osteomyelitis and septic arthritis - springer · osteomyelitis and septic arthritis andrew r....

Osteomyelitis and Septic Arthritis

Andrew R. Tysera and Douglas T. Hutchinsonb*aDepartment of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USAbDepartment of Orthopaedic Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA

Abstract

Osteomyelitis and septic arthritis in the pediatric population are potentially life-threatening infec-tions that will be encountered by practitioners who treat musculoskeletal disorders in children, andcommonly occur in the upper extremity. The pathogens responsible for these increasingly severeinfections have been changing in the past decades, most notably manifested as a rise in the rate ofmethicillin-resistant Staphlococcus aureus (MRSA) osteomyelitis and complex osteoarticular mus-culoskeletal infections. Similarly, the medical and surgical treatment of these infections has changedsignificantly over the prior decades, and controversy remains over the optimal treatment in certainclinical scenarios. As the complexity of these serious infections grows, an understanding of thecurrent data regarding the topic is required for effective treatment.

In this chapter, we summarize the epidemiology, pathoanatomy, and treatment recommendationsfor pediatric osteomyelitis and septic arthritis involving the upper extremity. The specifics of non-surgical and surgical interventions are presented in a manner that will allow the treating practitionerto use this text as an efficient reference for treatment planning. We also present our preferred methodof surgical treatment for these infections, when indicated, with illustrative case examples. Finally,we touch on relevant controversies and suggest future areas of investigation in an ever-evolvingfield.

Introduction

Osteomyelitis and septic arthritis affecting the upper extremity in children can be devastatinginfections. Despite early and appropriate treatment, these deep musculoskeletal infectious processescan lead to long-term dysfunction, disability, and even death. The proportion of these infections thataffect the upper extremity remains relatively low, and when present, the humerus is most commonlyaffected. An understanding of the historical and recent trends in the epidemiology of these diseasesassists the clinician in the recognition and treatment of osteomyelitis and septic arthritis.

Over the past century, both the treatment and outcome of these clinical entities have changedconsiderably. Most notably, the advent of effective antibiotic treatment has substantially reduced themorbidity and mortality associated with potentially severe musculoskeletal infections. In thepre-penicillin era the reported mortality of osteomyelitis was between 15 % and 30 %. This is incontrast to the reported mortality, less than 5 %, in the decades immediately following theintroduction of penicillin (Gilmour 1962). The epidemiology of osteomyelitis underwent furthersubstantial changes in the later half of the twentieth century. The development of the Haemophilusinfluenzae B (HiB) vaccine, the use of more sophisticated imaging techniques such as magneticresonance imaging (MRI), the emergence of antibiotic-resistant strands of bacteria and a wider range

*Email: [email protected]

The Pediatric Upper ExtremityDOI 10.1007/978-1-4614-8758-6_60-1# Springer Science+Business Media New York 2014

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of available antibiotics, and the clarification of surgical indications and techniques have all likelycontributed to a shift in both diagnosis and treatment of osteomyelitis and septic arthritis.

These changes are highlighted by several studies from the past two decades. With regard toosteomyelitis, in 1992 Craigen et al. reported a decrease of over 50 % in the incidence of acute andsubacute osteomyelitis during a 20-year period in children less than 13 years of age who wereadmitted to the Royal Hospital for Sick Children in Glasgow, Scotland. The incidence decreasedfrom 87 to 42 per 10,000 per year from 1970 to 1990 (Craigen et al. 1992). Of the 275 cases theyreported, 34 (12.3 %) were located in the upper extremity, with more than half of those occurring inthe proximal humerus and distal radius. The authors suggested that this decrease was at least in partdue to the general improvement in the health of the population due to improvements in livingstandards and nutrition. In 2001, the same group published a follow-up study on the continueddecreasing incidence of acute hematogenous osteomyelitis between 1990 and 1997, noting anadditional 44 % decrease (Blyth et al. 2001). Similarly, in 2005 Goergens et al. reported ona decreasing incidence of both septic arthritis and acute hematogenous osteomyelitis in a pediatricAustralian population, dropping from 1 per 574 admissions in a 4-year period from 1968 to 1972 to1 per 808 admissions in a 4-year period from 1998 to 2002 (Goergens et al. 2005).

A decrease in the incidence of osteomyelitis and septic arthritis caused by HiB was reported in1999 in a large retrospective series of 851 cases from Canada spanning the pre- and post-HiBvaccination effort. This shift was most dramatic in the cases of septic arthritis, dropping from 41 %of culture-positive cases caused by HiB prior to the introduction of the vaccine to no reported casesafter 1991 (Howard et al. 1999).

More recently, the emergence of antibiotic-resistant strains of bacteria, most importantly in theform of methicillin-resistant staphylococcus aureus (MRSA), has presented new challenges toclinicians (Young et al. 2011). In contrast to the above reports, in 2008 Gafur et al. reported a 2.8-fold increase in the incidence of acute and subacute hematogenous osteomyelitis in the pediatricpopulation treated at the University of Texas Southwestern between 1982 and 2002 (Gafuret al. 2008). This increase was not noted with septic arthritis. In addition, the authors noteda sharp decline in the isolation of HiB as the causative agent, from 22.6 % to 1 % over the sametime period. In the discussion of their results, one potential cause of the noted increase of osteomy-elitis was suggested to be the emergence of MRSA as a causative agent.

The influence of MRSA on the recent epidemiological changes is also supported by a report byArnold et al. from 2006, where the authors reported a more than twofold increase in the incidence ofacute hematogenous osteomyelitis and septic arthritis from 2000 to 2004 (Arnold et al. 2006). In thatstudy, carried out at a single children’s hospital in Memphis, Tennessee, MRSA increased as thecausative agent from 4 % to 40 % of cases and explained the overall increase in osteoarticularinfections. The authors also noted a perceived increase in the severity of many infections uponpresentation, as well as an increase in the rate and severity of the complications, such as deep venousthrombosis (DVT) and septic pulmonary emboli, in patients with MRSA osteoarticular infections incomparison to other causative pathogens.

It appears that after noting a significant decrease in incidence of acute and subacute hematogenousosteomyelitis in the latter half of the twentieth century, at least some centers are noting a rebound infrequency, in part due to the emergence of community-acquired MRSA (CA-MRSA) (Copley2009). This trend may be less apparent with septic arthritis. It is also worth noting that it can bedifficult to separate out the well-documented increasing use of MRI in the diagnosis of osteomyelitisfrom a true increase in the incidence of the disease.

In the industrialized world, chronic hematogenous osteomyelitis, defined as osteomyelitis presentfor greater than 3 months, has become a rare condition. However, in the developing world, the


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prevalence of musculoskeletal impairment due to infection has been estimated at roughly 3 %, asevidenced by a recent study performed in Rwanda (Atijosan et al. 2008). Jones et al. estimated that ifthis incidence is assumed to be similar among similarly developed countries, “in these countriesalone approximately 12 million children are affected (Jones et al. 2011).” This represents a hugeglobal burden of disease that uses a significant amount of limited resources in already stressed healthsystems in developing countries. In 2000, Bickler and Sanno-Duanda reported that 7.8 % ofpediatric surgical admissions and 15.4 % of total inpatient days in Banjul, Gambia, were due toosteomyelitis (Bickler and Sanno-Duanda 2000). This exists in stark contrast to reports from theindustrialized world where, in Scotland in 2001, Blyth et al. noted that “(chronic) hematogenousosteomyelitis in children in this area is becoming a rare disease” (Blyth et al. 2001).

Septic arthritis has an increased incidence in younger children, with 58 % of cases in one largestudy, present in those children less than 2 years of age (Goergens et al. 2005; Fig. 1). Pediatric septicarthritis has not seen the perceived increase in incidence that some authors have reported withosteomyelitis over the past decades. However, despite methicillin-sensitive Staphylococcus aureusremaining the most commonly identified pathogen in septic arthritis, there is an increasing reportedincidence of CA-MRSA as the causative agent (Young et al. 2011; Vander Have et al. 2009).Mirroring the reports on osteomyelitis, an increase in the rate of complicated musculoskeletalinfections involving both the bone and joint has been noted and is an important consideration inthe evaluation and treatment of suspected septic arthritis (Copley 2009).

There has been a reported dramatic decrease in the proportion of septic arthritis cases caused byHaemophilus influenzae type B after the introduction of the HiB vaccine in the early 1990s (Howardet al. 1999). More recently, there has been recognition that Kingella kingae may play a veryimportant role in pediatric septic arthritis and osteoarticular infection. In children under the age offour, K. kingae may be the most common causative pathogen (Yagupsky et al. 2011; Ceroniet al. 2010).

Fig. 1 Age distribution of children with acute hematogenous osteomyelitis (AHO) and septic arthritis (SA). White barsrepresent AHO, and dark bars represent SA


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Osteomyelitis

PathoanatomyOsteomyelitis can be categorized as acute hematogenous (AHO), subacute (SO) in those patientspresenting after 2 weeks of symptoms, or chronic (CO) in those patients with symptoms for greaterthan 3 months (Craigen et al. 1992; Beckles et al. 2010). The direct inoculation of bone, as occurswith open fractures, as well as hematogenous spread to an area of closed bony injury, is a well-recognized mechanism for developing an infection, and many authors believe that AHO is in manycases related to minor trauma or subtle fractures. Like septic arthritis, AHO has an increasedincidence in young children, with 40 % of cases in one large study present in those children lessthan 3 years of age, with a gender ratio of nearly 2:1 of boys to girls affected (Goergens et al. 2005;Fig. 1).

The majority of cases of osteomyelitis in the industrialized world are AHO and SO, and thepathoanatomy is closely related to the vascular anatomy of the pediatric bone. In the metaphysealregion of the long bones of children, the nutrient artery perforates the metaphysis and terminates nearthe physis in a series of dilated, low-flow venous sinusoids, which, after making a sharp turn,become a venous capillary network in the medullary bone. The numerous dilated metaphysealvenous capillaries have been described as “blood lakes.” The low-flow state of this anatomicalregion leads to the increased susceptibility of bacterial infection transferred from the blood, as theorganism “finds its ideal medium for development (Trueta 1959).” As the infection is initiated,thrombosis of the venous system is the initial vascular event, followed by thrombosis of the nutrientartery. Both thrombotic events further lead to an ideal milieu for the growth of bacteria in thepediatric metaphysis.

The vascular congestion and edema that occurs can lead to cortical breakthrough and elevation ofthe periosteum, which may then be followed by purulence in a similar tract down the diaphysis(Trueta 1959). The periosteal reaction caused by the infection then forms and can typically be seenon plain radiographs within several days. Over time, the new bone formation can lead to theformation of an involucrum, seen in chronic osteomyelitis. A sequestrum may also develop ifavascular bone becomes walled off from the surrounding bone. The epiphysis garners its bloodsupply from a separate artery, and this supports the postulated vascular etiology of disease, in that theepiphysis and metaphysis are rarely both involved with AHO. Therefore, the physis and epiphysisare classically protected from the majority of osteomyelitis infectious processes.

In cases of osteomyelitis following an open fracture, the bone is directly inoculated, and the site ofinfection and subsequent development of infection correspond to the fracture site which isinfluenced by varying degrees of avascularity of the affected bone due to trauma. For closedfractures that are seeded by the bloodstream and develop osteomyelitis, a similar mechanisminvolving localized slowing of blood flow and/or formation of hematoma in the region is postulatedto lead to infection via an analogous process to atraumatic metaphyseal osteomyelitis.

Assessment of DisorderChildren with acute and subacute osteomyelitis of the upper extremity classically present with fever,pain, and dysfunction of the affected extremity, but may exhibit a combination of only some or all ofthese findings. Localization of the affected region is typically possible by a thorough physical exam,as the patient can be tender to palpation, may exhibit swelling and/or erythema in the adjacent softtissues, and/or may demonstrate pain with range of motion and/or weight bearing. At times, inparticular with early acute hematogenous osteomyelitis, these findings may be subtle, without anyvisible changes in the surrounding soft tissues. A high index of suspicion is needed in particular in


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those children who are too young to adequately communicate with the physician, which is thedemographic most commonly affected. This can be especially true in osteomyelitis of the upperextremity, as many times parents or caregivers note a reluctance to bear weight when the lowerextremity is affected as the initial sign of pathology. This sign may be absent or delayed in therecognition of pathology in the upper extremity.

While always in the differential of musculoskeletal pain in children, the presence of osteomyelitismay still be missed by those treating physicians commonly involved prior to orthopedic consulta-tion. Treatment for presumed cellulitis or an abscess without typical resolution can last for daysbefore the true diagnosis of osteomyelitis is recognized and can compromise the outcome.

The initial imaging modality for suspected osteomyelitis is high-quality plain radiographs, and inaddition to the bony findings, soft tissue findings should be assessed for. Evidence of a joint effusionand/or soft tissue swelling with acute osteomyelitis is important, in particular, as bony changes maynot yet have occurred. When present, osseous findings can include bony destruction and/orperiosteal reaction (Fig. 2).

MRI with and without contrast has emerged as the most sensitive and specific imaging modality inthe diagnosis of osteomyelitis in children and has largely supplanted bone scintigraphy. In 1995,Mazur et al. reported a sensitivity of 0.97 and specificity of 0.92 with contrast-enhanced MRI(Mazur et al. 1995). In a subset of their cohort, bone scintigraphy was also obtained, witha sensitivity of 0.64 and specificity of 0.71. MRI also can aid in surgical planning, as it moreprecisely defines the anatomical extent of the infection (Fig. 3).

