eMedicine Specialties > Emergency Medicine > Infectious Diseases

Osteomyelitis: Differential Diagnoses & Workup

Author: Randall W King, MD, Assistant Clinical Professor of Emergency Medicine, Medical College of Ohio; Program Director, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center
Coauthor(s): David Johnson, MD, Assistant Clinical Professor, Department of Surgery, Medical University of Ohio; Associate Chair, Department of Emergency Services, Director, Lucas County Emergency, St Vincent's Mercy Medical Center
Contributor Information and Disclosures

Updated: Nov 4, 2008

Differential Diagnoses

Bites, Animal
Neoplasms, Spinal Cord
Cellulitis
Pediatrics, Limp
Deep Venous Thrombosis and Thrombophlebitis
Pediatrics, Sickle Cell Disease
Gas Gangrene
Plantar Fasciitis
Gout and Pseudogout
Septic Arthritis
Hand Infections
Septic Arthritis, Pediatrics
Juvenile Rheumatoid Arthritis
Spinal Cord Infections
Lumbar (Intervertebral) Disk Disorders
Transient Synovitis

Other Problems to Be Considered

Fractures
Aseptic bone infarction
Neuropathic joint disease

Workup

Laboratory Studies

  • CBC: The WBC count may be elevated, but it frequently is normal.
    • A leftward shift is common with increased polymorphonuclear leukocyte counts.
    • The C-reactive protein level usually is elevated and nonspecific; it may be more useful than the erythrocyte sedimentation rate. It will show elevation earlier than the erythrocyte sedimentation rate (ESR).
    • The erythrocyte sedimentation rate usually is elevated (90%); this finding is clinically nonspecific.
  • With osteomyelitis, culture or aspiration findings in samples of the infected site are normal in 25% of cases. Blood culture results are positive in only 50% of patients with hematogenous osteomyelitis.

Imaging Studies

  • Radiography
    • Radiographic evidence of acute osteomyelitis is first suggested by overlying soft-tissue edema at 3-5 days after infection.
    • Bony changes are not evident for 14-21 days and initially manifest as periosteal elevation followed by cortical or medullary lucencies. By 28 days, 90% of patients demonstrate some abnormality.
    • Approximately 40-50% focal bone loss is necessary to cause detectable lucency on plain films.
  • MRI
    • The MRI is effective in the early detection and surgical localization of osteomyelitis.
    • Studies have shown its superiority compared with plain radiography, CT, and radionuclide scanning in selected anatomic locations.
    • Sensitivity ranges from 90-100%.
  • Radionuclide bone scanning
    • A 3-phase bone scan with technetium 99m is probably the initial imaging modality of choice.
    • In special circumstances, additional information can be obtained from further scanning with leukocytes labeled with gallium 67 and/or indium 111.
  • CT scanning
    • CT scans can depict abnormal calcification, ossification, and intracortical abnormalities.
    • It probably is most useful in the evaluation of spinal vertebral lesions. It may also be superior in areas with complex anatomy: pelvis, sternum, and calcaneus.
  • Ultrasonography
    • This simple and inexpensive technique has shown promise, particularly in children with acute osteomyelitis.
    • Ultrasonography may demonstrate changes as early as 1-2 days after onset of symptoms.
    • Abnormalities include soft tissue abscess or fluid collection and periosteal elevation.
    • Ultrasonography allows for ultrasound-guided aspiration.
    • It does not allow for evaluation of bone cortex.

More on Osteomyelitis

Overview: Osteomyelitis
Differential Diagnoses & Workup: Osteomyelitis
Treatment & Medication: Osteomyelitis
Follow-up: Osteomyelitis
Multimedia: Osteomyelitis
References
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Further Reading

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Keywords

osteomyelitis, bone infection, central osteitis, hematogenous osteomyelitis, direct inoculation osteomyelitis, chronic osteomyelitis, osteomyelitis secondary to peripheral vascular disease, contiguous inoculation osteomyelitis, vertebral osteomyelitis, spinal-cord compression, spinal osteomyelitis, Staphylococcus aureus, Enterobacter species, Haemophilus influenzae, Streptococcus species, Pseudomonas species, Salmonellae species, diabetes mellitus, sickle cell disease, acquired immune deficiency syndrome, AIDS, IV drug abuse, alcoholism, chronic steroid use, immunosuppression, chronic joint disease, MRSA, methicillin-resistant Staphylococcus aureus, community-associated methicillin-resistant Staphylococcus aureus, Kingella kingae

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Contributor Information and Disclosures

Author

Randall W King, MD, Assistant Clinical Professor of Emergency Medicine, Medical College of Ohio; Program Director, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center
Randall W King, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, Ohio State Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Challenger corporation None Other

Coauthor(s)

David Johnson, MD, Assistant Clinical Professor, Department of Surgery, Medical University of Ohio; Associate Chair, Department of Emergency Services, Director, Lucas County Emergency, St Vincent's Mercy Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric L Weiss, MD, DTM&H, Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine
Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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