Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Hematogenous osteomyelitis in children: Clinical features and complications

Paul Krogstad, MD
Section Editors
Sheldon L Kaplan, MD
William Phillips, MD
Deputy Editor
Mary M Torchia, MD


Osteomyelitis is an infection localized to bone. It is usually caused by microorganisms (predominantly bacteria) that enter the bone hematogenously. Other pathogenic mechanisms include direct inoculation (usually traumatic, but also surgical), or local invasion from a contiguous infection (eg, decubitus ulcer, sinusitis, periodontal disease). Risk factors for nonhematogenous osteomyelitis include open fractures that require surgical reduction, implanted orthopedic hardware (such as pins or screws), and puncture wounds.

The clinical features and complications of hematogenous osteomyelitis in children will be discussed here. The epidemiology, microbiology, evaluation, diagnosis, and management of osteomyelitis in children are discussed separately:

(See "Hematogenous osteomyelitis in children: Epidemiology, pathogenesis, and microbiology".)

(See "Hematogenous osteomyelitis in children: Evaluation and diagnosis".)

(See "Hematogenous osteomyelitis in children: Management".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Sep 12, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health 2005; 41:59.
  2. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br 2012; 94:584.
  3. Knudsen CJ, Hoffman EB. Neonatal osteomyelitis. J Bone Joint Surg Br 1990; 72:846.
  4. Wong M, Isaacs D, Howman-Giles R, Uren R. Clinical and diagnostic features of osteomyelitis occurring in the first three months of life. Pediatr Infect Dis J 1995; 14:1047.
  5. Asmar BI. Osteomyelitis in the neonate. Infect Dis Clin North Am 1992; 6:117.
  6. Fox L, Sprunt K. Neonatal osteomyelitis. Pediatrics 1978; 62:535.
  7. Bergdahl S, Ekengren K, Eriksson M. Neonatal hematogenous osteomyelitis: risk factors for long-term sequelae. J Pediatr Orthop 1985; 5:564.
  8. Gonzalez BE, Martinez-Aguilar G, Hulten KG, et al. Severe Staphylococcal sepsis in adolescents in the era of community-acquired methicillin-resistant Staphylococcus aureus. Pediatrics 2005; 115:642.
  9. Gonzalez BE, Teruya J, Mahoney DH Jr, et al. Venous thrombosis associated with staphylococcal osteomyelitis in children. Pediatrics 2006; 117:1673.
  10. Jaramillo D, Treves ST, Kasser JR, et al. Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment. AJR Am J Roentgenol 1995; 165:399.
  11. 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.
  12. Martínez-Aguilar G, Avalos-Mishaan A, Hulten K, et al. Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J 2004; 23:701.
  13. Krogstad P. Osteomyelitis. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.711.
  14. Stone B, Street M, Leigh W, Crawford H. Pediatric Tibial Osteomyelitis. J Pediatr Orthop 2016; 36:534.
  15. Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics 2000; 105:1299.
  16. Overturf GD. Bacterial infections of the bones and joints. In: Infectious Diseases of the Fetus and Newborn Infant, 7th, Remington JS, Klein JO (Eds), Elsevier Saunders, Philadelphia 2011. p.296.
  17. Ein SH, Shandling B, Humphreys R, Krajbich I. Osteomyelitis of the cervical spine presenting as a neurenteric cyst. J Pediatr Surg 1988; 23:779.
  18. Barton LL, Villar RG, Rice SA. Neonatal group B streptococcal vertebral osteomyelitis. Pediatrics 1996; 98:459.
  19. Karabouta Z, Bisbinas I, Davidson A, Goldsworthy LL. Discitis in toddlers: a case series and review. Acta Paediatr 2005; 94:1516.
  20. Chandrasenan J, Klezl Z, Bommireddy R, Calthorpe D. Spondylodiscitis in children: a retrospective series. J Bone Joint Surg Br 2011; 93:1122.
