Osteomyelitis

Last reviewed: 7 Jan 2023

Last updated: 16 Nov 2021

Osteomyelitis should be suspected 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 may be used to determine diagnosis and treatment decisions.

Ideally, diagnosis should be confirmed by positive bacterial culture from deep microbiologic samples obtained 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.

Ideally, microbiologic samples should be taken before giving empiric antibiotics. However, if the patient is septic or otherwise unwell, sampling should not delay the administration of antibiotics.

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
back pain
malaise and fatigue
local inflammation, erythema, or swelling
low-grade fever

More key diagnostic factors

Other diagnostic factors

sinus and/or wound drainage
scars, previous flaps
reduced range of movement
reduced sensation
urinary tract symptoms
torticollis
limb deformity
tenderness to percussion

Other diagnostic factors

Risk factors

penetrating injuries
surgical contamination
intravenous drug misuse
diabetes mellitus
periodontitis

More risk factors

Diagnostic investigations

1st investigations to order

WBC count
erythrocyte sedimentation rate
CRP
plain x-rays of affected area
blood culture

More 1st investigations to order

Investigations to consider

guided bone biopsy or open bone biopsy
ultrasound
MRI of bone
CT scan
radionuclide scans
histology

More investigations to consider

Treatment algorithm

ACUTE

acute osteomyelitis

ONGOING

chronic osteomyelitis

Contributors

Authors

Adrian Kendal, MA, BMBCh, DPhil, FRCS (Ortho)

Honorary Departmental Clinical Research Fellow

The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences

Oxford

Disclosures

AK declares that he has no competing interests.

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

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. JF is an author of a number of references cited in this topic.

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 is an author of a number of references cited in this topic.

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

King James IV Professor and Consultant in Limb Reconstruction

Consultant in Limb Reconstruction

The Bone Infection Unit

Nuffield Orthopaedic Centre

Oxford University Hospitals Foundation NHS Trust

Oxford

Disclosures

MM is an executive board member of the European Bone & Joint Infection Society and the Girdlestone Orthopaedic Society. He has performed consultancy work for Bonesupport AB and the Oxford Bone Infection Consultancy. He has received travel expenses from Bonesupport AB and the AO Foundation to attend scientific conferences and symposia. He has received royalties from Oxford University Press for contributions to textbooks. MM is an author of a number of references cited in this topic.

Acknowledgements

Dr Jamie Ferguson, Dr Tse Hua Nicholas Wong, Dr Bridget L. Atkins, Dr Martin McNally, and Mr Adrian Kendal wish to gratefully acknowledge Dr Jason H. Calhoun, Dr Nalini Rao, and Dr M. M. Manring, previous contributors to this topic.

Disclosures

JHC, NR, and MMM declare that they have no competing interests.

Peer reviewers

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.

Differentials
- Metastatic bone cancer or osteosarcoma
- Old or new trauma
- Noninfected nonunion
More Differentials
Guidelines
- Guideline on diagnosis and management of acute hematogenous osteomyelitis in pediatrics
- Guidelines on the diagnosis and treatment of foot infection in persons with diabetes
More Guidelines
Patient leaflets
Osteomyelitis
More Patient leaflets
Log in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer

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

Adrian Kendal, MA, BMBCh, DPhil, FRCS (Ortho)

Disclosures

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

Disclosures

Peer reviewers

Kristine Johnson, MD

Disclosures

Silvano Esposito, MD

Disclosures

Edward Pesanti, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice