Chapter

7
Bone and joint sepsis, presenting in an acute manner, are
encountered in day to day practice in orthopedics. As some
of the infections might leave a lifelong disability, especially
in children, their prompt recognition and management,
assumes huge importance. Orthopedic infections are more
common in children as compared to adults. By definition
osteomyelitis is an inflammation of bone; unless specified
further, this term is conventionally used for infection of
bone by pyogenic organisms. Osteomyelitis can be acute,
subacute, chronic or acute exacerbation of chronic
osteomyelitis. Septic arthritis is pyogenic infection of a joint.
Bone and joint infection can be:
z
Hematogenous in origincalled acute hematogenous
osteomyelitis and acute septic arthritis. Most common
in first decade of life.
z
Secondary to an open injury (open fracture or open joint
injury) or as a consequence of bone or joint surgery
called secondary osteomyelitis/secondary septic arthritis.
More common in adults.
Though by strict definition acute hematogenous
osteomyelitis and septic arthritis are caused by bacteria,
commonly bacteria cannot be isolated. In such a situation
some general guidelines proposed by various authors are
shown in Tables 7.1 and 7.2.
As orthopedic infections present themselves and behave
in a different manner in children and adults, these will be
discussed separately.

Orthopedic
Infections

Anil Arora, Anil Agarwal

Table 7.1: Criteria for the diagnosis of osteomyelitis

Morrey and Petersons Criteria1
Definite: The pathogen is isolated from the bone or adjacent
soft tissue, or there is histological evidence of osteomyelitis.
Probable: A blood culture is positive in the setting of clinical
and radiographic features of osteomyelitis.
Likely: Typical clinical findings and definite radiographic
evidence of osteomyelitis are present, and there is a response
to antibiotic therapy.
Peltola and Vahvanens Criteria2
The diagnosis is established when two of the following four
criteria are met:
Pus is aspirated from the bone.
A bone or blood culture is positive.
The classic symptoms of localized pain, swelling, warmth
and limited range of motion of the adjacent joint are present.
Radiographic features characteristic of osteomyelitis are
present.

Table 7.2: Criteria for the diagnosis of septic arthritis in

patients with negative cultures
Morrey and Associates Criteria3
The diagnosis is established when five of the following six criteria
are present:
Body temperature exceeds 38.3C.
Swelling of the suspected joint is present.
Pain occurs in the suspected joint and is exacerbated with
movement.
Systemic symptoms are present.
No other pathologic processes are present.
There is a satisfactory response to antibiotic therapy.

Orthopedic Infections

ORTHOPEDIC INFECTIONS IN CHILDREN

Generally, septic arthritis occurs in the early years of first
decade (most common in neonates) whereas acute
hematogenous osteomyelitis (AHO) has peak occurrence
in the later years of first decade.

Clinical Presentation
History

The patient usually presents with the following complaints:

z
Pain: This may be expressed in many ways like excessive
cry of neonate during change of nappy or dress,
irritability in a small child, limp or refusal to bear weight
on affected extremity (Figs 7.1A to C).
z
Inability to move or difficulty in moving the affected
extremitythe so called pseudoparalysisis the most
common presenting symptom of septic arthritis in a
neonate. The neonate does not move the affected
extremity or there is less movement of the affected
extremity.
z
Swelling of the affected area: Usually it takes 48 to 72
hours for the infective process to show up swelling around
a bone or a joint (Fig. 7.2).
z
Fever and malaise: It is important to remember that
younger the child, lesser are the chances that fever will
be a presenting symptom. More than 90% neonates with
septic arthritis and about 50% children having acute
osteomyelitis do not have fever at presentation. Fever
and constitutional symptoms if present do support the

47

diagnosis of infection, but their absence (especially in

early case) does not rule out infection.
Trauma: In almost all children past the walking age,
parents try to correlate symptoms of pain with some
sort of antecedent trauma or fall while playing. Take a
meticulous history. Fall while playing is a common
occurrence in day to day activities in children. Directly
ask: Who witnessed the fall (In majority of cases the
parents tend to rely on the small buddy who was playing
with child!)? How did the child behave immediately after
fall (Did the child cry or refused to get-up or walk
immediately after fall)? Is there any symptom free
period between trauma and presenting complaints (in
cases of infection, there could be significant symptom
free period between antecedent trauma/assumed trauma
and presenting complaints)? Are the symptoms
increasing or decreasing overtime? (In case of trauma,
symptoms should not increase overtime). It is not
uncommon for a complacent health care provider to get
misled by a history of trivial trauma, overlooking the
possibility of infection.
Medication: If the child has already taken any NSAID
or antibiotic, the clinical picture might change, masking
the symptoms (for example, fever) or decreasing the
severity of manifestations of infection.
History of any:

Concomitant infection (like otitis media, pneumonitis, etc.)

Recent infection (like upper respiratory tract infection,

chickenpox, skin infection, etc.) (Figs 7.1A to C)

Figs 7.1A to C: This 12 months old child was presented with a history of refusal to bear weight on his right lower limb for the last 24 hours (A).
The child had a history of rashes all over the body (viral illness) of 5 days duration (B). Note that the child is quite comfortable, during
examination in his mothers lap (C). On investigations he was found to have distal femoral osteomyelitis. (For color version, see Plate 3)

48

First Aid and Emergency Management in Orthopedic Injuries

Co-morbid condition causing lowered immunity of

the host (like rheumatoid arthritis, leukemia, recent
surgery or anesthesia, etc.)
Do not forgeta serious disorder like leukemia in a child,
depressing immune function, may present as a case of bone or
joint sepsis.

Examination

Following are some general rules:

z
Children are best examined in the mothers lap, than on
examination couch (this keeps them quiet and less
apprehensive) (Figs 7.1A to C).
z
Perform general examination before examination of the
musculoskeletal system (to avoid missing general findings
like signs of meningitis, enlarged lymph nodes or
enlarged tonsils).
z
Perform general survey of musculoskeletal system before
performing local examination of a joint/bone (to avoid
missing another septic focus in bone or joint which is
not uncommon; about 1% children with septic hip are
known to have bilateral hip involvement).
z
Start the examination of affected bone/joint, away from
the area of greatest suspicion/apprehension.
z
Tenderness can be best demonstrated by a parent, once
the latter is clearly told what area, and how it is to be
palpated (Children will otherwise cry at the sight of a
doctor, clouding the clinical picture).
Look for following signs, if present:
z
Irritability
z
Fever
z
Erythema
z
Antalgic gait or limp
z
Failure to use upper extremity in an usual manner
z
Swelling: The swelling is usually metaphyseal in a case
of AHOM. A septic joint is held in a typical position
because of effusion into the synovial cavity (Table 7.3
and Fig. 7.3).
z
Loss of normal creases or concavities: In early cases this
subtle finding may indicate swelling in the underlying
structures (Fig. 7.2).
z
Range of movements restricted, especially with septic
joints. Always compare ROM with normal side. In early
case/or a child on antibiotic or NSAIDs, there may be
minimal or no restriction of movements!

