European Journal of Radiology 60 (2006) 221232

Review
Acute osteomyelitis, septic arthritis and discitis:
Differences between neonates and older children
A.C. Ofah

Department of Radiology, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
Received 22 June 2006; accepted 13 July 2006
Abstract
There are aetiological, clinical, radiological and therapeutic differences between musculoskeletal infection in the neonate (and infant) and
in older children and adults. Due to the anatomy and blood supply in neonates, osteomyelitis often co-exists with septic arthritis. Discitis is
more common in infants whereas vertebral body infection is more common in adults. This review article discusses the important clinical and
radiological differences that in the past have led many authors to consider neonatal osteomyelitis a separate entity from osteomyelitis in the
older child.
2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Neonate; Infection; Osteomyelitis; Arthritis; Discitis; Imaging
Contents
1. Nomenclature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
2. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
3. Anatomical considerations and pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
4. Clinical presentation and laboratory ndings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
5. Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
5.1. Radiography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
5.2. Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
5.3. Scintigraphy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
5.4. Magnetic resonance imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
5.5. Computed tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
6. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
7. Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
1. Nomenclature
The termosteomyelitis refers to infection of bone and/or bone
marrow. Depending on both the virulence of the organism and
the immune response mounted by the host, osteomyelitis may be
acute, subacute or chronic. Acute osteomyelitis is not common

Tel.: +44 20 7405 9200x5269; fax: +44 20 7829 8665.

E-mail address: ofaa@gosh.nhs.uk.
in adults [1]. Conversely, in neonates osteomyelitis is usually
acute [2].
Septic arthritis refers to infection of a joint. While this may
occur in isolation, in neonates it is much more likely to occur
as a consequence of bony infection (osteomyelitis) with spread
into the adjacent joint.
Discitis refers to infection of a disc space and adjacent ver-
tebral end plates.
Vertebral infection indicates infection of the vertebral body.
Because of the differences in vascular supply (see below), ver-
0720-048X/$ see front matter 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2006.07.016
222 A.C. Ofah / European Journal of Radiology 60 (2006) 221232
Fig. 1. AP chest of an infant with septic arthritis of the right shoulder. Notice
Salter Harris I injury of the shoulder (compare the relationship of epiphysis and
metaphysis with the normal left side) as a result of a large joint effusion.
tebral infection is less commonly seen in infants and young
children than in teenagers and adults.
2. Pathogenesis
Infection may reach the bone (or joint) via three main routes:
The bloodstream, i.e. haematogenous spread. This is the com-
monest route of infection in the neonate.
Direct contamination, e.g. penetrating or puncture wounds,
surgery. This route of infection is commoner in older children
and adults.
Indirect contamination froma nearby infection, e.g. cellulitis.
The causative organismdepends on the age of the patient, and
in the neonate is most commonly Staphylococcus aureus. Other
organisms include Escherichiacoli, Group-BStreptococci, other
Gram-negative rods and Candida albicans [68].
Since the introduction of the HiB vaccine, the incidence of
Haemophilus inuenza infection in infants and older children
is much reduced [9], with S. aureus and Group-A Streptococci
being the more common causative organisms.
Infection with Neisseria gonorrhoeae occurs in adolescents.
Salmonella should be considered in children with sickle cell dis-
ease. Fungal, parasitic and mycobacterial infection may occur,
particularly in the immunocompromised host and in endemic
regions [10].
In childhood discitis, a causative organism is not com-
monly isolated [11] and biopsy should be reserved for those
failing to respond to anti staphylococcal therapy. Atypical
Fig. 2. Sequential radiographs in a neonate with osteomyelitis of the left femur.
(A) Lateral of both knees on day of presentation. Note signicant swelling
of the left knee compared to the right. There is early periosteal reaction of
the distal femoral shaft (arrow). There is possibly increased metaphyseal and
epiphyseal radiolucency compared to the normal side. (B) AP radiograph left
knee on day of presentation. Periosteal reaction of the distal femur (arrows) is
better appreciated on this radiograph. (C) AP and lateral radiographs left knee
4 days following initial radiographs. Metaphyseal irregularity and radiolucency
and periosteal reaction of the distal femur are well demonstrated. (D) AP and
lateral radiographs left knee 16 days following initial radiographs. The soft tissue
swelling has resolved. Periosteal reaction has consolidated. (E) AP radiograph
left knee 2.5months after initial radiographs. There is almost complete resolution
of changes following adequate antibiotic therapy.
