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Imaging in Paediatric Osteomyelitis (the PICBONE study): a multi-centre cohort study to understand the role of MRI and ultrasound in the diagnosis of acute haematogenous osteomyelitis in children

Research question

What is the role of MRI and ultrasound in the diagnosis of paediatric osteomyelitis?


Osteomyelitis (OM) is a bacterial infection of bone. In children, it is typically introduced through the blood (haematogenous). Acute osteomyelitis presents with symptoms of less than two weeks, including pain, loss of limb function, raised temperature and malaise. The burden is significant, with approximately 1800 children admitted yearly to hospitals in England. Untreated OM rapidly progresses to irreversible joint damage and bone destruction, leading to a limb threatening situation, while systemic sepsis can be life threatening. Early differentiation of OM from less urgent conditions mimicking the symptoms is critical.

Patients typically present to the Emergency Department. After initial work-up (history, clinical examination, routine blood tests and radiographs), diagnosis is often uncertain and advanced imaging is considered: ultrasound scan (USS) and magnetic resonance imaging (MRI). USS is more accessible but the overall diagnostic value is unknown. MRI has high diagnostic value in adult OM but often requires anaesthesia in children. Understanding the sensitivity and specificity of diagnostic imaging, along with a clear decision tool that includes all diagnostic parameters, would be of great value. Relevant studies show this is a priority from both the clinicians’ and patients/families’ perspectives.

Aims and objectives

1.         To understand how helpful ultrasound and MRI scans are in diagnosing bone and joint infections in children.

2.         To create a pathway that clinicians can use in the Emergency Department to more successfully diagnose bone and joint infections.


1.         Retrospective study: Learn from children who have had bone infection.

We will look at past records of children who had “potential osteomyelitis” in 30 hospitals in the UK. These will tell us which tests were performed and when. We will work-out how useful the USS and MRI were at detecting bone infections, and develop the algorithm to define when these tests should be performed.

2.         Prospective study: Apply what we’ve learnt to diagnose future infections.

We will use the information from our first study to develop a clear pathway to investigate suspected bone infections. We shall then test how well this pathway works on a new group of children with suspected infections.


NIHR Funded by Feb2019


                 Registered with the Associate PI Scheme study Badge