Fig. 7.2: Fullness and loss of normal creases in region of flexor

adductor area in a case of septic hip left side.
(For color version, see Plate 3)

Fig. 7.3: Flexion, abduction and external rotation attitude in a

case of septic hip right side. (For color version, see Plate 4)
Table 7.3: Position of ease of common joints
Joint
Shoulder
Elbow
Wrist
Hip
Knee
Ankle

Position of ease
Abduction internal rotation
Flexion, mid-pronation
Flexion
Flexion, abduction, external rotation
Flexion
Plantar flexion

Do not forget to examine spine and sacroiliac joints.

Also, do not forget to examine iliac fossa in a suspected case
of septic hip or suspected AHO of proximal femur.
Clinically, iliac fossa pyogenic abscess may mimic septic
arthritis of hip.

Orthopedic Infections
Laboratory Investigations
z

Total leukocyte count with differential (TLC, DLC):

WBC counts are often elevated and differential may show
increased polymorphonuclear cells. However, the counts
may be normal, despite presence of bone and joint
infection in following:

Immunocompromised host

Some newborns/infants

In a very early case of infection.

Hemoglobin estimation, hematocrit, peripheral smear and
platelets countsto rule out any predisposing or comorbid conditions like leukemia or sickle cell anemia.
ESR: Less reliable in first 48 hours. Starts rising up after
48 to 72 hours. Can continue to rise for another 3 to 5
days after institution of antibiotic therapy and response.
Returns to normal over a period of 2 to 3 weeks after
elimination of infection. ESR may be unreliable in a
neonate, sickle cell disease, severe anemia, malnutrition
and if the patient is already on steroid therapy. The ESR
values are not affected by previous antibiotic therapy.
ESR is slow to respond to changes in the clinical picture
and hence, it is not a good monitoring tool in the first
week of therapy.
C-reactive protein (CRP): CRP, an acute phase reactant,
is a more sensitive index of infection and its response to
therapy. CRP begins to rise within first 6 hours of
infection, can increase several hundred folds over next

49

24 to 48 hours and tends to fall quickly to normal within

a few days of successful treatment.
Blood cultures: Draw a sample of blood culture, in a
suspected case, before instituting antibiotic therapy. It
may be positive in 30 to 50 percent cases of bone and
joint infection.

Imaging Studies
z

Plain radiography: Bone itself is slow to react to

infection and it may take 5 to 7 days, before bony changes
show up on a radiograph. On the other hand soft tissue
changes may appear much earlier (within 24-48 hours).
Following radiological findings may be present in a case
of bone or joint infection:

Loss of muscle planes and deep soft tissue swelling

(Figs 7.4A to C)

Periosteal reaction

Metaphyseal lucency (Figs 7.5A and B)

Areas of destruction and new bone formation (in a

late case > 7 days)

Increased joint space indicating join effusion or

decreased joint space indicating cartilage destruction
(Figs 7.4 and 7.6)

Extensive subperiosteal new bone formation and

sequestration (acute osteomyelitis going into the
phase of chronic osteomyelitis) (Fig. 7.7)

Subluxation or dislocation of the joint (Figs 7.8A to C).

Figs 7.4A to C: Swelling and loss of soft tissue planes in a case of acute osteomyelitis of tibia who presented with symptoms of 5 days
duration (A) and in a case of acute osteomyelitis humerus (B). The diagnosis was established by aspiration. (C) Loss of soft tissue planes
around left hip in a case of proximal femoral osteomyelitis with septic arthritis. Right proximal femoral metaphysis has a radiolucent zone.
The distance between the proximal femur and acetabulam is increased on the right side which could be due to marked joint effusion,
dislocation, destruction of unossified femoral head or following a pathological fracture of unossified femoral neck. In such a situation
ultrasound or MRI can determine the status of unossified femoral head and neck.

50

First Aid and Emergency Management in Orthopedic Injuries

Figs 7.5A and B: (A) Metaphyseal lucency along with area of destruction and periosteal reaction in a case of
proximal femoral AHOM left side. (B) Metaphyseal lucency in a case of lower femoral AHOM.

Figs 7.6A and B: Increased joint space in a case of septic shoulder right side, (A) septic hip in a 2-year-old child with ossified
proximal femoral epiphyses. (B) Decreased joint space because of cartilage destruction, on right side in a case of septic hip.

Fig. 7.7: Areas of destruction and new bone formation in a case of osteomyelitis
tibia who presented with high grade fever, off and on, of 3 weeks duration along with
pain and swelling of leg.

Orthopedic Infections

51

Figs 7.8A to C: (A) Dislocation of hip in a neonate (the femoral head is unossified). Ultrasound demonstrated the femoral head dislocation.
(B) Dislocation of hip in 8-year-old boy, having septic hip. The treating surgeon only drained the abscess. (C) Within 2 weeks femur
exhibited extensive changes of osteomyelitis.

Figs 7.9A and B: Ewings sarcoma in a 9-year-old child: (A) Clinical

picturethe child had soft fluctuant swelling. (B) X-ray showed areas
of lucency and periosteal reaction. The wise surgeon attempted
aspiration and subjected the aspirate to staining which revealed
abundant small round cells. Biopsy proved the diagnosis of Ewings
sarcoma. (For color version, see Plate 4)

A normal looking radiograph within first 7 days of infection

does not rule out bony involvement. It is not uncommon for
a junior house officer to label a case of acute osteomyelitis as
soft tissue infection after getting misled by normal looking
X-ray during this duration.
Remember, areas of destruction and new bone formation
can also be seen in bony neoplasms in children (like Ewings
sarcoma and osteogenic sarcoma) (Figs 7.9A and B).
Ultrasonography: Extremely useful noninvasive
investigation in a suspected case of bone and joint
infection (Figs 7.10A to C). It has been maximally used

in cases of hip joint effusions, where the positive findings

can be:

Thickening of hip capsule (if present, goes more in

favor of septic hip).

Increase in distance between hip capsule and femoral

neck cortexindicating intracapsular collection.
Do not forget to perform ultrasound of the iliac
fossa, if there are no positive findings in a strongly
suspected case of hip joint sepsis. Ultrasound can
differentiate irritable hip, secondary to an
extracapsular pathology such as iliac fossa abscess or
iliac osteomyelitis from septic arthritis.

Ultrasound cannot differentiate between septic hip

and nonseptic causes of hip effusion (like transient
synovitis).
In a case of osteomyelitis, a subperiosteal collection, if
present can be demonstrated by an ultrasound. However,
a normal ultrasound does not rule out AHO, as the latter
can exist without subperiosteal collection.
Aspiration: 4 Surpasses all investigations as it can
conclusively:

Confirm the diagnosis.

At times identify the organism (which no other

investigation can do before drainage). Aspiration does
not interfere or affect the results of other investigations (like bone scan).

For aspirating a bone in a suspected case of AHO,

take a wide bore shallow tapered needle (16G or

52

First Aid and Emergency Management in Orthopedic Injuries

Figs 7.10A to C: Ultrasound of hip: (A) Normal hipshowing (*) anterior synovial recess. The capsule is concave.
(B) Septic hipthe anterior synovial recess (*) is enlarged and (C) the capsule is convex and bulging.

18G). Sedate the child and aseptically prepare the

area (in almost all cases of AHO, it is the metaphyseal
area). Do aspiration in two steps: step one, try to
aspirate subperiosteal area in the metaphysis. If no
pus is aspirated, rotate the needle and puncture the
soft metaphyseal bone and go into the marrow, and
then again aspirate.

For aspirating a joint, sedate the child and prepare the

area aseptically (Figs 7.11A and B for approaches to
various joints).

Never discard the aspirate thinking it to be just blood.

Send the aspirate (pus, synovial fluid or blood) for

Grams stain, culture and synovial fluid examination.

Never try to rule out infection just by clear appearance

of the aspirate from a joint on gross examination.
Bone scan: Not required routinely.

Indicated when it is difficult to localize the site in a

suspected case of bone and joint sepsis.5,6

Technetium-99m (99m Tc) is the most favored scan.

Bone scan usually show increased uptake (hot spot)

in the area of infection.

Sometimes, extensive devascularization of bone by

infective thrombosis or subperiosteal access may show
up as cold spot on bone scan.

It shows increased uptake on either side of a joint or

limited uniform uptake within the joint capsule.

Bone scan will also localize multiple sites of infection,

if any.

Has a sensitivity of about 90% and specificity of 92%

with overall accuracy of 92% for AHO.

Limitations
z

Costly, time consuming investigation, not available

everywhere.

Bone scan may even be normal in patients with

osteoarticular infection (false negative).
Scan might not accurately differentiate between septic
arthritis and osteomyelitis of metaphyseal area in some
cases.
Cannot differentiate between infectious and noninfectious causes of arthritis.
Increased uptake of normal physis may mask the findings
of increased uptake in metaphyseal area in a case of AHO
(pinhole or convergingcollimator images help in this
situation).

Caution
z

Never delay aspiration for want of a bone scan. If strongly

suspected clinically, aspirate the site of pathology.
Bladder should be empty at the time of scanning, as the
accumulated isotope may hide the sacrum.
The limbs should be positioned symmetrically for
comparison of uptake.
Magnetic resonance imaging

Costly investigation which often requires sedation or

anesthesia for a child.

Useful in exact localization of the infective process

(bone soft tissue or joint); infectious of the axial
skeleton; helping differentiate between infection and
neoplasm.

Has a sensitivity of about 97% and specificity of 92%

in bone and joint infection.

The low intensity signal in the area of pathology seen

on T1-weighted image becomes high intensity signal
on T2-weighted images. These high intensity signals
persist on fat suppression images. This pattern indicates
increased water content (because of edema, hyperemia
or pus) in the marrow or joint (Figs 7.12A to C).

Orthopedic Infections

ii.

iii.

iv.
Figs 7.11A and B: Approach to aspiration of various joints for
aspiration: (A) Lower limb. (B) Upper limb.
Aspiration:
i.
The hip can be aspirated by anterior, medial, lateral and
posterior approach. Of these, first two are most commonly
used. (a) AnteriorPalpate femoral artery at the level of
inguinal ligament. Insert the needle below and lateral to this
point (in adults this distance is 2.5 cm caudal and 2.5 cm
lateral). Angle the needle proximal and medial making an
angle of about 45 with skin surface. (b) MedialThis
approach is very safe and straightforward in neonates.
Neonatal hip, usually remains flexed abducted and externally
rotated. This position becomes exaggerated after hip effusion,
permitting medial approach. Insert the needle just behind the

53

tendon of adductor longus, just distal to perineal crease,

pointing medially and upwards. Advance the needle till you
hit the femoral neck. (c) LateralInsert the needle just
anterior and inferior to greater trochanter, at an angle of about
45 to the surface of thigh (imagine passing the needle on
the anterior surface of femoral neck). Advance the needle
medially and superiorly across the intertrochanteric line,
sliding past the anterior cortex of femoral neck, to enter the
joint capsule. Remember, the anteversion of femoral neck is
more in children, as compared to adults
The knee being superficial joint can be easily aspirated by
lateral parapatellar approach. Insert the needle just lateral to
the lateral border of patella, at the level of superior pole,
directing if medially and slightly caudally
The ankle is aspirated from the palpable soft area between
lower end of tibia and dome of talus anteriorly, on lateral side,
to avoid injury to the neurovascular structures. In adults this
soft area is 2.5 cm proximal and about 1.25 cm medial to the
tip of lateral malleolus
Shouldercan be aspirated from anterior, lateral and
posterior sides. (a) Anterior approach, through deltopectoral
area is preferred. Insert the needle through the middle of
deltopectoral groove. Advance it posteriorly and slightly
laterally, towards the soft area just medial to humeral head.
Try to feel the humeral head by gently rotating it internally
and externally 2-3 times, if patient permits. (b) LateralIn
some cases, the fluctuant swelling points laterally beneath
the acromion. For lateral approach, insert the needle just
distal to the lateral border of acromion, directing it medially
and slightly inferiorily. The depth of advancement depends
on the size of shoulder (age of the patient). (c) Elbow is usually
aspirated posteriorly, just lateral to the olecranon, in a semiflexed elbow. (d) Wrist is aspirated from the dorsal aspect,
just medial to the anatomic snuffbox. Direct the needle
upwards and medially

Figs 7.12A to C: MRI in a case of acute pyogenic osteomyelitis of lower tibial metaphyseal area. (A) T1-weighted image shows areas of
hypointensity in right tibia in metaphyseal area. Left tibia is included for comparison. (B) The signal change become hyperintense in T2 weighted images. (C) These hyperintense signals persist in fat suppressed images indicating edema of marrow and bone.