A.C. Ofah / European Journal of Radiology 60 (2006) 221232 223
Fig. 2. (Continued ).
224 A.C. Ofah / European Journal of Radiology 60 (2006) 221232
infections include tuberculosis, brucellosis, and fungal disease
[12].
3. Anatomical considerations and pathophysiology
The unique vascular anatomy of the epiphyses in neonates
and infants accounts for the frequency with which osteomyelitis
and septic arthritis co-exist.
The reduced rate of blood ow within vessels at the meta-
physis renders this region more susceptible to haematogenous
seeding of infection [13]. Before the appearance of secondary
ossication centres, the cartilaginous epiphyses receive their
blood supply directly from metaphyseal blood vessels. Hence,
septic arthritis is a relatively common sequel to osteomyelitis in
the neonate, particularly in joints such as the hip, in which the
metaphysis is intracapsular. It is said that in neonatal osteomyeli-
tis, infection leads to epiphyseal insult or septic arthritis in 76%
of cases [4].
Because of the lax nature of the surrounding muscles, the
presence of a joint effusion in neonates may lead to subluxation
or dislocation of the affected joint (Fig. 1).
In addition, the accumulation of inammatory exudate within
the joint causes vascular compression and may result in avas-
cular necrosis of the affected epiphysis. Septic arthritis is a
clinical emergency, and prevention of signicant long-termmor-
bidity depends on timely diagnosis and relief of pressure; either
by ultrasound guided joint aspiration or more invasive surgical
techniques.
In older children and adults, the epiphyses and metaphyses
have a separate blood supply, and spread of infection from bone
to joint (or vice versa) is far less common. Furthermore once
epiphyseal fusion has occurred, long-term complications relat-
ing to epiphyseal damage and limb length discrepancies are less
of an issue.
Bones and joints of the lower limb are most commonly
affected. Other sites include the upper limbs, and more com-
plicated locations such as the pelvis and the spine (discitis).
Discitis in the neonate and young child most commonly
affects the lumbar spine. Infection is more likely to reach the
spine through the nutrient arteries than via the paravertebral
venous system [14]. In a similar way to metaphyseal infec-
tion, spinal infection follows arterial septic embolisation. In
infants and young children, the cartilaginous vertebral end plates
are traversed by numerous canals through which small blood
vessels pass. These vessels terminate adjacent to the inter-
vertebral disc thus rendering the disc susceptible to infection.
The vascular channels disappear by the third decade of life
[15], hence the reduced incidence of discitis in older children
and adults. The vertebral bodies of infants and small chil-
dren have a large network of interosseous collateral arteries
which is not found in adults. This renders the vertebral bod-
ies of infants less susceptible to infarction from septic emboli
and more able to clear bacteria following septic embolisation.
This explains the reduced incidence of vertebral body infection
in infants and young children compared to older children and
adults [12].
Fig. 3. AP pelvis in an infant with septic arthritis and osteomyelitis of the L
hip. Notice the patchy radiolucency and sclerosis of the femoral neck at the
site of osteomyelitis. The left femoral head is irregular, small and fragmented
compared to the right consistent with an associated septic arthritis (in infants,
osteomyelitis of the proximal femoral metaphysis often co-exists with septic
arthritis).
4. Clinical presentation and laboratory ndings
Osteomyelitis and arthritis are commoner in young children
than in older children and adults, peaking at around the age of 3
years for osteomyelitis and 2 years for septic arthritis [25].
Compared to older children and adults, there are fewer clini-
cal signs and the diagnosis of osteomyelitis and/or arthritis may
Fig. 4. AP right arm. Osteomyelitis of the humerus. There is soft tissue swelling
with pockets of gas within the soft tissues. There is permeative destruction of
the entire length of the humerus and associated periosteal reaction.
A.C. Ofah / European Journal of Radiology 60 (2006) 221232 225
therefore be harder to make. This is largely because of the poorly
developed immune systemof neonates, rendering themless able
to mount an immune response. For this reason, they are at greater
risk of infection by less virulent organisms and may not present
with fever. Furthermore, neonates with osteomyelitis and/or sep-
tic arthritis may have a normal leucocyte count and erythrocyte
sedimentation rate [2].
Clinical symptoms include poor feeding and/or irritability.
