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Pediatric Osteomyelitis Workup

  • Author: Sabah Kalyoussef, DO; Chief Editor: Russell W Steele, MD  more...
Updated: May 02, 2016

Laboratory Studies

See the list below:

  • To confirm a clinical diagnosis of osteomyelitis, adequate radiologic and laboratory data are necessary.
  • The WBC count is elevated in only one half of patients with or without thrombocytosis.
  • The C-reactive protein and erythrocyte sedimentation rate (ESR) are almost always elevated (except in small bones infections).
  • There are many methods to attempt to recover the organism causing the bone infection, such as blood, bone, or joint aspirate cultures. It is important to obtain these cultures before any antibiotics are given.
  • However, at times cultures may be negative or difficult to obtain and therapy should be guided by the most common causes in local area.
  • If one is able to obtain bone and/or joint fluid aspirate for culture, a Gram stain is vital, as the procedure itself can be bactericidal.
  • Consult with the microbiology laboratory prior to obtaining cultures to ensure proper culture mediums and technique are used.
  • If a clinician is considering, Kingella kingae, notify the microbiology department as recovery is improved by inoculating synovial fluid directly into blood culture bottles.
  • Consider performing a bone biopsy if the patient does not respond to standard therapy.

Imaging Studies

See the list below:

  • MRI
    • This test remains the criterion standard, especially in early infections.
    • On T2-weighted images, increased marrow intensity with surrounding inflammation is suggestive of osteomyelitis. Gadolinium contrast is important to help elucidate edema from an abscess.[8] These abnormalities need to be correlated with the clinical picture before a diagnosis is made, as they are not specific for osteomyelitis.
    • A study by Schallert et al found that children with joint effusions identified by MRI, in the setting of metaphyseal osteomyelitis, should be presumed to have septic arthritis until proven otherwise.[9]
  • Radiography
    • Initial films may be normal, with or without soft tissue swelling. Bone destruction occurs 10-15 days later and then can be appreciated on radiographs.[10, 11]
    • 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.
    • Chronic recurrent multifocal osteomyelitis, fractures, bone tumors, and surgery also cause enhanced technetium uptake.
    • It is an inexpensive test without need for sedation and with relatively quick turnaround.
  • 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:
    • This modality is difficult to use in acute cases of osteomyelitis, with limitations based on availability, technician-dependent results, and an inability to differentiate fluid patterns as infectious versus traumatic.
    • 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.[1, 2, 4]


See the list below:

  • Bone aspiration may be necessary to identify the pathogen.
  •  The study on 250 children by McNeil et al examined the impact of interventional radiology (IR) and surgically obtained cultures in the diagnosis and management of acute hematogenous osteomyelitis. The study found that IR or operating room culture was the only means of identifying a pathogen in 80 of 216 cases (37%), and the results changed antibiotic therapy in 85% of patients. The authors further added that IR can be used effectively to obtain bone cultures in children with acute hematogenous osteomyelitis not requiring open surgical drainage. IR was able to obtain cultures in difficult to acess areas important to obtaining a positive culture and resulted in a shorter hospital stay. The most common pathogen isolated was Staphyloccus aureus (32.5% MRSA, 9.8% MSSA) and no Kingella cases were reported.[12]
  • Consider bone biopsy if other diagnoses are possible (eg, tumors).
  • Joint aspiration is recommended if signs and symptoms suggest pathology near shoulder, knee, or hip joints. This is critical because arthrotomy is indicated if evidence of hip or shoulder arthritis is present.
  • If signs and symptoms do not begin to resolve within 48-72 hours of initiation of appropriate antimicrobial treatment, consider bone aspiration to drain the pus, in consultation with the orthopedic surgeon.


An osteomyelitis staging system is present in the literature for adult treatment and diagnosis of osteomyelitis. The Cierny-Mader classification is the newest system to account for host factors to aid with treatment. It categorizes the first part by anatomical involvement of infection, such as type 1 as medullary osteomyelitis and host type A as a normal host.[13]


Other Tests

The study on 250 children by McNeil et al examined the impact of interventional radiology and surgically obtained cultures in the diagnosis and management of acute hematogenous osteomyelitis. The study found that interventional radiology or operating room culture was the only means of identifying a pathogen in 80 of 216 cases (37%), and the results changed antibiotic therapy in 85% of patients. The authors further added that interventional radiology can be used effectively to obtain bone cultures in children with acute hematogenous osteomyelitis not requiring open surgical drainage.[12]

Contributor Information and Disclosures

Sabah Kalyoussef, DO Attending Physician, Pediatric Infectious Diseases and Hospital Medicine, The Children's Hospital at St Peter's University Hospital

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

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

Disclosure: Nothing to disclose.

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