54

First Aid and Emergency Management in Orthopedic Injuries

It can demonstrate fluid collection in a joint

(Fig. 7.13) or abscess collection associated with
osteomyelitis.
Computed tomography (CT): Show better bony outline,
less costly and has greater availability as compared to MRI.

Soft tissue windows can demonstrate abscess

collection associated with bone and joint infections.

Can aid in guided aspiration, e.g. CT guided

aspiration from iliac fossa.

Useful for axial skeleton.

Can demonstrate even small bony destruction.

Differential Diagnosis
Fig. 7.13: Fluid collection in hip (on T2-weighted image)
in a case of septic hip.

1. AHO versus septic arthritis: As the metaphyses (the

area which commonly gets involved in AHO) is located
very close to a joint, sometimes differentiation between
the two can be difficult. Both can occur concurrently
where metaphyses are intra-articular (Figs 7.14A to D).
In latter, the osteomyelitic focus can burst into the joint
leading to septic arthritis.

Figs 7.14A to D: Intra-articular metaphyses at various joints. (A) Hip, (B) Shoulder, (C) Elbow, (D) Ankle.

Orthopedic Infections

Where clinical differentiation between the two

becomes difficult, routine investigations are not able
to discern and sophisticated investigations like MRI
are not available, aspiration can localize the exact site.
2. Transient synovitis versus septic arthritis of hip: In septic
hip, the symptoms and signs are of greater magnitude.
But in an early case of septic hip or a case of septic hip
already on antibiotics can be confused with transient
synovitis. However, high grade fever, history of
nonweightbearing, ESR > 40 mm/hr and TLC >12,000
cells/cumm of blood go more in favor of septic arthritis.
Grams stain of aspirate may reveal bacteria in septic
hip. In case of doubt, overtreating transient synovitis
rather than undertreating septic hip is safer.
3. Neoplastic lesions:
i. Leukemia: About 30% children with leukemia
present with bone pains. Leukemic child can also
have constitutional symptoms, fever, easy bruising,
bleeding, anemia and generalized bone tenderness.
These patients may have leukocytosis or leukopenia,
abnormal peripheral blood smear, low platelets
counts, radiographic lucent metaphyseal bands,
lytic or sclerotic lesions. Leukemic lytic lesions do
not demonstrate increased uptake on bone scan, as
there is no new bone formation or reaction.
ii. Ewings sarcoma/Osteogenic sarcoma: Both these may
at times resemble subacute osteomyelitis (Figs 7.9A
and B). In these sarcomatous lesions the clinical
course is less dramatic and constitutional symptoms,
if present are of lesser magnitude.
Bony changes like areas and periosteal reaction
(onion peel appearance in Ewings and sunburst
appearance in osteogenic sarcoma) are usually
evident, by the time, patient presents clinically. In
an atypical osteomyelitic lesion, dont hesitate in
performing a biopsy if there is any doubt.
iii. Other tumours like lymphoma, metastatic neuroblastoma or eosinophilic granuloma may mimic
subacute osteomyelitic (lytic area with or without
periosteal reaction).
4. Juvenile rheumatoid arthritis (JRA): Pain is not a
prominent feature in JRA.

5.

6.

7.

8.

9.

55

Other features are:

Small joint involvement
The laboratory parameters like TLC, DLC and
synovial fluid WBC counts are comparatively less
severely deranged
RA factor may be positive.
Acute rheumatic arthritis: Has
Fleeting joint pains.
Elevated ASLO and CRP titers.
Toddlers fracture: Could be confused with AHO in a
limping child, if clear-cut history is not forthcoming,
X-ray usually shows up a hairline fracture in tibia.
Scurvy: Should be considered in d/d in developing
countries. Typical features of scurvy are:
Irritable child, does not like handling even by mother
(as has generalized bony tenderness).
May have swollen knees or ankles (because of
subperiosteal hemorrhage in these areas).
Radiological findings of osteoporotic skeleton with
a circular, opaque radiologic shadow surrounding
epiphyseal centers of ossification (Wimburger sign),
pencil thin cortices, increased opacity of distal
diaphysis (Frankel line) may be accompanied by a
subjacent zone of decreased opacity (Trummerfeld
zone).
Acute poliomyelitis: Though on decline, a true acute
flaccid paralyses (AFP) may be presented as child
inability to more limb(s). However, true bony
tenderness is absent. AFP may involve both lower limbs
which is an unusual feature for infection.
Tuberculosis: Osteoarticular tuberculosis usually has
chronic symptomatology. If an associated abscess (called
Cold Abscess) is present, the local symptoms and signs
of inflammation are usually absent. The sinus(es) has
undermined margins. In a rare event, even tuberculosis
can present in an acute manner. Never forget to look
for associated lymph node enlargement in a case of
osteoarticular infection(s). In TB the lymph nodes are
usually matted. Tubercular hip in an infant, though
rare, may mimic septic hip, as in developing countries
correct history regarding duration of symptoms may
not be forthcoming. Invariably in tubercular hips (or
other joints), during drainage, one will encounter

56

First Aid and Emergency Management in Orthopedic Injuries

synovial thickening or granulation tissue. In case of

slightest doubt, submit material for AFB staining,
polymerase chain reaction for Mycobacterium
tuberculosis and histopathological examination.
10. Congenital syphilis: It has typical punched out
metaphyseal lucencies and changes of periostitis.

z
z

Management (Flow chart 7.1)

z

Once the diagnosis of infection is established/entertained,

start IV antibiotics after obtaining blood culture samples.
z
Start broad spectrum antibiotic.
z
Choice of antibiotic is on the basis of intelligent guess
till the organism is revealed by culture reports. In neonates
gram-positive cocci (Staphylococcus aureus, streptococci)
are the most common organisms. Other common
organisms are gram-negative cocci like Klebsiella, Proteus
or E. coli. Cefotaxime or ceftriaxone is a good choice for
broad coverage.
z
In children less than 4 years of age Gram ve rods (such as
H. influenzae) are common so ceftriaxone is preferred.
z
Above 4 years of age Staphylococcus aureus remains the
most common infecting organism. So semisynthetic
penicillin like cloxacillin or oxacillin; or vancomycin or
cefazolin are preferred.
z
At all ages if the infection is hospital acquired (which
usually is the case in neonates), there are high chances of
gram-negative bacilli, so adding an aminoglycoside
(Gentamycin/Amikacin) provides excellent coverage.
z
IV antibiotics are given for 4 to 21 days depending upon
the response. This is followed by oral antibiotics for
another 2 to 3 weeks.

