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

doi:10.1016/j.ejrad.2006.07.016

European Journal of Radiology

Volume 60, Issue 2, November 2006, Pages 221-232

https://doi.org/10.1016/j.ejrad.2006.07.016 Get rights and content

Abstract

There are aetiological, clinical, radiological and therapeutic differences between musculoskeletal infection in the neonate (and infant) and in older children and adults. Due to the anatomy and blood supply in neonates, osteomyelitis often co-exists with septic arthritis. Discitis is more common in infants whereas vertebral body infection is more common in adults. This review article discusses the important clinical and radiological differences that in the past have led many authors to consider neonatal osteomyelitis a separate entity from osteomyelitis in the older child.

Section snippets

Nomenclature

The term osteomyelitis refers to infection of bone and/or bone marrow. Depending on both the virulence of the organism and the immune response mounted by the host, osteomyelitis may be acute, subacute or chronic. Acute osteomyelitis is not common in adults [1]. Conversely, in neonates osteomyelitis is usually acute [2].

Septic arthritis refers to infection of a joint. While this may occur in isolation, in neonates it is much more likely to occur as a consequence of bony infection (osteomyelitis)

Pathogenesis

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

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

The causative organism depends on the age of the patient, and in the neonate is most commonly Staphylococcus aureus. Other organisms include

Anatomical considerations and pathophysiology

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

The reduced rate of blood flow within vessels at the metaphysis renders this region more susceptible to haematogenous seeding of infection [13]. Before the appearance of secondary ossification centres, the cartilaginous epiphyses receive their blood supply directly from metaphyseal blood vessels. Hence, septic arthritis is a relatively common

Clinical presentation and laboratory findings

Osteomyelitis and arthritis are commoner in young children than in older children and adults, peaking at around the age of 3 years for osteomyelitis and 2 years for septic arthritis [2], [3], [4], [5].

Compared to older children and adults, there are fewer clinical signs and the diagnosis of osteomyelitis and/or arthritis may therefore be harder to make. This is largely because of the poorly developed immune system of neonates, rendering them less able to mount an immune response. For this

Imaging

The role of imaging is to confirm the presence and site of infection, to differentiate unifocal from multifocal disease, to locate and guide aspiration of collections and to identify present or impending complications such as joint or extradural involvement.

Radiography is usually the first radiological investigation in a neonate with suspected osteomyelitis/septic arthritis/discitis. Other modalities include ultrasound (US), bone scintigraphy, magnetic resonance imaging (MRI) and computed

Complications

Considerable morbidity may be associated with neonatal osteomyelitis and/or septic arthritis. Early diagnosis and treatment are critical if complications are to be minimised. This is particularly true of septic arthritis, as damage to articular cartilage (secondary to proteolytic enzymes released from synovial cells) begins rapidly [4]. Complications include:

•
damage to the growth plate with premature and/or asymmetrical closure of the growth plate;
•
avascular necrosis of the femoral head with or

Summary

There are anatomical and pathophysiological differences that account for differences in the patterns of musculoskeletal infection seen in infants and young children compared to older children and adults.

The various imaging techniques outlined above each play an individual role in the diagnostic work up of a neonate with suspected osteomyelitis and/or septic arthritis. They should be seen as complimentary tools [29], and any particular child will often have multiple investigations.

The sequelae

References (29)

G. Frank et al.
Musculoskeletal infections in children
Pediatr Clin North Am
(2005)
B.F. Morrey et al.
Septic arthritis in children
Orthop Clin North Am
(1975)
N.A. Kothari et al.
Imaging of musculoskeletal infections
Radiol Clin North Am
(2001)
G. Saigal et al.
Imaging of osteomyelitis with special reference to children
Semin Musculoskelet Radiol
(2004)
P.M. Mok et al.
Osteomyelitis in the neonate: clinical aspects and role of radiography and scintigraphy in diagnosis and management
Radiology
(1982)
J.D. Nelson
Skeletal infections in children
Adv Pediatr Infect Dis
(1991)
J.J. McCarthy et al.
Musculoskeletal infections in children: basic treatment and recent advances
JBJS
(2004)
Scarfone RJ. Arthritis, septic emedicine; 2006....
M.R. Ish-Horowicz et al.
Bone and joint infections caused by multiply resistant Staphylococcus aureus in a neonatal intensive care unit
Pediatr Infect Dis J
(1992)
H.-C. Kao et al.
Acute haematogenous osteomyelitis and septic arthritis in children
J Microbiol Immunol Infect
(2003)

A.W. Howard et al.

Reduction in osteomyelitis and septic arthritis related to H. influenzae type b vaccination

J Pediatr Orthop

(1999)

R. Arkun

Parasitic and fungal disease of bones and joints

Semin Musculoskelet Radiol

(2004)

E. Garron et al.

Non tuberculous spondylodiscitis in children

J Pediatr Orthop

(2002)

S.D. Early et al.

Childhood diskitis

J Am Acad Orthop Surg

(2003)

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

Abstract

Section snippets

Nomenclature

Pathogenesis

Anatomical considerations and pathophysiology

Clinical presentation and laboratory findings

Imaging

Complications

Summary

Pediatr Clin North Am

Orthop Clin North Am

Radiol Clin North Am

Imaging of osteomyelitis with special reference to children

Semin Musculoskelet Radiol

Osteomyelitis in the neonate: clinical aspects and role of radiography and scintigraphy in diagnosis and management

Radiology

Skeletal infections in children

Adv Pediatr Infect Dis

Musculoskeletal infections in children: basic treatment and recent advances

JBJS

Bone and joint infections caused by multiply resistant Staphylococcus aureus in a neonatal intensive care unit

Pediatr Infect Dis J

Acute haematogenous osteomyelitis and septic arthritis in children

J Microbiol Immunol Infect

Reduction in osteomyelitis and septic arthritis related to H. influenzae type b vaccination

J Pediatr Orthop

Parasitic and fungal disease of bones and joints

Semin Musculoskelet Radiol

Non tuberculous spondylodiscitis in children

J Pediatr Orthop

Childhood diskitis

J Am Acad Orthop Surg

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