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.
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
- scars, previous flaps
- reduced range of movement
- reduced sensation
- urinary tract symptoms
- limb deformity
- tenderness to percussion
- penetrating injuries
- surgical contamination
- intravenous drug misuse
- diabetes mellitus
1st investigations to order
- WBC count
- erythrocyte sedimentation rate
- plain x-rays of affected area
- blood culture
Investigations to consider
- guided bone biopsy or open bone biopsy
- MRI of bone
- CT scan
- radionuclide scans
- Metastatic bone cancer or osteosarcoma
- Old or new trauma
- Noninfected nonunion
- Guideline on diagnosis and management of acute hematogenous osteomyelitis in pediatrics
- Guidelines on the diagnosis and treatment of foot infection in persons with diabetes
OsteomyelitisMore Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer