Patterns of Musculoskeletal Infection in Childhood

Musculoskeletal infection during childhood is a diminishing problem in the United Kingdom. The clinical presentation may be muted and often covert. The condition remains a difficult diagnostic problem in paediatric orthopaedic practice. The clinician is faced by a child who is unwell with indeterminate symptoms and worried parents, and is concerned that subdued infection, particularly within the confines of a joint, will leave destructive changes if effective treatment is delayed. Tuberculosis presents relatively rarely, but should be considered when the social, ethnic or travel details are indicative. Pyogenic organisms are ubiquitous, often preferring the axial skeleton to a more obvious presentation in the long bones. The declaration of the inflammatory process is not simply a matter of site but reflects the effectiveness of the host response. Immunodeficiency 1 plays a role in the premature infant, in the malnourished or the child receiving cytotoxic drugs. A diminished response may also characterise ineffectual treatment with antibiotics. The altered pattern of presentation described in the paper from Glasgow in this issue of the Journal (pp 99-102) complements an earlier report by Craigen, Walters and Hackett. 2 This longitudinal study, while based on data from the Information and Statistics Division of the National Health Service (ISDN) derived from the often inaccurate SMR1 form (Scottish Hospitals discharge system), confirms a lowering of the incidence of infection in long bones in a childhood population of approximately 150 000. The review does not specifically examine whether other sites of musculoskeletal infection are still as common, or more so, but it does suggest a real alteration in the pattern of disease, possibly allied to improving standards of living. The staphylococcus is still predominant and therefore flucloxacillin remains an acceptable, if provisional, antibiotic. Surgical drainage and complications after acute osteomyelitis are unusual. The increasingly common subacute form 3 presents after a history of at least two weeks.