S P E C I A L

F O C U S

Pediatric Orthopaedics
Musculoskeletal infection in children:
literature review and update 20072009
Lawson A. B. Copley

ABSTRACT
The epidemiology of musculoskeletal infection is affected by
local community factors and must be evaluated by each
healthcare facility regarding the most common causative
organisms, antibiotic resistance patterns, and disease severity.
Because substantial time, effort, and resources are devoted to
managing the evaluation and treatment of children with these
infections, a coordinated and collaborative process of care
should be established to ensure that timely and efficient
intervention is enacted so as to improve clinical outcomes and
avoid adverse sequelae. This review summarizes the recent
literature regarding pediatric musculoskeletal infections.
Keywords
deep venous thrombosis, osteomyelits, pyomyositis, septic
arthritis

INTRODUCTION

ecent literature focuses on the recognized threat of

community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) as a cause of potentially
severe forms of musculoskeletal infection in children.1,
2,3,4,5
The ability to recognize the various forms of
infection and make a comprehensive and accurate diagnosis
in a timely manner appears to be improved by obtaining an
MRI with and without contrast as early as possible during
the evaluation process.1,6 The information obtained from
this study can guide surgical decision making, facilitate
minimally invasive methods for obtaining diagnostic culture specimens, and potentially help categorize risk for
having increased disease severity. Careful review of the
diagnostic MRI may identify deep venous thrombosis in
some children.5 Sequelae, which are thought to result from
delayed or missed diagnoses of hip and shoulder sepsis in
the neonatal and infantile age groups, might be circum-

Department of Orthopedics, Childrens Medical Center of Dallas,

Dallas, Texas
Correspondence to Lawson A. B. Copley, MD, Childrens Medical Center
of Dallas, E2300, 1935 Medical District Drive, Dallas, TX 75235
Tel: +1 214 456 5614; fax: +1 214 456 5071
e-mail: lawson.copley@childrens.com
1940-7041 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Volume 20  Number 6  November/December 2009

vented by having a high index of suspicion and early

diagnostic imaging.7,8,9

OSTEOMYELITIS
The epidemiology of osteomyelitis is community dependent. A report from Oslo, Norway indicated a stable annual
incidence rate of 13 per 100,000, whereas a 2.8-fold increase
was noted in the annualized per capita incidence reported
in Dallas, Texas when comparison was made to an historic
reference group from 20 years earlier.1,10 The Norway study
reported no children with MRSA infections, while the Texas
study identified methicillin resistance in 43% of children
with osteomyelitis.1,10
The diagnosis of osteomyelitis is facilitated by prompt
supplemental imaging. MRI arguably has become the most
useful tool in portraying the anatomic and spatial extent
of the infection and provides guidance for the surgical
approach, when indicated.1,5,6 The value of MRI does not
appear to be compromised when it is performed in the
aftermath of initial invasive procedures such as aspiration or
surgical debridement.6 However, it is arguable that such
procedures may better be delayed until an expedited MRI
can be arranged to ensure that the aspiration or decompression is directed at the epicenter of the inflammation and all
potential foci.1,6 This, of course, requires a collaborative
interaction between orthopaedic surgery, radiology, and
anesthesia. Color power Doppler sonography has been
reported as a potential adjunct in the early diagnosis of
osteomyelitis and may indeed prove useful on rare occasions
when an MRI would be substantially delayed.11
The clinical evaluation of a child, laboratory findings, and
imaging results often are adequate to guide surgical decision
making. In general, surgery is necessary for osteomyelitis
associated with abscesses or in children who have not
demonstrated clinical and laboratory improvement within
an appropriate timeframe after the initiation of empiric
antibiotic treatment.
Beyond the decision for surgical decompression, the
mainstay of treatment for osteomyelitis involves proper
antibiotic selection, dosing, route, and duration. In the
absence of a specific organism and antibiotic sensitivities,
the choice of antibiotic is regionally variable and driven by
the local prevalence of CA-MRSA.12 Ample experience
suggests that sequential parenteral to oral therapy is
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successful in most of children with deep musculoskeletal