Fig. 2 Periosteal reaction and bony destruction involving the humerus seen in a combined osteoarticular infection ina 4-year-old boy


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Bone scintigraphy may still be advantageous in suspected cases of osteomyelitis where thephysical exam does not localize the process or in cases where multifocal osteomyelitis is suspected.In addition, ultrasound has been reported to be a viable mechanism to detect osteomyelitis prior toany plain radiographic findings being present (Riebel et al. 1996; Mah et al. 1994). However, whereMRI is readily available, it has largely supplanted the use of both ultrasound and bone scintigraphydue to the accuracy and anatomic detail it affords. In addition, it is one of the first pieces ofinformation that guides treatment.

Laboratory studies that should be routinely obtained during the initial evaluation of osteomyelitisinclude complete blood cell count with differential (CBC), erythrocyte sedimentation rate (ESR),and C-reactive protein (CRP). An essential aspect in the interpretation of the laboratory studies is theconsistent finding that the CBC can be normal in up to 80 % of children with osteomyelitis, andtherefore the laboratory workup should be focused on the ESR and CRP (Pääkkönen et al. 2009).Multiple reports have noted the increase in both ESR and CRP in a very high percentage of childrenwith acute osteomyelitis upon admission to the hospital (Pääkkönen et al. 2009; Khachatourianset al. 2003; Roine et al. 1995). In 1995, Unkila-Kallio et al. reported elevations of ESR and CRPupon admission in bacteriologically confirmed AHO in 92% and 98% of children, respectively. Themean values of the ESR and CRP were 45 mm/h and 71 mg/L, respectively. Similar rates ofsensitivity and specificity have been reported by other authors more recently, with rates nearing100 % when ESR and CRP are analyzed together (Pääkkönen et al. 2009). The CRP and ESR cantherefore be very useful to the clinician for several reasons, including ruling out osteomyelitis,tracking the response to treatment, and making the decision to stop antibiotic therapy (Fig. 4).

Blood cultures should also be obtained, and, when possible, a tissue sample through aspirationshould be obtained prior to the administration of antibiotics in order to facilitate accurate treatmentof the causative organism. While these tests are standard in the evaluation of pediatric osteomyelitis,it is important to note that a negative culture result from the blood, aspiration, or direct biopsy is notuncommon. Arnold et al. noted a 49 % positive culture result (from blood, bone, or joint aspirate) in

Fig. 3 MRI of the humerus with a severe osteoarticular infection


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their series of 89 patients with osteomyelitis, which is similar to the report from Georgenset al. where they noted a rate of 45 % (Goergens et al. 2005; Arnold et al. 2006). For complexosteoarticular infections, however, the rate of positive blood cultures was 82 % (Goergenset al. 2005; Arnold et al. 2006). Persistently positive blood cultures (3 or more days) have beenassociated with MRSA infection (Arnold et al. 2006).

The most common causative pathogens in the postvaccination era are overwhelmingly varieties ofStaph aureus (MSSA, MRSA, and coagulase negative), but other pathogens including Kingellakingae, Salmonella group D, Enterobacter, and Pseudomonas species have all been reported(Copley et al. 2013).

Combined osteoarticular infectionESRa

Septic arthritis

mm/H100

80

60

40

20

DAYS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 29 2 wks 3 mo 1 y

Osteomyelitis

Combined osteoarticular infection

CRPb

c

Septic arthritis

150

mg/L

100

80

60

40

20

DAYS

DAYS

2,000

4,000

6,000

8,00010,000

15,000

/mm3

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

23 29 2 wks 3 mo 1 y

29 2 wks 3 mo 1 y

Osteomyelitis

Combined osteoarticular infectionWBC

Septic arthritisOsteomyelitis

Fig. 4 Time course of laboratory values in osteomyelitis, septic arthritis, and combined osteoarticular infection


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Kingella osteoarticular infection and its detection deserve a special note as an emerging pathogenin pediatric osteoarticular infections. In children less than 4 years of age, osteoarticular infectionwithKingella has increasingly been recognized as an important and frequent pathogen – possibly themost common bacteria responsible for the infection in this age group. The clinical presentation andlaboratory investigations can be mild and normal, respectively. Furthermore, Kingella has histori-cally been a difficult pathogen to culture on solid medium, even when suspected. Newer polymerasechain reaction (PCR) techniques have been developed to allow for more accurate identification ofthis pathogen and have been applied clinically at some centers. In 2010, Ceroni et al. reported that82.1 % of cases of pediatric osteoarticular infections in children less than 4 years of age were causedby Kingella, as determined by PCR identification (Ceroni et al. 2010). In each of these cases,traditional methods of staining and cultures were all negative. The authors’ findings led them tostate, “Kingella kingae is an emerging pathogen that may be recognized as the most commonbacteria responsible for osteoarticular infections (OAI) in young children.” Laboratory and speci-men collection protocols that routinely attempt identification of this fastidious and commonorganism may alter the current treatment algorithms at many institutions (Yagupsky et al. 2011).

While rare in comparison to hematogenous osteomyelitis, direct inoculation of bone occurring asa result of open fractures, soft tissue trauma, or surgical interventions can lead to the development ofosteomyelitis. In addition, closed fractures or minor injuries to the upper extremity may predisposethe affected bone to the vascular stasis that underlies the development of spontaneous hematogenousosteomyelitis. Appropriate urgent management of open fractures with debridement and irrigation,parenteral antibiotics, and modern surgical care has led to a decreased incidence of osteomyelitisassociated with open fractures in children.

A special note should also be made about chronic recurrent multifocal osteomyelitis(CRMO) – a rare, noninfectious condition characterized by the presence of bony lytic lesions thatcan affect one to multiple locations around the body. In isolation, lesions may mimic AHO in regardto their presentation (pain, swelling, redness), but typically multiple sites are affected. The differ-entiation of CRMO from AHO early in the course is important, as the recommended treatments foreach disorder are significantly different.

Treatment OptionsNonoperative In AHO or SHO, after the above workup is complete (laboratory, radiographs, andMRI), the decisions for bone aspiration and/or the need for surgical treatment are made. In mostcases, bone aspiration is recommended to guide the selection of antibiotics. For children withuncomplicated acute or subacute hematogenous osteomyelitis, parenteral antibiotics remain themainstay of treatment (Table 1). After bone biopsy and blood cultures are obtained, empiricparenteral antibiotics are initiated. Guidelines for empiric treatment are typically dependent on theage of the patient and the epidemiology of infectious agents in the locality of treatment (Fig. 5;Copley 2009). For instance, in areas with a high incidence of community-acquired MRSA, selectingan antibiotic regimen that is effective against this pathogen is advisable (Copley 2009).

