Osteomyelitis is an infection of the bone. It can be caused by a
variety of microbial agents (most common in staphylococcus aureus) and
- An open injury to the bone, such as an open fracture with the bone ends
piercing the skin.
- An infection from elsewhere in the body, such as pneumonia or a urinary
tract infection that has spread to the bone through the blood (bacteremia,
- A minor trauma, which can lead to a blood clot around the bone and then
a secondary infection from seeding of bacteria.
- Bacteria in the bloodstream bacteremia (poor dentition), which is
deposited in a focal (localized) area of the bone. This bacterial site in
the bone then grows, resulting in destruction of the bone. However, new bone
often forms around the site.
- A chronic open wound or soft tissue infection can eventually extend down
to the bone surface, leading to a secondary bone infection.
Osteomyelitis affects about two out of every 10,000 people. If
left untreated, the infection can become chronic and cause a loss of blood
supply to the affected bone. When this happens, it can lead to the eventual
death of the bone tissue.
Osteomyelitis can affect both adults and children. The bacteria
or fungus that can cause osteomyelitis, however, differs among age groups. In
adults, osteomyelitis often affects the vertebrae and the pelvis. In children,
osteomyelitis usually affects the adjacent ends of long bones. Long bones (bones
of the limbs) are large, dense bones that provide strength, structure, and
mobility. They include the femur and tibia in the legs and the humerus and
radius in the arms.
Osteomyelitis does not occur more commonly in a particular race
or gender. However, some people are more at risk for developing the disease, including:
- People with diabetes
- Patients receiving hemodialysis
- People with weakened immune systems
- People with sickle cell disease
- Intravenous drug abusers
- The elderly
Symptoms of osteomyelitis
The symptoms of osteomyelitis can include:
- Pain and/or tenderness in the infected area
- Swelling and warmth in the infected area
- Nausea, secondarily from being ill with infection
- General discomfort, uneasiness, or ill feeling
- Drainage of pus through the skin
Additional symptoms that may be associated with this disease include:
- Excessive sweating
- Lower back pain (if the spine is involved)
- Swelling of the ankles, feet, and legs
- Changes in gait (walking pattern that is a painful, yielding a limp)
To diagnose osteomyelitis, the doctor will first perform a history, review
of systems, and a complete physical examination. In doing so, the physician will
look for signs or symptoms of soft tissue and bone tenderness and possibly
swelling and redness. The doctor will also ask you to describe your symptoms and
will evaluate your personal and family medical history. The doctor can then
order any of the following tests to assist in confirming the diagnosis:
- Blood tests: When testing the blood, measurements are taken to
confirm an infection: a CBC (complete blood count), which will show if there
is an increased white blood cell count; an ESR (erythrocyte sedimentation
rate); and/or CRP (C-reactive protein) in the bloodstream, which detects and
measures inflammation in the body.
- Blood culture: A blood culture is a test used to detect bacteria. A
sample of blood is taken and then placed into an environment that will
support the growth of bacteria. By allowing the bacteria to grow, the
infectious agent can then be identified and tested against different
antibiotics in hopes of finding the most effective treatment.
- Needle aspiration: During this test, a needle is used to remove a
sample of fluid and cells from the vertebral space, or bony area. It is then
sent to the lab to be evaluated by allowing the infectious agent to grow on
- Biopsy: A biopsy (tissue sample) of the infected bone may be taken
and tested for signs of an invading organism.
- Bone scan: During this test, a small amount of Technetium-99
pyrophosphate, a radioactive material, is injected intravenously into the
body. If the bone tissue is healthy, the material will spread in a uniform
fashion. However, a tumor or infection in the bone will absorb the material
and show an increased concentration of the radioactive material, which can
be seen with a special camera that produces the images on a computer screen.
The scan can help your doctor detect these abnormalities in their early
stages, when X-ray findings may only show normal findings.
Treating and managing osteomyelitis
The objective of treating osteomyelitis is to eliminate the infection and
prevent the development of chronic infection. Chronic osteomyelitis can lead to
permanent deformity, possible fracture, and chronic problems, so it is important
to treat the disease as soon as possible.
Drainage: If there is an open wound or abscess, it may be
drained through a procedure called needle aspiration. In this procedure, a
needle is inserted into the infected area and the fluid is withdrawn. For
culturing to identify the bacteria, deep aspiration is preferred over
often-unreliable surface swabs. Most pockets of infected fluid collections (pus
pocket or abscess) are drained by open surgical procedures.
Medications: Prescribing antibiotics is the first step in
treating osteomyelitis. Antibiotics help the body get rid of bacteria in the
bloodstream that may otherwise re-infect the bone. The dosage and type of
antibiotic prescribed depends on the type of bacteria present and the extent of
infection. While antibiotics are often given intravenously, some are also very
effective when given in an oral dosage. It is important to first identify the
offending organism through blood cultures, aspiration, and biopsy so that the
organism is not masked by an initial inappropriate dose of antibiotics. The
preference is to first make attempts to do procedures (aspiration or bone
biopsy) to identify the organisms prior to starting antibiotics.
Splinting or cast immobilization: This may be necessary to
immobilize the affected bone and nearby joints in order to avoid further trauma
and to help the area heal adequately and as quickly as possible. Splinting and
cast immobilization are frequently done in children, although motion of joints
after initial control is important to prevent stiffness and atrophy.
Surgery: Most well-established bone infections are managed
through open surgical procedures during which the destroyed bone is scraped out.
In the case of spinal abscesses, surgery is not performed unless there is
compression of the spinal cord or nerve roots. Instead, patients with spinal
osteomyelitis are given intravenous antibiotics. After surgery, antibiotics
against the specific bacteria involved in the infection are then intensively
administered during the hospital stay and for many weeks afterward.
With proper treatment, the outcome is usually good for
osteomyelitis, although results tend to be worse for chronic osteomyelitis, even
with surgery. Some cases of chronic osteomyelitis can be so resistant to
treatment that amputation may be required; however, this is rare. Also, over many years,
chronic infectious draining sites can evolve into a squamous-cell type of skin cancer; this,
too, is rare. Any change in the nature of the chronic drainage, or change of the nature of the
chronic drainage site, should be evaluated by a physician experienced in
treating chronic bone infections. Because it is important that osteomyelitis
receives prompt medical attention, people who are at a higher risk of developing
osteomyelitis should call their doctors as soon as possible if any symptoms arise.
For more information on osteomyelitis, contact the following organizations:
NIH/National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
One AMS Circle
Bethesda MD 20892-3675
Back Pain Association of America, Inc.
P.O. Box 135
Pasadena MD 21123-0135
Ryan KJ, Ray C. Chapter 58. Bone and Joint Infections. In: Ryan KJ, Ray C. eds. Sherris Medical Microbiology, 5e. New York, NY: McGraw-Hill; 2010.
Grad YH, Ross JJ. Chapter 200. Osteomyelitis and Septic Arthritis. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS. eds. Principles and Practice of Hospital Medicine. New York, NY: McGraw-Hill; 2012.
State Government of Victoria. Better Health Channel.
Journal of the American Medical Association.
JAMA Patient Page: Osteomyelitis
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