infection and that the timeframe to switch from intravenous
to oral antibiotics may be brief as long as there are
appropriate clinical and laboratory improvements.13 Evidence-based clinical practice guidelines for duration of
antibiotic use are currently limited to retrospective and
observational studies with a standard recommendation of
4--6 weeks.14 At our institution, we make the transition from
intravenous to oral antibiotic when the C-reactive protein
(CRP) level has reached < 2 mg/dl, the child is afebrile and is
clinically improving with respect to range of motion and
overall mobility. We continue antibiotics on an outpatient
basis, monitoring laboratory indices until both the CRP and
the erythrocyte sedimentation rate (ESR) have stabilized. In
general, this falls within the standard guideline of 4--6
weeks, but occasionally it is necessary to continue antibiotics while monitoring laboratory resolution in 2--3 week
intervals, until normalization. If resolution has not occurred
within 12 weeks, consideration is given to repeating an MRI
so as to ensure that no abscess or sequestrum has developed
that may require additional intervention. This is exceedingly rare.
It is important to be aware that the pelvic osteomyelitis is
relatively common in children and that diagnostic delay is
common.15--17 There are multiple metaphyseal equivalents
in the pelvic osseous anatomy that permit infections to
occur, and the manner of clinical presentation can mimic
septic arthritis of the hip. MRI has proven to be a valuable
study in clarifying the location and treatment options in
children with pelvic musculoskeletal infections.15--17

SEPTIC ARTHRITIS
Current recommendations for the treatment of septic
arthritis involve making the diagnosis in a timely manner,
aspirating the joint for fluid examination and culture, and
performing prompt and thorough joint irrigation and debridement. This sometimes requires judicious clinical judgment from an experienced physician.18 The differentiation
between septic arthritis and transient synovitis remains
challenging in some cases, and it is important to gather all
of the relevant clinical and laboratory information to weigh
in the evaluation. While observation of non-steroidal antiinflammatory medication is possible in patients with
suspected transient synovitis, this process can be expedited
and abbreviated by joint aspiration to ensure that septic
arthritis is not overlooked.
Culture negative septic arthritis is more common than
other culture negative forms of musculoskeletal infection.
This is because joint fluid appears to exert an inhibitory
effect on the growth of most bacteria. Sending joint fluid in
an aerobic blood culture bottle allows the broth to dilute the
joint fluid and improve the potential for positive culture
identification of the causative organism. This practice is
essential when concern exists for possible Kingella kingae
infection in children between the ages of 6 months and
4 years.
Surgical decompression of the septic joint should be
timely, particularly in the neonatal and infantile periods
because this is thought to reduce the likelihood and severity

Volume 20  Number 6  November/December 2009

of adverse sequelae.7,8,9 Surgical technique is somewhat

surgeon dependent, but arthroscopic and open methods are
equally successful. A recent report suggested a combined
technique of anterior arthrotomy with posterior drainage
for septic arthritis of the hip in older children.19
Antibiotic duration for septic arthritis generally is 3--4
weeks. One study suggested increasing this duration to 6
weeks in light of the fact that osseous changes were noted
on follow-up radiographs, revealing a previously unrecognized osteomyelitis of the adjacent bone in 21 of 96 cases
(21.9%) of septic arthritis.20 However, this is not likely to be
necessary if a thorough initial evaluation is performed in an
effort to reach a comprehensive disease categorization.1

