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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;15\\\/7\\\/25\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;15\\\/7\\\/25\u0022}],\u0022ac\u0022:{\u0022spmdc;15\\\/7\\\/25\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;15\\\/7\\\/25\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n\u003Cp id=\u0022p-1\u0022\u003EMusculoskeletal infections are on the rise, and physicians need to recognize the patterns of variability to accurately diagnose and treat. Including magnetic resonance imaging in the diagnostic workup can help understand the full extent of a patient\u2019s infectious disease. Proposed scoring systems can also help predict severe disease.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Emusculoskeletal infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eosteomyelitis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eseptic arthritis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epericapsular pyomyositis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emultidisciplinary treatment\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Earthritis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ehip \u0026amp; knee conditions\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eorthopaedic pediatrics\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einfections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Esoft tissue disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n\n\u003Cp id=\u0022p-2\u0022\u003EThe wide variability in which patients present with musculoskeletal infections requires physicians to recognize and understand patterns of infection presentation for accurate diagnosis and treatment. Included among the different diagnoses are isolated osteomyelitis (OM), septic arthritis, pericapsular pyomyositis, and complication from the infections, such as deep vein thrombosis and pulmonary embolism. Often, however, recognizing patterns of infection can be very difficult. For most physicians on the front lines, as in emergency rooms, who are faced with a patient presenting with symptoms suggesting infection surrounding, for example, the hip, the most common default diagnosis is septic arthritis unless proven otherwise, according to Jonathan G. Schoenecker, MD, Vanderbilt University, Nashville, Tennessee, USA. However, he said, this diagnosis is often either not correct or incomplete, and what he and his colleagues are seeing in their clinic is that the majority of these patients have either pericapsular pyomyositis or a combination of bone, muscle, and joint infections.\u003C\/p\u003E\n\u003Cp id=\u0022p-3\u0022\u003EDr Schoenecker and colleagues undertook a 2-year prospective study to test the hypothesis that current diagnostic criteria are not sufficient to distinguish an infection of bone or soft tissue surrounding the hip from septic hip arthritis. In their study, they included the addition of a rapid-sequence magnetic resonance imaging (MRI) in children presenting with acutely irritable hip. The study found that about one-third of the children had pericapsular pyomyositis, and only 15% had septic hip arthritis [Mignemi ME et al. \u003Cem\u003EJ Pediatr Orthop.\u003C\/em\u003E 2014].\u003C\/p\u003E\n\u003Cp id=\u0022p-4\u0022\u003EBased on these findings, he emphasized that pericapsular pyomyositis and septic arthritis are indistinguishable without MRI. Accurate diagnosis is critical, he said, as treatment of the 2 can be very different. For patients without abscess pericapsular pyomyositis, the infection can improve with antibiotics. He also said that serial monitoring of physical examination and C-reactive protein (CRP), along with repeat MRI, are helpful in following patients with pericapsular pyomyositis.\u003C\/p\u003E\n\u003Cp id=\u0022p-5\u0022\u003EHe also emphasized the need to consider musculoskeletal infections overall as a spectrum of disease, beginning with injury and moving on to abscess and, finally, dissemination of disease. To avoid an infection reaching the dissemination phase, he encouraged physicians to monitor the acute-phase response and to use imaging to determine the location of the infection.\u003C\/p\u003E\n\u003Cp id=\u0022p-6\u0022\u003ETo illustrate the variability in which children present with musculoskeletal infections, Scott Rosenfeld, MD, Texas Children\u2019s Hospital, Baylor College of Medicine, Houston, Texas, USA, walked participants through several case studies of variable presentations of OM. Highlighted in these case studies were the varying degrees of illness in which children present with OM and the appropriate treatments based on the degree of illness, ranging from antibiotics to surgery to intensive care.\u003C\/p\u003E\n\u003Cp id=\u0022p-7\u0022\u003EFor example, one case study highlighted the need for further workup of a child with suspected septic arthritis to confirm the diagnosis and determine whether the child also may have adjacent or concomitant infections, such as OM (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). Dr Rosenfeld cited data showing that children with suspected septic arthritis often can have concomitant or adjacent infections, with one study showing 59% of children having adjacent infections and another study showing 21.5% of children with probable septic arthritis having a concomitant infection [Rosenfeld S et al. \u003Cem\u003EJ Pediatr Orthop\u003C\/em\u003E. 2015; Montgomery CO et al. \u003Cem\u003EJ Pediatr Orthop\u003C\/em\u003E. 2013].\u003C\/p\u003E\n\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16272\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16272\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16272\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003ECase Study\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-10\u0022\u003EAlthough, historically, the treatment of isolated infection of the bone was straightforward, Dr Rosenfeld said that infection has evolved into an often multisystem disease with the emergence and greater prevalence of more virulent organisms, such as methicillin-resistant \u003Cem\u003EStaphylococcus aureus\u003C\/em\u003E (MRSA) or methicillin-sensitive \u003Cem\u003ES aureus\u003C\/em\u003E. Over the past decade, he said, evidence has shown an increase in the incidence and severity of OM. Data from one study showed less isolated OM and more OM associated with abscess and septic arthritis in 2009 compared with 2002 to 2004 [Copley LA et al. \u003Cem\u003EJ Bone Joint Surg Am.\u003C\/em\u003E 2013], and another study found a clear increase in the incidence and severity of acute hematogenous OM [Arnold SR et al. \u003Cem\u003EJ Pediatr Orthop.\u003C\/em\u003E 2006]. As such, he emphasized that treatment for severe disease requires a multidisciplinary approach that often includes critical care, hematology, cardiothoracic surgery, infectious disease, interventional radiology, and orthopedic surgery.\u003C\/p\u003E\n\u003Cp id=\u0022p-11\u0022\u003EWith the increased severity of the disease, several groups are now working on ways to predict disease severity, including a proposed scoring system developed by Copley et al [\u003Cem\u003EPediatr Infect Dis J\u003C\/em\u003E. 2014] that looks at admission respiratory rate, CRP (initial measure and at 48 and 96 hours), febrile days on antibiotics, evidence of disseminated disease, and need for intensive care unit admission. Using this scoring system, they found higher disease severity scores in patients with MRSA, those requiring intensive care, those who had \u2265\u20052 surgeries, those with longer hospital stays, and those with \u2265\u20052 complications.\u003C\/p\u003E\n\u003Cp id=\u0022p-12\u0022\u003E\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E shows another scoring system to identify disease severity using CRP levels as an indicator of tissue injury [Mignemi M et al. AAOS 2015 (paper 325)].\u003C\/p\u003E\n\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16273\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16273\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16273\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003EScoring System to Identify Disease Severity\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n\u003Cp id=\u0022p-16\u0022\u003EIn addition to identifying patients most likely to have disease severity and get sick, Dr Rosenfeld highlighted that OM is no longer just about the bone; it is also about multiple organ systems that requires a multidisciplinary team to manage.\u003C\/p\u003E\n\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/7\/25.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlqbq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlqbq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}