Dosages of various antibiotics are given in Table 7.4.

SurgeryAs a matter of sound surgical principle, if there
is pus, it needs to be drained. Every hour counts. It is a
matter of a few hours that a permanent bone or joint
damage can occur, if left undrained. Damage to growing
end of a bone can lead to lifelong disability or deformity,
shortening of limp.
Remember, the risks of a negative arthrotomy are far
less than leaving a septic joint undrained.
Septic foci in bone and joint in children are an emergency
urgent action is desirable.

ORTHOPEDIC INFECTIONS IN ADULTS

Exogenous osteomyelitis, acute exacerbation of chronic
osteomyelitis and septic arthritis secondary to penetrating
wounds are more common in adults rather than hematogenous variety.
z
Hematogenous infection in adults should arouse
suspicion of an immune compromised host or presence
of a predisposing condition like diabetes mellitus or sickle
cell anemia.
Following varieties of osteomyelitis are seen in adults:
Brodies abscess: Patient has insidious onset of pain. Systemic
manifestations are absent or minimal. Typical radiological
findings include a lytic area in the metaphysis of a long
bone, well-marginated by sclerotic borders.
Subacute osteomyelitis: It is characterized by insidious onset
of pain (> 2 weeks duration) usually without signs of systemic
illness. Radiographic features include lytic area, serpentine
in shape or punched out lesion in metaphyseal, diaphyseal

Table 7.4. Doses of antibiotics commonly used in the treatment of bone and joint sepsis*
S. No.
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
*

Drug
Cefotaxime
Ceftriaxone
Cefuroxime
Ceftazidime
Cefazoline
Oxacillin
Methicillin
Vancomycin
Clindamycin
Gentamicin

Route
IV
IV/IM
IV
IV
IV
IV
IV
IV
IV/Oral
IV

Dosage mg/kg/day
100-150
50-75
100-150
100-150
75-100
150
150
40
25-40
6.0-7.5

Maximum (gm/day)
8-10
8
4-6
8
8
4-12
2-4
1.2-2.7
Monitor peak and trough start at third dose

Dosing interval
q 6-8h
q 24h
q 8h
q 8h
q 8h
q 6h
q 6h
q 6h
q 6h
q 8h

Above doses for patients with normal hepatic and renal functions. Monitor blood levels for effective therapy. Neonatal doses may be different.
Monitor blood counts in patients with prolonged IV or oral antibiotics. Preferably give antibiotic doses in consultation with pediatrician.

Orthopedic Infections

57

Flow Chart 7.1: Algorithm defining treatment protocols in suspected orthopedic infection

* Get appropriate laboratory blood tests, (like TLC, DLC, peripheral smear, ESR, CRP) and to rule out other pathologies like leukemia which
might mimic infection.
** About 90% neonates with septic arthritis do not have fever at presentation.
*** If patient is on medication, clinical picture of infection might change. Patient might not have fever or decreased range of movement.
**** If aspiration yields blood only beware of bleeding disorder (joint), malignancy (bone).
***** Fluid collection in hip along with these clinical findings could be present in transient synovitis. Take help of clinical picture as a whole and
laboratory parameters before making a decision of draining the hip.

58

First Aid and Emergency Management in Orthopedic Injuries

or epiphyseal area, centric or eccentric in location, wellmarginated by sclerotic border, with or without periosteal
reaction (Fig. 7.15).
z
Hematological parameters may be normal.
z
These lesions might resemble neoplasm.
z
Majority of cases respond to conservative treatment
(antibiotics).
z
If the patient has systemic illness, look for abscess
collection.
z
If there is abscess formation (palpable clinically or
demonstrable by ultrasound), drain it and debride the
bony focus.

SPECIAL SITUATIONS
Discitis

Common in preadolescent and adolescents. Considered to

be of pyogenic organism, secondary to vertebral
osteomyelitis or as a separate entity.
Clinical Features
z
z

Acute onset back pain, may be referred to abdomen.

Refusal to bear weight or difficulty in walking in a small
child (less than 5 years of age).
Fever (mild or absent).

z
z

Loss of normal curvature (e.g. lumbar lordosis).

Spasm and tenderness at the affected level.

Investigations

X-raymay initially show loss of normal curvature only.

Destruction and reduction in disk space may be evident
after 1 to 3 weeks.
z
Laboratory parametersTLC, ESR and CRP are usually
elevated. DLC may show a left shift.
z
Bone scanan extremely useful investigation in this
situation to localize the infection and the level of
involvement. Demonstrates increased uptake at the
affected level.
z
MRIcan further delineate the lesion and demonstrate
edema of the adjacent vertebral bodies, if present.
z
CT scanis able to demonstrate destruction of end
plates (vertebral involvement) if present.
z
Biopsyusually not done routinely. If performed, CT
guided biopsy can be performed. A positive biopsy grows
Staphylococcus aureus in almost 50% cases.
Treatment: Majority of authors now agree on giving IV
antistaphylococcal antibiotics (semisynthetic penicillin like
cloxacillin or vancomycin or first generation cephalosporins)
for initial 7 to 10 days, and then depending upon the response
switching to oral antibiotics for another 3 to 4 weeks.
z

Septic Arthritis of Sacroiliac Joint

z
z

Fig. 7.15: Lytic lesion in the distal femur in a case of subacute

osteomyelitis. Note the serpiginous morphology of the lesion in
lateral view.

Usually occurs at a mean age of around 10 years.

Common organisms are:

Staphylococcus aureus

Salmonella

Brucella
Symptoms (varied presentation)

Fever (may be mild sometimes)

Pain in SI joint area referred to back or thigh or

abdomen (Gluteal, lumbar or abdominal presentation) and sometimes up to calf

Pain is exaggerated while taking turns in bed.

Examination

Tenderness in sacroiliac area

Swelling in sacroiliac area in some cases (Fig. 7.16)

Positive pelvic compression test; FABER (Flexion,

abduction, external rotation) test or Patrick test.