PYOMYOSITIS
There have been numerous recent publications regarding
the identification of non-tropical pyomyositis in children
who have no underlying risk factor or disease that might
impair the immune sytem.1,21--28 This may reflect, in part,
the recent change in epidemiology of pediatric musculoskeletal infection, particularly in temperate climates. CA-MRSA
may have evolved to the point where an increased invasive
behavior is demonstrated, resulting in the potential to infect
striated muscle.
It is important to be aware that severe complications have
been reported in association with pyomyositis in children,
including compartment syndrome, deep venous thrombosis, septic pulmonary emboli, and toxic shock.1,27,28 A high
index of suspicion and vigilant early intervention is
necessary to debride the foci of infection. Intensive medical
management may be necessary to stabilize these children.
Pyomyositis associated with abscess is best managed by
surgical or CT-guided drainage and antibiotic treatment.
Empiric coverage should be directed toward the two most
common causative organisms Staphylococcus aureus and
Group A beta hemolytic streptococcus. Duration of treatment typically is 3--4 weeks with good clinical outcomes in
the most children.

CHRONIC RECURRENT MULTIFOCAL

OSTEOMYELITIS
Attention has been directed to the underlying inflammatory
cause of childhood chronic recurrent multifocal osteomyelitis (CRMO).29,30 CRMO is a self-limiting, inflammatory
condition of bone with disease activity potentially extending for several years. The disabling pain of this condition
can result in substantial functional impairment. Antibiotics
do not play a role in the treatment of this condition. When
nonsteroidal anti-inflammatory treatment fails as the first
line of therapy, consideration may be given to bisphosphonate treatment. Recent reports highlight the potential
for dramatic pain relief and the potential to arrest the
progression of spinal deformity that may ensue from
advanced vertebral involvement in some children.29,30
Pamidronate reduced the MRI documented bone inflammation in all patients with persistent CRMO and reduced the
urinary N-telopeptide excretion in these children.

Current Orthopaedic Practice

CONCLUSION
Pediatric musculoskeletal infection represents a wide array
of conditions including osteomyelitis, septic arthritis,
pyomyositis, and absess. The broad spectra of clinical
manifestations and disease severity create diagnostic and
treatment challenges and necessitate a collaborative, multidisciplinary approach to provide efficient and thorough
care. Good clinical judgment, awareness of potential
complications and timely intervention are helpful to
achieve good clinical outcomes. Early acquisition of MRI
to derive a comprehensive picture of the anatomic and
spatial extent of the infection will guide surgical decision
making and adequate decompression of the foci of infection, when necessary. Awareness of the potential threat of
CA-MRSA within a given community will orient empiric
antibiotic coverage and raise concern for the potential of
increased severity of illness and a greater risk for certain
complications, such as deep venous thrombosis. There is a
need for high quality, prospective research, and the development of evidence-based clinical practice guidelines to
help improve care of children with this disease.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the period of review,
have been highlighted as:
 of special interest.
 of outstanding interest.
1. Gafur OA, Copley LA, Hollmig ST, et al. The impact of the
 current epidemiology of pediatric musculoskeletal infection on
evaluation and treatment guidelines. J Pediatr Orthop. 2008;
28:777--785.
This retrospective study suggests a novel classification strategy for
pediatric musculoskeletal infection that offers a framework for
assessing the severity of illness. It offers evidence to suggest that CAMRSA is partly responsible for the changing epidemiology of this
disease within the reporting community.
2. Saavedra-Lozano J, Mejias A, Ahmad N, et al. Changing trends
 in acute osteomyelitis in children: impact of methicillinresistant Staphylococcus aureus infections. J Pediatr Orthop. 2008;
28:569--575.
This is an excellent comparison of the clinical manifestations of
musculoskeletal infection as a factor of CA-MRSA compared against
MSSA, osteomyelitis caused by other organisms, and culture negative
osteomyelitis. The attempt at defining the severity of illness for these
children is a valuable endeavor, and these authors have done a great
job in this regard.
3. Hawkshead JJ, Patel NB, Steele RW, et al. Comparative severity
 of pediatric osteomyelitis attributable to methicillin-resistant
versus methicillin-sensitive Staphylococcus aureus. J Pediatr Orthop.
2009; 29:85--90.
Another valid effort to define severity of illness and draw distinction
between MRSA and MSSA sub-groups. The conclusion that MRSA
produces more severe infection and requires more aggressive surgical
and medical management is consistent with our experience.
 Mitchell PD, Hunt DM, Lyall H, et al. Panton-Valentine
4.
leukocidin-secreting Staphylococcus aureus causing severe musculoskeletal sepsis in children. J Bone Joint Surg. 2007; 89:1239--1242.
Panton-Valentine leukocidin has been recently and repeatedly cited
as a putative virulence factor in S. aureus infections. However, there
are 39 genetically encoded proteins in the S. aureus genome. It
is unclear that PVL is the only culprit. As the USA 300 clone becomes
increasingly recognized within the Houston area as the predominant strain of S. aureus most are also being identified as PVL raising
some question as to the validity that this report echoes. Further

