Triage Considerations The patient with limp or localized musculoskeletal symptoms is often triaged as urgent Those with a question of neurovascular compromise, severe pain, or who appear systemically ill should be evaluated more immediately These patients should have their degree of pain documented and should receive analgesics on arrival Initial Assessment/H&P Physical signs of osteomyelitis are age dependent and recognition requires patience and diligence on the part of the clinician The older child is more likely to have localized infection and is more capable of expressing or identifying a specific site of pain and point tenderness The neonate or young infant may present with a pseudoparalysis of the affected limb Another common, although nonspecific, finding in this age group is paradoxical irritability in which the infant exhibits pain or distress upon handling and is more comfortable when left alone Fever and pain are classic findings but are not universally present Fever is described in up to 90% of children with acute hematogenous osteomyelitis upon presentation and may be quite elevated Signs of pain may include limp, refusal to bear weight, or a decreased range of motion when a limb is involved Erythema and swelling are less frequent but can also be observed at the site, and usually suggest more advanced periosteal involvement Osteomyelitis typically follows an indolent course and is less likely to present with the acute onset of symptoms that is more typical of traumatic injuries A history of minor trauma is common and often coincidental in an active child A history of sickle cell disease, prior surgery or skeletal manipulation places the patient at higher risk for osteomyelitis Management/Diagnostic Testing In addition to clinical findings, the diagnosis of osteomyelitis depends on culture results A blood culture and bone aspirate should be obtained in suspected cases of osteomyelitis Isolation of the causative organism is important not only for diagnosis, but also in antibiotic selection and determining the length of therapy Reports of positive blood cultures in the setting of osteomyelitis range from 30% to 57% An organism is recovered from a bone aspirate in 51% to 90% of cases The combination will identify a pathogen in 75% to 80% of cases Although blood cultures are often sterile within 24 hours of the initiation of antibiotics, bone aspirates may remain positive for several days after medication administration Therefore, therapy should not be withheld if the patient’s