Intended for healthcare professionals

Clinical Review

Acute haematogenous osteomyelitis in children

BMJ 2014; 348 doi: (Published 20 January 2014) Cite this as: BMJ 2014;348:g66

This article has a correction. Please see:

  1. Andrea Yeo, specialty registrar,
  2. Manoj Ramachandran, consultant paediatric orthopaedic surgeon
  1. 1Centre for Orthopaedics, The Royal London and Barts and The London Children’s Hospitals, Barts Health NHS Trust, London E1 1BB
  1. Correspondence to: M Ramachandran manoj.ramachandran{at}
  • Accepted 23 December 2013

Acute osteomyelitis is an uncommon but important disease that affects previously healthy children. A high index of suspicion is required as early treatment is essential for a good outcome. In the past decade, rapid changes in the epidemiology of the condition, in particular of infections as a result of meticillin resistant Staphylococcus aureus (MRSA), and advances in diagnostics have highlighted a need to change practice based on current evidence. We review the pertinent aspects of acute osteomyelitis, highlighting the pitfalls in diagnosis and providing a framework for management.

Summary points

  • Acute osteomyelitis in children is an infection of the bone of less than two weeks’ duration, which typically spreads haematogenously

  • Meticillin resistant Staphylococcus aureus osteomyelitis in particular is on the increase

  • Children may present insidiously, hence careful history and clinical examination with a high index of suspicion are required

  • A delay in diagnosis may cause growth disturbance, deformity, or even death

  • Treatment includes intravenous antibiotics administered promptly

  • A multidisciplinary approach involving primary, secondary, and tertiary care teams is essential to ensuring a good outcome

What is acute osteomyelitis?

Osteomyelitis is the inflammation of bone caused by pyogenic organisms. In the acute setting, the duration of symptoms is less than two weeks. The major sources of infection are haematogenous spread, tracking from adjacent foci of infection, and direct inoculation from trauma or surgery.1 Haematogenous spread is the most common source of infection in children, typically affecting the long bones. The infection seeds in the metaphysis, where blood flow is rich but sluggish.2 The femur and tibia are most commonly affected (27% and 26%, respectively, fig 1).3

Sources and selection criteria

We searched Medline and Google Scholar using the terms “p(a)ediatric”, “acute osteomyelitis”, “bone infection”, “septic arthritis”, “antibiotics” and “imaging”. Wherever possible we used evidence from randomised controlled trials, systematic reviews (including Cochrane reviews), and expert review …

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