There may be a history of swelling or failure to move the affected
limb (pseudoparalysis). An older child with discitis may com-
plain of back pain. Younger children will have reduced mobility
or may present with a limp. The young child with discitis may
be afebrile. Because of these non-specic clinical symptoms, a
high index of suspicion is required in order to make an early
diagnosis of osteomyelitis, septic arthritis or discitis.
Risk factors in neonates and young children include prema-
ture birth, umbilical catheterisation (artery or vein), urinary tract
infections and other pre-existing disease. Risk factors in adults
include diabetes mellitus and a compromised immune system
(including HIV).
5. Imaging
The role of imaging is to conrm the presence and site of
infection, to differentiate unifocal from multifocal disease, to
locate and guide aspiration of collections and to identify present
or impending complications such as joint or extradural involve-
ment.
Radiography is usually the rst radiological investigation in
a neonate with suspected osteomyelitis/septic arthritis/discitis.
Other modalities include ultrasound (US), bone scintigraphy,
magnetic resonance imaging (MRI) and computed tomography
(CT). These are each discussed separately below.
5.1. Radiography
Radiographic features in osteomyelitis and/or septic arthritis
include deep soft tissue swelling, widening of the joint space
with or without subluxation (Fig. 1) or frank dislocation, osteo-
porosis, periosteal new bone formation and bony destruction
(Figs. 25). Deep soft tissue swelling may be difcult to recog-
Fig. 5. Sequential radiographs in an infant with osteomyelitis of the left humerus. (A) Radiograph obtained at time of referral to tertiary center. Bony destruction
is better dened than in the patient illustrated in Fig. 4. The soft tissues plains do not appear obliterated (however see MRI obtained at the same time, Fig. 11). (B)
Radiograph obtained 8 months after that shown in (A). Almost complete return to normal following adequate therapy.
226 A.C. Ofah / European Journal of Radiology 60 (2006) 221232
Fig. 6. AP and lateral spine in a child with discitis. Note narrowing of the affected disc space and irregularity and sclerosis of the vertebral end plates at that level,
particularly anteriorly (B).
nise inthe neonate because of the poor denitionof fascial planes
and relative lack of subcutaneous fat present at this age [2].
It should be noted that radiographs have a low sensitivity for
detecting the presence of a joint effusion [16]suspicious fea-
tures include widening of the joint space and bulging of the soft
tissues. Radiography allows the exclusion of other conditions
such as fractures and is useful for the long-term follow up of
complications.
Soft tissue swelling can be detected as early as 48 h after onset
of infection [17]. However, bony destruction is not detectable
radiologicallyuntil at least a thirdof the matrixhas beeninvolved
[18]. This accounts for the low prevalence of abnormal radio-
graphs at presentation, e.g. Capitanio and Kirkpatrick reported
that only 20%of radiographs were abnormal at 1014 days [19].
Ahigh index of suspicion and further imaging with other modal-
ities will often be required.
Initial ndings in the spine may be limited to a loss of the nor-
mal lumbar lordosis. Subsequently disc space narrowing (Fig. 6)
with end plate erosions will develop. Long standing infection
may lead to pressure erosion of the superior and inferior mar-
gins of the adjacent vertebral body. Although contiguous disease
is recognised, infection is more commonly seen to affect a single
level.
5.2. Ultrasound
Although non-invasive, ultrasound is an operator dependant
technique. In able hands, changes of acute osteomyelitis may be
detected as early as 48 h after onset of infection [20]. Ultrasound
allows the detection of subperiosteal collections [21] and joint
effusions and therefore is extremely useful in neonates suspected
of having a septic arthritis. It should be emphasised however,
A.C. Ofah / European Journal of Radiology 60 (2006) 221232 227
that neither the size nor the echogenicity allows the radiologist
to rmly conclude whether the detected effusion is infected or
otherwise [22]. Conversely, the same authors showed that septic
arthritis of the hip was extremely unlikely in the absence of
an effusion [22]. Note that a normal ultrasound scan does not
exclude osteomyelitis [23].
Mah et al. documented the chronology of ultrasound nd-
ings in acute osteomyelitis. The earliest nding was deep soft
tissue swelling, followed by elevation of the periosteum by
a thin layer of uid (Fig. 7), a denite subperiosteal collec-
tion (Fig. 8) and nally cortical erosion. The prevalence of
these ndings depended on the duration of clinical signs; thus
soft tissue swelling was at a maximum prevalence in patients
with symptoms of 13 days duration while cortical erosions
were commonest at 24 weeks. Concurrent septic arthritis was
diagnosed in just under a third of patients. All ultrasound
scans had returned to normal by 4 weeks after clinical cure
[24].
