Scapular osteomyelitis, a challenging diagnosis: a systematic review in pediatric age

Osteomyelitis of the scapula is a rare site of bone infection. Early diagnosis is difficult because of the rarity of localization, the rapid progression, and the misleading atypical manifestations. We systematically reviewed the current available evidence on osteomyelitis of the scapula to provide a synthesis on the epidemiology, clinical presentation, complications, and management of this infection. PubMed, Scopus, and Google Scholar databases were explored to identify studies, case series, and case reports with no time limits focused on children with scapular osteomyelitis. Thirteen articles were included in the final analysis, for a total of 17 patients (14 children and three newborns). The most frequently reported symptoms in children were pain (100%), limitation of shoulder movements (100%), and fever (79%). Several imaging tests were adopted (X-ray, ultrasound, computed tomography scan, and MRI) with pathological findings in most cases. Blood tests always showed a phlogistic state. The most frequent causative agent was methicillin-sensitive Staphylococcus aureus in children and group B Streptococcus in newborns. The mean total duration of antibiotic treatment was 51.5 days, with intravenous cephalosporins (43%), penicillins (36%), and aminoglycosides (29%) adopted as first-choice antibiotics in most cases. Full recovery was reported in most cases (79% in children). Osteomyelitis should be suspected in cases of osteomuscular symptoms even in the absence of fever or local signs. Inflammatory indices and white blood cell count can be only slightly elevated and normal X-rays cannot exclude the diagnosis, and in case of suspicion, MRI is mandatory.