Table 1 Indications/contraindications for nonoperative treatment of osteomyelitis

Osteomyelitis nonoperative treatment

Indications Contraindications

Mild to moderate acute and subacute hematogenous infection Failed nonoperative management

Chronic osteomyelitis

Significant abscess


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The duration of antibiotic treatment as well as the transition from parenteral to oral antibioticsremains an area of debate at this time. The duration of treatment varies among the developedcountries of the world, with Finland averaging 3 weeks and Germany 8 weeks. In general, theduration of antibiotic treatment is guided by clinical response and normalization of serum inflam-matory markers (CRP, ESR). Traditionally, non-infant AHO has been treated with a prolongedcourse of intravenous antibiotics (2–4 weeks) followed by another 2–8 weeks of oral antibiotics formost presentations of acute hematogenous osteomyelitis. However, recently published data has ledto a general trend toward a shorter duration of both intravenous (IV) and oral treatments at somecenters (Pääkkönen and Peltola 2011).

In 2009, a large retrospective study comparing prolonged IV therapy to oral antimicrobial therapyin acute osteomyelitis in children found no significant differences in the rate of treatment failure(Zaoutis et al. 2009). In a prospective, randomized trial of short versus longer course antibiotictreatment of culture-positive AHO in 131 children published in 2010, Peltola et al. noted nodifference in outcome between a 20- and a 30-day course of antibiotics, of which the first 2–4days were parenteral (Peltola et al. 2010). In this study, the authors noted noMRSA in the report andtreated children with clindamycin or a first-generation cephalosporin with a 98 % rate of success ineach group.

With the move toward shorter-course regimens, some authors have cautioned that while shorter-course treatments may be appropriate for the majority of uncomplicated situations, each case ofAHO remains unique and can prove to be a serious, life-threatening entity (Pääkkönen and Peltola2011). In particular, the optimal treatment duration for MRSA infections or AHO caused by otherpathogens such as Kingella or Salmonella remains a matter of debate, with short-course treatmentsnot universally accepted by most clinicians for those pathogens.

OperativeIn AHO and SHO, the decision for operative intervention is made on a case-by-case basis by thetreating surgeon after a careful assessment of all the available clinical information. Surgery ratesvary widely in the peer-reviewed literature, with no agreed-upon criteria for surgical intervention inmany cases. However, there are certain instances where there is relative consensus (Table 2).

Fig. 5 MRI of the humerus with a severe osteoarticular infection


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The complexity of the infection (isolated versus extensive osteomyelitis, osteoarticular involve-ment), the degree of systemic illness of the patient, the degree of inflammatory marker elevation, theprevalence of MRSA in the community, and the lack of adequate response to antibiotic treatment areall factors that one may weigh when considering operative intervention. In general, the presence ofabscess has been an indication for surgery, although small collections of infection may be able to betreated without debridement.

When surgery is chosen, the approach should be planned to allow for debridement of the entireextent of the infection. The surgical approach will vary widely between patients depending on thelocation of the infection, and we have found MRI to be particularly useful in clarifying the mostdirect route to access the involved osseous region (Table 3). Debridement of all soft tissue fluidcollections, adjacent joints where infection is suspected, and periosteal and/or bony abscesses arerecommended. As noted above, many cases of AHO involve primarily the metaphyseal region of thelong bones, and the creation of a bony window is typically needed to gain access to the main portionof the infection. As with the determination for initial surgical intervention, similar variables areweighed in making the decision for repeat surgery.

The treatment of chronic osteomyelitis remains a challenge to even the most experiencedpractitioner. The principals of surgery for chronic osteomyelitis in the upper extremity includethorough and extensive debridement of the involved bone and soft tissue, removal of any foreignmaterials including prior implants, excision of involucrum and/or sequestrum if present, stabiliza-tion with methods (i.e., external fixation, splinting, casting) that do not cause further contaminationor introduction of foreign materials (when possible), and wound care that in many cases relies onhealing by secondary intention. Long-term treatment with targeted intravenous antibiotics with orwithout local antibiotic cement bead augmentation is also recommended by many.

Table 2 Indications/contraindications for operative treatment of osteomyelitis

Osteomyelitis operative treatment

Indications Contraindications

Failed nonoperative treatment Uncomplicated acute and subacute hematogenous osteomyelitis

Chronic osteomyelitis Resolving clinical picture with nonoperative management

Combined osteoarticular infection

Significant abscess

Table 3 Surgical planning for osteomyelitis

Surgical planning – osteomyelitis

Positioning Supine with a radiolucent hand table

Patient with operative arm at the edge of the bed

Sterile tourniquet on upper arm for nearly all infections, excluding those in the proximal humerus

Mini-fluoroscopy positioned at the end of the hand table

Equipment Standard hand set including osteotomes and curettes

Other Culture swabs and receptacles for tissue samples (for culture and pathology)

Hold preoperative antibiotics until cultures have been taken

Gravity exsanguination to minimize the chance of spread of bacteria


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Septic Arthritis

PathoanatomyThe route of bacterial entry in septic arthritis in the child mirrors that of acute osteomyelitis, althoughthe pathoanatomy is different thereafter. Hematogenous spread of bacteria from a distant site isconsidered to be the most common route of entry to the joint, and in many cases a history ofa concurrent or recent bacterial infection can be elicited from a detailed history. Septic arthritis canalso be caused by direct extension (e.g., from abscess or osteomyelitis), or by direct inoculation, as ina traumatic arthrotomy or from medical intervention (aspiration, postsurgical). In neonates withtransphyseal blood flow, adjacent osteomyelitis can lead to a joint infection via direct extension.Direct extension can occur in older children where the synovial reflections extend to the metaphysisof the proximal radius and proximal humerus.

Once infected, the synovium becomes edematous, increases the production of synovial fluid, andleads to joint distention. Due to the lack of the body’s immune system to adequately gain functionalaccess to the intra-articular process, bacteria proliferate within the joint, and purulence fills theavailable space, further distending the affected joint space. The effect on the hyaline cartilage by theinfectious process has been shown to be destructive and time dependent. If the infection persists,chondrolysis occurs by first destroying the cartilaginous matrix, then progressing to collagendegradation, and finally leading to bony destruction and/or ankylosis.

In the classic studies by Smith et al. using a rabbit model, cartilage destruction continued to occurdespite antibiotic administration within 4 h of infection (Smith et al. 1987). Similarly, the effect ofjoint lavage was studied by Daniel et al., who noted that lavage decreased the amount of cartilagedegradation but did not prevent it entirely (Daniel et al. 1976).

Utilizing modern PCR testing, Kingella kingae has also been increasingly recognized as a likelyfrequent cause of osteoarticular infections in children – in particular, children less than 4 years of age(Yagupsky et al. 2011; Ceroni et al. 2010) (from (Yagupsky et al. 2011)).

