Acute hematogenous osteomyelitis in children: a case series

  • Komang Agung Irianto and Department of Child Health, Universitas Airlangga Medical School/Dr. Soetomo General Hospital, Surabaya, East Java
  • Adhinanda Gema and Department of Child Health, Universitas Airlangga Medical School/Dr. Soetomo General Hospital, Surabaya, East Java
  • William Putera Sukmajaya Jombang General Hospital, Jombang, East Java
Keywords: chronic hematogenous osteomyelitis; diagnosis pitfall; morbidity; pediatric; C-HAQ-DI


Background Chronic osteomyelitis is still a major cause of morbidity and disability in children living in developing countries. Neglect of acute osteomyelitis and its progression to chronic osteomyelitis leads to significant morbidity. This report is the first series to describe such cases in Indonesia.

Objective To describe 12 pediatric cases of chronic osteomyelitis in order to remind clinicians about the debilitating complications of musculoskeletal infection.

Methods This report is a case series of 12 children with chronic osteomyelitis admitted to dr. Soetomo General Hospital, Surabaya, East Java, in 2011-2017. We acquired data from medical records. The patients' quality of life was measured using the Child Health Assessment Questionnaire Disability Index (C-HAQ-DI).

Results The patients' mean age was eight years and they were predominantly male. The most common infection location was the femur (7/12). Microbial cultures were positive in 9/12 of cases, predominantly with Staphylococcus aureus. Erythrocyte sedimentation rate (ESR) was elevated in 11 patients. All patients were diagnosed late, with an average delay of presentation to Orthopedics of 10.5 months. Most of patients experienced mild to moderate disability after the disease, as assessed by the C-HAQ-DI.

Conclusion Diagnosis of osteomyelitis in children is quite difficult, given the lack of specific diagnostic tests. Delayed diagnosis and inappropriate treatment may result in long-term morbidity and disability. Clinicians should have an increased awareness of the clinical features of osteomyelitis, including unusual presentations such as calcaneal osteomyelitis.


