Osteomyelitis should be suspected in those with a history of open fracture, recent orthopedic surgery, or a discharging sinus; in immunocompromised patients; or in unwell children.
Suggestive clinical features include fever, bone pain, and reduced mobility; local erythema, tenderness, warmth, and swelling; and reduced range of movement.
Plain radiographs provide a good initial imaging modality for screening acute and chronic osteomyelitis.
Magnetic resonance imaging (MRI) is the imaging modality with greatest sensitivity for diagnosing osteomyelitis.
The diagnosis should be confirmed by culture obtained from biopsy of the involved bone.
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.
In chronic osteomyelitis, surgery to remove the dead bone is the primary treatment modality. Antibiotics alone cannot achieve a cure.
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
Other diagnostic factors
- sinus and/or wound drainage
- reduced range of movement
- reduced sensation
- urinary tract symptoms
- limb deformity
- tenderness to percussion
- previous osteomyelitis
- penetrating injuries
- surgical contamination
- distant or local infections
- intravenous drug misuse
- diabetes mellitus
- sickle cell anemia
1st investigations to order
- WBC count
- erythrocyte sedimentation rate
- plain x-rays of affected area
- blood culture
- MRI of bone
- guided bone biopsy or open bone biopsy
Investigations to consider
- CT scan
- radionuclide scans
- three-phase bone scans
suspected acute peripheral osteomyelitis: low MRSA prevalence
suspected acute peripheral osteomyelitis: high MRSA prevalence
suspected acute native vertebral osteomyelitis
suspected acute osteomyelitis in diabetic foot
confirmed acute peripheral osteomyelitis: adults and children
confirmed acute native vertebral osteomyelitis: adults and children
confirmed acute osteomyelitis in diabetic foot: adults and children
- Septic arthritis
- Juvenile idiopathic arthritis
- Transient synovitis
- ACR appropriateness criteria: suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot)
- Guideline on diagnosis and management of acute hematogenous osteomyelitis in pediatrics
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