www.c-orthopaedicpractice.com | 625

research is necessary taking a more comprehensive look at both

human and bacterial genetic factors and their impact on disease
severity.
5. Hollmig ST, Copley LA, Browne RH, et al. Deep venous
 thrombosis associated with osteomyelitis in children. J Bone
Joint Surg. 2007; 89:1517--1523.
This is a valuable guide to practitioners in helping to recognize
children who are at increased risk for DVT associated with
musculoskeletal infection on the basis of recognizable clinical and
laboratory features. Children older than the age of 6 years with an
initial CRP > 6 mg/dL who have osteomyelitis caused by MRSA
involving the lower extremities have approximately a 40% risk of
DVT. This patient population should have additional studies
(Doppler or MR angiography) to ensure this complication is
recognized.
6. Kan HJ, Hilmes MA, Martus JE, et al. Value of MRI after recent
 diagnostic or surgical intervention in children with suspected
osteomyelitis. AJR. 2008; 191:1595--1600.
Most of the procedures described in this report are minor
aspirations. We have noted marrow edema on MRI images following
bone aspiration. The signal is linear with a small blush and is easily
distinguished from osteomyelitis. I am in complete agreement with
the authors suggestion that MRI should be ideally done before these
procedures as the images will likely advise a more comprehensive
and definitive procedure and thereby reduce the likelihood of
unnecessary or inadequate procedures.
7. Saisu T, Kawashima A, Kamegaya M, et al. Humeral shortening
 and inferior subluxation as sequelae of septic arthritis of the
shoulder in neonates and infants. J Bone Joint Surg. 2007;
89:1784--1793.
The most severe deformity and dysfunction occurred in those who
had not undergone arthrotomy of the shoulder within 10 days of
the onset of infection. This is a recurring theme.
8. Forlin E, Milani C. Sequelae of septic arthritis of the hip in
 children; a new classification and review of 41 hips. J Pediatr
Orthop. 2008; 28:524--528.
I like the simplicity of this classification system. It is easier to
manage than the Choi classification and demonstrated greater
concordance among reviewers in this study. It also appears to be
clinically relevant. The numbers are small in this review but appear
to represent the spectrum of these deformities.
9. Wada A, Fujii T, Takamura K, et al. Operative reconstruction of
 the severe sequelae of infantile septic arthritis of the hip.
J Pediatr Orthop. 2007; 27:910--914.
This is essentially a case series with the same conclusions of previous publications in this regard. However, the conclusions remain
valid. Surgical reconstruction is difficult and successful results
are rare. Regardless, clinical function and hip stability may be
improved with careful planning and the technical alternatives
outlined.
10. Riise OR, Kirkhus E, Handeland KS, et al. Childhood osteomyelitis-incidence and differentiation from other acute onset
musculoskeletal features in a population-based study. BMC
Pediatrics. 2008; 8:45--55.
11. Collado P, Naredo E, Calvo C, et al. Role of power Doppler
sonography in early diagnosis of osteomyelitis in children.
J Clin Ultrasound. 2008; 36:251--253.
12. Afghani B, Kong V, Wu FL. What would pediatric infectious
disease consultants recommend for management of culturenegative acute hematogenous osteomyelitis? J Pediatr Orthop.
2007; 27:805--809.
13. Bachur R, Pagon Z. Success of short-course parenteral antibiotic
therapy for acute osteomyelitis of childhood. Clin Pediatr. 2007;
46:30--35.
14. Weichert S, Sharland M, Clarke NMP, et al. Acute haematogenous osteomyelitis in children: is there any evidence for
how long we should treat? Curr Opin Infect Dis. 2008; 21:
258--262.
15. Klein JD, Leach KA. Pediatric pelvic osteomyelitis. Clin Pediatr.
2007; 46:787--790.
16. Weber-Chrysochoou C, Corti N, Goetschel P, et al. Pelvic
osteomyelitis: a diagnostic challenge in children. J Ped Surg.
2007; 42:553--557.