  21. Spencer SJ, Wilson NI. Childhood discitis in a regional children's hospital. J Pediatr Orthop B 2012; 21:264.
  22. Garron E, Viehweger E, Launay F, et al. Nontuberculous spondylodiscitis in children. J Pediatr Orthop 2002; 22:321.
  23. Kumar J, Ramachandran M, Little D, Zenios M. Pelvic osteomyelitis in children. J Pediatr Orthop B 2010; 19:38.
  24. Weber-Chrysochoou C, Corti N, Goetschel P, et al. Pelvic osteomyelitis: a diagnostic challenge in children. J Pediatr Surg 2007; 42:553.
  25. Davidson D, Letts M, Khoshhal K. Pelvic osteomyelitis in children: a comparison of decades from 1980-1989 with 1990-2001. J Pediatr Orthop 2003; 23:514.
  26. Mustafa MM, Sáez-Llorens X, McCracken GH Jr, Nelson JD. Acute hematogenous pelvic osteomyelitis in infants and children. Pediatr Infect Dis J 1990; 9:416.
  27. Bocchini CE, Hulten KG, Mason EO Jr, et al. Panton-Valentine leukocidin genes are associated with enhanced inflammatory response and local disease in acute hematogenous Staphylococcus aureus osteomyelitis in children. Pediatrics 2006; 117:433.
  28. McCaskill ML, Mason EO Jr, Kaplan SL, et al. Increase of the USA300 clone among community-acquired methicillin-susceptible Staphylococcus aureus causing invasive infections. Pediatr Infect Dis J 2007; 26:1122.
  29. Ritz N, Curtis N. The role of Panton-Valentine leukocidin in Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J 2012; 31:514.
  30. Ju KL, Zurakowski D, Kocher MS. Differentiating between methicillin-resistant and methicillin-sensitive Staphylococcus aureus osteomyelitis in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am 2011; 93:1693.
  31. Gaviria-Agudelo C, Aroh C, Tareen N, et al. Genomic Heterogeneity of Methicillin Resistant Staphylococcus aureus Associated with Variation in Severity of Illness among Children with Acute Hematogenous Osteomyelitis. PLoS One 2015; 10:e0130415.
  32. Ceroni D, Cherkaoui A, Ferey S, et al. Kingella kingae osteoarticular infections in young children: clinical features and contribution of a new specific real-time PCR assay to the diagnosis. J Pediatr Orthop 2010; 30:301.
  33. Chometon S, Benito Y, Chaker M, et al. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children. Pediatr Infect Dis J 2007; 26:377.
  34. Hajjaji N, Hocqueloux L, Kerdraon R, Bret L. Bone infection in cat-scratch disease: a review of the literature. J Infect 2007; 54:417.
  35. Vermeulen MJ, Rutten GJ, Verhagen I, et al. Transient paresis associated with cat-scratch disease: case report and literature review of vertebral osteomyelitis caused by Bartonella henselae. Pediatr Infect Dis J 2006; 25:1177.
  36. Floyed RL, Steele RW. Culture-negative osteomyelitis. Pediatr Infect Dis J 2003; 22:731.
  37. Pääkkönen M, Kallio MJ, Kallio PE, Peltola H. Significance of Negative Cultures in the Treatment of Acute Hematogenous Bone and Joint Infections in Children. J Pediatric Infect Dis Soc 2013; 2:119.
  38. Ho AK, Shrader MW, Falk MN, Segal LS. Diagnosis and initial management of musculoskeletal coccidioidomycosis in children. J Pediatr Orthop 2014; 34:571.
  39. Akakpo-Numado GK, Gnassingbé K, Abalo A, et al. Locations of osteomyelitis in children with sickle-cell disease at Tokoin teaching hospital (Togo). Pediatr Surg Int 2009; 25:723.
  40. Berger E, Saunders N, Wang L, Friedman JN. Sickle cell disease in children: differentiating osteomyelitis from vaso-occlusive crisis. Arch Pediatr Adolesc Med 2009; 163:251.
  41. Sexton DJ. Vascular access infections in patients undergoing dialysis with special emphasis on the role and treatment of Staphylococcus aureus. Infect Dis Clin North Am 2001; 15:731.
  42. Unkila-Kallio L, Kallio MJ, Eskola J, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics 1994; 93:59.
  43. Pääkkönen M, Kallio MJ, Kallio PE, Peltola H. Sensitivity of erythrocyte sedimentation rate and C-reactive protein in childhood bone and joint infections. Clin Orthop Relat Res 2010; 468:861.
  44. Khachatourians AG, Patzakis MJ, Roidis N, Holtom PD. Laboratory monitoring in pediatric acute osteomyelitis and septic arthritis. Clin Orthop Relat Res 2003; :186.
  45. Hawkshead JJ 3rd, Patel NB, Steele RW, Heinrich SD. Comparative severity of pediatric osteomyelitis attributable to methicillin-resistant versus methicillin-sensitive Staphylococcus aureus. J Pediatr Orthop 2009; 29:85.
  46. Ibia EO, Imoisili M, Pikis A. Group A beta-hemolytic streptococcal osteomyelitis in children. Pediatrics 2003; 112:e22.
  47. Bradley JS, Kaplan SL, Tan TQ, et al. Pediatric pneumococcal bone and joint infections. The Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG). Pediatrics 1998; 102:1376.
  48. Vinod MB, Matussek J, Curtis N, et al. Duration of antibiotics in children with osteomyelitis and septic arthritis. J Paediatr Child Health 2002; 38:363.
  49. Saavedra-Lozano J, Mejías A, Ahmad N, et al. Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections. J Pediatr Orthop 2008; 28:569.
  50. Unkila-Kallio L, Kallio MJ, Peltola H. The usefulness of C-reactive protein levels in the identification of concurrent septic arthritis in children who have acute hematogenous osteomyelitis. A comparison with the usefulness of the erythrocyte sedimentation rate and the white blood-cell count. J Bone Joint Surg Am 1994; 76:848.
  51. Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop 2006; 26:703.
  52. Schmit P, Glorion C. Osteomyelitis in infants and children. Eur Radiol 2004; 14 Suppl 4:L44.
  53. Saigal G, Azouz EM, Abdenour G. Imaging of osteomyelitis with special reference to children. Semin Musculoskelet Radiol 2004; 8:255.
  54. Guillerman RP. Osteomyelitis and beyond. Pediatr Radiol 2013; 43 Suppl 1:S193.
  55. Shih HN, Shih LY, Wong YC. Diagnosis and treatment of subacute osteomyelitis. J Trauma 2005; 58:83.
  56. Peters W, Irving J, Letts M. Long-term effects of neonatal bone and joint infection on adjacent growth plates. J Pediatr Orthop 1992; 12:806.
  57. Williamson JB, Galasko CS, Robinson MJ. Outcome after acute osteomyelitis in preterm infants. Arch Dis Child 1990; 65:1060.
  58. Overturf GD. Bacterial infections of the bone and joints. In: Infectious Diseases of the Fetus and Newborn, 7th ed, Remington JS, Klein JO, Wilson CB, et al (Eds), Elsevier Saunders, Philadelphia 2011. p.296.
  59. Martínez-Aguilar G, Hammerman WA, Mason EO Jr, Kaplan SL. Clindamycin treatment of invasive infections caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children. Pediatr Infect Dis J 2003; 22:593.
  60. McNeil JC, Forbes AR, Vallejo JG, et al. Role of Operative or Interventional Radiology-Guided Cultures for Osteomyelitis. Pediatrics 2016; 137.
  61. Belthur MV, Birchansky SB, Verdugo AA, et al. Pathologic fractures in children with acute Staphylococcus aureus osteomyelitis. J Bone Joint Surg Am 2012; 94:34.
  62. Ramos OM. Chronic osteomyelitis in children. Pediatr Infect Dis J 2002; 21:431.
  63. Gorenstein A, Gross E, Houri S, et al. The pivotal role of deep vein thrombophlebitis in the development of acute disseminated staphylococcal disease in children. Pediatrics 2000; 106:E87.
  64. Walsh S, Phillips F. Deep vein thrombosis associated with pediatric musculoskeletal sepsis. J Pediatr Orthop 2002; 22:329.
  65. Crary SE, Buchanan GR, Drake CE, Journeycake JM. Venous thrombosis and thromboembolism in children with osteomyelitis. J Pediatr 2006; 149:537.
  66. Hollmig ST, Copley LA, Browne RH, et al. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am 2007; 89:1517.