Bone and Joint Infections in Children: Diagnosis and Treatment
Bone and Joint Infections in Children: Diagnosis and Treatment
Authors: Robert A. Felter, MD, FAAP, Medical Director, Chair, Department of Pediatrics and Adolescent Medicine, Tod Children’s Hospital; John Venglarcik, III, MD, FAAP, Director, Pediatric Infectious Disease, Tod Children’s Hospital, Youngstown, OH.
Peer Reviewer: Steven M. Winograd, MD, FACEP, Attending Physician, Department of Emergency Medicine, Lakeland Regional Health System, St. Joseph, MI.
Osteomyelitis and septic arthritis are two infections that, although relatively uncommon, may result in significant morbidity. This is a diagnosis that should be considered in every child with unexplained irritability, fever, or asymmetric use of an extremity. The author presents a comprehensive discussion of the laboratory and radiographic evaluations that should be considered in a patient with a potential bone or joint infection. Only with early detection and aggressive management can we minimize the complications associated with bone and joint infections.
—The Editor
Introduction
Although not common, bone and joint infections are serious problems in children. They present a significant dilemma to the emergency physician. While signs and symptoms may be obvious, more often, especially in the young child, they are nonspecific. Because of significant sequelae, which may result from a diagnostic delay, especially in children younger than 1 year of age, it is imperative that the emergency physician consider these diagnoses when dealing with a febrile child with bone or joint pain or refusal to bear weight on extremity. Especially in younger children, osteomyelitis may be associated with septic arthritis. Clinical signs and symptoms vary depending on the age of the child, the causative organism, and the underlying clinical condition. This article will review the presentation, differential diagnosis, and management approach for children with osteomyelitis and septic arthritis.
Osteomyelitis
Epidemiology. In the United States, the incidence of osteomyelitis is 1 in 5000 children younger than the age of 13.1 Osteomyelitis may be caused by hematogenous spread,1-5 spread from a contiguous infected source,1,6 or due to trauma.1,2,12,13,28 In the last century, this disease was often fatal.7 Most frequently due to hematogenous spread, this disease may represent a serious complication of occult bacteremia.8 Today, however, because of the availability of antibiotics, death from osteomyelitis is rare.
Etiology. In all ages, Staphylococcus aureus is the most common organism causing osteomyelitis.1-3,5 In neonates, group B streptococcus is a common cause.9 Patients with sickle cell disease or other hemoglobinopathies have a higher incidence of Salmonella infection, although Salmonella infection can occur in otherwise normal children.10,11 Children who have a puncture wound of the foot frequently develop infection from Pseudomonas aeruginosa.12,13 In younger children, Mycobacterium tuberculosis spreads to the skeletal system more often than in older children because of the greater amount of blood flowing through growing bone.14 One to six percent of children with M. tuberculosis disease develop skeletal tuberculosis.15 In children who develop osteomyelitis following chickenpox, group A streptococcus is a common organism.16 Osteomyelitis is one of the few serious complications of intraosseous infusion.17
Pathophysiology. As mentioned, hematogenous spread is the most common cause of osteomyelitis. The nutrient vessels laterally migrate through the Volkman canals and the haversian system to the metaphyseal capillaries where blood flow is slow. These vessels handle infection poorly for the following reasons: the metaphyseal capillaries either lack or possess functionally inactive phagocytic lining cells; blood flow is slow and turbulent, and the vessels near the epiphysis are nonanastomosing branches of the nutrient artery, meaning that any obstruction leads to avascular necrosis.5 A nidus of infection causes an inflammatory response, which leads to clot formation. As noted above, this leads to avascular necrosis.
As the infection spreads, polymorphonuclear cells accumulate, pH drops, and edema develops. All of these factors then contribute to the breakdown of the trabecular structure of the bone and removal of matrix and calcium. The process extends to nearby bone by the haversian and Volkmann canals, thus spreading and intensifying the infectious process.
In older children and adolescents, who have tightly adherent, dense periosteum and thick cortex, the infection is limited and the symptoms are focal.3 In younger children, who have a cortex that is not as thick and a thinner, loosely applied periosteum, the infection may spread through the bone and may be limited by the periosteum. In infants, who have a thin cortex and a thin, very loosely applied periosteum, the infection quickly spreads through these tissues to the surrounding soft tissues. This leads to inflammatory changes in the involved extremity such as erythema, swelling, and induration.
In the young child, the metaphyses of certain bones, such as the femur, are partially located within the joint space. Thus, there can be an associated septic arthritis. In the newborn, the nutrient metaphyseal capillaries traverse the epiphyseal growth plate, especially in the proximal femur. This can damage the growth plate when the blood flow through these vessels is compromised from infection.
There frequently is a history of trauma in proximity to the development of signs and symptoms of osteomyelitis, probably secondary to compromised blood flow through the nutrient artery or the metaphyseal capillaries.2 Infection may also be secondary to direct penetration of the bone by a foreign body or open fracture. In the child who has a penetrating injury to the foot, especially when wearing old tennis shoes,18 there is a higher incidence of infection due to Pseudomonas.12
Clinical Symptoms. Osteomyelitis occurs in the femur, tibia, fibula, and humerus in up to 60% of cases, but any bone can be affected.5,19 In neonates, multiple sites may be simultaneously affected.
An older child may present with fever and pain localized to the affected bone. Approximately 50% will have localized symptoms,2 and, in half these cases, there will be point tenderness20 secondary to pressure on the periosteum.
The diagnosis is much more difficult in the young child, where the symptoms may be very nonspecific. Fever, irritability, and failure to bear weight or move the extremity may be the only signs. Osteomyelitis may be a cause of paradoxical irritability. Thus, the young child may appear fussy when moved but may have minimal signs when left undisturbed. Pseudoparalysis may also be the presenting complaint in a child with osteomyelitis. If the lower extremity is involved, there may be a limp or the child may refuse to bear weight on the affected extremity.1
In the infant, the infection can break through the periosteum and cause swelling and inflammation of the soft tissue. On physical examination, the soft tissue findings may be the initial presenting complaint. If the child has been partially treated with antibiotics, the signs and symptoms may be more subtle.
The location of a puncture wound has been found to be a risk factor for the development of osteomyelitis. Puncture wounds in the forefoot are more likely to result in osteomyelitis than rear-foot injuries. This is probably secondary to the lack of soft tissue interface between skin and bone in the forefoot when compared with other parts of the foot.21
Diagnosis. Because of the significant sequelae associated with a delay in diagnosis, it is imperative to maintain a high index of suspicion for osteomyelitis when dealing with a child with fever and pain. Osteomyelitis must also be considered as a potential diagnosis when evaluating the irritable child or child with asymmetric movement of the extremities. Pain or swelling of an extremity may localize an infection, but, more commonly, the child will not have these symptoms. Failure to move an extremity or pain with motion of an extremity may indicate an underlying osteomyelitis. In a young, febrile, irritable child, it may be difficult to localize pain or the decreased range of motion of a bone or joint. Parents may assist by moving their child’s extremities to identify or eliminate sites of potential inflammation. Further complicating the clinical picture is that the child will not have a fever in up to 35% of cases.7 This is especially true in neonates.
Laboratory Evaluation. Laboratory evaluation includes a complete blood count, ESR, CRP, and blood culture. Twenty seven percent of children will have a normal white count but only 5% have a normal ESR.7 Bone infections may be associated with significant elevation of the white count. The CRP may be more useful in evaluating a child with a potential bone infection because it increases within the first 24 hours of infection, often as early as six hours, peaks at approximately 48 hours, and is usually normal within one week of therapy.22 The ESR may show delayed rise and prolonged elevation. Blood cultures are positive in about 60% of cases, especially if the infection is secondary to S. aureus.1 The combination of blood culture and bone aspiration increases the yield to 80%.2 A bone biopsy has been reported to result in the recovery of an organism 90% of the time.23 A positive blood culture with S. aureus in children must lead one to suspect a bone infection.
Radiographic Evaluation. Plain films are usually not helpful in making the diagnosis early in the course of the disease.5,24 Three features are considered pathognomonic of osteomyelitis: swelling of soft tissue, periosteal new bone formation, and bony demineralization. (See Figure 1.) These changes occur 10-14 days after the infection starts.25 Thus, plain radiographs should never be acutely relied upon to determine a definitive diagnosis. A three-phase technetium -99m bone scan is more accurate in determining bone and joint infections early in the disease course. A positive scan has a positive predictive value of 83%.1,24 The scan has a sensitivity of 90% and a specificity of 50-90% depending on the age of the patient and the site of the study.2,24,25 Be aware, however, that the scan can be negative in the first 24-48 hours because of relative ischemia to the affected area.26 The MRI has a positive predictive value of 85%.1 An MRI is not usually recommended as the initial diagnostic evaluation because of the need to sedate the child for the procedure.14
While joint aspiration is always indicated in suspected septic arthritis, there is disagreement about aspiration of bone infections. The decision to aspirate should be made in conjunction with an orthopedist. If a bone specimen is obtained, the chances that it will yield a positive culture is approximately 80%.1
While it is not always possible to make a definitive diagnosis in the emergency department, any two of the following four diagnostic criteria make the diagnosis of osteomyelitis likely.2
1. Purulence of bone;
2. Positive bone or blood culture;
3. Localized erythema, edema, or both; and/or
4. Positive imaging study.
Special Situations. Neonatal osteomyelitis. Neonatal osteomyelitis occurs in children younger than 28 days of age and may be a particularly challenging diagnosis. Reports indicate that approximately 50% of newborns will not have a fever. In addition, they may lack other constitutional symptoms such as fussiness, irritability, or poor feeding. Multiple sites may be affected and about 75% will decompress from the bone into a joint.
Pelvic osteomyelitis. Pelvic osteomyelitis is also a challenging diagnosis with a wide variety of clinical presentations that may range from an acute surgical abdomen to hip pain. This diagnosis may be confirmed with the use of the gallium scan.
Management. Management of an osteomyelitis consists of both medical and surgical therapy.
Medical Management. Medical management consists of the institution of age appropriate intravenous antibiotics following the acquisition of appropriate cultures. Intravenous antibiotics should be based on the suspected etiology consistent with the age of the child. (See Table 1.) Duration of antibiotic therapy remains controversial, but most authors suggest a minimum of three weeks of therapy for a staphylococcal or gram-negative bacilli infection. Because of damage to epiphysis, osteomyelitis may result in limb discrepencies.35 (See Table 5.)
| Table 1. Antibiotic Therapy of Osteomyelitis |
| Newborn: Empiric Therapy |
| Nafcillin 50-150 mg/kg/d q 6-12 h*
OR (if methicillin-resistant staphylococcus suspected) Vancomycin (consult dosing guide for neonate dosage) AND Cefotaxime 100-150 mg/kg/d q 6-12 h* *adjust dose for age and weight |
| Children age 3 Months to 3 Years: Empiric Therapy |
| Cefuroxime 100-150 mg/kg/d q 8 h
OR Cefotaxime 100-150 mg/kg/d q 8 h OR (if gram-positive cocci in chains, clumps, or pairs are seen on gram stain) Nafcillin 150 mg/kg/d q 6 h OR Vancomycin 40 mg/kg/d q 6 h |
| Children 4 Years and Older: Empiric Therapy |
| Nafcillin 150 mg/kg/d q 6 h
OR Cefazolin 100 mg/kg/d q 8 h OR Clindamycin 40 mg/kg/d q 6 h AND (if gram-negative rods seen on gram stain) Ceftazidime 150 mg/kg/d q 8 h |
| Puncture Wound to Foot: Empiric Therapy |
| Ceftazidime 150 mg/kg/d q 8 h
OR Mezlocillin 300 mg/kg/d q 6 h AND (if underlying disease) Tobramycin 7.5 mg/kg/d q 8 h _________________________________________________________ |
Surgical Therapy. In suspected osteomyelitis, aspiration of the bone should be done in consultation with an orthopedist. Not only will it assist in the diagnosis but drainage also may help raise the pH, a potential benefit if an antistaphylococcal penicillin is being considered for therapy.27 Surgical debridement should be considered in the management of Pseudomonas infections of the foot resulting from a puncture wound.13
Septic Arthritis
Epidemiology. Cases of septic arthritis in children have been variously estimated at 5.5 to 12 per 100,000 individuals.4 Males are more commonly affected than females. However, these estimates do not reflect the recent increase in the number of young girls who participate in a variety of athletic endeavors. Septic arthritis may be caused by hematogenous spread,1-5 spread from a contiguous infected source,1,6 or due to trauma.1,2,12,13,28 In the last century, this disease was often fatal,7 but currently death from septic arthritis is rare.
Etiology. In all age groups, S. aureus is the most common cause of septic arthritis.1,4 In the neonate, group B streptococcus is commonly seen but Candida albicans must also be considered, especially in the premature infant.1,29 Until recently, the most common cause of septic arthritis in children from 3 months to 3 years of age was Hemophilus influenzae type b. With the advent of universal immunization against H. influenzae, it is now a rare cause of septic arthritis. Recent reports have mentioned that Kingella kingae may replace H. influenzae as a common organism in this age group.30 In sexually active teenagers, Neisseria gonorrhea must be considered, especially when the arthritis affects the small joints of the hand. In adolescent intravenous drug abusers gram-negative organisms are predominant. Osteomyelitis and septic arthritis can be a complication of dog and cat bites. In these cases, Pasturella multocida may be the infecting agent.28
Pathophysiology. Septic arthritis is usually caused by hematogenous spread. The capillary network of the synovium is responsible for producing synovial fluid. As a consequence, this network can allow bacteria to enter the synovial space. As the bacteria multiply, there is an accumulation of inflammatory cells, the breakdown of hyaluronic acid, and subsequent damage to the articular surface.4 Once lost, the cartilagenous surface cannot be replaced with further growth because it has no ability to regenerate.
Clinical Features. The presenting signs and symptoms of septic arthritis depend on the age of the child, the causative organism, and the joint affected. Septic arthritis most commonly occurs in the knee, hip, ankle, and elbow joints. These joints account for about 90% of childhood septic arthritis. A single joint is usually affected.31 Only 4-6% of children have more than one joint affected.31 In gonococcal arthritis, multiple small joints may be affected.
Pain and loss of motion may be the initial complaint in an older child. An older child will complain of significant pain in the affected joint in 50% of cases.2 In half of the cases, there is point tenderness.20 A septic joint will be held in the position that minimizes the pressure inside. For example, the ankle will be held in plantarflexion, the shoulder will be held in abduction and external rotation, and the hip will be held in flexion, abduction, and external rotation. Any attempt at passive motion will be exquisitely painful.
Younger children may be more difficult to diagnose because of nonspecific symptoms. Fever, irritability, and failure to bear weight or move extremity may be the only signs. Paradoxical irritability, a young child who appears fussy when moved but has minimal signs when left undisturbed, or pseudoparalysis may be associated with septic arthritis. If the child is currently being treated with antibiotics, the signs and symptoms may be subtle. Likewise, the use of anti-inflammatory agents may confuse the clinical presentation.
Diagnosis. Septic arthritis may result in physeal injury or articular deformity if the diagnosis is delayed. A prolonged duration of the symptoms prior to the treatment is the most important factor associated with clinical complications. A high index of suspicion for this disease process should be maintained when confronted with a child with fever, irritability, and pain. Parents should be carefully questioned regarding ambulation and movement of extremities. Parental concerns of asymmetric extremity use or tenderness should be thoroughly investigated.
A complete physical examination should be conducted that identifies joint swelling, tenderness, or decreased range of motion. Young children should be observed for positioning of the extremity and voluntary movement. Classically, a septic hip will be held in a position of abduction and external rotation. It may be difficult to ascertain pain with motion in the young, irritable child. In up to 35% of cases, the child will not have a fever.7 This is especially true in neonates.
| Table 2. Differential Diagnosis of Septic Arthritis |
|
Laboratory Evaluation. Laboratory evaluation includes a complete blood count, ESR, CRP, and blood culture. Twenty seven percent of children will have a normal white count but only 5% have a normal ESR.7 Joint infections may be associated with significant elevation of the white count. The CRP may be more useful in evaluating a child with an infected joint because it increases within the first 24 hours of infection, often as early as six hours, peaks at approximately 48 hours, and is usually normal within one week of therapy.22 The ESR may show delayed rise and prolonged elevation. Blood culture is positive in about 60% of cases especially with S. aureus.1 A positive blood culture with S. aureus in children must lead to a suspected bone or joint infection.
Radiographic Evaluation. Plain films are usually not helpful in making the diagnosis of septic arthritis early in the course of the disease.5,24 More than 50% of children with a septic hip will have a normal plain radiograph. When abnormal, the earliest sign of joint involvement on a plain radiograph may be obliteration of normal intramuscular fat planes. This occurs within 3-7 days of onset of symptoms.5 Dislocation or subluxation of the femoral head may be seen, particularly in newborns. Ultrasound evaluation may be useful in diagnosing septic arthritis.5 Detection of an effusion by ultrasound is an indication for joint aspiration. (See Figure 2.)
Joint Aspiration. Joint aspiration may be required even with a negative radiographic and laboratory evaluation with suspicious signs and symptoms. Aspiration of the joint is the most critical step in the diagnosis of septic arthritis. Joint fluid aspiration may be cloudy with poor mucin clot. The white blood cell count in the fluid is high, mostly with polymorphonuclear neutrophils, and the glucose is usually decreased. A WBC count of 25,000-50,000 and higher than 90% PMNs is highly suggestive of a septic arthritis. The gram stain may reveal microorganisms in 30-60% of the cases. Joint fluid cultures are positive in up to 75% of cases.32 In septic arthritis, blood cultures are positive 30% of the time.1 Joint fluid analysis also may be helpful in establishing a definitive diagnosis. (See Table 3.)
| Table 3. Joint Fluid Analysis | |||
| Analysis |
|
|
|
| Color |
|
|
|
| Clarity |
|
|
|
| Viscosity |
|
|
|
| WBC |
|
|
|
| PMN (%) |
|
|
|
| ___________________________________________ | |||
Management. Septic arthritis is an orthopedic emergency. Suspected septic arthritis always requires joint aspiration for a definitive diagnosis.
Medical Management. Intravenous antimicrobial therapy should be started immediately and based on the most likely etiologic agent. (See table 4.) Prompt initiation of antibiotics is essential. It has been shown in an animal model that articular cartilage loss was 17% if antibiotics were started within 12 hours after the infection was induced. If antibiotics were begun 12 hours later, the amount of cartilage loss was doubled.33 Appropriate blood and joint fluid cultures should be obtained, when possible prior to the initiation of antibiotic therapy.
| Table 4. Antibiotic Therapy for Septic Arthritis |
| Newborns: Empiric Therapy |
| Nafcillin 50-150 mg/kg/d q 6-12 h*
OR (if methicillin-resistant staphylococcus suspected) Vancomycin (consult dosing guide for neonate dosage) AND Cefotaxime 100-150 mg/kg/d q 6-12 h* *adjust dose for age and weight |
| Children age 3 Months to 3 Years: Empiric Therapy |
| Cefuroxime 100-150 mg/kg/d q 8 h
OR Cefotaxime 100-150 mg/kg/d q 8 h OR (if gram-positive cocci in chains on gram stain) Penicillin 100,000 mcg/kg/d q 4 h OR (if gram-positive cocci in clumps or diplococci on gram stain) Nafcillin 150 mg/kg/d q 6 h OR (if resistant staphylococcus or pneumococcus suspected) Vancomycin 40 mg/kg/d q 6 h |
| Children 4 years and Older: Empiric Therapy |
| Nafcillin 150 mg/kg/d q 6 h
OR Cefazolin 100 mg/kg/d q 8 h OR Clindamycin 40 mg/kg/d q 6 h OR (if resistant staphylococcus or pneumococccus suspected) Vancomycin 40mg/kg/d q 6 h OR (if gonococcus suspected) Ceftriaxone 50 mg/kg/d q 24 h _______________________________________________________ |
Surgical Management. Joint fluid should be sent for culture gram stain and cell count. Orthopedic consultation should be promptly obtained during the evaluation of a septic joint. Controversy exists regarded the efficacy of repeated aspirations of an infected joint, particularly the knee. Septic effusions that are not caused by a staphylococcal infection and do not involve the hip joint may be managed, in certain situations, by repeated aspirations of the joint. Some researchers feel that repeated aspirations do not provide adequate debridement of fibrinous excudate. One series, in which 49 joints other than the hip were managed with repeated aspirations, resulted in 15 treatment failures, all of which required arthrotomy.34 Septic arthritis of the hip is a surgical emergency and requires immediate orthopedic consultation and operative drainage to prevent irreparable damage to articulating cartilage. The shoulder joint is similar to the hip, intraarticular epiphysis, and should be managed in a similar fashion. Other indications for surgical drainage of an infected joint include the presence of large amounts of pus, fibrin, debris, or loculations within the joint space or lack of clinical improvement within three days on appropriate antibiotics.
Complications. Even with ideal treatment, there may be long term sequelae of bone and joint infections in children. Delay in diagnosis makes the sequelae more likely. The most significant complication of septic arthritis is destruction of the joint in the growing child. (See Table 5.)
| Table 5. Long-term Sequelae Associations with Bone and Joint Infections in Children2 |
|
Special Considerations. Fungal arthritis. Although uncommon, fungal arthritis is associated with several high-risk factors. These include pre-maturity, use of central venous catheters, prolonged use of antibiotics, immunodeficiencies, malignancies, malnutrition, hyperalimentation, steroid usage, traumatized or abnormal skin barriers, gastrointestinal tract defects, and surgery.29 Thus, it is obvious that neonates are a high-risk category for the development of a fungal arthritis. It must also be remembered that fungal arthritis can follow fungemia anywhere from weeks to a year. Usually, fungal arthritis presents insidiously with chronic, low-grade inflammation of a single joint. Initial therapy should include amphotericin.
Transient synovitis. Transient synovitis is the most common cause of acute hip pain in children from 3-10 years of age. Males are affected twice as frequently as females. This is a self-limited, usually benign disorder. Usually, the child is afebrile and presents with unilateral hip pain. While the hip is the most frequently affected joint, other joints may also be involved. The etiology is unknown but it is probably viral. The diagnosis is one of exclusion. (See Table 6.)
| Table 6. Symptoms for Considering Septic Arthritis as Opposed to Transient Synovitis10 |
|
Ultrasound may be used to delineate the joint effusion. Any questionable effusion should be aspirated to confirm the diagnosis. A well appearing child with minimal physical findings and normal laboratory tests may be closely followed as an outpatient.
Diskitis. Diskitis is actually a spectrum of infections ranging from inflammation of the disk space to vertebral osteomyelitis.31 Diskitis is commonly seen in preschool children, probably because of the changes in blood flow over time as well as other factors.2,36 Vertebral osteomyelitis is seen more often in adolescents and may be associated with trauma in the adolescent athlete. Fever may be absent in diskitis, but tenderness in the affected area of the spine is always present. Onset is sudden, and many children have a history of sore throat or upper respiratory infection. Children younger than 3 years may be unable to walk or stand.37 The child’s symptoms may range from irritability, and/or intermittent fever, to inability to walk. S. aureus causes approximately 25% of the cases of diskitis and 80% of the cases of vertebral osteomyelitis. Plain radiographs are usually normal early in the course of the disease. Bone imaging may be used as a diagnostic tool, but may be normal in some patients. MRI provides clear imaging of the inflammatory process and has been advocated as the diagnostic procedure of choice in difficult cases.
Other Causes of Arthritis. Lyme arthritis occurs weeks to months after the initial infection in endemic areas. It is an acute, oligoarticular, episodic arthritis.31 Each episode lasts several days. Some patients, probably those with a genetic predisposition, may develop chronic arthritis. Initial therapy consists of intravenous ceftriaxone.
Reactive or post-infectious arthritis is, by far, more common than septic arthritis. It usually follows a viral infection, including human parvovirus, rubella, and chickenpox. Occasionally a post-infectious arthritis will follow a group A streptococcal infection.38 Reactive arthritis is defined as a sterile, inflammatory arthritis occurring in association with an infection at a distant site, in which no infectious agent can be found within the joint.
