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      Drugs & Diseases > Orthopedic Surgery

      Osteomyelitis Clinical Presentation

      Updated: Jul 11, 2022
      • Author: Jigar Gandhi, MD, PharmD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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      History

      Acute osteomyelitis requires that the clinician maintain a high degree of suspicion so as to minimize delayed diagnosis and the consequences thereof. Osteomyelitis is often diagnosed clinically on the basis of nonspecific symptoms such as fever, chills, fatigue, lethargy, or irritability. The classic signs of inflammation, including local pain, swelling, or redness, may also occur and usually disappear within 5-7 days. [1]  

      Chronic posttraumatic osteomyelitis requires a detailed history for diagnosis, including information regarding the initial injury and previous antibiotic and surgical treatment. Weightbearing and function of the involved extremity are typically disturbed. Local pain, swelling, erythema, and edema may also be reported. [2]

      Before the introduction of penicillin in the 1940s, management of osteomyelitis was mainly surgical, consisting of extensive debridement, saucerization, and wound packing, after which the affected area is left to heal by secondary intention, resulting in high mortality from sepsis. Since the availability of antibiotics, mortality from osteomyelitis, including staphylococcal osteomyelitis, has improved significantly. [17]

       

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      Physical Examination

      On physical examination, scars or local disturbance of wound healing may be noted along with the cardinal signs of inflammation. [2] Range of motion ROM), deformity, and local signs of impaired vascularity are also sought in the involved extremity. If periosteal tissues are involved, point tenderness may be present. [9]

      In children, the clinical presentation of osteomyelitis can be challenging for physicians because it can present with only nonspecific signs and symptoms and because the clinical findings are extremely variable. Children may present with decreased movement and pain in the affected limb and adjacent joint, as well as edema and erythema over the involved area. In addition, children may also present with fever, malaise, and irritability. Newborns with osteomyelitis may demonstrate decreased movement of a limb without any other signs or symptoms.

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      Complications

      The most common complication in children with osteomyelitis is recurrence of bone infection. Complications as a result of acute hematogenous osteomyelitis due to methicillin-resistant S aureus (MRSA) is often attributed to more complicated illness, as compared with osteomyelitis caused by methicillin-sensitive S aureus (MSSA) or any other organism. Potential complications of osteomyelitis include the following:

      • Septic pulmonary emboli
      • Deep vein thrombosis in the region near the infected bone
      • Intraosseous and subperiosteal abscess
      • Pathologic fracture - This is a rare complication and can occur as a result of extreme bone destruction or thinning of the cortex
      • Growth disturbance when epiphyseal plate is involved
      • Bone deformity
      • Disseminated infection with multiorgan failure resulting in sepsis

      These complications contribute to longer median hospital stay and a higher likelihood that surgical intervention will be needed to drain deep abscesses. The severity of the disease can relate to S aureus virulence factor (also known as PVL), which is a cytotoxin that destroys leukocytes. In general, complications are more likely to arise when proper diagnosis and initiation of therapy are delayed. Such delay contributes to significant morbidity, which can include longitudinal bone growth and angular deformity, as well as sepsis and chronic infection. 

      With a diagnosis of acute hematogenous osteomyelitis, it is crucial to establish a 2-week follow-up after discharge to reduce the likelihood of a complication and to ensure that there is continued clinical improvement. Children who developed osteomyelitis near the growth plate are at increased risk for bone deformities and growth impairment; therefore, they must be followed clinically and radiographically on a yearly basis until they reach skeletal maturity to ensure that no further interventions are required to address the potential sequelae. [18]

      Patient must receive proper education about the duration of therapy and the importance of compliance with treatment recommendations to promote healing and to decrease the rate of recurrence. [5, 17]

      Adverse outcomes are common with delayed treatment; however, even when appropriate treatment is provided, chronic infection may still develop in 5-10% of cases. Chronic osteomyelitis presents 6 weeks or longer after a bone infection, and its characteristics include bone destruction and formation of sequestra. Leading complications resulting from chronic osteomyelitis include sinus tracts and extension to adjacent structures, as well as abscess formation. One complication that must not be missed is malignant transformation (ie, Marjolin ulcer). This typically has a latency period of 27-30 years from the initial onset of osteomyelitis, and it involves aggressive squamous cell carcinoma (SCC). [19]

      When centrally placed intravenous (IV) catheters are used in cases that require prolonged IV antibiotic treatment, catheter-associated complications can occur. However, the use of peripherally inserted central venous catheters (PICC lines) has reduced the frequency of these complications.

      In a study of 17,238 Taiwanese patients newly diagnosed with chronic osteomyelitis from 2000 to 2008 who were identified on the basis of Taiwanese National Health Insurance (NHI) inpatient claims, Tseng et al found chronic osteomyelitis to be associated with an increased risk of dementia, particularly among the younger patients studied. [20]

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