K. kingae infections typically begin in the posterior oropharynx, may breach the epithelium, andenter the bloodstream whereby they can hematogenously seed articulations. It has been difficult toculture this organism using traditional means, but the use of PCR has led to some authors noting thatthis relatively less-virulent pathogen may be the leading cause of osteoarticular infection in childrenunder the age of four (Ceroni et al. 2010).

Gonococcal septic arthritis, caused byNeisseria gonorrhoeae, also deserves special mention, as itcan affect older adolescents as well as newborns and has a unique pathoanatomy. In the 1970s,gonococcal arthritis made up nearly 70 % of septic arthritis and tenosynovitis cases in the UnitedStates, but its incidence has declined by nearly 60% since then. This pathogen typically gains accessto the articulations of the body after initial infection of a mucosal surface, classically as a sexuallytransmitted infection, which then spreads via the bloodstream. The incidence of polyarthritis ishigher with gonococcal arthritis than with other pathogens, but gonococcal arthritis is still mostcommonly monoarticular (Bardin 2003).

In the hand and upper extremity, direct inoculation or adjacent spread from soft tissue infection ismore common than in other joints – for instance, the hip – largely due to the relatively thin soft tissueenvelope overlying the fingers and hand. Specifically, bites from animals or humans (fight bites),penetrating wounds, injection injuries from drug use, or spread from soft tissue infections such asfelons or flexor tenosynovitis can lead to septic arthritis of the small joints of the hand or wrist.


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Assessment of the DisorderThe signs and symptoms of acute septic arthritis are classically a painful, hot, red, swollen joint andin many cases are not subtle. Pain with passive and active range of motion is essentially alwaysfound. The presence of “pseudoparalysis” representing a distended joint that limits its motion by thepatient can also be present in the upper extremity. In addition, systemic symptoms including fever,chills, malaise, and/or a rash are classically present. With Lyme arthritis or K. kingae infection, theabove signs and symptoms may be subtle or absent, and fever is less common.

The fact that the arm and hand are not obligate weight-bearing structures can lead to a delayedpresentation of septic arthritis in the upper extremity in children, in comparison to when it occurs inthe lower extremity. Having a high index of suspicion of upper extremity septic arthritis in childrenwithout a history of trauma may help to avoid long-term complications, which can occur if treatmentis delayed. The patient should be carefully questioned regarding a history of penetrating injury, prioror underlying infection, history of tick bites or travel to areas endemic for Lyme disease, sexuallytransmitted infection, other painful joints, surgical procedures or injections, or intravenous orsubcutaneous injection drug use.

In addition, special note should be made regarding the signs and symptoms of infectionsinvolving the carpometacarpal (CMC) joints of the index, long, ring, and small fingers which canpresent differently than in most other joints of the upper extremity. In these infections, the lack of theclassic range of motion exam may make it more difficult to isolate which, if any, of these joints mayharbor infection. There is commonly diffuse dorsal hand swelling present with tenderness topalpation and redness, consistent with cellulitis of the dorsal hand. With the minimized ability toperform active and passive range of motion in these joints, the clinical suspicion should be high forunderlying CMC septic arthritis, in particular in children that have been treated for presumedcellulitis without rapid or significant improvement.

Due to the propensity of the hands and upper extremity to undergo injury – and in particular,penetrating trauma – septic arthritis due to direct inoculation from trauma is relatively common.Involvement of the metacarpal-phalangeal (MCP) joints in the classic “fight bite” is relatively lesscommon in children, but remains a concern especially in adolescents. Direct penetration of the smalljoints of the fingers due to trauma can lead to suppurative infection. Open dislocations of the distalinterphalangeal (DIP), proximal interphalangeal (PIP), and MCP joints can lead to septic arthritis asforeign material can be retained after reduction, even if recognized and treated appropriately withirrigation and debridement. Traumatic arthrotomy of the wrist and elbow is commonly encounteredand typically involves more high-energy mechanisms. Postoperative septic arthritis is also a well-recognized complication of many periarticular procedures performed in the upper extremity and inthe correct presentation, should be suspected as a cause of uncharacteristic postoperative pain.

The most commonly encountered classification of septic arthritis is related to the identifiedpathogen (or lack thereof). When cultures from either blood, aspirate, or intraoperative tissuesamples are positive, the infection is described as “culture-positive” septic arthritis. When theclinical picture is consistent with septic arthritis and the patient is treated as such, yet no pathogenis able to be isolated by the above means, the infection is designated “culture-negative” septicarthritis. There is, therefore, significant debate regarding the data and its interpretation in this arena;thus, strict criteria that lead to a diagnosis of “culture-negative” septic arthritis have not beenuniversally implemented. Future improvements in our ability to recognize and identify pathogensresponsible for septic arthritis may help to reduce the incidence of culture-negative musculoskeletalinfections. An example of a recent advance in this field is the improved identification techniques thatled to the recognition of K. kingae as an important pathogen in osteoarticular infections in children.


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High-quality plain radiographs of the affected joint should be obtained and evaluated for anyabnormalities, but in particular for the presence of a fracture, adjacent osteomyelitis, or effusion. Inthe absence of other radiographic abnormalities, the presence of effusion in the joint on plainradiographs can be helpful in deciding whether or not to perform joint aspiration. We have foundthis especially helpful in the elbow, where overlying cellulitis may mimic many signs and symptomsof a septic elbow. However, if there is a lack of an effusion on the plain radiographs, this makesa serious intra-articular process unlikely. Some authors have reported on the use of ultrasound as anaid in the diagnosis of septic joints of the upper extremity, and it may add valuable information incertain cases where the presence or absence of a joint effusion is in question (Lim-Dunhamet al. 1995). In most cases, further advanced imaging is not required; however, in cases wherethere is a suspected complex osteoarticular infection or where the diagnosis is truly in question, MRIwith and without contrast may be indicated. CMC joint infections of the hand may be more difficultto recognize in an early fashion as the exam and superficial findings can be unclear, andMRI may bea benefit to the clinician to clarify the diagnosis and help to change or guide treatment. As notedearlier, the recent increase in severe osteoarticular infection with multiple tissues involved may leadto the increased use of MRI in an attempt to delineate the extent of perceived severe infection thatmay include a septic joint.

Laboratory investigations are in many cases vital to both the diagnosis and treatment of septicarthritis. A complete white blood cell count with differential, erythrocyte sedimentation rate,C-reactive protein, and blood cultures (in particular if there are systemic symptoms) is the standardset of laboratory tests that most authors recommend on presentation. If Lyme arthritis is suspected,Lyme titers should be obtained in addition to the above tests.

