Summary
Definition
History and exam
Key diagnostic factors
- risk factors
- limp or reluctance to weight-bear
- non-specific pain at site of infection
- malaise and fatigue
- local back pain associated with systemic symptoms
- paravertebral muscle tenderness and spasm
- local inflammation, tenderness, erythema, or swelling
- fever
- spinal cord or nerve root compression
Other diagnostic factors
- wound drainage, acute or old healed sinuses
- scars, previous flaps, fracture fixation
- reduced range of movement
- reduced sensation in diabetic foot infection
- urinary tract symptoms
- torticollis
- skin or other infections, recent episode of Staphylococcus aureus bloodstream infection, indwelling catheter
- limb deformity
- tenderness to percussion
- meningitis
Risk factors
- previous osteomyelitis
- penetrating injury
- intravenous drug misuse
- diabetes
- HIV infection
- recent surgery
- distant or local infections
- sickle cell anaemia
- rheumatoid arthritis
- chronic kidney disease
- immunocompromising conditions
- upper respiratory tract or varicella infection (in children)
Diagnostic investigations
1st investigations to order
- FBC
- erythrocyte sedimentation rate (ESR)
- CRP
- blood culture
- plain x-rays of affected area
Investigations to consider
- bone samples and bone biopsy
- polymerase chain reaction (PCR)
- MALDI-TOF mass spectrometry
- swabs
- urine microscopy, culture, and sensitivities
- histology
- probe-to-bone test
- bone MRI
- ultrasound
- CT scan
- radionuclide scan
- bone scintigraphy
- echocardiogram
- chest x-ray
- Mantoux test
Treatment algorithm
suspected sepsis
suspected acute peripheral osteomyelitis
suspected acute native vertebral osteomyelitis
suspected acute osteomyelitis in diabetic foot
chronic osteomyelitis
Contributors
Expert advisers
Michael Barrett, MB ChB, FRCS (Tr&Orth), PGCert Med Ed
ST8 in Trauma and Orthopaedic Surgery
Royal London Hospital
Barts Health NHS Trust
London
UK
Disclosures
MB discloses that he owns, runs, and produces educational content for the www.frcsortho.com membership website. He is also a director of www.orthohub.xyz, a free interactive orthopaedic educational resource. This website receives funding from industry partners.
Acknowledgements
BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:
Jamie Ferguson, MB ChB (hons), MEd., FRCS (Orth)
Consultant in Trauma and Reconstruction Surgery
The Bone Infection Unit
Nuffield Orthopaedic Centre
Oxford University Hospitals Foundation NHS Trust
Oxford
Tse Hua Nicholas Wong, BSc, MB BS, DPhil, MRCP, FRCPath
Consultant in Infectious Diseases and Microbiology
Buckinghamshire Healthcare NHS Trust
Aylesbury
Bridget L. Atkins, MA, MBBS, MSc, FRCPath, FRCP
Consultant Infectious Diseases, Microbiology and Bone Infection
Oxford University Hospitals NHS Foundation Trust
Oxford
Martin McNally, MB, BCh, MD, FRCSEd, FRCS(Orth)
King James IV Professor and Consultant in Limb Reconstruction
The Bone Infection Unit
Nuffield Orthopaedic Centre
Oxford University Hospitals Foundation NHS Trust
Oxford
UK
Disclosures
JF and MM received a research grant in 2013 from Bonesupport AB, Lund, Sweden to collect data for a study on antibiotic carriers in osteomyelitis treatment. THNW and BLA declare that they have no competing interests.
Peer reviewers
Martin McNally, MB, BCh, MD, FRCSEd, FRCS(Orth)
King James IV Professor and Consultant in Limb Reconstruction
The Bone Infection Unit
Nuffield Orthopaedic Centre
Oxford University Hospitals Foundation NHS Trust
Oxford
UK
Disclosures
MM received a research grant in 2013 from Bonesupport AB, Lund, Sweden to collect data for a study on antibiotic carriers in osteomyelitis treatment.
Emma Nickerson, MRCP
Infectious Diseases Consultant
Addenbrooke’s Hospital
Cambridge University Hospitals NHS Foundation Trust
Cambridge
UK
Disclosures
EN declares that she has no competing interests.
Editors
Celia Pincus
Section Editor, BMJ Best Practice
Disclosures
CP declares that she has no competing interests.
Tannaz Aliabadi-Oglesby
Lead Section Editor, BMJ Best Practice
Disclosures
TAO declares that she has no competing interests.
Anna Ellis
Head of Editorial, BMJ Best Practice
Disclosures
AE declares that she has no competing interests.
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Differentials
- Septic arthritis
- Juvenile idiopathic arthritis
- Transient synovitis
More DifferentialsGuidelines
- Consensus document for the diagnosis of peripheral bone infection in adults: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement)
- Bone and joint infections
More GuidelinesPatient information
Osteomyelitis
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