Osteomyelitis

Last reviewed: March 2019

Last updated: June 2018

Summary

Suspect osteomyelitis in those with a history of open fracture, recent orthopedic surgery, or a discharging sinus; in the immunocompromised patient; or in the unwell child.

Plain radiographs provide a good initial imaging modality for screening acute and chronic osteomyelitis.

Magnetic resonance imaging and computed tomography (CT) may be used to determine diagnosis and treatment decisions. In some cases positron emission tomography/CT or single-photon emission computed tomography/CT may have a role.

Diagnosis must be confirmed using deep microbiologic samples via radiologic guided biopsy or open surgery.

In chronic osteomyelitis, surgery to remove the dead bone is the primary treatment modality. Antibiotics alone cannot achieve a cure.

Giving empiric antibiotics without microbiologic sampling should be avoided, with the exception of patients who are septic and unwell. Even then, blood cultures should be taken before antibiotics are given.

Only cultures from deep sites are reliable. There is no value in surface or sinus swabs.

Definition

Osteomyelitis is an inflammatory condition of bone caused by an infecting organism, most commonly Staphylococcus aureus . It usually involves a single bone but may rarely affect multiple sites.

Severity can be staged depending on the etiology of the infection, its pathogenesis, the extent of bone involvement, duration, and host factors particular to the individual patient. Broadly, bone infection is either hematogenous (originating from bacteremia) or contiguous focus (originating from a focus of infection adjacent to the area of osteomyelitis). Despite these different causes all forms of acute osteomyelitis may evolve and become chronic, sharing a final common pathophysiology, with a compromised soft-tissue envelope surrounding dead, infected, and reactive new bone.

History and exam

Key diagnostic factors

nonspecific pain at site of infection
malaise and fatigue
local inflammation, erythema, or swelling
low-grade fever

Full details

Other diagnostic factors

wound drainage
scars, previous flaps
reduced range of movement
reduced sensation in diabetic foot ulcer
urinary tract symptoms
torticollis
limb deformity
tenderness to percussion

Full details

Risk factors

penetrating injuries
surgical contamination
intravenous drug misuse
diabetes mellitus
periodontitis

Full details

Diagnostic investigations

1st investigations to order

WBC count
erythrocyte sedimentation rate (ESR)
CRP
plain x-rays of affected area

Full details

Investigations to consider

ultrasound
MRI of bone
CT scan
radionuclide scans
histology

Full details

Treatment algorithm

ACUTE

acute osteomyelitis

ONGOING

chronic osteomyelitis

Contributors

Authors VIEW ALL 

Jamie Ferguson, MB ChB (hons), MEd., FRCS (Orth)

Senior Clinical Fellow in Limb Reconstruction

The Bone Infection Unit

Nuffield Orthopaedic Centre

Oxford University Hospitals Foundation NHS Trust

Oxford

Disclosures

JF received a research grant in 2013 from Bonesupport AB, Lund, Sweden to collect data for a study on antibiotic carriers in osteomyelitis treatment.

Tse Hua Nicholas Wong, BSc, MB BS, DPhil, MRCP, FRCPath

Consultant in Infectious Diseases and Microbiology

Buckinghamshire Healthcare NHS Trust

Aylesbury

Disclosures

THNW declares that he has no competing interests.

Bridget L. Atkins, MA, MBBS, MSc, FRCPath, FRCP

Consultant

Infectious Diseases, Microbiology and Bone Infection

Oxford University Hospitals NHS Foundation Trust

Oxford

Disclosures

BLA declares that she has no competing interests.

Martin McNally, MB, BCh, MD, FRCSEd, FRCS(Orth)

Consultant in Limb Reconstruction

The Bone Infection Unit

Nuffield Orthopaedic Centre

Oxford University Hospitals Foundation NHS Trust

Oxford

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.

Acknowledgements

Dr Jamie Ferguson, Dr Tse Hua Nicholas Wong, Dr Bridget L. Atkins, and Dr Martin McNally wish to gratefully acknowledge Dr Jason H. Calhoun, Dr Nalini Rao, and Dr M. M. Manring, previous contributors to this topic. JHC, NR, and MMM declare that they have no competing interests.

Peer reviewers VIEW ALL 

Kristine Johnson, MD

Assistant Professor

Infectious Diseases

Bayview Medical Center

Baltimore

Disclosures

KJ declares that she has no competing interests.

Silvano Esposito, MD

Associate Professor

Department of Infectious Diseases

University of Naples

Naples

Italy

Disclosures

SE has been reimbursed for attending several conferences and received fees for speaking and running educational programs by Pfizer, Novartis, Wyeth Lederle, Sanofi Aventis, and GSK.

Edward Pesanti, MD

Professor of Medicine

Infectious Diseases Division

University of Connecticut Health Center

Hartford

Disclosures

EP declares that he has no competing interests.

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Osteomyelitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute osteomyelitis

chronic osteomyelitis

Contributors

Authors VIEW ALL 

Jamie Ferguson, MB ChB (hons), MEd., FRCS (Orth)

Disclosures

Tse Hua Nicholas Wong, BSc, MB BS, DPhil, MRCP, FRCPath

Disclosures

Bridget L. Atkins, MA, MBBS, MSc, FRCPath, FRCP

Disclosures

Martin McNally, MB, BCh, MD, FRCSEd, FRCS(Orth)

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Kristine Johnson, MD

Disclosures

Silvano Esposito, MD

Disclosures

Edward Pesanti, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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