Orthopedic Infections
z

Fig. 7.16: Swelling in right sacroiliac area in a case of sacroiliac

osteomyelitis. (For color version, see Plate 4)
z

Investigations

Routine laboratory parameters like TLC, DLC, ESR,

and CRP may be deranged.

Blood cultures are positive in 50% cases.

Stool cultures may show up Salmonella

X-ray may not show destruction in early stages. Later

on (after 1-2 weeks) loss of subchondral margins and
erosions may be present.

Bone scan localizes the infection in a suspected case.

Very useful in early case (symptoms < 7 days).

MRI may show edema of bone on either side of the

sacroiliac joint or abscess.
Treatment

Majority of patients respond to conservative treatment. Initial IV antibiotics (semisynthetic penicillins

like cloxacillin or oxacillin; or vancomycin or first
generation cephalosporins, cefazolin are preferred),
as used in bone and joint sepsis, followed by oral
antibiotics for 3 to 4 weeks.

Surgery is indicated for: Biopsy in case of doubtful

diagnosis; nonresponse to conservative treatment;
drainage of large abscess or debridement of
sequestered bone.

Chronic Recurrent Multifocal Osteomyelitis6,7

z

An inflammatory bone disorder of children and

adolescents that can mimic osteomyelitis.

59

Clinical presentation:

Insidious onset of pain, swelling and erythema of

multiple bony sites with malaise. Majority of patients
are ambulatory at presentation. Sometimes these signs
may be present at one single site. The characteristic
behavior of this disease is subsequent resolution,
followed by relapse of similar symptoms, with or
without fever, at similar or different sites, within next
2 to 5 years. Some patients may have associated
palmoplantar pustulosis.

Clavicle, long bones of extremities, spine are common

sites, of involvement, but no bone is exempt.
Investigations:

X-rayusually show lytic eccentric metaphyseal

lesions, with or without periosteal reaction. The lesion
may cross physis. Healing is characterized by sclerotic
response around the lesion.

TLC is usually normal. ESR is elevated. Bone cultures

are negative. Biopsy shows changes characteristic of
inflammation of bone.
Treatment: The disease undergoes spontaneous
resolution. Only anti-inflammatory medication is
required for pain. No antibiotics are required.

Osteomyelitis in Sickle Cell Disease

Patients with sickle cell disease are prone for sickle cell crisis
(bone infarction) leading to bone pains. About 0.2 to 5%
of these patients have coexisting osteoarticular infection.
Staphylococcus aureus and Salmonella are the common
organisms responsible (of these two, which is more common,
is still a matter of controversy in the literature).
The vaso-occlusive sickle cell crisis (infarction) is
characterized by:
z
Pain in one or more bone or joint
z
Fever
z
Point tenderness, swelling joint effusion and warmth.
These features are also present in osteomyelitis co-existent
with bone infarction. However, the pain because of vasoocclusive sickle cell crisis tends to settle down rapidly, within
3 to 5 days, with appropriate medical management
(analgesics, hydration and oxygen). If the patient fails to
improve within 2 to 4 days, a strong clinical suspicion of
infection should be raised.
z
Laboratory investigations:

TLC, DLC and ESR are deranged in both, i.e. vasoocclusive crisis and coexistent infection. ESR is usually

60

First Aid and Emergency Management in Orthopedic Injuries

higher in latter (> 20 mm in 1st hour). ESR may

otherwise be falsely low in patients of sickle cell
disease.

X-ray changes of diaphyseal periosteal reaction are

common to sickle cell infarction and osteomyelitis
alike. But, infective process leads to moth eaten lytic
areas in the bone, progressive periosteal reaction and
longitudinal fissuring, indicative of chronic
diaphyseal osteomyelitis. Sequestration and
involucrum formation may follow.

Bone scan if performed within first 72 hours will

demonstrate decreased uptake in case of infarction
without co-existent infection. After about 3 days,
increased vascularity around infarction reflects
changes similar to bone infection on bone scan.
So, bone scan performed within first 72 hours may be
of some help, though not absolute, in differentiating
vaso-occulsive crisis from infection. Additional bone
marrow scans with 67Ga citrate (Increased uptake on
99
Tc, with decreased uptake on marrow scans suggest
infection) and ultrasound (showing any collection in case
of infection) may further help in identifying the infection.
z
Aspiration: In case of strong clinical suspicion of
infection, aspiration of the suspected bone with Gram
stain and culture of the aspirate, may prove quite useful
in confirming the diagnosis.
z
Treatment: In large majority of cases the cause of bone
pains is infarction rather than infection. Medical
treatment (analgesics, hydration and oxygen) for initial
2 to 3 days are justified unless there is a strong suspicion
of infection. Patients with infarction tend to settle with
this treatment in 2 to 4 days. If patient fails to improve
in 2 to 4 days or the patient has high grade fever with
high ESR (usually > 20 mm 1st hour), then it is wise to
start IV antibiotic. Cefotaxime or ceftriaxone are
preferred antibiotics as they cover both, Salmonella as
well as Staphylococcus aureus. The role of surgical debrima
is controversial in literature; unless there is frank abscess,
which if present, should be drained.
If the patient has septic arthritis associated with sickle
cell disease, the most common infecting organism is
Staphylococcus aureus. Drain the joint if there is collection.

manner in emergency setting. However, in an immunecompromised host, it may present in an atypical acute
exudative manner. 8 In subcutaneous areas also, the
tubercular process may lead to rapid accumulation of abscess
and the overlying skin may become tense and glossy with
some amount of inflammation. In this situation also
tubercular process may seem to appear in an acute manner
with history of few days or a week or two (Fig. 7.17).
The typical feature of osteoarticular tubercular infection
include general malaise, easy fatigability, loss of appetite,
loss of weight and local signs and symptoms pertaining to
the involved area. Formation of (caseous material) cold
abscess is hallmark of Tuberculosis. Of all the musculoskeletal involvements, spine is affected in 50% of patients.
Tubercular process can also involve a bone or a joint.
Spinal Tuberculosis (Potts Spine)

Potts spine is common in thoracic and lumbar areas.

The classical presentation of spinal tuberculosis (Potts
spine) is that of:
z
Chronic back pain, spasm and restriction of spine
movements.
z
Kyphotic deformity in late cases (Fig. 7.18).
z
The cold abscess from spine can track along facial planes
or may remain prevertebral

In cervical spine prevertebral collection can produce

dysphagia, stridor or difficulty in breathing (called
Milar Asthma) (Figs 7.19A and B).

