Doctors Revision

Musculoskeletal System & Rheumatology

Osteomyelitis

Infection and inflammation of the bone and bone marrow, usually caused by bacteria. Can be acute or chronic.

Also known as: Bone Infection

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Referral and warning signs

When to refer

Referral to hospital (HC4/H/RR) / Orthopaedic Surgeon required for ALL suspected cases for diagnosis confirmation, IV antibiotics, and consideration of surgical debridement.

Red flags

  • Localized bone pain with fever/systemic illness
  • Failure to bear weight on limb (child)
  • Non-healing ulcer overlying bone
  • Draining sinus tract
  • Signs of sepsis
  • Failure to improve on initial antibiotics for presumed soft tissue infection

Signs and symptoms

  • Acute Osteomyelitis: Gradual onset over several days. Localized bone pain (often severe, constant, boring). Tenderness, warmth, redness, swelling over the affected bone. Reduced movement or inability to use the affected limb ('pseudoparalysis'). Fever, chills, malaise (may be absent, especially in neonates). History of preceding infection or trauma may be present.
  • Chronic Osteomyelitis: Persistent or recurrent bone pain. Draining sinus tract from skin overlying affected bone. Chronic wound or ulcer overlying bone (e.g., diabetic foot ulcer). Erythema, swelling. History of previous bone injury, surgery, or acute osteomyelitis.

Risk factors

  • Haematogenous spread (common in children affecting metaphysis of long bones).
  • Contiguous spread (from adjacent soft tissue infection, septic arthritis).
  • Direct inoculation (open fracture, surgery, penetrating trauma).
  • Diabetes Mellitus (especially foot osteomyelitis).
  • Peripheral vascular disease.
  • Sickle Cell Disease (Salmonella common, also S. aureus).
  • Immunosuppression.
  • Intravenous drug use.
  • Presence of orthopaedic hardware.

Diagnosis

Clinical assessment

Suspect acute osteomyelitis with localized bone pain, tenderness, swelling, +/- fever, especially in children or those with risk factors. Suspect chronic osteomyelitis with draining sinus, non-healing ulcer over bone, or recurrent pain/swelling. Differentiate from septic arthritis, cellulitis, pyomyositis, bone tumour, fracture, sickle cell pain crisis.

Investigations

  • Blood tests: CBC (leucocytosis), ESR/CRP (markedly elevated in acute, may be normal/mildly elevated in chronic), Blood cultures (positive in ~50% acute haematogenous cases).
  • Imaging: Plain X-ray (often normal early; later shows periosteal reaction, lytic lesions, sequestrum, involucrum). MRI Scan (most sensitive for early detection). CT Scan (good for cortical bone, sequestra). Bone Scan (sensitive early, less specific).
  • Microbiology: Bone Biopsy (percutaneous or open) - Gold standard. Histology and Culture (aerobic, anaerobic, fungal, AFB). Culture of draining sinus tract less reliable.
  • Consider GeneXpert/AFB/Fungal on biopsy if TB/fungal suspected.

Diagnostic criteria

Combination of clinical suspicion, elevated inflammatory markers, characteristic imaging findings (esp. MRI or later X-ray), and ideally, positive bone biopsy culture/histology.

Management

Non-pharmacological management

  • Immobilisation (splinting) during acute phase.
  • Pain management.
  • Elevation.
  • Surgical Debridement: Essential for chronic osteomyelitis (remove dead bone/tissue/hardware). May be needed acutely for abscess or failure of medical therapy.
  • Wound care.

Pharmacological treatment

  • Antibiotics: Prolonged course (4-6 weeks+, often start IV then switch to oral). Choice based on likely pathogens & biopsy results.
  • - Empirical (Acute): Cover S. aureus. IV Cloxacillin +/- Ceftriaxone. Vancomycin if MRSA risk.
  • - Salmonella (Sickle Cell): Fluoroquinolone (Ciprofloxacin) or Ceftriaxone.
  • - Chronic: Tailor to cultures. Often broad initially. Good oral options needed (Fluoroquinolones, Clindamycin, Rifampicin [combo], TMP-SMX).
  • Analgesia (Paracetamol, NSAIDs, Opioids).

Monitoring

Monitor clinical response (pain, swelling, fever). Monitor inflammatory markers (ESR/CRP). Monitor antibiotic side effects. Follow-up imaging.

Complications

  • Chronic osteomyelitis
  • Pathological fracture
  • Bone deformity / Growth disturbance (children)
  • Septic arthritis
  • Abscess formation
  • Sinus tract formation
  • Sepsis
  • Squamous cell carcinoma (in chronic sinus)

Prevention

  • Prompt treatment of bacteraemia.
  • Appropriate management of open fractures.
  • Good diabetic foot care.
  • Aseptic surgical technique.

Patient education

  • Explain osteomyelitis as bone infection.
  • Need for prolonged antibiotics (often IV initially).
  • Importance of completing full course.
  • Potential need for surgery.
  • Importance of immobilization/rest then physiotherapy.
  • Monitoring for side effects and recurrence.

Uganda-specific notes

Common, esp. haematogenous in children and secondary to trauma. Sickle cell disease major risk (Salmonella). TB osteomyelitis (Pott's) important. Diagnosis often clinical + X-ray. Prolonged antibiotics +/- surgery required.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 10, Section 10.1.2

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