1. Pathophysiology
   1. Bacteria adhere to bone
      1. infection with inflammatory cells and edema
      2. bone destruction, abscess formation and dead bone
      3. new bone is formed along live bone and infection borders
         1. involucrum - surrounding sheath of live bone
      4. infection contained by growth plate and joint infection is less likely (unless the infection is intracapsular)
2. Clinical manifestations
   1. Severe pain, fever, irritability and tenderness with or without local signs of inflammation. Affected extremity is tender and the child may somehow hold it in semiflexion and resist movement. Typically the metaphysis of long bones, the tibia and femur is involved.
      1. Tenderness to palpation over left sacral area and left iliac crest, pain with resistance to range of motion exam of left lower extremity, fever
3. Causes
   1. Exogenous osteomyelitis is acquired from direct inoculation of the bone from a puncture wound or adjacent tissue infection.
      1. Patient's skin integrity on the left knee became compromised during football practice 2 weeks ago. Patient continued to play football without disinfecting and covering the wound.
4. Diagnostic Evaluation
   1. Organism identification and antibiotic susceptibility, obtain cultures of aspirated pus, bone biopsy, radiographic findings, leukocytosis and elevated erythrocyte sedimentation rate, bone scan, CT scan, MRI
      1. radiographic signs, except tissue swelling, are evident only after 2-3 weeks
      2. C-Reactive protein elevated (14.6), MRI results showed infection involvement over left sacrum
5. Therapeutic Management
   1. IV antibiotics initiated and continued for at least 4 weeks (for S. aureus nafcillin or clindamycin is generally used; methicillin resistant S. aureus may require vancomycin), surgery may be indicated if there is no response to specific antibiotic therapy, persistent soft tissue abscess or infection that spreads to the joint
      1. Clindamycin IV antibiotics every 6 hours; Patient discharged with Clindamycin oral tablets for 6 weeks.
6. Nursing Care Management
   1. Position child comfortably with the affected limb supported, moving and turning carried out carefully and gently to minimize discomfort, pain medication, take vital signs frequently and reduce significant temperature elevation
      1. Patient positioned supine in bed with pillow supporting lower extremities, Acetaminophen PRN for pain, vital signs every 4 hours
7. Kline, J. (2011, January 10). Osteomyelitis . KidsHealth - the Web's most visited site about children's health. Retrieved September 3, 2011, from http://kidshealth.org/teen/diseases