In addition to allowing the conrmation of a joint effusion,
ultrasound serves to guide needle aspiration of the affected
joint(s).
Fig. 7. Ultrasound left femur in a 14-day neonate. There is increased echogenic-
ity of the deep soft tissues around the distal femur. This is associated with
minimal elevation of the periosteum by a small amount of subperiosteal uid
(arrow).
Fig. 8. Ultrasound left femur in a 16-day neonate. There is a 2 mmsubperiosteal
collection in the lateral aspect of the left distal femur.
5.3. Scintigraphy
Bone scintigraphy is more sensitive than radiography for
the detection of osteomyelitis in the early stages of disease;
for example, in one study it was found that in the rst week
of disease, radiography and technetium (
99m
Tc)-labelled bone
scans were positive in 42% and 87% of cases, respectively [25].
Scintigraphy is useful for detecting multiple foci of infection.
Fig. 9. Triple phase
99m
Tc-labelled isotope bone scan (same patient as Fig. 7).
Figures illustrate increased uptake in the distal left femur in the blood pool
(A) and delayed phases (B). Note the physiological increased uptake of the
metaphyses (B)this may obscure subtle pathological increased uptake in less
obvious cases than that illustrated.
228 A.C. Ofah / European Journal of Radiology 60 (2006) 221232
Fig. 9. (Continued ).
Multifocal disease is more commonly seen in neonates than in
older children in whom either monoarticular septic arthritis or
unifocal osteomyelitis is the norm [5,26].
Because of the increased vascularity of the metaphyseal
region in neonates and children, high quality images, magni-
cation and pin-hole collimation are required to differentiate
physiological from pathological increased uptake [1]. Single
photon emission computed tomography (SPECT) and positron
emission tomography with
18
F-labelled FDG further increase
the spatial resolution, allowing improved visualisation of abnor-
mal sites [27].
Various isotopes may be employed. Typically bone scans are
performed using a
99m
Tc-labelled phosphonate complex. When
infection is suspected then a triple phase bone scan is performed.
In the past, the use of gallium-67 citrate (Ga) has been advo-
cated; it should be noted that Ga does not differentiate soft
tissue from bony uptake, and for this, as well as radiation dose
considerations, is increasingly being replaced by
99m
Tc hexam-
ethylpropylene amineoxamine (
99m
TcHMPAO) labelled white
blood cells [1].
Diagnostic (but non-specic) features on scintigraphic stud-
ies include evidence of hyperperfusion (Fig. 9) with increased
A.C. Ofah / European Journal of Radiology 60 (2006) 221232 229
uptake in all three phases (perfusion, blood pool activity and
bone metabolism) of the triple phase bone scan. In contrast to
adults, infection in children rarely involves the entire length of
the diaphysis [1]. The radiologist should beware of cold spots
(photopaenic areas), which in neonates may lead to a false neg-
ative scan. These cold spots occur as a result of decreased blood
ow secondary to oedema and infection (subperiosteal or artic-
ular) [27].
Bone scans are often reserved for cases in which clinical sus-
picion is high, yet radiographs and/or ultrasound are equivocal,
and in neonates for suspected multifocal infection. Bone scans
are also useful in suspected chronic multifocal osteomyelitis
CRMO, in the older child and to conrm suspected discitis in
children whose radiographs are normal.
5.4. Magnetic resonance imaging
MRI plays an important role in dening the (multiplanar)
extent of soft tissue involvement. This is particularly true in
complex sites such as the spine (discitis) for the exclusion of
extradural collections causing spinal cord compression. MRI
gives excellent soft tissue and bone contrast, and is particularly
useful in the neonate and young child, allowing the assessment
of cartilaginous (including growth plate) involvement.
Active inammation and infection returns a low signal on T1
weighted and a high signal on T2 weighted and STIR sequences
(Fig. 10C). The degree of bony involvement in osteomyelitis
may be overestimated as areas of reactive/sympathetic inam-
mation will return a similar signal pattern. In isolated septic
Fig. 10. AP radiographs and coronal STIR MRI of left arm and shoulder in a neonate aged 3 weeks at presentation. (A) AP left humerus at presentation. There is a
faint area of radiolucency in the left proximal humeral metaphysis (long arrow). There is also periosteal reaction medially (short arrow). (B) AP left humerus 7 days
after presentation. The lucent metaphyseal lesion is nowreadily identied. (C) AP left humerus 3 weeks after initial presentation. As healing begins, there is increased
sclerosis around the margins of the lesion. (D) Coronal STIR left humerus. Note the focus of high signal in the humeral metaphysis (arrow) which corresponds to
the lucent metaphyseal lesion seen on the radiographs. There is high signal (oedema) of the surrounding soft tissues.
