Acute bone and joint infections in children are serious, and misdiagnosis can threaten limb and life. Most young children who present acutely with pain, limping, and/or loss of function have transient synovitis, which will resolve spontaneously within a few days. A minority will have a bone or joint infection. Clinicians are faced with a diagnostic challenge: children with transient synovitis can safely be sent home, but children with bone and joint infection require urgent treatment to avoid complications. Clinicians often respond to this challenge by using a series of rudimentary decision support tools, based on clinical, haematological, and biochemical parameters, to differentiate childhood osteoarticular infection from other diagnoses. However, these tools were developed without methodological expertise in diagnostic accuracy and do not consider the importance of imaging (ultrasound scan and MRI). There is wide variation in clinical practice with regard to the indications, choice, sequence, and timing of imaging. This variation is most likely due to the lack of evidence concerning the role of imaging in acute bone and joint infection in children. We describe the first steps of a large UK multicentre study, funded by the National Institute for Health Research, which seeks to integrate definitively the role of imaging into a decision support tool, developed with the assistance of individuals with expertise in the development of clinical prediction tools.

Cite this article: Bone Joint J 2023;105-B(3):227–229.

Sinus-track cultures were compared prospectively with cultures from operative specimens in 55 patients with chronic bone infection. There was a total of 115 operative isolates; 102 of the sinus-track isolates were identical (88.7%), showing a specificity of 95.7% and a predictive value of 90.3%. A sinus-track specimen proved to be a reliable source for the isolation of all bacteria causing chronic bone infection except Staphylococcus epidermidis, provided that material from the depths of the sinus was aspirated by syringe from an active flowing sinus and inoculated immediately on culture media. Cotton-swab sinus specimens were unreliable for the isolation of mycobacteria, and could miss many pyogenic bacteria, or contain contaminants. Tuberculous bone infection should be suspected if there is no growth of any pyogenic bacteria or if there is growth of Staphyloccocus epidermidis alone on routine aerobic and anaerobic sinus cultures. Mycobacteria can often be identified from sinus-track culture from patients in whom operative culture, histopathology and clinical examination have failed to confirm the diagnosis of tuberculosis

We have reviewed 60 patients with primary bone infections; 21 of these (35%) had subacute osteomyelitis, a figure which supports other recent observations that this variant of bone infection is becoming more widespread. In this group open culture and biopsy were necessary in order to exclude bony malignancy, and a raised erythrocyte sedimentation rate proved a useful diagnostic aid. All the patients with acute osteomyelitis or with vertebral infection responded to primary treatment, but five of those with subacute osteomyelitis had recurrences

The purpose of this report is not to describe a new condition but to remind those who seldom see smallpox of one of its most important and easily recognised complications. Bone infection can be late, almost silent and often most unexpected. It is usually symmetrical and almost always multiple. It does not affect the spine, pelvis and ribs, but does affect the arms, hands, legs and feet. It is destructive, unpreventable and untreatable. It ends with deformity but not with loss of life. The recognition of its etiology will prevent a great deal of unnecessary and unrewarding interference with a self-limiting disease

1. The literature on acute osteomyelitis of the maxilla in infants is reviewed and the improvement in the prognosis since the introduction of chemotherapy is noted. 2. The clinical features, diagnosis, surgical anatomy, pathology, and bacteriology are discussed and the constant pathogenicity of the staphylococcus aureus stressed. It is suggested that the first deciduous molar tooth is the centre of the early bone infection, and that the infection begins in the mucosa overlying this tooth. 3. Two cases are reported. Both were caused by a penicillin-resistant staphylococcus aureus. 4. The early use of aureomycin in an attempt to abort the infection is advocated

1. A technique of closed instillation-suction for the treatment of chronic bone infection is described in which infected bone is first exposed and all necrotic material removed. Three perforated drainage tubes are inserted, and brought out through the skin some distance from the wound. The perforated parts of the tubes are laid close to the infected area and the wound closed in layers. Two of the tubes are connected to a drip bottle containing antibiotic solution, and the third to a continuous suction pump. Closed continuous instillation-suction is thus established, and has been maintained for up to six weeks. 2. The results in twelve cases are presented, two-thirds of which showed clinical resolution of the infection

Tuberculous osteomyelitis which does not involve a joint is uncommon and may fail to be diagnosed by an orthopaedic surgeon. We treated 28 lesions of tuberculous osteomyelitis in 25 patients between 1988 and 1995. The duration of symptoms was from two to 39 months, and most of our patients had been treated initially with non-steroidal anti-inflammatory drugs which failed to provide relief. Bone pain which does not promptly respond to analgesic medication is often due to infection or neoplasia.

In the early stages, when plain radiographs are normal, MRI or CT may help to localise lesions. On plain radiographs, more advanced lesions may mimic chronic pyogenic osteomyelitis, Brodie’s abscess, tumours or granulomatous lesions. Biopsy is mandatory to confirm the diagnosis, and antituberculous drugs are the mainstay of treatment. When operative findings at biopsy have the features of skeletal tuberculosis curettage of the affected bone may promote earlier healing.

Four cases of osteomyelitis of the pelvis are reported to demonstrate the several clinical syndromes to which this disease can give rise. Extensive surgical drainage and antibiotic treatment led to recovery in all cases.

We reviewed 52 cases of osteomyelitis of the calcaneum. The clinical symptoms and signs were well defined, but different and less dramatic than those of long-bone osteomyelitis. Blood cultures were positive in 41% of cases and tissue cultures in 91%. Routine haematological tests were of little value, and radiological changes were often delayed, and were absent in 12%. With early diagnosis, treatment with antibiotics alone was usually effective, but complications and chronic disease were more likely if there was delay. Early diagnosis is the key to successful treatment. We describe a new physical sign and consider that diagnosis is almost always possible by clinical methods.

