Osteomyelitis in Emergency Medicine Clinical Presentation

Updated: Nov 03, 2022
  • Author: Randall W King, MD, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Hematogenous osteomyelitis usually presents with a slow insidious progression of symptoms. Direct osteomyelitis generally is more localized, with prominent signs and symptoms. General symptoms of osteomyelitis are dicussed below.

The following are general symptoms of hematogenous long-bone osteomyelitis:

  • Abrupt onset of high fever (fever may present in only 50% of neonates with osteomyelitis)

  • Fatigue

  • Irritability

  • Malaise

  • Restriction of movement (pseudoparalysis of limb in neonates)

  • Local edema, erythema, and tenderness

The following are general symptoms of hematogenous vertebral osteomyelitis:

  • Insidious onset

  • History of an acute bacteremic episode

  • May be associated with contiguous vascular insufficiency

  • Local edema, erythema, and tenderness

  • Failure of a young child to sit up normally [8]

The following are general symptoms of chronic osteomyelitis:

  • Nonhealing ulcer

  • Sinus tract drainage

  • Chronic fatigue

  • Malaise



Findings at physical examination may include the following:

  • Fever (may be absent particularly in neonates)

  • Edema

  • Erythema

  • Warmth

  • Fluctuance

  • Tenderness to palpation

  • Reduction in the use of the extremity (eg, reluctance to ambulate, if the lower extremity is involved or pseudoparalysis of limb in neonates)

  • Failure of a young child to sit up normally

  • Sinus tract drainage (usually a late finding or one that occurs with chronic infection)



Note that responsible pathogens may be isolated in only 35%-40% of infections.

Causes of acute hematogenous osteomyelitis are as follows (note increasing reports of other pathogens in bone and joint infections including community-associated methicillin-resistant Staphylococcus aureus [MRSA], [1, 9] Kingella kingae, [10] and others):

  • Newborns (younger than 4 mo): Saureus, Enterobacter species, and group A and B Streptococcus species

  • Children (aged 4 mo to 4 y): S aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species

  • Children, adolescents (aged 4 y to adult): S aureus (80%), group A Streptococcus species, H influenzae, and Enterobacter species

  • Adults: S aureus and occasionally Enterobacter or Streptococcus species

  • Tuberculosis (TB): TB has been a historical cause of hematogenous osteomyelitis and should be considered in patients with a history of TB risk or impaired immune status

Causes of direct osteomyelitis are as follows:

  • General -S aureus, Enterobacter species, and Pseudomonas species [1]

  • Puncture wound through an athletic shoe -S aureus and Pseudomonas species

  • Sickle cell disease -S aureus and Salmonellae species

Also see Medscape's Infectious Diseases Resource Center.



Complications of osteomyelitis may include the following:

  • Bone abscess

  • Paravertebral/epidural abscess

  • Bacteremia

  • Fracture

  • Loosening of the prosthetic implant

  • Overlying soft-tissue cellulitis

  • Draining soft-tissue sinus tracts