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17. Connolly SA, Connolly LP, Drubach LA, et al. MRI for detection
of abscess in acute osteomyelitis of the pelvis in children. AJR.
2007; 189:867--872.
18. Mathews CJ, Coakley G. Septic arthritis: current diagnostic
and therapeutic algorithm. Curr Opin Theumatol. 2008; 20:
457--462.
19. Smith MJ, White RA, Gainor BJ. Combined technique for
draining septic arthritis of the pediatric hip. Am J Orthop. 2007;
36:165--166.
20. Lavy CBD, Thyoka M. For how long should antibiotics be given
in acute paediatric septic arthritis? A prospective audit of 96
cases. Tropical Doctor. 2007; 37:195--197.
21. Block AA, Marshall C, Ratcliffe A, et al. Staphylococcal pyomyositis in a temperate region: epidemiology and modern management. MJA. 2008; 189:323--325.
22. Van den Bergh MR, Schiering IAM, Gubler FM, et al. Pyomyositis: a limping diagnosis. Eur J Pediatr. 2007; 166:259--261.
23. Ovadia D, Ezra E, Ben-Sira L, et al. Primary pyomyositis in
children: a retrospective analysis of 11 cases. J Pediatr Orthop B.
2007; 16:153--159.
24. Taksande A, Vilhekar K, Gupta S. Primary pyomyositis in a
child. Int J Infect Disease. 2008; E1--E3.
25. Weinberg J, Friedman S, Sood S, et al. Tropical myositis
(pyomyositis) in children in temperate climates: a report of 3

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cases on Long Island, New York, and a review of the literature.

Am J Orthop. 2007; 36:E71--E75.
26. Kumar A, Anderson D. Primary obturator externus pyomyositis in
a child presenting as hip pain. Ped Emerg Care. 2008; 24:97--98.
27. Yuksel H, Yilmaz O, Orguc S, et al. A pediatric case of
pyomyositis presenting with septic pulmonary emboli. Joint
Bone Spine. 2007; 74:491--494.
 Park S, Shatsky JB, Pawel BR, et al. Atraumatic compartment
28.
syndrome: a manifestation of toxic shock and infectious
pyomyositis in a child. J Bone Joint Surg. 2007; 89:1337--1342.
This is an interesting case and important to be mindful of the
risk for these complications in children with Streptococcal pyomyositis. Appropriate and timely intervention may be life and limb
saving.
29. Gleeson H, Wiltshire E, Briody J, et al. Childhood chronic
 recurrent multifocal osteomyelitis: pamidronate therapy decreases pain and improves vertebral shape. J Rheumatol. 2008;
35:707--712.
This is a valuable tool in the arsenal against this challenging and
disabling condition.
30. Miettunen PMH, Wei X, Kaura D, et al. Dramatic pain relief and
resolution of bone inflammation following pamidronate in
9 pediatric patients with persistent chronic recurrent multifocal
osteomyelitis (CRMO). Pediatr Rheumatol. 2009; 7:2--15.