In combination, an elevated ESR (>20 mm/h) and CRP (>20 mg/L) has a sensitivity of 98 % onthe day of admission and 100 % within 3 days for the diagnosis of culture-positive septic arthritis orosteomyelitis (Pääkkönen et al. 2009). On average, the elevation of these markers in cases of septicarthritis is higher than in osteomyelitis and less than with a combined osteoarticular infection (Fig. 4;Pääkkönen et al. 2009).

In addition to aiding in diagnosis, the CRP, in particular, is of value in tracking the response totreatment. In uncomplicated cases that are responding to treatment, the CRP will typically showa decrease over time, and any increase may aid the practitioner in diagnosing recurrent infection orcomplication (Pääkkönen et al. 2009). It is very important to note, however, that these values applyto non-Lyme, culture-positive infections. These data were reported prior to more advanced pathogenidentification techniques (such as PCR) and therefore should be interpreted with caution, inparticular with the recent recognition that K. kingae septic arthritis may be a common entity inchildren less than 4 years of age.

Based on the history, physical exam, and laboratory data, a decision to aspirate the joint is made.In cases where the diagnosis appears clear and where aspiration may delay operative intervention,one may choose to forgo aspiration of the joint in question and proceed directly to the operatingroom. However, as a general practice, joint aspiration is done prior to initiating therapy to bothconfirm the diagnosis and to obtain cultures that may help to guide treatment.

Aspiration of the small joints of the fingers can be difficult, but is achievable via dorsal or volarapproaches. The small volume of fluid aspirated, however, is in many cases not sufficient to providefor a full laboratory investigation. The wrist is more easily accessed dorsally, 1 cm distal to Lister’stubercle, using an 18 or 20 gauge needle directed slightly proximally in order to mimic the volar tiltof the distal radius. The elbow is traditionally accessed via a needle laterally, with entry in the middleof a triangle formed by the surface anatomy of the lateral epicondyle, the olecranon tip, and theradial head.


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Interpretation of the joint aspirate of suspected septic arthritis can be a critical aspect of thediagnosis of septic arthritis. As few studies on the topic have been performed specific to upperextremity septic arthritis, much of our rationale for interpreting the aspirate is extrapolated fromstudies involving the lower extremity, and in particular the hip, where distinguishing septic arthritisfrom transient synovitis is a common diagnostic dilemma.

The joint aspirate should be sent for a WBC count with a manual differential, glucose, protein,Gram stain, and culture. A WBC count of > 50,000, polymorphonuclear cells > 90 %, and/orglucose of 40mg/dl or less than the fasting serum blood glucose suggests a septic joint (Green 2005).Cultures are commonly negative for growth, but when positive help to guide treatment.

There is limited data at this time on the laboratory workup and aspirate results of Kingella septicarthritis. As with osteomyelitis, in K. kingae septic arthritis, the clinical findings as well as thelaboratory examinations may be only slightly abnormal or even normal (Fig. 6 from (Dubnov-Razet al. 2010)).

Specifically, the ESR and CRP may be normal or only mildly elevated (Dubnov-Raz et al. 2008).Therefore, in a child with a history and physical exam consistent with septic arthritis orosteoarticular infection with normal or only slightly elevated inflammatory markers, a high indexof suspicion for K. kingae infection may be appropriate.

Treatment OptionsIn the United States, septic arthritis of the upper extremity in any age patient is considered, by mostclinicians, to be a surgical emergency that requires an arthrotomy, joint irrigation, and debridement,followed by parenteral and/or oral antibiotics.

Nonoperative It is important to note that there are several reports, mainly from outside of theUnited States, that have reported on protocols that routinely treat septic arthritis in children withsingle or serial aspirations followed by a short course of parenteral and oral antibiotics, reservingsurgical intervention for severe presentations. For instance, in 2009 Peltola et al. published data on130 cases of septic arthritis in Finnish children managed primarily with joint aspiration followed byantibiotics, with a reported 12% of children undergoing arthrotomy. The authors noted that at 1-yearfollow-up “none of the patients experienced relapse, recrudescence, residual dysfunction, growthdisturbance, or other clinically significant sequelae,” although no patient reported clinical outcomesor radiographic findings were reported (Peltola et al. 2010). In a separate review on this topic, theauthors note that in areas where MRSA is prevalent, “routine drainage or debridement of the jointspace is recommended” (Pääkkönen and Peltola 2012).

Antibiotic treatment is essential in the treatment of septic arthritis. As in the treatment ofosteomyelitis, the type, route of administration, and duration of antibiotic treatment are an area ofsignificant debate. Initially, after aspiration or surgical debridement, broad-spectrum parenteral

Fig. 6 Clinical and laboratory data of children with K. Kingae infection


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antibiotics are initiated based on the experience of the institutional trends in reported pathogens formusculoskeletal infection (Fig. 5 from (Copley 2009)).

If a pathogen has been identified, then treatment proceeds with a more directed antibioticselection. The duration of antibiotic treatment is an area of debate, with the most commonly reportedrecommendations being 3 or 4 weeks. The recommendations regarding transition to oral medicationfrom parenteral antibiotics are also variable and can be dependent on the date of discharge, severityof infection, laboratory values, or time to defervescence. Of note, a prospective, randomized trialfrom Finland published in 2009 compared a 10-day versus a 30-day course of antimicrobial therapyfor children with septic arthritis not limited to the upper extremity, which included a 2–4-dayparenteral course initially. The authors noted no differences in outcomes between the two cohorts(Peltola et al. 2010).

OperativeThe emergent operative treatment of septic arthritis in the upper extremity in children is accepted asthe standard of care in most centers in the United States. The most widely practiced procedure isarthrotomy, irrigation, debridement of the joint space and any necrotic tissue, and removal of anyforeign material. In adults, arthroscopic irrigation and debridement of septic wrists has been reportedto be a viable alternative to an open procedure, but no data exists in children regarding the use of thistechnique (Sammer and Shin 2009).

The specific surgical technique selected is obviously dependent upon which joint or joints areinvolved. With all techniques described hereafter, prior to debridement or irrigation, but followingexposure of the affected joint, two sets of culture swabs and a synovial tissue sample are taken andsent for Gram stain, anaerobic and aerobic bacterial culture, acid-fast bacilli (AFB), and fungalculture. In addition, the swabs are commonly tested by PCR for Kingella at our institution.

In the DIP, PIP, and MCP joints of the fingers, the joint is approached via a dorsal incision, unlessthere has been prior trauma, as with a penetrating wound, in which case the already present woundsare utilized. The small superficial branches of the dorsal radial and ulnar sensory nerves areidentified and protected, in particular during the approach to the MCP joints.

Irrigation and debridement follows the surgical exposure in each case, as follows: synovium andany foreign material is sharply debrided from the joint, and 1 L of normal saline is utilized to irrigatethe wound using bulb or cystoscopy tubing. The capsulotomy is left unrepaired, a drain is left in thedeep tissues, and one or two loose nylon sutures are placed into the skin in an interrupted fashion.

