Updated: 7/2/2019

Osteomyelitis

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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
      • 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
  • Prognosis
    • mortality has significantly decreased since the use of antibiotics
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
 

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(M2.OR.16.4679) A 55-year-old obese woman is admitted to your floor for chronic fevers. She states she has had fevers of of over 101F as measured on her oral thermometer for the past month. Her vitals are T 100.9 F, HR 95 and regular, RR 16, BP 150/95. On history she states that she has a history of diabetes and is noncompliant with her insulin. She was recently treated for a foot infection with antibiotics, but her fevers have remained. Her last HbA1C was 8.5%. On exam, the patient has no gross deficits, but does admit to pain in her left lower leg and foot. Physical exam reveals a Grade IV ulcer, as displayed in Figure A. She states she has severe pain when bearing weight on her left leg. Otherwise, all extremities have diminished pulses and sensation. There is no erythema in the surrounding area and no areas of fluctuance. Figure B shows AP and lateral radiographs of the patient's left leg. What is the most likely diagnosis? Tested Concept

QID: 107280
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(M3.OR.15.56) A 66-year-old man presents to his primary care physician complaining of increasing discharge from a lesion on his foot. He noticed it a month ago and states it has been gradually worsening. He has a long history of poorly controlled diabetes with complications including chronic renal failure and peripheral neuropathy. He denies any pain or fevers/chills. Physical exam is notable for the finding in Figure A. Laboratory evaluation is significant for an erythrocyte sedimentation rate of 226 mm/h. Which of the following would be the most accurate imaging test for this patient's condition? Tested Concept

QID: 102997
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(M2.OR.14.28) A 45-year-old woman with a history of diabetes presents with 1 week of progressively worsening back pain and subjective fevers. Six months ago, she was treated for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, thought to be secondary to an infected diabetic foot ulcer. There was no inciting trauma for the back pain, and she has no urinary incontinence or altered sensation in her back or legs. Her temperature is 101.3°F (38.5°C), blood pressure is 157/99 mm Hg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. She has point tenderness in her back at the L4 level but no apparent swelling or overlying erythema. Her left foot has the findings depicted in Figure A. Which of the following is the most accurate test for this patient's back pain? Tested Concept

QID: 104913
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