History and exam
Key diagnostic factors
common
nonspecific pain at site of infection
Adults with primary or recurrent hematogenous osteomyelitis usually present with vague symptoms consisting of nonspecific pain and low-grade fever of 1-3 months' duration.[4][47]
Lumbar vertebral osteomyelitis will present with low back pain and may be associated with intravenous drug use, lower extremity and hip infections, and tuberculosis, due to the anatomy of the Batson plexus.[50][51] Note, however, that patients with diabetes may not report pain due to neuropathy.[36][37]
back pain
Vertebral osteomyelitis should be suspected in patients with new or worsening back or neck pain with one or more of the following: fever; elevated ESR or CRP; bloodstream infection; or infective endocarditis.[13] The pain is typically localized to the infected disk space area and is exacerbated by physical activity or percussion to the affected area.[13] Pain may radiate to the abdomen, hip, leg, scrotum, groin, or perineum.[44] Paravertebral muscle tenderness and spasm, and limitation of spine movement, are the predominant physical examination findings.[13]
malaise and fatigue
local inflammation, erythema, or swelling
Other diagnostic factors
common
sinus and/or wound drainage
reduced range of movement
reduced sensation
In patients with diabetes with foot infection, the level of sensation in the foot should be assessed quantitatively with methods such as light touch and pin-prick sensation, 2-point discrimination, and proprioception. This may be restricted due to pain from the site of infection. A sensory deficit may indicate the presence of native vertebral osteomyelitis.[13][37]
uncommon
urinary tract symptoms
In older adults, the urinary tract may be a source of infection from gram-negative organisms in cases of vertebral osteomyelitis.[88]
torticollis
limb deformity
Associated deformity of the limb, particularly following childhood osteomyelitis that may have resulted in premature fusion of the physeal plate, resulting in limb shortening or angular deformity.[4]
tenderness to percussion
May be detected over the subcutaneous border of affected bones in chronic osteomyelitis.
Risk factors
strong
previous osteomyelitis
Patients may present with an acute exacerbation of chronic osteomyelitis. Relapse of infection may occur in the same site (bone) weeks to years after apparently successful treatment of the initial infection, particularly in older patients.[4]
penetrating injuries
Open fracture is a risk factor for osteomyelitis.[1][9] Osteomyelitis can occur in up to 25% of open fractures.[24] The risk depends on the severity of injury (higher risk of surgical infections with open proximal femoral and tibial fractures and proximal humeral fractures), the degree of bacterial contamination, the timing and adequacy of surgical debridement, and the timing and administration of antibiotics.[25]
Bacteria can enter the fracture site through the open wound, and the soft-tissue stripping may leave devitalized bone and soft tissues that may become infected. Fracture fixation can also become infected.[26]
Not being given appropriate antibiotic prophylaxis, or delays in providing definitive soft-tissue cover, are risk factors for subsequent infection.[26] In patients with open extremity fractures, a delay to debridement increases the rate of deep infection in patients with higher-grade injuries.[27][28]
surgical contamination
Surgical site infections are common following surgery for injuries such as open fractures, bullet wounds, knife wounds, and lacerations.[29]
Surgical contamination during orthopedic surgery can lead to postoperative vertebral osteomyelitis and prosthetic joint infection.[9] Similarly, osteomyelitis of the skull bones can result following craniotomy. Sternal osteomyelitis is a complication of acute mediastinitis following coronary artery bypass surgery. Harvesting of internal mammary artery during coronary artery bypass surgery can lead to sternal ischemia predisposing to sternal osteomyelitis.[30]
distant or local infections
Hematogenous osteomyelitis is seen in patients with distant foci of infection, such as those with infected urinary catheters. Periodontal abscess can result in osteomyelitis of the mandible, which is more susceptible to osteomyelitis than the maxilla because the cortical plates of the mandible are thin and its medullary tissues have relatively poor vascular supply.[31] Osteomyelitis of the maxilla or mandible is caused by the aerobic and anaerobic bacterial microbiota of the oral cavity and may be either monomicrobial or polymicrobial.[9]Actinomyces species are recognized pathogens in this setting.[9]
intravenous drug misuse
Spinal and joint infections can occur in people who misuse intravenous drugs because of the high likelihood of bacteremia following injections. The commonest pathogen is Staphylococcus aureus,but pathogens such as Pseudomonas aeruginosa are also implicated (classically in the spine and sacroiliac joints).[9][11] Injecting drug users are susceptible to skeletal infections in uncommon places such as the sternoclavicular and sacroiliac joints or the pubic symphysis.[32][33] Infections of the sternoclavicular and sacroiliac joints may result, in part, from injecting in high-risk areas such as the jugular vein (termed a "pocket shot") and femoral vein (known as a "groin hit").[32] Such musculoskeletal infections are also more likely to be polymicrobial or anaerobic, especially if the injecting drug user contaminates the injection site, equipment, or drugs with saliva.[32]
diabetes mellitus
Foot infections occur frequently in patients with diabetes. These infections usually follow minor trauma and dramatically increase the risk of amputation.[34]
Specific guidelines are available for the diagnosis and management of osteomyelitis in the foot of patients with diabetes mellitus.[35][36][37] See Diabetic foot complications.
periodontitis
Periodontal abscess can result in osteomyelitis of the mandible. The mandible is much more susceptible to osteomyelitis than the maxilla because the cortical plates of the mandible are thin and its medullary tissues have relatively poor vascular supply.[31] Osteomyelitis of the maxilla or mandible is caused by the aerobic and anaerobic bacterial microbiota of the oral cavity and may be either monomicrobial or polymicrobial.[9]Actinomyces species are recognized pathogens in this setting.[9]
immunocompromise
Risk of osteomyelitis increases in patients who are immunocompromised due to HIV or autoimmune diseases, chemotherapy, or immunosuppressive treatment, and in those who misuse drugs or alcohol.[1]
sickle cell anemia
Bone and joint infections are common complications of sickle cell disease, occurring in more than 10% of patients.[38][39][40] Long bones are the most common sites of infection, predominantly in pediatric patients and young adults.[41] Sickle cell anemia is often associated with adult hematogenous osteomyelitis. Osteomyelitis may mimic a sickle cell crisis in these patients; therefore, culture results are important to establish the diagnosis and to determine the pathogen (which is often atypical).[41] The most commonly isolated pathogens are Salmonella and Staphylococcus aureus.[9][38]
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