At the DIP level, a 1 cm incision slightly off of midline is utilized and sharply taken down throughthe skin and subcutaneous tissues. The extensor tendon is identified, inspected for integrity, andretracted, exposing the capsule. A longitudinal arthrotomy is made in the interval between theextensor tendon and the collateral ligament, typically on the ulnar side of the digit, unless it is thethumb. Synovium and any foreign material are sharply debrided from the joint, and 1 L of normalsaline is utilized to irrigate the wound. The capsulotomy is left unrepaired, and one or two loosenylon sutures are placed into the skin in an interrupted fashion.

At the PIP level, a similar dorsal approach, debridement, culture, and wound closure protocol isused, but at this location the interval between the extensor and the collateral band on the ulnar side isexploited, taking care not to injure either the central slip or the lateral band itself.

At the MCP level, a 2 cm dorsal incision is used and carried down to the extensor hood. The ulnarsagittal band is incised as a separate layer from the underlying capsule, and a longitudinalcapsulotomy is made on the dorsal aspect of the joint. With cases involving a fight bite, we attemptto identify the prior traumatic arthrotomy in the extensor hood and take care to fully inspect theextensor tendons proximal to the joint for possible partial or complete lacerations.


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It is important to inspect the extensor tendon proximally because a laceration suffered with thehand in a clenched position may retract a significant distance proximally when the fingers are in themore extended resting position encountered during surgery.

While rare, infections of the carpometacarpal joints can and do occur. Aside from the thumb, theclinical presentation oftentimes makes the identification of which joints are involved difficult, andtypically it is prudent to plan to explore the 2nd–5th CMC joints if septic arthritis of one or more ofthese joints is suspected. Two longitudinal 3 cm dorsal incisions are made, with the first centeredbetween the bases of the index and long finger metacarpals and the second centered between thebases of the ring and small finger metacarpals. The incision is carried down sharply to the level of theextensor tendons, taking care to protect branches of the radial and ulnar sensory nerves. Theextensors are carefully retracted, and the CMC joints of each ray are opened in a longitudinalfashion.

For a septic wrist, Lister’s tubercle is identified, and a 3 cm midline incision is made just ulnar tothis surface landmark, centered just distal to the distal edge of the dorsal distal radius. The incision iscarried down sharply to the extensor retinaculum, and the interval between the 2nd and 4th extensorcompartments is identified distally. This interval is sharply incised and carried down to the level ofthe dorsal capsule. Typically, the midcarpal and radiocarpal joints are able to be entered withoutincising the more proximal critical portion of the extensor retinaculum. Once the arthrotomies aremade, the irrigation and debridement can be performed via this window. However, if the infectionappears severe or more widespread than usual, the exposure is expanded with transposition of theEPL and elevation of the 2nd and 4th compartments from the dorsal capsule more proximally.

For a septic elbow, a lateral approach affords excellent access to the joint. Some authors prefer toutilize a Kocher approach between the anconeus and the FCU, while others prefer a Kaplanapproach, between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis(EDC). With the joint swelling and relative proximity of the posterior interosseous nerve to thesurgical field in a Kaplan approach, traditionally a Kocher approach is preferred. Care must be takento leave the lateral ulnar collateral ligament intact with either approach.

In the shoulder, a traditional deltopectoral approach is performed to access the joint. After the skinincision, dissection along the medial edge and protection of the cephalic vein while retracting it withthe deltoid laterally, and development of the deltopectoral interval, the biceps tendon is identified.We minimize medial retraction to avoid injury to the neurovascular structures. The biceps tendon isthen dissected free proximally and used to help identify the rotator interval, between thesubscapularis and supraspinatus tendons. Army-Navy retractors are used to bluntly retract therotator interval, allowing for exposure of the underlying capsule and subsequent irrigation anddebridement. The capsulotomy is made sharply in the capsule to access the articulation (Table 4).

Lyme ArthritisA tick-borne pathogen that commonly affects the articulations of children in endemic areas of theUnited States is the spirochete Borrelia burgdorferi, the causative agent in Lyme disease. Lymedisease can affect multiple organ systems, including the musculoskeletal system. Septic arthritis dueto Lyme disease typically has a less severe presentation than other forms of septic arthritis and maybe managed differently. It most commonly affects the knee, but can involve the shoulder, elbow,wrist, and/or small joints of the hand (Puius and Kalish 2008).

Areas where Lyme disease is endemic include states in the Northeastern United States(Connecticut, Delaware, Massachusetts, New Jersey, New York, Pennsylvania, and Rhode Island)as well as in the Upper Midwest (Wisconsin and Minnesota) and Pacific Northwest. Between 1992and 2006 the reported cases of Lyme disease have risen from 9,908 to 19,931, thus doubling in


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incidence. There is a bimodal distribution of incidence of Lyme disease, with children between theages of 5 and 9 representing the pediatric cohort most likely to develop the condition.

In 2011, Milewski et al. reported that 31 % of all pediatric patients who underwent joint aspirationfor suspected septic arthritis in an endemic area were seropositive for Lyme disease (Milewskiet al. 2011). In areas where Borrelia burgdorferi is endemic, the diagnosis of Lyme arthritis shouldtherefore also be strongly considered in the workup of suspected septic arthritis in children (Williset al. 2003).

In Lyme arthritis, the bacteria Borrelia burgdorferi is introduced into the patient via the bite ofa deer tick, genus Ixodes. In the early stages, there is classically an expanding skin rash presentknown as erythema migrans, although this is not always noted. The development of joint swellingcan occur within weeks to years after the exposure to the spirochete, with a median of 3.4 months(Szer et al. 1991).

The laboratory workup and aspirate results in Lyme arthritis differ significantly from culture-positive septic arthritis involving more traditional pathogens, and in general, the degree of elevationof all inflammatory markers measured is less with Lyme arthritis than with septic arthritis (from(Milewski et al. 2011)).

In patients presenting with a clinical picture of Lyme arthritis, two-tier serological testing utilizingELISA followed by a confirmatory Western blot (if the ELISA is positive or indeterminate) isstandard. For cases in which there is an incomplete response to antibiotic treatment or the diagnosisremains in question, PCR analysis of a joint aspirate may be indicated (Puius and Kalish 2008). Inaddition, it has been reported that 49% of patients with Lyme arthritis had an aspirate with a synovialWBC > 50,000 cells/mm3, which was a lower percentage than those patients with septic arthritis(61 %). 13 % of patients with Lyme arthritis had a synovial WBC count > 100,000 cells/mm3,compared to 37 % of those patients with septic arthritis (Milewski et al. 2011).

The treatment of Lyme arthritis typically involves a 4-week course of one of several oralantibiotics, with the response followed closely. If there are persistent symptoms, then treatmentwith an extended course of oral antibiotics, parenteral antibiotics, or synovectomy has beenrecommended (Puius and Kalish 2008). Surgery is typically reserved only for recalcitrant cases.Therefore, early recognition of this infection is critical in guiding clinical decision making.

