Diagnosis Of Acute Hematogenous Osteomyelitis Research Articles

Multimodal approach in radiation diagnostics to determining the intramedullary phase of strictly hematogenic osteomyelitis in children: a prospective study

INTRODUCTION: Despite the fact that acute hematogenous osteomyelitis is classified as a sufficiently studied disease, the percentage of diagnostic errors is still quite high. Timely diagnosis is crucial for the successful outcome of the disease, therefore, visualization should be aimed at early diagnosis and, as a result, successful treatment of the disease.OBJECTIVE: To identify early patterns in the intramedullary phase of the course of acute hematogenous osteomyelitis (CSO) with a multimodal approach of radiation research methods.MATERIALS AND METHODS: Twenty patients underwent a comprehensive examination, including multispiral computed tomography (MSCT) using color mapping techniques.RESULTS: In the intramedullary phase of the course of CSF, no pathological changes were detected during X-ray examination of the affected limb. Ultrasound in 75% of observations revealed a thickening of the periosteum of more than 1 millimeter (mm) in the affected bone. When using MRI in 93% of cases, and with MSCT in 95% of patients, signs of bone marrow edema were detected.DISCUSSION: The role of computed tomography in the diagnosis of acute hematogenous osteomyelitis in children has received significant recognition in pediatric surgical practice in recent years, and the use of MSCT in the diagnosis of CSO has found application in domestic healthcare. At the same time, a fairly large number of researchers reported on the high informativeness of MSCT in the diagnosis of CSOs.CONCLUSION: MSCT using the color mapping technique has a higher specificity compared to MRI and can be used as an integral method of the first level in the diagnosis of the intramedullary phase of the CSF course.

Comparative analysis of the results of multispiral computed tomography using color mapping and magnetic resonance imaging in the diagnosis of acute hematogenous osteomyelitis in children

BACKGROUND: Although acute hematogenous osteomyelitis is considered a fairly well-studied disease, several articles emphasize that the frequency of diagnostic errors remains quite high. The clinical presentation of acute hematogenous osteomyelitis largely depends on its reactivity and localization. The latter has features of the clinical course in children of different age groups. Osteomyelitis can be difficult to detect because of the variability and nonspecificity of symptoms and physical and laboratory parameters. Rapid diagnosis is crucial for successful disease outcomes because untimely treatment increases the number of complications. Therefore, visualization should be aimed at early diagnosis and, ultimately, successful treatment.
 AIM: This study aimed to evaluate the informative value of magnetic resonance imaging and multispiral computed tomography (MSCT) in the diagnosis of the intramedullary phase of acute hematogenous osteomyelitis as its earliest stage.
 MATERIALS AND METHODS: Thirty patients suspected with acute hematogenous osteomyelitis underwent magnetic resonance imaging and MSCT using color mapping techniques and X-ray density assessment. At the final stage of the diagnostic algorithm, osteotonometry was performed. The contents of the bone marrow canal were taken for microbiological and bacteriological studies.
 RESULTS: In the intramedullary phase of acute hematogenous osteomyelitis, magnetic resonance imaging and MSCT revealed signs of bone marrow edema in 96% of the cases. The sensitivity of magnetic resonance imaging was 96%, the same as that of MSCT; however, the specificity was significantly lower than that of MSCT using the color mapping method and X-ray density assessment, which was 67% and 83%, respectively (p 0.05).
 DISCUSSION: In recent years, the role of computed tomography in the diagnosis of acute hematogenous osteomyelitis has received considerable recognition in pediatric surgical practice, and MSCT with color mapping and X-ray density assessment in the diagnosis of acute hematogenous osteomyelitis in children has been used relatively recently. Simultaneously, many researchers have reported the high informativeness of MSCT in the diagnosis of acute hematogenous osteomyelitis.
 CONCLUSIONS: The intramedullary phase of acute hematogenous osteomyelitis according to magnetic resonance imaging and MSCT indicates bone marrow edema as its earliest stage. According to the data of the present study, MSCT using color mapping and X-ray density assessment has high specificity and can be used with MRI as the main method for diagnosing the intramedullary phase of acute hematogenous osteomyelitis.

