. These cold spots occur as a result of decreased bloodow secondary to oedema and infection (subperiosteal or artic-lar) [27].

Bone scans are often reserved for cases in which clinical sus-icion is high, yet radiographs and/or ultrasound are equivocal,


nd in neonates for suspected multifocal infection. Bone scansre also useful in suspected chronic multifocal osteomyelitisRMO, in the older child and to confirm suspected discitis inhildren whose radiographs are normal.

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ig. 10. AP radiographs and coronal STIR MRI of left arm and shoulder in a neonateaint area of radiolucency in the left proximal humeral metaphysis (long arrow). Therfter presentation. The lucent metaphyseal lesion is now readily identified. (C) AP leftclerosis around the margins of the lesion. (D) Coronal STIR left humerus. Note thehe lucent metaphyseal lesion seen on the radiographs. There is high signal (oedema)


adiology 60 (2006) 221–232 229

.4. Magnetic resonance imaging

MRI plays an important role in defining the (multiplanar)xtent of soft tissue involvement. This is particularly true inomplex sites such as the spine (discitis) for the exclusion ofxtradural collections causing spinal cord compression. MRIives excellent soft tissue and bone contrast, and is particularlyseful in the neonate and young child, allowing the assessmentf cartilaginous (including growth plate) involvement.

Active inflammation and infection returns a low signal on T1


eighted and a high signal on T2 weighted and STIR sequencesFig. 10C). The degree of bony involvement in osteomyelitisay be overestimated as areas of reactive/sympathetic inflam-ation will return a similar signal pattern. In isolated septic

aged 3 weeks at presentation. (A) AP left humerus at presentation. There is ae is also periosteal reaction medially (short arrow). (B) AP left humerus 7 dayshumerus 3 weeks after initial presentation. As healing begins, there is increasedfocus of high signal in the humeral metaphysis (arrow) which corresponds toof the surrounding soft tissues.



Fig. 10. (Continued ).

Fig. 11. Coronal T1 pre- and post-gadolinium left arm (same patient as Fig. 5). On the pre-contrast image (A), the humeral shaft is seen to return a lower signal thanthe metaphysis and epiphysis. The post-contrast image (B) illustrates the degree of soft tissue inflammation (which is not apparent on the radiograph—Fig. 5). Theproximal humeral epiphysis is spared from the infective/inflammatory process, and does not enhance.



A.C. Offiah / European Journal of Radiology 60 (2006) 221–232 231

Fig. 12. Contrast enhanced T1 weighted MR images of the spine: (A) axialand (B) sagittal. Both images demonstrate a collection beneath the anteriorlongitudinal ligament (arrows). On the sagittal images, notice the enhancementof superior and inferior end plates of the adjacent vertebral bodies.

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ig. 13. Axial CT scan spine (same patient as Fig. 12). CT guided aspiration ofhe collection identified on MRI.

rthritis, abnormal signal from bone marrow should rarely beeen. The use of gadolinium (Fig. 11) allows the definition ofoft tissue, subperiosteal and interosseous collections which aredentified following peripheral enhancement (of their walls) withentral low signal non-enhancement (debris/pus/fluid).

MRI of the spine is useful in children not respondingo therapy and/or to detect complications such as extraduralnd paraspinal collections that will require surgical treatmentFig. 12).

.5. Computed tomography

CT has a limited role in the diagnosis of acute haematoge-ous musculoskeletal infection in the neonate. It is more useful
n chronic osteomyelitis where it is superior to MRI for theemonstration of cortical destruction, air and sequestra [28]. Itay also be used to guide aspiration and biopsy, especially when
he spine and paraspinal soft tissues are involved (Fig. 13).

ig. 14. AP pelvic radiograph of a child aged 5 years and 2 months. This patientad a history of septic arthritis of the left hip. There is significant abnormal-ty of the left hip which is dislocated with secondary acetabular dysplasia.here is no ossified femoral head. There is partial resorption of the femoraleck and proximal shaft. Notice the pelvic tilt—compensating for the leg lengthiscrepancy.


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32 A.C. Offiah / European Journa

. Complications

Considerable morbidity may be associated with neonatalsteomyelitis and/or septic arthritis. Early diagnosis and treat-ent are critical if complications are to be minimised. This is

articularly true of septic arthritis, as damage to articular carti-age (secondary to proteolytic enzymes released from synovialells) begins rapidly [4]. Complications include:

damage to the growth plate with premature and/or asymmet-rical closure of the growth plate;avascular necrosis of the femoral head with or without com-plete dissolution of the femoral head and neck (Fig. 14);pseudoarthrosis;limb length discrepancies, made more obvious as the childgrows;angular deformities at joints, also made more obvious withprogressive growth;joint dislocations;joint arthrodesis;vertebra magna (with narrowing of the spinal canal);block vertebrae.

Many of these will require surgical intervention includingimb lengthening procedures, contralateral arthrodesis, insertionf prostheses, etc.

It has been documented that as many as 40% of children witheptic arthritis of the hip will develop a serious complication, andong-term follow up for early identification of complications is

andatory [4].

. Summary

There are anatomical and pathophysiological differences thatccount for differences in the patterns of musculoskeletal infec-ion seen in infants and young children compared to older chil-ren and adults.

The various imaging techniques outlined above each playn individual role in the diagnostic work up of a neonate withuspected osteomyelitis and/or septic arthritis. They should beeen as complimentary tools [29], and any particular child willften have multiple investigations.

The sequelae of late diagnosis and delayed treatment may beevastating, and a high index of suspicion is always required,articularly in neonates where clinical findings are often non-pecific.

eferences

FOR HKMA CME MEMBER USE ONLY

[1] Saigal G, Azouz EM, Abdenour G. Imaging of osteomyelitis with specialreference to children. Semin Musculoskelet Radiol 2004;8:255–65.

[2] Mok PM, Reilly BJ, Ash JM. Osteomyelitis in the neonate: clinical aspectsand role of radiography and scintigraphy in diagnosis and management.Radiology 1982;145:677–82.

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[3] Nelson JD. Skeletal infections in children. Adv Pediatr Infect Dis1991;6:59–78.

[4] McCarthy JJ, Dormans JP, Kozin SH, Pizzutillo PD. Musculoskele-tal infections in children: basic treatment and recent advances. JBJS2004;86A:850–63.

[5] Scarfone RJ. Arthritis, septic emedicine; 2006. http://www.emedicine.com/ped/topi2695.htm.

[6] Frank G, Mahoney HM, Eppes SC. Musculoskeletal infections in children.Pediatr Clin North Am 2005;52:1083–106.

[7] Ish-Horowicz MR, McIntyre P, Nade S. Bone and joint infections causedby multiply resistant Staphylococcus aureus in a neonatal intensive careunit. Pediatr Infect Dis J 1992;11:82–7.

[8] Kao H-C, Huang Y-C, Chiu C-H, et al. Acute haematogenous osteomyeli-tis and septic arthritis in children. J Microbiol Immunol Infect 2003;36:260–5.

[9] Howard AW, Viskontas D, Sabbagh C. Reduction in osteomyelitis andseptic arthritis related to H. influenzae type b vaccination. J Pediatr Orthop1999;19:705–9.

10] Arkun R. Parasitic and fungal disease of bones and joints. Semin Muscu-loskelet Radiol 2004;8:231–42.

11] Garron E, Viehweger E, Launay F, Guillaume JM, Jouve JL, Bollini G.Non tuberculous spondylodiscitis in children. J Pediatr Orthop 2002;22:321–8.

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