Osteomyelitis

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ICD10 CODE: M86

Infection of bone by pus-forming bacteria, mainly affecting older children and adults.

Cause

  • Any type of bacterium but most commonly aureus, following infection elsewhere in the body
  • Risk factor: sickle cell disease (causative agent mostly S. Aureus, Salmonella also common)

Clinical features

Acute osteomyelitis

  • Onset is usually over several days
  • Fever, usually high but may be absent, especially in neonates
  • Pain (usually severe)
  • Tenderness and increased “heat” at the site of infection, swelling of the surrounding tissues and joint
  • Reduced or complete loss of use of the affected limb
  • The patient is usually a child of 4 years or above with reduced immunity, but adults may also be affected
  • History of injury may be given, and may be misleading, especially if there is no fever

Chronic osteomyelitis

  • May present with pain, erythema, or swelling, sometimes in association with a draining sinus tract
  • Deep or extensive ulcers that fail to heal after several weeks of appropriate ulcer care (e.g. in diabetic foot), and non-healing fractures, should raise suspicion of chronic osteomyelitis

Differential diagnosis

  • Infection of joints
  • Injury (trauma) to a limb, fracture (children)
  • Bone cancer (osteosarcoma, around the knee)
  • Pyomyositis (bacterial infection of muscle)
  • Cellulitis
  • Sickle-cell disease (thrombotic crisis)

Investigations

  • X-ray shows
    • Nothing abnormal in first 1-2 weeks
    • Loss of bone density (rarefaction) at about 2 weeks
    • May show a thin “white” line on the surface of the infected part of the bone (periosteal reaction)
    • Later, may show a piece of dead bone (sequestrum)
  • Blood: CBC, ESR, C&S: Type of bacterium may be detected
  • Attempt ZN stain, gene expert, culture if lesion suspect
  • Calcoflour stain for fungus

Management

Patients with suspected osteomyelitis need to be referred to hospital for appropriate management.

Treatment LOC
  • Immobilize the limb, splint
  • Provide pain and fever relief with paracetamol, or ibuprofen
  • Refer URGENTLY to hospital
  • Admit and elevate affected limb
  • Cloxacillin 500 mg IV every 6 hours for 2 weeks. Continue orally for at least 4 weeks (but up to 3 months)
    • Child: 50 mg/kg every 6 hours
  • See pyogenic arthritis for other antibiotic treatments
  • Osteomyelitis in SCD: see Sickle Cell Disease - Infection Management 
  • Surgical intervention may be indicated in the following cases:
    • Drainage of subperiosteal and soft tissue abscesses, and intramedullary purulence
      • Debridement of contiguous foci of infection (which also require antimicrobial therapy)
      • Excision of sequestra (i.e. devitalized bone)
      • Failure to improve after 48-72 hours of antimicrobial therapy

HC3

 

 

 

H

 

 

RR

 

HC3

 

H

 

RR

 

Chronic osteomyelitis

  • Surgery and antibiotics