Magnetic resonance imaging in the diagnosis of acute hematogenous osteomyelitis in children

Aim of the study: to show the possibilities of magnetic resonance imaging for the diagnosis of acute osteomyelitis. Materials and methods. One hundred thirty two children with hematogenous osteomyelitis (n = 112 - 84.8%), including BCG-osteomyelitis (n = 20 - 15.2%), aged 1 to 17 years, average age - 9.1 ± 4.9 years, were examined between 2011 and 2020. Out of 132 children, 77 were operated on (58.3%). Boys predominated - 70 (53%) patients, girls - 62 (47%). MRI was performed on a Philips Achieva dStream 3.0 T. Results. Over the first three days after onset of the disease, when radiography and CT did not reveal bone pathological changes, according to MRI acute osteomyelitis was detected in all patients (n = 51). The topical location of osteomyelitis foci was clearly established. Discussion. MRI is the most informative method for visualizing acute hematogenous osteomyelitis over first days of the disease. MRI clearly shows initial bone remodelling and bone marrow edema, including the such earliest sign as perifocal myositis. The most effective MRI sequences are STIR and T2WI, regardless of the pulse sequence, in which a pronounced hyperintense signal is visualized. Whole body MRI combined with clinical data is considered a promising method for distinguishing inflammatory processes from other specific diseases.

ARTHROSCOPIC TREATMENT OF HEMATOGENOUS PATELLA OSTEOMYELITIS IN A 12-YEAR OLD CHILD

Introduction. A rare disease in pediatric population - acute hematogenous osteomyelitis of the patella - is presented in the article by the authors. Diagnostic approaches and specificity in choosing a curative modality are described as well. A purulent focus in the patella was treated arthroscopically. Satisfactory outcomes in the shortest possible period were achieved due to the combined curative modality: antibiotic therapy, flow-lavage drainage of the joint and early rehabilitative measures. Purpose. To demonstrate potentials of modern diagnostic and endosurgical techniques for treating acute hematogenous osteomyelitis of the patella of rare location. Material and methods. In February 2017, a 12-year-old boy with acute hematogenous osteomyelitis of the right patella was examined and treated at the department of purulent surgery of the Research Institute of Emergency Pediatric Surgery and Trauma (CRIEPST). A complex of diagnostic techniques included laboratory (clinical analysis of blood and urine, biochemical blood test) and instrumental (ultrasound diagnostics of knee joints, computed tomography) examinations. Conservative treatment included antibacterial, anti-inflammatory and symptomatic therapy . Surgical debridement of the osteomyelitis focus in the knee joint was made arthroscopically. Results. Given the obtained data, the diagnosis of acute hematogenous osteomyelitis of the right patella was put. Location of the process, purulent effusion in the joint cavity and damaged articular surface of the patella urged surgeons to decide on the endosurgical treatment: arthroscopic cleansing of the purulent-necrotic focus of the patella and sanitation of the knee joint cavity. In the postoperative period, the child had medicamentous therapy, apparatus therapy, hyperbaric oxygenation therapy. The right lower limb was immobilized with a posterior plaster cast for 7 days. The joint was washed with physiological saline solution for 5 days, after which the drainage was left for passive aspiration for another two days. Standing-up position with crutches and emphasis on the low legs were achieved on the 7th postoperative day. On the 14th postoperative day, the child was discharged home in a satisfactory state. Catamnestic examination 4 months later revealed that the right knee joint was not externally changed, movements in the joint were in full range. Ultrasound examination did not reveal any pathology either. MRI examination revealed an area with reparative signs at the site of operated purulent focus which looked like a partial replacement of the bone defect. Conclusions. The arthroscopy is a minimally invasive and effective technique for surgical treatment of intra-articular purulent foci in acute hematogenous osteomyelitis of the patella.

Diagnostic value of radiography and ultrasound for suspected acute hematogenous osteomyelitis

Objective:to evaluate the informativeness of ultrasonography and radiography in the early diagnosis of acute hematogenous osteomyelitis in children.Material and methods. Children (from 3 weeks to 1 year old) with suspected acute hematogenous osteomyelitis (n = 40) were examined and X-rays and ultrasound scan of the affected skeleton were performed. 39 (97.5%) of children underwent surgery.Results.Radiography in the first 3 days of the disease gave only false-negative results. On the 5th-7th day of the disease, the fuzziness of the outline of the growth zone, the uneven contour of the ossification core, was found, which resulted in 33% sensitivity. X-ray symptoms of bone destruction were obtained in the second week of the disease in 83% of the subjects.The resultsof ultrasound examination in the first 3 days of the disease exceeded the radiographic parameters and corresponded to 66.7% of sensitivity based on the definition of increased vascularization of edematous parasal soft tissues, epiphyseal cartilage. On the 5th-7th days of the disease, local hyperechoic areas were found in the epiphyseal cartilage, with additional color signals around it, an uneven contour of the ossification nucleus, which almost equalized the sensitivity parameters of X-ray and ultrasound studies (83.33% and 88.8%, respectively).The most sensitive, specific and accurate are the studies in the third week from the onset of the disease, in determining the sites of destruction in the metaphysis and the nucleus of ossification of the epiphysis, both in X-ray and ultrasound studies.Conclusion.X-ray and ultrasound studies should be considered complementary modalities for obtaining optimally complete information about the morphological substrate of the pathological inflammatory process.

Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline.

Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA. This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course. Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline. Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use. Level III- retrospective comparative study.

TO THE QUESTION OF EARLY DIAGNOSIS OF ACUTE HEMATOGENOUS OSTEOMYELITIS OF BONES OF THE HIP JOINT IN CHILDREN

Our goal was to develop objective criteria for early diagnosis of acute hematogenous osteomyelitis (AHO) of bones of the hip joint (BHJ)) in children. For the differential diagnosis between AHO and the reactive coxitis (RC) we examined a total of 93 children (61 AHO BHJ and 32 RC cases). AHO BHJ patients are characterized by a higher degree of endogenous intoxication when compared with RC patients. CT allows diagnose AHO BHJ before the appearance of radiological signs (starting from 3 days from the onset of the disease) in the bone tissue and can be used to differentiate AHO BHJ from RC. These features allow using these parameters as objective criteria for the differential diagnosis in children with acutely developed pain in hip joint area

Bone and Joint Infections in Children: Acute Hematogenous Osteomyelitis.

Acute hematogenous osteomyelitis (AHO) is one of the commonest bone infection in childhood. Staphylococcus aureus is the commonest organism causing AHO. With use of advanced diagnostic methods, fastidious Kingella kingae is increasingly becoming an important organism in etiology of osteoarticular infections in children under the age of 3y. The diagnosis of AHO is primarily clinical. The main clinical symptom and sign in AHO is pain and tenderness over the affected bone especially in the metaphyseal region. However, in a neonate the clinical presentation may be subtle and misleading. Laboratory and radiological investigations supplement the clinical findings. The acute phase reactants such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are frequently elevated. Ultrasonography and MRI are key imaging modalities for early detection of AHO. Determination of infecting organism in AHO is the key to the correct antibiotic choice, treatment duration and overall management and therefore, organism isolation using blood cultures and site aspiration should be attempted. Several effective antibiotics regimes are available for managing AHO in children. The choice of antibiotic and its duration and mode of delivery requires individualization depending upon severity of infection, causative organism, regional sensitivity patterns, time elapsed between onset of symptoms and child's presentation and the clinical and laboratory response to the treatment. If pus has been evidenced in the soft tissues or bone region, surgical decompression of abscess is mandatory.

Early Acute Hematogenous Osteomyelitis Detected by Bone Scintigraphy but not MRI

Early diagnosis of acute hematogenous osteomyelitis (AHO) is crucial for effective management and to reduce the potential risk of lifelong deformities in pediatric patients. Both bone scintigraphy and MRI as current diagnostic imaging claim their high sensitivity in early detection of the disease. We present a 9-year-old girl patient with AHO in the distal right tibia, which was demonstrated on bone scintigraphy while a subsequent MRI on the same day was negative.

Acute Hematogenous Osteomyelitis

1. Dennis A. Conrad, MD* 1. *Professor of Pediatrics and Associate Chairman for Continuing Medical Education, Department of Pediatrics/Division of Infectious Diseases, University of Texas Health Science Center at San Antonio; Medical Director, Infection Control, CHRISTUS Santa Rosa Children's Hospital, San Antonio, Tex. After completing this article, readers should be able to: 1. Describe the pathophysiology of acute hematogenous osteomyelitis. 2. Correlate most common infectious causes of osteomyelitis with the age of the patient. 3. Recognize the typical clinical manifestations of acute hematogenous osteomyelitis. 4. Explain the appropriate use of ancillary information obtained by laboratory determinations and imaging studies to establish the diagnosis of acute hematogenous osteomyelitis. 5. Discuss the medical and surgical principles of management in the treatment of acute hematogenous osteomyelitis. The most common type of osteomyelitis, an infection of bone, that occurs in children is acute hematogenous osteomyelitis. Infection initially is established in the metaphyseal region of tubular bones, beginning as a metaphysitis following seeding by bacteria. The appendicular skeleton is the most common site of osteomyelitis. The lower extremity, especially the femur, is involved more often than the upper extremity, where the humerus is most likely to be infected. The pelvic bones or clavicles are less likely to be involved than the long bones of the extremities. The most common bone involved in acute hematogenous osteomyelitis in children is the femur. The axial skeleton is less likely to be the site of acute hematogenous osteomyelitis. Manifestations of osteomyelitis involving the axial skeleton are most commonly discitis, vertebral osteomyelitis, and infection involving the ribs and cranial bones. In most cases, the preceding bacteremia leading to acute hematogenous osteomyelitis is cryptic and asymptomatic, although osteomyelitis can be a focal complication of clinically symptomatic bacteremia and even overt septicemia. The nidus of infection begins in the valveless sinusoidal loops of the venules at their reflection at the epiphysis and is attributed to slow and nonlaminar blood flow through this vascular …

