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Am J Emerg Med. 2019 Aug 24:158416. doi: 10.1016/j.ajem.2019.158416. [Epub ahead of print]

Inflammatory markers limitations in the diagnosis of pediatric calcaneal osteomyelitis.

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Uniformed Services University School of Medicine, Bethesda, MD, United States of America. Electronic address:
Naval Medical Center Portsmouth, Portsmouth, VA, United States of America.
Naval Medical Center San Diego, San Diego, CA, United States of America.
Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, United States of America.


Calcaneal osteomyelitis is an uncommon, but clinically important emergent condition in the differential of the limping child. Early recognition is paramount to prevent complications from delayed diagnosis like formation of periosteal abscesses or growth plate injury. The diagnosis of pediatric osteoarticular infection relies on a combination of clinical exam, imaging and inflammatory markers. Erythrocyte sedation rate (ESR) and C-reactive protein (CRP) have reported sensitivities for osteomyelitis of 94% and 95%, respectively. However, clinicians should be aware that certain clinical factors can decrease the reliability of inflammatory markers in this pediatric condition. Location of infection in small bones like the calcaneus can lead to significantly lower sensitivities than in long bones. Pretreatment with antibiotics prior presentation can also decrease the reliability of ESR and CRP. In this case, we highlight two unique clinical factors that diminish the sensitivity of commonly used inflammatory markers in the diagnosis of pediatric osteomyelitis.


Calcaneus; Inflammatory markers; Kingella kingae; Osteomyelitis; Pediatric


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