Summary
Osteomyelitis and septic arthritis are somewhat uncommon diseases. The clinical presentation of each is dependent on the age of the patient, location of infection, and the etiologic agent. Diagnosis requires a familiarity with the clinical course as well as a thorough understanding of the strengths and weaknesses of a variety of tests and procedures. Treatment should be quickly instituted and the choice of therapeutic agents is based on a knowledge of the causative organisms. Although sequelae are relatively rare, they can be devastating; delays in diagnosis increase the risk of complications.
References
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12. Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of Pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. J Pediatrics 1985:106;607-609.
13. Jacobs RF, Adelman L, Sack CM, et al. Management of Pseudomonas osteochondritis complicating puncture wounds of the foot. Pediatrics 1982;69:432-435.
14. Starke JR, Smith MHD. Tuberculosis. In: Fegin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases, 4th ed. Philadelphia: WB Saunder; 1998:1196-1239.
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16. Bradley TM, Dormans JP. Streptococcus pyogenes septic arthritis of the elbow complicating chicken pox. Pediatr Emerg Care 1997;13:380-381.
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18. Venglarcik JS, Black M. Bacterial Colonization of Sneakers, Presented at the 14th Annual Meeting of the European Society for Paediatric Infectious Diseases, Copenhagen, Denmark, June 18-21, 1996.
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20. Chan E, Kennedy K, Baltimore RS. Osteomyeltis masquerading as renal stones. Curr Opin Pediatr 1998;10:98-100.
21. Laughlin TJ, et al. Puncture wounds in children. WMJ 1997:166:126-128.
22. Kallio MJ. Serum C-reactive protein, erythrocyte sedimentation rate and white blood cell count in septic arthritis of children. Pediatr Infect Dis J 1997;16:411-412.
23. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: A Review of clinical features, therapeutic considerations and unusual aspects (third of three parts). N Engl J Med 1970;282:316-322.
24. Mandell GA. Imaging in the diagnosis of musculoskeletal infections in children. Curr Probl Pediatr 1996;26:218-237.
25. Sutter CW, Shelton DK. Three phase bone scan in osteomyelitis and other musculoskeletal disorders. Am Fam Physician 1996;54: 1639-1645.
26. Barron SA. Index of suspicion. Pediatr Rev 1998;19:51-52.
27. Venglarcik JS, Blair LL, Dunkle, LM. pH dependent oxacillin tolerant Staphylococcus aureus. Antimicrob Agents Chemother 1983:23:232-235.
28. Lewis KT, Stiles M. Management of cat and dog bites. Am Fam Physician 1995;52:479-485.
29. Barson WJ, Marcon MJ. Succesful therapy of Candida albicans arthritis with a sequential intravenous amphotericin B and oral fluconazole regimen. Pediatr Infect Dis J 1996;15:1119-1122.
30. Lundy DW, Kehl DK. Increasing prevalence of Kingella kingae in osteoarticular infections in young children. J Pediatr Orthop 1998;18:262-267.
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32. Hart JJ. Transient synovitis of the hip in children. Am Fam Physician 1996;54:1587-1591.
33. Ice R. Tidal irrigation in septic arthritis of the knee: a potential alternative to surgical drainage. J Rheumatol 1993:20;2104.
34. Herndon W, et al. Management of septic arthritis in children. J Pediatr Orthop 1986:6;576-578.
35. Longjohn DB, Zionts LE, Stott NS. Acute hematogenous osteomyelitis of the epiphysis. Clin Orthop 1995;316:227-234.
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37. Payne WK, Ogilvie JW. Back pain in children and adolescents. Pediatr Clin North Am 1996;43:899-917.
Recommended Reading
Ayoub EM, Ahmed S. Update on complications of group A streptococcal infections. Curr Probl Pediatr 1997;27:90-101.
Goldstein EJC, Ahonkhal VI, Cristofaro RL, et al. Source of Pseudomonas in osteomyelitis of heels. J Clin Micro 1980;12:711-713.
Wenger DR, Bobechko WP, Gilday DL. The spectrum of intervertebral disc-space infection in children. J Bone and Joint Surgery 1978: 60A;100-108.
Smith R, et al. The effect of antibiotics on the destruction of cartilage in experimental infectious arthritis. J Bone Joint Surg 1987:69;1063.
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