Diagnosis

Osteomyelitis

Inflammation of the bone caused by an infecting organism:

  • Acute: <2 weeks

  • Subacute: 2-6weeks

  • Chronic: >6 weeks

Etiology

Cause [k3b][sqc]

Pathophysiology [sqc]

  1. Route of infection:

    • Hematogenous infection: bacteremia

    • Contiguous osteomyelitis: spread from nearby tissue (cellulitis)

    • Direct inoculation from trauma, open fracture or surgery

  2. Location: tarsal/metatarsal, long bones (children), vertebra (adults) [k3b][sgb]

  3. Inflammation --> Abscess formation

  4. Intramedullary pressure increases -> Ischemia/necrosis (sequestra formation)

  5. Some bacteria create a protective biofilm coating around themselves --> phenotypic resistance to antibiotic therapy

Risk factors

Complications [sqc]

Epidemiology

Incidence per 100.000 [cch][k3b][5hg][55w][orf][tsh][zn6]

Epidemiology chart for Incidence

Symptoms & findings

Symptoms

Anorexia, Chills, Fever, Irritability, Malaise, Nausea, Tachycardia

Clinical findings

Anemia, Elevated CRP, Elevated Sedimentation Rate, Leukocytosis, Periosteal thickening, Sclerotic bone lesion

Anamneses

Trauma

Localized findings

Pain
Radiates
Bone (skeleton)Joints
Onset
Subacute (hours)Gradual (days)
Pattern
Constant
Provoked by
ActivityPalpation
Quality
AchingDull
Severity
Mild (1-3)Moderate (4-7)

Approach

Treatment

  1. Antibiotic treatment: [ks3][3cu]

    • Clindamycin, rifampin, trimethoprim-sulfamethoxazole, fluoroquinolone

    • Treatment durations:

      • S. aureus, and enterobacterials: 6 weeks

      • Streptococcus spp.: 4 weeks

      • Neisseria gonorrhoeae: 7 days

      • Arthritis: 4 weeks

      • Pseudomonas: ceftazidime or cefepime for >2 weeks

      • Prosthetic joint infection: rifampin and levofloxacin for 8 weeks

  2. Surgery: [fyr]

    • Adequate drainage with negative-pressure wound therapy

    • Extensive debridement of necrotic tissue

    • Management of dead space: Antibiotic-impregnated beads and cements, Bone transport (Ilizarov method)

    • External fixation to restore skeletal stability

    • Adequate soft-tissue coverage

    • Restoration of blood supply

    • Amputation

    • Prosthetic joint infection -> may need implant removal and later replacement

Differential diagnoses

Brodies abscess, Cellulitis, Ewing sarcoma, Fracture, Gout, Leukemia, Metastatic bone tumors, Pseudogout, Rheumatic fever, Rheumatoid arthritis, Septic arthritis, Septic bursitis, Sickle cell disease

References

[1] Kremers HM, Nwojo ME, Ransom JE, Wood-Wentz CM, Melton LJ 3rd, Huddleston PM 3rd. Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009. J Bone Joint Surg Am. 2015 May 20;97(10):837-45.

[2] Momodu II, Savaliya V. Osteomyelitis. [Updated 2023 May 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532250/

[3] Lu S, Wang L, Luo W, Wang G, Zhu Z, Liu Y, Gao H, Fu C, Ren J, Zhang Y, Zhang Y. Analysis of the epidemiological status, microbiology, treatment methods and financial burden of hematogenous osteomyelitis based on 259 patients in Northwest China. Front Endocrinol (Lausanne). 2023 Jan 4;13:1097147.

[4] Gigante A, Coppa V, Marinelli M, Giampaolini N, Falcioni D, Specchia N. Acute osteomyelitis and septic arthritis in children: a systematic review of systematic reviews. Eur Rev Med Pharmacol Sci. 2019 Apr;23(2 Suppl):145-158.

[5] Kim J, Lee MU, Kim TH. Nationwide epidemiologic study for pediatric osteomyelitis and septic arthritis in South Korea: A cross-sectional study of national health insurance review and assessment service. Medicine (Baltimore). 2019 Apr;98(17):e15355.

[6] Walter N, Bärtl S, Alt V, Rupp M. The Epidemiology of Osteomyelitis in Children. Children (Basel). 2021 Nov 3;8(11):1000.

[7] Riise ØR, Kirkhus E, Handeland KS, Flatø B, Reiseter T, Cvancarova M, Nakstad B, Wathne KO. Childhood osteomyelitis-incidence and differentiation from other acute onset musculoskeletal features in a population-based study. BMC Pediatr. 2008 Oct 20;8:45.

[8] Brischetto A, Leung G, Marshall CS, Bowen AC. A Retrospective Case-Series of Children With Bone and Joint Infection From Northern Australia. Medicine (Baltimore). 2016 Feb;95(8):e2885.

[9] von Heideken J, Bennet R, Eriksson M, Hertting O. A 10-year retrospective survey of acute childhood osteomyelitis in Stockholm, Sweden. J Paediatr Child Health. 2020 Dec;56(12):1912-1917.

[10] Woods CR, Bradley JS, Chatterjee A, et al. Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics. J Pediatric Infect Dis Soc. 2021;10(8):801-844.

[11] Stahl JP, Canouï E, Pavese P, et al. SPILF update on bacterial arthritis in adults and children. Infect Dis Now. 2023;53(4).

[12] http://emedicine.medscape.com/article/1348767 (2014-01-02); [Medscape]

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