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Updated: Dec 26 2021


  • Snapshot
    • A 52-year-old man presents to the emergency department for fever, chills, and pain in the left foot. His symptoms progessively worsened over the course of a week. Medical history is significant for poorly controlled type II diabetes mellitus. On physical exam, there is tenderness to palpation of the left foot. Laboratory testing is significant for an elevated erythrocyte sedimentation rate and C-reactive protein; as well as, a leukocytosis. A plain radiograph demonstrates periosteal thickening and soft tissue swelling.
  • Introduction
    • Clinical definition
      • inflammation of the bone and bone marrow most commonly due secondarily to infection that can be categorized as
        • acute osteomyelitis
          • more common in children
          • typically symptom onset is within 2 weeks postinfection
        • chronic osteomyelitis
          • more common in adults
          • typically symptoms persists months or years postinfection
  • Epidemiology
    • Risk factors
      • diabetes
      • peripheral vascular disease
      • open fracture
      • intravenous drug use
      • catheter use
      • surgery
  • Etiology
    • Note that infection can be due to bacteria, fungi, and mycobacteria
    • Microbiology
      • Staphylococcus aureus
        • most common cause overall (including pediatric patients)
          • may be seen in
            • sickle cell disease
            • prosthetic joint replacement
            • vertebral involvement
              • focal back pain/tenderness
            • intravenous drug use
      • Salmonella
        • specific cause in sickle cell disease
      • Neisseria gonorrhoeae
        • rare
      • Staphylococcus epidermidis
        • can also be seen in prosthetic joint involvement
      • Mycobacterium tuberculosis
        • can also be seen in cases of vertebral involvement (Pott disease)
      • Pasteurella multocida
        • seen in cases caused by cat and dog bites
      • Pseudomonas and Candida
        • can also be seen in cases caused by intravenous drug abuse
    • Pathogenesis
      • hematogenous seeding of bone
      • contiguous spread of infection from adjacent structures (e.g., soft tissues and joints)
      • direct inoculation
        • e.g., penetrating trauma and contaminated surgical tools
  • Presentation
    • Symptoms
      • acute osteomyelitis
        • lethargy
        • acute pain in affected site
        • erythema and
      • chronic osteomyelitis
        • chronic pain
    • Physical exam
      • swelling
      • erythema
      • tenderness
      • reduced range of motion
      • bone tenderness
      • ulcers
      • exposed bone may be seen
      • sinus tract
        • pathognomonic for chronic osteomyelitis
      • must perform a neurovascular exam
  • Imaging
    • Radiographs
      • indication
        • preferred initial test in evaluating for osteomyelitis
          • note that it takes 10-14 days postinfection for findings to appear
      • findings
        • periosteal thickening and elevation "Codman triangle"
    • Magnetic resonance imaging
      • indication
        • considered when radiography is unrevealing
      • findigs
        • may reveal bone necrosis, abscess, and sinus tracts
  • Studies
    • Labs
      • ↑ C-reactive protein
      • ↑ erythrocyte sedimentation rate
      • leukocytosis
        • present in acute osteomyelitis
        • unlikely to be found in chronic osteomyelitis
    • Biopsy and culture
      • confirms the diagnosis
  • Differential
    • Septic arthritis
    • Gout
    • Cellulitis
    • Osteosarcoma
  • Treatment
    • Medical
      • empiric antibiotics
        • indication
          • considered the mainstay of treatment
            • eventually tailored to organism after culture sensitivities return
    • Operative
      • debridement
        • indication
          • to remove necrotic tissue
  • Complications
    • Bone necrosis
    • Sepsis
    • Squamous cell carcinoma
      • most common tumor associated with osteomyelitis
  • Prognosis
    • Mortality has significantly decreased since the use of antibiotics
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