Pediatric Osteomyelitis Workup

  • Author: Sabah Kalyoussef, DO; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jul 27, 2010
 

Laboratory Studies

  • To confirm a diagnosis of osteomyelitis, adequate radiologic and laboratory data are necessary.
  • In most cases, the etiologic agent is identified if blood, bone, and joint aspirate cultures are obtained before any antibiotics are given.
  • Obtain bone and joint fluid aspirate for Gram staining because the aspirate itself can be bactericidal. The yield of K kingae is improved by inoculating synovial fluid directly into blood culture bottles. Consult with your microbiology laboratory prior to obtaining cultures to ensure proper collection.
  • The WBC count is elevated in only one half of patients.
  • The C-reactive protein and erythrocyte sedimentation rate (ESR) are almost always elevated (except in small bones infections).
  • Consider performing a bone biopsy if the patient does not respond to therapy.
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Imaging Studies

  • Radiography
    • Plain radiography usually only reveals soft tissue swelling and loss of normally visible tissue planes; however, radiography can be useful in revealing bone tumors, fractures, and healing fractures.
    • Osteopenia, lytic lesions, and periosteal changes are late radiographic signs; their absence does not exclude a diagnosis of acute osteomyelitis.
  • Three-phase technetium radionuclide bone scanning
    • Through enhanced uptake of the radioisotope, this procedure reveals increased osteoblastic activity of the infected bone and distinguishes osteomyelitis from deep cellulitis.
    • Technetium bone scanning has a false-negative rate of as much as 20%, particularly in the first few days of illness.
    • Fractures, bone tumors, and surgery also cause enhanced technetium uptake.
  • MRI
    • This test remains the criterion standard, especially in early infections.
    • Changes in bone marrow caused by inflammation result in an area of low signal intensity within bright fatty marrow. These abnormalities need to be correlated with the clinical picture before a diagnosis is made because they are not specific for osteomyelitis.
  • Indium scanning: This test, which uses indium-labeled leukocytes, is also useful, although it has limitations in newborns, infants, and patients with neutropenia.
  • Gallium scanning: This study is usually not recommended because of lower specificity and exposure to higher levels of radiation.
  • Ultrasonography: Clinical suspicion for deep vein thrombosis should be especially high in patients with osteomyelitis caused by CA-MRSA who have an elevated C-reactive protein level. Doppler venous ultrasonography is the first imaging study indicated in such cases. However, routine screening is not yet recommended.
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Contributor Information and Disclosures
Author

Sabah Kalyoussef, DO  Fellow in Pediatric Infectious Diseases, Children's Hospital at Montefiore

Sabah Kalyoussef, DO is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Specialty Editor Board

Gary J Noel, MD  Department of Pediatrics, Clinical Associate Professor, Weill Medical College of Cornell University

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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