Figure 117-1 A, Major structures of the bone of an infant before maturation of the epiphyseal growth plate. Note the transphyseal vessel, which connects the vascular supply of the epiphysis and metaphysis, facilitating spread of infection between these two areas. B, Major structures of the bone of a child. Joint capsule A inserts below the epiphyseal growth plate, as in the hip, elbow, ankle, and shoulder. Rupture of a metaphyseal abscess in these bones is likely to produce pyarthrosis. Joint capsule B inserts at the epiphyseal growth plate, as in other tubular bones. Rupture of a metaphyseal abscess in these bones is likely to lead to a subperiosteal abscess but seldom to an associated pyarthrosis. (From Gutman LT: Acute, subacute, and chronic osteomyelitis and pyogenic arthritis in children, Curr Probl Pediatr 15:1−72, 1985.) follow cat or dog bites. The use of polymerase chain reaction testing reveals that a significant proportion of culture negative osteomyelitis is due to Kingella kingae. Conjugate vaccine has reduced greatly the incidence of Haemophilus influenzae type b infections.
Subacute focal bone infections caused by Pseudomonas aeruginosa and S. aureus usually occur in ambulatory persons who sustain puncture wounds of the foot. Pseudomonas chondritis is strongly associated with puncture wounds through sneakers, which harbor Pseudomonas in the foam insole. S. aureus is the most common cause of chronic osteomyelitis. Chronic recurrent multifocal osteomyelitis is an autoinflammatory syndrome characterized by recurrent episodes of fever, bone pain, and radiographic findings of osteomyelitis. Bones uncommonly involved in acute hematogenous osteomyelitis such as the clavicle, scapula, or small bones of the hands or feet are often affected, pathogens are not identified on culture, and histopathology demonstrates plasmacytic infiltrates.
Osteomyelitis may occur at any age but is most common in children 3 to 12 years of age and affects boys twice as frequently as girls. Osteomyelitis from penetrating trauma or peripheral vascular disease is more common in adults.
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Limp Knee Pain Extremity Pain Stiff or Painful Neck Fever without a Source Fever of Unknown Origin
The most common presenting complaints are focal pain, exquisite point tenderness over the bone, warmth, erythema, and swelling. Fever, anorexia, irritability, and lethargy may accompany the focal findings. Weight bearing and active and passive motion of the affected extremity are decreased, mimicking paralysis (pseudoparalysis). Muscle spasm may make the extremity difficult to examine. The adjacent joint space may be involved in young children, suggested by pain with minimal joint range of motion (see Chapter 118).
Usually only one bone is involved. The femur, tibia, or humerus is affected in approximately two thirds of patients. Approximately 15% of cases involve the bones of the hands or feet, and 10% involve the pelvis. Vertebral osteomyelitis is notable for an insidious onset, vague symptoms, backache, occasional spinal cord compression, and, usually, little associated fever or systemic toxicity. Patients with osteomyelitis of the pelvis may present with fever, limp, and vague abdominal, hip, groin, or thigh pain. Pyomyositis of pelvic muscles may mimic osteomyelitis.