Outcome tools for osteomyelitis and septic arthritis. The majority of peer-reviewed publicationsto date have reported clinical outcomes in pediatric osteomyelitis and septic arthritis in the form ofduration of symptoms (e.g., fever, pain), duration of hospitalization, rate of surgical interventions,

Table 4

Surgical planning – septic arthritis

Positioning Supine with a radiolucent hand table

Patient with operative arm at the edge of the bed

Sterile tourniquet on upper arm for nearly all infections, excluding those in the shoulder

Mini-fluoroscopy positioned at the end of the hand table (optional)

Equipment Extremity hand drape unless shoulder involved

Split drapes to the mid-pectoral and midscapular region if shoulder involvement

Bump under the upper back, midline, if shoulder involvement

Standard hand set including osteotomes and curettes

Other Culture swabs and receptacles for tissue samples (for culture and pathology)

Hold preoperative antibiotics until cultures have been taken

Gravity exsanguination to minimize the chance of spread of bacteria


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and complications (e.g., deep venous thrombosis, disseminated infection, extensive bony involve-ment, relapse).

The use of validated clinical outcome scores in the pediatric population lags behind their use in theadult population at this point in time. One of the directions for future research in this arena will likelyfocus on the validation and widespread adoption of precise, responsive, and reliable clinicaloutcome tools designed for the pediatric population.

OutcomesIn general, outcomes of treatment of acute uncomplicated hematogenous osteomyelitis and septicarthritis are generally considered to be good, although long-term clinical outcome studies arerelatively lacking in the peer-reviewed literature. In particular, given the relative rarity of upperextremity osteomyelitis, published outcomes are limited to small case series or descriptions ofcomplications encountered. In one of the most recent large series published on acute hematogenousosteomyelitis that was not limited to the upper extremity, readmission frequency was noted to be6.6 %, mean length of initial hospital stay was 9.25 days, and mean number of surgeries per childwas 1.1 (Copley et al. 2013). Complications of osteomyelitis and/or septic arthritis in the upperextremity include deep venous thrombosis, relapsed infection, growth disturbance or arrest, sepsis,and bony destruction requiring reconstruction (Vander Have et al. 2009; Copley et al. 2013;McDonald and Copley 2010; Mattar Júnior et al. 1994; Dunkle and Brock 1982). Rates ofcomplications appear to be significantly higher when the causative organism is MRSA, which isincreasing in frequency.

Preferred TreatmentInfection in the bone and especially in the joint needs to be treated with expediency and a tendency toerr on the side of surgery. Surgical management is the right thing to do when there is a “gray” area ofdecision making and one is thinking about changing from nonoperative to operative management.Surgical management is often the “conservative” route because it answers so many questions andquickly directs care enabling the patient to often be symptom-free and out of the hospital and offantibiotics much sooner.

Surgical Pearls and PitfallsWhereas arthrotomy is the standard for upper extremity infections, an excellent alternative in thewrist and shoulder is arthroscopic lavage and partial synovectomy. In general a drain is not veryuseful and instead a source of difficulty and pain for the patient. Therefore, unless a large infection ispresent, a drain is not placed. In addition, wounds can often be left open, allowing secondary closureto occur on their own without issue. Sometimes a simple wick in a small joint for 24 h can be utilizedwith these open wounds. If wounds are closed, usually they are done so very loosely and leaving thearea directly over the joint open. Immobilization of the affected extremity will help postoperativelyas well as preoperatively in cases where antibiotics are utilized alone. This helps the pain andcontinued “distribution” of bacteria along tissue planes. Typically, immobilization until IV antibi-otics are continued until the course is completed and/or the patient is sent home, depending on thejoint involved. Rarely, formal therapy can be required after the period of immobilization to regainmotion, but in most cases in this young group of patients, it is unnecessary.

With open osteomyelitis surgery one should always be aware of the exact location of the physis soas not to disrupt it in any way. The frequent use of a 25 gauge needle placed into the physis andviewed on the image intensifier is warranted and worth the time.


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Management of ComplicationsThe negatives of an “aggressive” approach are few, as the complications of surgery are low and thecomplications of inadequate nonoperative care are well described and can be serious. Drilling of themetaphysis without identification of purulence is not a failure of diagnosis but instead perhapsmakes the diagnosis and causes little harm. Obviously, avoiding surgery is the best, but one needs tobe certain, and false exploration rates are necessary occasionally for good patient care.

The prospect of recurrent infection represents a complication of both operative and nonoperativemanagement of acute and subacute hematogenous osteomyelitis and septic arthritis. This is thank-fully rare, but should be recognized in a timely fashion and treated similarly to the guidelines laid outpreviously. A lower threshold is present to perform surgery in refractory or recurrent cases in ourinstitution.

SummaryThere are few large-scale reports specific to acute hematogenous osteomyelitis, chronic osteomy-elitis, or septic arthritis involving exclusively the pediatric upper extremity in the peer-reviewedliterature. While it appears that the overall incidence of acute osteomyelitis may be currentlyundergoing important changes, the proportion localized primarily to the upper extremity does notappear to be changing, and remains between 10 % and 20 %, and is most commonly reported in thehumerus (Gafur et al. 2008).

To summarize the epidemiological data, it appears that in the latter half of the twentieth century,there was a decrease in the rate of osteomyelitis in the pediatric population of the industrializedworld due to increased use of antibiotics, advances in public health infrastructure and hygiene, moresensitive imaging modalities, and better access to care. Several reports have noted that this trendappears to have reversed itself in the past decade, and we may be currently in an era of increasingincidence and severity of acute osteomyelitis and complicated deep musculoskeletal infection,presumably due to the emergence of antibiotic-resistant bacterial strains such as MRSA. However,with the increasing use of MRI in the past decades, one may also consider the possibility that thediagnosis of AHO has increased due to a much more sensitive detection method.

Chronic osteomyelitis remains a huge global health-care burden that remains a challenge to thehealth systems of the developing world. Epidemiological data is limited, and conclusions on large-scale disease trends are difficult to make.

Population based reports on pediatric septic arthritis are less common, but of the data available,the increasing incidence noted in osteomyelitis is not apparent with septic arthritis. The recognitionof Kingella kingae as an important pathogen in pediatric osteoarticular infections has led to changesin the management of these infections and should be suspected, in particular in children less than4 years old. In endemic areas, the high prevalence of Borrelia burgdorferi as a cause of a suspectedseptic joint should be considered.

Despite the advances that have been made surrounding these diseases since the early part of thetwentieth century, significant challenges remain in the management of osteomyelitis and septicarthritis, and the diseases remain a global health-care concern.

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