Acute osteomyelitis in children: The pathogenesis revisited?

The present study reviews our experience of acute hematogenous osteomyelitis in 450 children over a period of 20 years from 1985 to 2004 at the Nouméa Territorial Hospital in New Caledonia. The objective was to formulate a new theory of the pathogenesis of this affection and to report our research on the disparity in the pathology between temperate countries and our own tropical Pacific area. Only children with an initially normal X-ray and showing symptoms for less than one week were included in the study. Subacute osteomyelitis, infant osteoarthritis and spinal and sacroiliac joint infections were all excluded. All children were treated according to a preestablished protocol including: clinical examination; blood tests; ultrasound, to determine the presence and size of the periosteal elevation and to exclude soft tissue abscess and frequent pyomyositis. Ultrasound was used in the decision to treat with antibiotics alone or with surgery. Computed Tomography was used for deep structures assessment and medical therapy guidance Surgery was limited to open drainage of the subperiosteal abscess only. Regular follow-up of outpatients was continued until normal blood test and X-ray results were achieved. Four hundred and fifty children with a diagnosis of acute hematogenous osteomyelitis were identified, giving an average incidence of 22 new cases per year (range, 12-35). This incidence was two to five times as high as found in Europe. Fifty-three percent of our cases required surgical drainage (vs. 20 % in Europe). Ethnically, 60 % of the children were Melanesian and 20 % Polynesian (both represented less than 50 % of the local population). A similar incidence, about four times as high as in the population of European descent, was reported in Polynesians by our neighbors in New Zealand. The limbs were affected in 90 % of cases, and specifically lower limbs in 70 %. Multiple osseous lesions and systemic infection were recorded in 43 children (9.5 %). Blood cultures and surgical samples were positive in 80 % of cases, and otherwise negative. All the children were successfully treated, without chronic evolution or sequelae needing secondary surgery. The predominant microorganisms isolated were Staphylococcus aureus, in 81 % of cases, none of which were methicillin-resistant, and group A Streptococcus in 7.5 % of cases. A previous study of soft-tissue S. aureus infection showed the presence of Panton-Valentine Leukocidin (PVL) genes in 89 % of cases. These very infrequent genes are responsible for leukotoxic apoptosis, producing leukocidin, causing local acute aggressiveness. A parallel study, in progress for more than a year, is focusing on detecting PVL genes in S. aureus isolated from acute osteomyelitis: in the first nine children analyzed, PVL genes were likewise detected in 89 % of the S. aureus isolated, with no methicillin resistance. Ultrasonography allowed positive diagnosis in 64 % of cases on the day of admission and 84 % by the second day. Because of this very early presence of subperiosteal abscess at the beginning of the disease, and several other issues raised in the present study, we believe that Trueta's theory of acute osteomyelitis pathogenesis does not provide any logical explanation for our anatomoclinical observations. We believe that the primary focus of infection is in the osteoperiosteal area rather than under the growth plate in the metaphyseal bone. The term of Acute Osteo-Periostitis would therefore be much more suitable. A history of blunt trauma was found in 63 % of cases in the present series, and often reported in the literature. We speculate that two forms of infection fixation may develop: a local form, where bacteria carried by the blood stream reach a subperiosteal edema or hematoma secondary to blunt trauma, which is in our opinion the most frequent cause; and a general form, where fixation occurs as single or multifocal osteoperiostitis, and multivisceral locations in severe forms of septicemia. The disparity in this pathology between temperate countries and our own tropical Pacific area is certainly due to PVL-positive S. aureus and ethnic factors. The high prevalence of Melanesian and Polynesian patients confirms that they are at high risk of musculoskeletal infection in New Caledonia as in other Pacific countries, and it is possible that these ethnic groups are genetically susceptible to PVL-positive strains. Level IV. Retrospective case series.