1. Five new cases of pyogenic osteomyelitis of the patella are reported.

2. The clinical features are reviewed and the diagnostic pitfalls enumerated.

1. Recent published reports of neonatal osteomyelitis in long bones are reviewed.

2. Six further cases are described.

3. The source of infection is usually the skin or the umbilicus, and the common organisms are the haemolytic streptococcus and staphylococcus aureus.

4. Cases fall into two groups: in one the patient is acutely ill with septicaemia and the bone lesion is of secondary importance; in the other the general condition is well maintained even though there may be multiple bone lesions.

5. Sequestration is uncommon; but when it occurs it prevents the rapid healing that is usually observed after drainage.

6. The most important complication is suppurative arthritis, which may lead to total destruction of a joint.

7. It is probable that the lowered mortality from infantile septicaemia will be matched by a corresponding increase in the cases of acute osteomyelitis encountered in clinical practice.

1. Acute osteomyelitis is defined.

2. An analysis of 113 cases is given.

3. An effective programme of treatment was evolved from experience over a period of nine years.

4. Recommendations regarding a programme of treatment are given.

1. Sixty-seven patients with subacute haematogenous osteomyelitis are reported.

2. The benign nature of the disease is noted.

3. The clinical types of infection are reported, with regard to the site of the lesion.

4. The treatment is described.

1. Three cases of osteomyelitis of a metatarsal sesamoid bone are described.

2. The diagnosis should be considered in patients with acute pain under the first metatarsophalangeal joint, particularly if the temperature is elevated.

3. Failure ofdiagnosis may lead to persistent disability until sinus formation and sequestration dictate operative intervention.

4. Early antibiotic therapy may lead to resolution of the infection.

1. Five cases of Salmonella osteomyelitis in infants without red-cell sickling are reported.

2. All these cases occurred in children under eighteen months of age and within a period of five months of time, suggesting a seasonal incidence.

3. Only one strain of Salmonella was isolated–Salmonella typhimurium.

4. There was complete healing in four of the cases.

5. In one case there was destruction and complete absorption ofthe upper humeral epiphysis.

1. A series of 328 cases of acute haematogenous osteomyelitis in children is analysed.

2. In the first group ofseventy-seven cases from 1944 to 1950 penicillin gave excellent results.

3. After 1950 the disease took on new characteristics in terms of frequency, severity and age incidence, with the appearance of a staphylococcus resistant to penicillin: 251 cases are recorded from 1951 to 1960.

4. The importance of the early assessment ofthe disease into degrees of severity is emphasised as the surgeon's guide in his form of management.

5. The value of operative decompression is discussed.

6. The frequent and dire consequences of hip joint involvement are analysed and draillage of the hip joint is described.

This new blood test for infection is based on the phenomenon of leukergy in which white cells agglomerate in the peripheral blood of patients with inflammatory diseases. It was used in 26 patients with proven bone or joint infection and was positive in 25. The leukergy test was more accurate than the ESR, white cell count or blood culture. The percentage of cells agglomerated correlated with the clinical severity of the infection and the test detected reactivation of the septic process better than the other haematological tests. It is a rapid and inexpensive method which is useful in the diagnosis and management of bone and joint infections.

1. Continued follow-up of the 113 children with acute osteomyelitis previously reported and a study of a further thirty-eight proven cases has not changed our opinion that the correct management is rest and effective antibiotics. Operation should be undertaken only if pus is detectable clinically.

2. Bacteriological evidence shows that the flora causing this disease are less sensitive to benzylpenicillin than ten years ago and that a proportion are also likely to become resistant to methicillin and cloxacillin.

3. The most effective antibiotic combination used was fusidic acid and erythromycin. This lowered the failure rate to 10·5 per cent in thirty-eight proven cases. Two of the four failures were in haemophilus infections. No staphylococcal infection of a long bone became chronic, and all lesions were healed within three months of onset.

4. The duration of treatment (twenty-one days) and the method of splintage (removable plaster slabs) remained the same as in the previous series.

5. Careful watch must be kept on the incidence of haemophilus infections. If it rises, increasing the erythromycin or adding ampicillin may be necessary.

6. Use of the newer aqueous suspension of fusidic acid may lower the incidence of troublesome vomiting (12 per cent in this series).

7. Only 7 per cent of staphylococcus aureus infections in this hospital, and 17 per cent of such infections in our thirty-eight cases were sensitive to benzylpenicillin. It is thought that this drug has outlived its usefulness in osteomyelitis.

8. It is recommended that, on diagnosis, fusidic acid aqueous suspension 5 millilitres should be given three times a day to children aged one to five, and 10 millilitres twice a day for children aged six to twelve, with erythromycin stearate 30 milligrams per kilogram of body weight each day in divided doses.

1. In the treatment of chronic osteomyelitis the most troublesome factor is the infected bone cavity. This is seldom obliterated spontaneously by bone regeneration. The number of procedures designed to fill the cavity, since the beginning of the century, show how much it troubles the surgeon.

2. The use of bone grafts in the treatment of chronic osteomyelitis has been studied. One hundred and twenty cases are reviewed (the largest series in the literature), the follow-up being between two and ten years. The most common lesion was a bone cavity, with or without a sequestrum.

3. Treatment must include the removal of infected soft tissues as well as sclerosed bone, and must be done under appropriate antibiotic control. The value of cancellous bone grafts in filling infected cavities in the metaphysio-epiphysial regions is especially emphasised.

4. The results were gratifying, only four relapses occurring in 120 cases.