TUBERCULOSIS
Tuberculosis being a chronic osteoarticular infection, caused
by Mycobacterium, usually does not present in an acute

Fig. 7.17: Acute exudative presentation of tubercular

osteomyelitis of ulna. (For color version, see Plate 4)

61

Orthopedic Infections
z

Fig. 7.18: Gibbus (kyphotic deformity) in a case of Potts spine.

Note the prominence of spinous process in midthoracic area.
(For color version, see Plate 4)

Cold abscess from thoracic spine may present in

midaxillary line or anterior chest wall.
Cold abscess from lower thoracic spine or lumbar
spine can track along psoas sheath (psoas abscess) or
present in lumbar area or groin or inguinal or gluteal
area, tracking along various neurovascular structures.
Case of Potts spine may present with neurological
deficit in emergency set-up (called as Potts paraplegia)
due to cord compression or infective thrombosis of
arteries supplying spinal cord.
Epidural collection of caseous material can cause acute
outset paraplegia or quadriplegia (Fig. 7.20).

Radiographic Features
z

Figs 7.19A and B: Huge prevertebral collection of cold abscess

in tuberculosis of cervical spine in a child (A), and an adult (B).

Classicinvolvement of paradiscal area (destruction/ lysis/

fuzziness) of two contiguous vertebral with reduction in
the height of intervertebral disk space coupled with
paraspinal soft tissue shadow (picture almost
pathognomonic of TB spine) (Figs 7.21A and B).
In early case where vertebral destruction is not evident
on an X-ray, MRI shows vertebral body edema of two
contiguous vertebral with prevertebral or paravertrebal
soft tissue collection (Figs 7.22A to C) (Rememberit
requires 50% decalcification of the involved area or the
size of the area of destruction, by any destructive process,
has to be > 1cm to show up on a plain X-ray).

MRI is extremely useful in diagnosis of intraspinal

tubercular granuloma with normal bony architecture
on X-ray (Fig. 7.20).

CT scan demonstrates minor vertebral erosions or

involvement of posterior vertebral elements, findings
which may not be visible on plain.

Tubercular Arthritis
z
z

Fig. 7.20: Large extradural tubercular granuloma, extending from

D4 to D12, as seen on MRI.

z
z

Hip and knee are commonly involved.

Usually a chronic disorder characterized by pain,
swelling, effusion, marked muscle wasting (out of
proportion) and deformity (in late case).
Tubercular joints usually do not have signs of acute
inflammation.
Synovium may be palpably thickened (knee).
There can be palpable, fluctuant cold abscess.

62
z

First Aid and Emergency Management in Orthopedic Injuries

Cold abscess may burst and form a sinus. The sinus

typically has undermined margins and discharge serous
fluid, with or without caseous material (Fig. 7.23).
Draining lymph modes may be enlarged and matted.
Sometimes these lymph nodes may caseate and form cold
abscess (Figs 7.24A and B).
Rarely, tubercular arthritis may present with acute
symptoms of few days duration in an immunocompromised host.

Radiographic Features
z

The classical triad ismarked osteopenia of the

articulating bones, reduction in radiological joint space
and erosion or fuzziness of margins of bone(s) at articular
ends (Figs 7.25A and B).
There could be associated soft tissue swelling or
radiological shadow of cold abscess (Fig. 7.26).
In some cases there may be lytic (areas of destruction)
areas in adjacent bones. These lytic areas have fuzzy
margins (Figs 7.27A and B).

Tubercular Osteomyelitis
z

z
z
z
z

Figs 7.21A and B: Classical radiological picture of Potts spine

involving D7-D8 and D8-D9. (A) AP view showing destruction in
D7-D8 and D8-D9 paradiscal area along with paravertebral soft
tissue shadow. (B) Lateral view showing reduction in radiological
disk space height between D7-D8 and D8-D9 with fuzzy paradiscal
margins. Compare the height of intervertrebral disk in the diseased
area with disk height above and below (i.e. disk space between
D6-D7 and D9-D10). This radiological picture is almost pathognomonic of Potts spine.

Most common involvement, by tubercular osteomyelitis

process, is seen in vertebral bodies.
Usually involves short tubular bone of hand and feet.
May involve long bones.
Multiple bones may be involved in a child (Fig. 7.28).
There may be swelling, discharging sinus with serous or
caseous discharge (Fig. 7.23).
Draining lymph modes may be enlarged and matted.
Sometimes, these lymph nodes may caseate and form
cold abscess (Figs 7.24A and B).
Tubercular swelling usually does not have signs of acute
inflammation, unless it is about to burst on the skin
surface (Figs 7.29 and 7.30).
Concomitant arthritis can develop if the tubercular focus
at the end of bone bursts into the joint (Fig. 7.31).

Figs 7.22A to C: Early tuberculosis of spine as seen on MRI. (A) T1-weighted image showing signal change, i.e. hypointense signal in
D6-D7 vertebra. (B) T2-weighted image showing hyperintense signal at the same level. (C) Transverse section showing pre- and
paravertrebral collection. The plain X-ray in this case was normal.

Orthopedic Infections

63

Fig. 7.23: Classical caseous discharge from the sinus in a case of pes anserinus tubercular
bursitis. (For color version, see Plate 4)

Figs 7.24A and B: Inguinal lymph nodes enlargement in a case of tubercular knee right side. (A) Swelling and fullness in right knee in
infrapatellar region. (B) Inguinal lymphadenopathy right side. (For color version, see Plate 5)

Figs 7.25A and B: Classical radiological findings of tuberculosis of ankle left side. (A) AP view showing marked osteoporosis of the
regional bones, reduction in joint space, fuzziness of bone margins at articular ends and soft tissue swelling. Normal right side included
for comparison. (B) Lateral view of the same patient showing marked osteopenia.

64

First Aid and Emergency Management in Orthopedic Injuries

Fig. 7.26: Soft tissue shadow of cold abscess in a case of proximal humeral tubercular osteomyelitis
with tubercular arthritis of left shoulder.

Figs 7.27A and B: Tubercular osteomyelitis lower end right tibia with tubercular arthritis of right ankle: (A) AP and (B) Lateral view. Normal
left side given for comparison. Please note lytic expansile lesion in the lower part of tibia on right side with ill-defined fuzzy margins.

Fig. 7.28: Multiple bony involvement by tubercular process in child. Right humerus, left ulna, left first metacarpal,
proximal phalanges of right index and ring finger, second and third metatarsals on left side are involved.