The accuracy of different imaging techniques in diagnosis of acute hematogenous osteomyelitis

The aim of this study was to establish and compare diagnostic accuracy (sensitivity, specificity, and diagnostic odds ratio) of plain x-ray, ultrasonography, bone scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI) in pediatric acute hematogenous osteomyelitis. Analysis of patients' data, hospitalized at the Department of Pediatric Surgery with suspected acute hematogenous osteomyelitis in the period of 2002-2008, was carried out prospectively. Inclusion criteria were age of 1-18 years, pain in bone area, fever, functional disorder, and (or) signs of infection. Plain x-ray, ultrasonography, bone scintigraphy, computed tomography, and magnetic resonance imaging were performed. The recommendations of Standards for Reporting of Diagnostic Accuracy were used in study design. A total of 183 patients were included into the study. Acute hematogenous osteomyelitis was diagnosed in 156 (85%) patients, and 27 (15%) had other diseases. A total of 169 early plain x-rays (median on the first day of hospital stay), 142 late x-rays (15th day of hospital stay), 82 ultrasonographies (second day), 76 bone scintigraphy (third day), 38 MRI scans (seventh day), and 17 CT (15th day) were performed. The sensitivity of ultrasonography was 0.55 (95% CI, 0.43-0.67); specificity, 0.47 (95% CI, 0.24-0.7); and diagnostic odds ratio, 1.08 (95% CI, 0.3-3.84). The sensitivity of CT was 0.67 (95% CI, 0.38-0.88); specificity, 0.5 (95% CI, 0.01-0.98); and diagnostic odds ratio, 2.0 (95% CI, 0.02-172.4). The sensitivity of early x-ray was 0.16 (95% CI 0.1-0.23); specificity, 0.96 (95% CI, 0.78-1.0); and diagnostic odds ratio, 4.34 (95% CI, 0.63-186.3). The sensitivity of MRI was 0.81 (95% CI, 0.64-0.93); specificity, 0.67 (95% CI, 0.22-0.96); and diagnostic odds ratio, 8.67 (95% CI, 0.91-108.5). The sensitivity of late x-ray was 0.82 (95% CI, 0.75-0.88); specificity, 0.92 (95% CI, 0.62-1.0); and diagnostic odds ratio, 51.17 (95% CI, 6.61-2222.0). The sensitivity of bone scintigraphy was 0.81 (95% CI, 0.68-0.90); specificity, 0.84 (95% CI, 0.60-0.97); and diagnostic odds ratio, 22.30 (95% CI, 4.9-132.7). Our analysis showed that late x-ray is the most valuable radiologic method in the diagnosis of acute hematogenous osteomyelitis, but bone scintigraphy and magnetic resonance imaging are the most valuable tests at the onset of the disease.

Delayed Diagnosis of Acute Hematogenous Osteomyelitis of the Acetabulum - Report of Two Cases -

Acute hematogenous osteomyelitis of the acetabulum is not a common disease with similar clinical symptoms and hematological findings to those of pyogenic arthritis of the hip joint. This symptom similarity might lead to a delayed diagnosis of the disease, and even to unnecessary surgery. We report two cases of acute hematogenous osteomyelitis of the acetabulum. One was a 13-year-old boy with non-specific radiological findings of the hip joint, who was initially diagnosed with fever of unknown origin. The other was an 11-year-old boy with hip joint pain and a recent history of minor trauma, which lead to a delayed diagnosis.

Complications of Central Venous Catheters Used for the Treatment of Acute Hematogenous Osteomyelitis

To determine the complications and risk factors for complications associated with using central venous catheters (CVCs) for the treatment of acute hematogenous osteomyelitis (AHO). We conducted a retrospective cohort study of all patients admitted to the Children's Hospital of Philadelphia between January 1, 2000, and December 31, 2003, with a diagnosis of AHO. Eighty patients with AHO met inclusion criteria. The median age was 5 years, and 66% of the patients were male. The most commonly affected bones were the femur (25%), tibia (20%), and pelvis (16%). Staphylococcus aureus was the most common organism identified from cultures of bone (67%) and blood (30%). Seventy-five patients (94%) received >2 weeks of intravenous (IV) antibiotic therapy via a CVC and 5 (6%) received <2 weeks of IV antibiotic therapy before conversion to oral therapy for a median of 25 days. None of the patients who switched to oral therapy within 2 weeks was rehospitalized or returned to the emergency department. Of the 75 patients who received >2 weeks of IV therapy, 41% had > or =1 CVC-associated complication. Seventeen patients (23%) had a CVC malfunction or displacement, 8 (11%) had a catheter-associated bloodstream infection, 8 (11%) had fever with negative blood culture results, and 4 (5%) had a local skin infection at the site of catheter insertion. Older age was protective against the development of a CVC-associated complication, whereas the lowest median household income was associated with development of a CVC-associated complication. Interventions to reduce CVC-associated complications should be developed and evaluated, particularly for young children and those from families with low household incomes. Clinical trials are needed to evaluate the safety and efficacy of oral antibiotic therapy after a short course of IV therapy as an alternative to prolonged IV therapy.

Sonographic diagnosis of acute hematogenous osteomyelitis in the early stage.

This article presents sonographic diagnosis of acute hematogenous osteomyelitis in early stage. 24 children with clinically suspected acute hematogenous osteomyelitis were detected to have subperiosteal abscesses by ultrasound during four to fourteen days after onset. The mean length and anteroposterior distance of the subperiosteal abscesses were 86.4 mm and 10.7 mm, respectively. Of 24 cases of subperiosteal abscesses, aspiration performed under ultrasound guidance revealed purulent fluid in all and 23 were verified surgically. The results obtained indicate that ultrasound can be used in diagnosis of acute hematogenous osteomyelitis in the early stage. The earliest case was diagnosed by ultrasound 4 days after onset. By use of ultrasound, differentiation diagnosis of acute hematogenous osteomyelitis from other diseases such as cellulitis, soft tissue abscess, acute septic arthritis and malignant bone tumors is also discussed.

Diagnosis of Osteomyelitis

The early diagnosis of acute hematogenous osteomyelitis depends on a high index of suspicion whenever the physician is confronted with a child experiencing acute onset of bone pain or limited motion of an extremity, regardless of the presence or absence of signs of infection such as fever, local tenderness, redness, swelling or heat (Table 4). Early diagnosis is aided greatly by the use of plain radiography to exclude other conditions and radionuclide bone scans to detect evidence of inflammation at the site of bone pain. "High-tech" procedures such as CAT and MRI should be reserved for situations in which the diagnosis cannot be made by the simpler methods, such as osteomyelitis of the spine or pelvis, or when the anatomic detail provided by MRI is required for planning of surgery. It is very unlikely that CAT or MRI will every be required in the majority of cases of uncomplicated osteomyelitis in children.

Diagnosis of Osteomyelitis

The early diagnosis of acute hematogenous osteomyelitis depends on a high index of suspicion whenever the physician is confronted with a child experiencing acute onset of bone pain or limited motion of an extremity, regardless of the presence or absence of signs of infection such as fever, local tenderness, redness, swelling, or heat (Table 4). Early diagnosis is aided greatly by the use of plain radiography to exclude other conditions and radionuclide bone scans to detect evidence of inflammation at the site of bone pain. "High-tech" procedures such as CAT and MRI should be reserved for situations in which the diagnosis cannot be made by the simpler methods, such as osteomyelitis of the spine or pelvis, or when the anatomic detail provided by MRI is required for planning of surgery. It is very unlikely that CAT or MRI will every be required in the majority of cases of uncomplicated osteomyelitis in children.

Acute hematogenous osteomyelitis: has the bone scan betrayed us?

Technetium-99m bone scanning reveals a spectrum of findings in the diagnosis of acute hematogenous osteomyelitis. Both "cold" and "hot" abnormalities are found. Gallium-67 citrate imaging is recommended when 99Tc phosphate scans are inconclusive.

Hematogenous Pyogenic Osteomyelitis in Children

Early diagnosis of acute hematogenous osteomyelitis is difficult. The diagnosis can be positively established only by isolation of the organism from bone or by histologic confirmation. The diagnosis should always be suspected when clinical signs are suggestive. In these cases aspirated material should be obtained for culture and the patient should be treated with antibiotics and observed closely. If the clinical response is good and no bone destruction occurs, surgical intervention may not be necessary. If the clinical response is not satisfactory or if bone destruction occurs, surgical treatment should be carried out to drain the area and to identify the etiologic organism. When osteomyelitis is associated with joint involvement, the prognosis is poor, and our data show no obvious improvement even with long-term antibiotic therapy. The key is prevention by early recognition and treatment. If culture fails to isolate a pathogenic organism, the prognosis appears to be good. Overall, in recent years the prognosis of hematogenous osteomyelitis has continued to improve, probably as a result of early detection and better antibiotic therapy.