Musculoskeletal Infection Scottish Rite for Children Lawson Copley

Jan 26, 2022 / General News

Evaluation of Musculoskeletal Infection and When to Refer

Orthopedist Lawson A. Copley, M.D., presented this as part of Coffee, Kids and Orthopedics education series. Lawson provided a detailed discussion of evaluating musculoskeletal infection in children.

You can watch the full lecture and print the pdf.

There has been a dramatic increase in musculoskeletal infections (MSI) in children in the last twenty years. Lawson A. Copley, M.D., who recognized this as a problem in North Texas in 2002, says the climate in this region plays some role in the increased incidence here.

Musculoskeletal Infection (MSI) is a collection of many conditions with similar presentations which present on a broad spectrum of illness severity. Unfortunately, this contributes to inaccurate or delayed diagnoses and referral for appropriate evaluation and care.

Structured (Systematic) MSI Work-up

An evidence-based, structured four-part MSI work-up is the foundation that guides most decisions.


A thorough history helps to isolate the location of the symptoms and identify the details surrounding symptom onset, such as acuity and the presence or absence of trauma. Copley finds that the family’s information is often accurate and reliable. Most infections evolve relatively quickly after symptoms show. Symptoms such as fever, malaise, aches and nausea, referred to as the viral prodrome, should also be assessed during this conversation.

Physical Examination

Most musculoskeletal infections are unifocal, so the physical examination should isolate the area of concern to a very specific area. Multifocal presentations are most often not infections.


  • CBC differential
  • CRP
  • ESR
  • Blood culture
    • With any concern for deep infection, a blood culture is indicated.


Using the physical exam findings, a plain X-ray of the symptomatic region can provide a definitive finding or guide further imaging needs. Ultrasound can be helpful, specifically when looking for an effusion of the hip joint.

The Decision for Admission

  • Very concerned
    • If the child looks like they are spiraling into septic shock, they need to go to the ICU to receive broad-spectrum antibiotics and resuscitation. Infections this serious are very hard to miss.
  • Generally concerned
    • If the child doesn’t look like they are spiraling downward, but there is still some concern that something serious may be happening, they should be referred to the emergency room and admitted for an inpatient evaluation.
  • Not concerned
    • If the child appears healthy but has symptoms like a minor limp or minimally elevated labs, they should be referred to an outpatient clinic for a second look.

Common Conditions (Pattern Recognition)

Performing those four basic evaluations will help physicians in making a decision based on pattern recognition. Knowing the underlying conditions of infection and the related conditions that look like infection will help guide that decision.

Copley encourages health care providers to use caution in evaluating patients with possible MSI. In his experience, there are a handful of conditions that are likely diagnoses for children presenting with infectious symptoms. However, he emphasized that there are many other diagnoses that should not be ignored in the systematic evaluation of these children.

The most common conditions include:

  • Osteomyelitis
    • Inflammation in the bone seen in otherwise healthy children
    • Usually preceded by a minor trauma
    • Can happen at any age, but the median age is 8
  • Septic Arthritis
    • A joint space infection that happens in otherwise healthy children.
    • Minor trauma is less frequent
    • Mostly affects younger children with a median age of 4
  • Transient Synovitis
    • A very common cause of hip pain children
    • Caused by inflammation of the lining of the hip joint
    • Affects children between 3 and 10 years of age

Familiarizing yourself with the patterns of presentation of these conditions will help guide your treatment and referral decision-making process. There is a risk in jumping to a conclusive diagnosis too quickly, but these patterns can help you improve the patient and family experience.


LAWSON A.B. COPLEY, M.D., is a staff orthopedist at Scottish Rite for Children who cares for patients with musculoskeletal infections and other pediatric orthopedic conditions at Children’s Health in Dallas, Texas.


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