Osteomyelitis

Last reviewed: 28 Apr 2022
Last updated: 07 Apr 2021

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
Full details

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
Full details

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)
Full details

Diagnostic investigations

1st investigations to order

  • FBC
  • erythrocyte sedimentation rate (ESR)
  • CRP
  • blood culture
  • plain x-rays of affected area
Full details

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
Full details

Treatment algorithm

INITIAL

suspected sepsis

ACUTE

suspected acute peripheral osteomyelitis

suspected acute native vertebral osteomyelitis

suspected acute osteomyelitis in diabetic foot

ONGOING

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.

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  • Patient leaflets

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