1. Panteli M, Giannoudis P V. Chronic osteomyelitis: what the surgeon needs to know. EFORT Open Rev. 2017;1:128-35.
2. Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. Am Fam Physician. 2011;84:1027-33.
3. Beckles VLL, Jones HW, Harrison WJ. Chronic haematogenous osteomyelitis in children: a retrospective review of 167 patients in Malawi. J Bone Joint Surg Br. 2010;92:1138-43.
4. Stoesser N, Pocock J, Moore CE, Soeng S, Chhat HP, Sar P, et al. The epidemiology of pediatric bone and joint infections in Cambodia, 2007-11. J Trop Pediatr. 2013;59:36-42.
5. Committee on Registry of Childhood Disease (ICD-10). ICD 10 Registry. Philippine Pediatric Society, Inc. [cited 2018 June 29]. Available from:
6. World Health Organization, Regional Office for South-East Asia. The Republic of Indonesia health system review. New Delhi: WHO; 2017. p.229.
7. Omoke NI. Childhood pyogenic osteomyelitis in Abakaliki, South East Nigeria. Niger J Surg. 2018;24:27-33.
8. Singh G, Athreya BH, Fries JF, Goldsmith DP. Measurement of health status in children with juvenile rheumatoid arthritis. Arthritis Rheum. 1994;37:1761-9.
9. Onuminya JE. The role of the traditional bonesetter in primary fracture care in Nigeria. S Afr Med J. 2004;94:652-8.
10. Warman PL, Ismiarto YD, Ruhimat U. Complications of fracture treatment by traditional bonesetters. Althea Med J. 2018;5:47-52.
11. Dinesh Dhar MS. Acute haematogenous osteomyelitis in children. Retrospective review of 57 cases. Nigerean J Orthopaedics Trauma. 2006;5:41-4.
12. Yeo A, Ramachandran M. Acute haematogenous osteomyelitis in children. BMJ. 2014;348:g66.
13. Ponio SS, Delos Reyes CA. An epidemiologic investigation of chronic osteomyelitis among pediatric patients admitted from 2006 to 2010 at the Philippine General Hospital. Pediatr Infect Dis Soc Philipp J. 2013;14:14-23.
14. Dartnell J, Ramachandran M, Katchburian M. Haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. J Bone Joint Surg Br. 2012;94:584-95.
15. Okoroma EO, Agbo DC. Childhood osteomyelitis. A five-year analysis of 118 cases in Nigerian children. Clin Pediatr (Phila). 1984;23:548-52.
16. Jenzri M, Safi H, Nessib MN, Smida M, Jalel C, Ammar C, et al. Hematogenous osteomyelitis of the calcaneus in children: 26 cases. Rev Chir Orthop Reparatrice Appar Mot. 2008;94:434-42.
17. Mallia AJ, Ashwood N, Arealis G, Bindi F, Zamfir G, Galanopoulos I. Delayed recognition of pediatric calcaneal osteomyelitis: a case report. J Med Case Rep. 2015;9:185.
18. Mooney ML, Haidet K, Liu J, Ebraheim NA. Hematogenous calcaneal osteomyelitis in children. Foot Ankle Spec. 2017;10:63-8.
19. Yeh TC, Chiu NC, Li WC, Chi H, Lee YJ, Huang FY. Characteristics of primary osteomyelitis among children in a medical center in Taipei, 1984-2002. J Formos Med Assoc. 2005;104:29-33.
20. Peltola H, Paakkonen M. Acute osteomyelitis in children. N Engl J Med. 2014;370:352-60.
21. Maharajan K, Patro DK, Menon J, Hariharan AP, Parija SC, Poduval M, et al. Serum procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis. J Orthop Surg Res. 2013;8:19.
22. Onche II, Obiano SK. Chronic osteomyelitis of long bones: reasons for delay in presentation. Niger J Med. 2004;13:355-8.
23. Issa K, Pourtaheri S, Vijapura A, Stewart T, Sinha K, Hwang K, et al. Delay in diagnosis of vertebral osteomyelitis affects the utility of cultures. Surg Technol Int. 2016;29:379-83.
24. Sousa C, Rebelo J, Moreira A, Portugal I, Cunha R, Guerra C, et al. Pediatric osteomyelitis: an approach to differential diagnoses. Electronic Presentation Online System (EPOS): European Society Radiology; 2017. p. 1-41.
25. Oudjhane K, Azouz EM. Imaging of osteomyelitis in children. Radiol Clin North Am. 2001;39:251-66.
26. Pineda C, Vargas A, Rodríguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am. 2006;20:789-825.
27. Lee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G. The imaging of osteomyelitis. Quant Imaging Med Surg. 2016;6:184-98.
28. Canavese F, Corradin M, Khan A, Mansour M, Rousset M, Samba A. Successful treatment of chronic osteomyelitis in children with debridement, antibiotic-laden cement spacer and bone graft substitute. Eur J Orthop Surg Traumatol. 2017;27:221-8.
29. Wirbel R, Hermans K. Surgical treatment of chronic osteomyelitis in children admitted from developing countries. Afr J Paediatr Surg. 2014;11:297-303.
30. Dodwell ER. Osteomyelitis and septic arthritis in children: current concepts. Curr Opin Pediatr. 2013;25:58-63.
31. Iliadis AD, Ramachandran M. Paediatric bone and joint infection. EFORT Open Rev. 2017;2:7-12.
32. Arkader A, Brusalis C, Warner WC, Conway JH, Noonan K. Update in pediatric musculoskeletal infections: when it is, when it isn't, and what to do. J Am Acad Orthop Surg. 2016;24:e112-21.
How to Cite
Irianto K, Gema A, Sukmajaya W. Acute hematogenous osteomyelitis in children: a case series. PI [Internet]. 1Aug.2019 [cited 23Mar.2023];59(4):222-. Available from:
Case Report
Received 2019-01-01
Accepted 2019-08-01
Published 2019-08-01