230 A.C. Ofah / European Journal of Radiology 60 (2006) 221232
Fig. 10. (Continued ).
Fig. 11. Coronal T1 pre- and post-gadolinium left arm (same patient as Fig. 5). On the pre-contrast image (A), the humeral shaft is seen to return a lower signal than
the metaphysis and epiphysis. The post-contrast image (B) illustrates the degree of soft tissue inammation (which is not apparent on the radiographFig. 5). The
proximal humeral epiphysis is spared from the infective/inammatory process, and does not enhance.
A.C. Ofah / European Journal of Radiology 60 (2006) 221232 231
Fig. 12. Contrast enhanced T1 weighted MR images of the spine: (A) axial
and (B) sagittal. Both images demonstrate a collection beneath the anterior
longitudinal ligament (arrows). On the sagittal images, notice the enhancement
of superior and inferior end plates of the adjacent vertebral bodies.
Fig. 13. Axial CT scan spine (same patient as Fig. 12). CT guided aspiration of
the collection identied on MRI.
arthritis, abnormal signal from bone marrow should rarely be
seen. The use of gadolinium (Fig. 11) allows the denition of
soft tissue, subperiosteal and interosseous collections which are
identiedfollowingperipheral enhancement (of their walls) with
central low signal non-enhancement (debris/pus/uid).
MRI of the spine is useful in children not responding
to therapy and/or to detect complications such as extradural
and paraspinal collections that will require surgical treatment
(Fig. 12).
5.5. Computed tomography
CT has a limited role in the diagnosis of acute haematoge-
nous musculoskeletal infection in the neonate. It is more useful
in chronic osteomyelitis where it is superior to MRI for the
demonstration of cortical destruction, air and sequestra [28]. It
may also be used to guide aspiration and biopsy, especially when
the spine and paraspinal soft tissues are involved (Fig. 13).
Fig. 14. AP pelvic radiograph of a child aged 5 years and 2 months. This patient
had a history of septic arthritis of the left hip. There is signicant abnormal-
ity of the left hip which is dislocated with secondary acetabular dysplasia.
There is no ossied femoral head. There is partial resorption of the femoral
neck and proximal shaft. Notice the pelvic tiltcompensating for the leg length
discrepancy.
232 A.C. Ofah / European Journal of Radiology 60 (2006) 221232
6. Complications
Considerable morbidity may be associated with neonatal
osteomyelitis and/or septic arthritis. Early diagnosis and treat-
ment are critical if complications are to be minimised. This is
particularly true of septic arthritis, as damage to articular carti-
lage (secondary to proteolytic enzymes released from synovial
cells) begins rapidly [4]. Complications include:
damage to the growth plate with premature and/or asymmet-
rical closure of the growth plate;
avascular necrosis of the femoral head with or without com-
plete dissolution of the femoral head and neck (Fig. 14);
pseudoarthrosis;
limb length discrepancies, made more obvious as the child
grows;
angular deformities at joints, also made more obvious with
progressive growth;
joint dislocations;
joint arthrodesis;
vertebra magna (with narrowing of the spinal canal);
block vertebrae.
Many of these will require surgical intervention including
limb lengthening procedures, contralateral arthrodesis, insertion
of prostheses, etc.
It has been documented that as many as 40%of children with
septic arthritis of the hip will develop a serious complication, and
long-term follow up for early identication of complications is
mandatory [4].
7. Summary
There are anatomical and pathophysiological differences that
account for differences in the patterns of musculoskeletal infec-
tion seen in infants and young children compared to older chil-
dren and adults.
The various imaging techniques outlined above each play
an individual role in the diagnostic work up of a neonate with
suspected osteomyelitis and/or septic arthritis. They should be
seen as complimentary tools [29], and any particular child will
often have multiple investigations.
The sequelae of late diagnosis and delayed treatment may be
devastating, and a high index of suspicion is always required,
particularly in neonates where clinical ndings are often non-
specic.
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