Orthopedic Infections

Fig. 7.29: Cold abscess associated with tubercular osteomyelitis

of second metatarsal. Note that there are no signs of inflammation
around swelling. (For color version, see Plate 5)

65

Fig. 7.31: Classical tubercular focus in the lower end of humerus

medial to olecranon fossa. This patient developed tuberculosis of
elbow. The tubercular focus has fuzzy undefined margins. Similar
focus can be observed in capitellar area also.

Radiographic Picture
z

Tubercular bony lesions are typically lytic areas

(metaphyseal or diaphyseal) with ill-defined, fuzzy
margins. At times these lesions have soft coke like
sequestrum (Figs 7.31 and 7.32).
There is little or no bone reaction (nonbone formation/
periosteal reaction) unless there is a discharging sinus
(which permits secondary pyogenic infection).
In children tubercular lesions may be cystic on X-ray
(Fig. 7.28).
Tubercular lesion in children can typically transgress
growth plate (Fig. 7.32B).
Small tubular bones of hand and feet give ballooned out
appearance, called spina ventosa.

Diagnosis of Osteoarticular Tuberculosis

z

Fig. 7.30: Cold abscess around left elbow, associated with

tubercular osteomyelitis of proximal ulna. The abscess is about to
burst and hence the overlying skin is showing redness and signs of
inflammation. (For color version, see Plate 5)

In endemic areas, diagnosis of osteoarticular TB can be

confidently made on clinicoradiological picture only, as
has been described above.
Supportive parameters includeraised TLC, lymphocytes (on DLC), ESR and CRP.

66

First Aid and Emergency Management in Orthopedic Injuries

Figs 7.32A and B: (A) Classical tubercular focusa lytic area with
fuzzy margins in the upper end of tibia on lateral side. This focus has
a soft coke like sequestrum contained in it. This radiological picture
is almost classical of tubercular osteomyelitis. (B) Tubercular focus
in the lower end of femur in a child. Note that the lesion transgresses
the physis and has a soft coke like sequestrum in it along with soft
tissue swellinga picture classical of tubercular focus.

Fig. 7.33: Scar mark of naturally healed untreated lymph node

tuberculosis in left supraclavicular area in a female. This patient
had a history of swelling in this area in childhood which had burst,
then discharged for a few months and then healed on its own without
any medication. Note that tubercular lesion can sometimes heal by
natural immunity or by antibiotics prescribed for pyogenic lesions,
such as quinolones. (For color version, see Plate 5)

Normal blood parameters do not rule out TB.

Mantoux test is positive (except in case with low immune
status).
Patient may exhibit an old healed scar of untreated, naturally healed skin or lymph node tuberculosis (Fig. 7.33).
Chest X-ray is positive for a focus of pulmonary
tuberculosis in 16 to 20% cases.
Estimation of IgG, IgM and IgA in serum, against
Mycobacterium tuberculosis, are of not much help. One
should not rely on the levels of these immunoglobulins
to make a diagnosis of osteoarticular TB.
Aspiration of fluctuant swelling (cold abscess) if yields
caseous flakes in serous background, strongly indicate
tubercular infection. The tubercular pus however may
resemble pyogenic pus, and one should not make a
diagnosis solely on the gross appearance of the pus.
Smear made out of material from diseased area may
demonstrate acid fast bacilli, in about 10% cases, on
Ziehl-Neelsen staining.
The most conclusive proof of tuberculosis lies in
demonstration of Mycobacterium tuberculosis on culture.
Culture on Lowenstein-Jensen media takes about 4 weeks
to show mycobacterial growth. Bactec method may show
growth in 4 to 14 days.
Polymerase chain reaction (PCR) or Nucleic acid
amplification test for Mycobacterium tuberculosis, from
material obtained from diseased area, can demonstrate

Mycobacterium within 24 to 48 hours. This test rapidly

identifies atypical Mycobacterium also.
FNAC from enlarged draining lymph node(s) is also
helpful in making a diagnosis. However, an experienced
pathologist is required for interpretation.
Caseation necrosis seen on histopathological examination, in tubercle (Granuloma) is diagnostic of
tuberculosis.

z
z

Treatment of Osteoarticular Tuberculosis

z

Rule out concomitant HIV infection or other disorders

causing immunosuppression (like diabetes mellitus or
patient on anticancer therapy), if the patient is from nonendemic area.
Multidrug antitubercular chemotherapy is prescribed
according to the weight of the patient.
First line antitubercular drugs (ATT) include Isoniazid,
Rifampicin, Ethambutol and Pyrazinamide.
Acute onset rapid paraplegia (or quadriplegia) secondary
to Potts spine or intraspinal tubercular granuloma are
emergencies and require immediate decompression
surgery. Such patients should be immediately put on
ATT. Do not permit sitting or walking, to a patient of
neurological deficit secondary to Potts spine, to avoid
worsening of neural deficit.
Cervical prevertebral cold abscess if causing dysphagia
or stridor require immediate aspiration/drainage.

Orthopedic Infections
z

Any large cold abscess threatening to burst (characterized

by subcutaneous swelling with tense glossy overlying
skin) or large psoas abscess should be aspirated. Repeated
reformation of large cold abscess(es) despite multiple
aspirations (3 aspirations) require evacuation.
Indicated orthopedic treatment (in form of support, slab
or cast, splint or traction) depending upon site of
involvement is added.

REFERENCES
1. Morrey BF, Peterson HA. Hematogenous pyogenic
osteomyelitis in children. Orthop Clin North Am 1975;
6(4):935-51.
2. Peltola H, Vahvanen V. A comparative study of osteomyelitis
and purulent arthritis with special reference to aetiology and
recovery. Infection 1984;12(2):75-9.

67

3. Morrey BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in

children. Orthop Clin North Am 1975;6(4):923-34.
4. Kolyvas E, Shronheim G, Marks MI, et al. Oral antibiotic
therapy of skeletal infections in children. Pediatrics
1980;65:867.
5. Tuson CE, Hoffman EB, Mann MD. Isotope bone scanning
for acute osteomyelitis and septic arthritis in children. J Bone
Joint Surg 1994;76-B:306.
6. Carr AJ, Cole WG, Roberton DM, et al. Bone scintigraphy
in the detection of chronic recurrent multifocal osteomyelitis.
J Nucl Med 1998;39:1778.
7. Gamble JG, Rinsky LA. Chronic recurrent multifocal
osteomyelitis: a distinct clinical entity. J Pediatr Orthop
1986;6:579.
8. Tuli SM. Tuberculosis of the skeletal system. Jaypee Brothers
Medical Publishers: New Delhi; 1997.