History

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

Physical

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)

Causes

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

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

Differential Diagnoses

Bury DC, Rogers TS, Dickman MM. Osteomyelitis: Diagnosis and Treatment. Am Fam Physician. 2021 Oct 1. 104 (4):395-402. [QxMD MEDLINE Link].
Zimmerli W. Clinical practice. Vertebral osteomyelitis. N Engl J Med. 2010 Mar 18. 362(11):1022-9. [QxMD MEDLINE Link].
[Guideline] Schweitzer ME, Daffner RH, Weissman BN, et al. Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® suspected osteomyelitis in patients with diabetes mellitus. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. [Full Text].
Crary SE, Buchanan GR, Drake CE, Journeycake JM. Venous thrombosis and thromboembolism in children with osteomyelitis. J Pediatr. 2006 Oct. 149(4):537-41. [QxMD MEDLINE Link].
Schaub RL, Rodkey ML. Deep vein thrombosis and septic pulmonary emboli with MRSA osteomyelitis in a pediatric patient. Pediatr Emerg Care. 2012 Sep. 28(9):911-2. [QxMD MEDLINE Link].
Kaplan SL. Osteomyelitis in children. Infect Dis Clin North Am. 2005 Dec. 19(4):787-97, vii. [QxMD MEDLINE Link].
Chihara S, Segreti J. Osteomyelitis. Dis Mon. 2010 Jan. 56(1):5-31. [QxMD MEDLINE Link].
Germain ML, Krenzer KA, Hasley BP, Varman M. 11-month-old child refuses to sit up. Pediatr Ann. 2008 May. 37(5):290-3. [QxMD MEDLINE Link].
Saavedra-Lozano J, Mejias A, Ahmad N, et al. Changing trends in acute osteomyelitis in children: impact of methicillin-resistant Staphylococcus aureus infections. J Pediatr Orthop. 2008 Jul-Aug. 28(5):569-75. [QxMD MEDLINE Link].
Kiang KM, Ogunmodede F, Juni BA, et al. Outbreak of osteomyelitis/septic arthritis caused by Kingella kingae among child care center attendees. Pediatrics. 2005 Aug. 116(2):e206-13. [QxMD MEDLINE Link].
Barclay L. First US guidelines for vertebral osteomyelitis released. Medscape Medical News. WebMD Inc. Available at http://www.medscape.com/viewarticle/848897. July 31, 2015; Accessed: September 29, 2015.
[Guideline] Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adultsa. Clin Infect Dis. 2015 Sep 15. 61 (6):e26-46. [QxMD MEDLINE Link].
Shen CJ, Wu MS, Lin KH, Lin WL, Chen HC, Wu JY, et al. The use of procalcitonin in the diagnosis of bone and joint infection: a systemic review and meta-analysis. Eur J Clin Microbiol Infect Dis. 2013 Jun. 32(6):807-14. [QxMD MEDLINE Link].
Aloui N, Nessib N, Jalel C, et al. [Acute osteomyelitis in children: early MRI diagnosis]. J Radiol. 2004 Apr. 85(4 Pt 1):403-8. [QxMD MEDLINE Link].
Pruthi S, Thapa MM. Infectious and inflammatory disorders. Radiol Clin North Am. 2009 Nov. 47(6):911-26.
Álvaro-Afonso FJ, Lázaro-Martínez JL, Aragón-Sánchez FJ, García-Morales E, Carabantes-Alarcón D, Molines-Barroso RJ. Does the location of the ulcer affect the interpretation of the probe-to-bone test in the diagnosis of osteomyelitis in diabetic foot ulcers?. Diabet Med. 2014 Jan. 31 (1):112-3. [QxMD MEDLINE Link].
Lam K, van Asten SA, Nguyen T, La Fontaine J, Lavery LA. Diagnostic Accuracy of Probe to Bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review. Clin Infect Dis. 2016 Oct 1. 63 (7):944-8. [QxMD MEDLINE Link].
Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve Clin J Med. 1992 Sep-Oct. 59(5):517-28. [QxMD MEDLINE Link].
Byren I, Peters EJ, Hoey C, Berendt A, Lipsky BA. Pharmacotherapy of diabetic foot osteomyelitis. Expert Opin Pharmacother. 2009 Dec. 10(18):3033-47. [QxMD MEDLINE Link].
Kaplan SL, Deville JG, Yogev R, Morfin MR, Wu E, Adler S, et al. Linezolid versus vancomycin for treatment of resistant Gram-positive infections in children. Pediatr Infect Dis J. 2003 Aug. 22 (8):677-86. [QxMD MEDLINE Link].
Kimberlin DW, Brady MT, Jackson MA, Long SS. Staphylococcal infections. American Academy of Pediatrics Red Book. 30th. 2015. 715.
Moenster RP, Linneman TW, Call WB, Kay CL, McEvoy TA, Sanders JL. The potential role of newer gram-positive antibiotics in the setting of osteomyelitis of adults. J Clin Pharm Ther. 2013 Apr. 38 (2):89-96. [QxMD MEDLINE Link].
Asmar BI. Osteomyelitis in the neonate. Infect Dis Clin North Am. 1992 Mar. 6(1):117-32. [QxMD MEDLINE Link].
Bamberger DM. Diagnosis and treatment of osteomyelitis. Compr Ther. 2000 Summer. 26(2):89-95. [QxMD MEDLINE Link].
Bocchini CE, Hulten KG, Mason EO Jr, Gonzalez BE, Hammerman WA, Kaplan SL. Panton-Valentine leukocidin genes are associated with enhanced inflammatory response and local disease in acute hematogenous Staphylococcus aureus osteomyelitis in children. Pediatrics. 2006 Feb. 117(2):433-40. [QxMD MEDLINE Link].
Cheatle MD. The effect of chronic orthopedic infection on quality of life. Orthop Clin North Am. 1991 Jul. 22(3):539-47. [QxMD MEDLINE Link].
Chisholm CD, Schlesser JF. Plantar puncture wounds: controversies and treatment recommendations. Ann Emerg Med. 1989 Dec. 18(12):1352-7. [QxMD MEDLINE Link].
Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis. 2008 Aug 15. 47(4):519-27. [QxMD MEDLINE Link].
Euba G, Murillo O, Fernández-Sabé N, Mascaró J, Cabo J, Pérez A, et al. Long-term follow-up trial of oral rifampin-cotrimoxazole combination versus intravenous cloxacillin in treatment of chronic staphylococcal osteomyelitis. Antimicrob Agents Chemother. 2009 Jun. 53(6):2672-6. [QxMD MEDLINE Link]. [Full Text].
Fowler VG Jr, Justice A, Moore C, et al. Risk factors for hematogenous complications of intravascular catheter-associated Staphylococcus aureus bacteremia. Clin Infect Dis. 2005 Mar 1. 40(5):695-703. [QxMD MEDLINE Link].
Gelfand MS, Cleveland KO. Vancomycin therapy and the progression of methicillin-resistant Staphylococcus aureus vertebral osteomyelitis. South Med J. 2004 Jun. 97(6):593-7. [QxMD MEDLINE Link].
Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health. 2005 Jan-Feb. 41(1-2):59-62. [QxMD MEDLINE Link].
Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004. CD003764. [QxMD MEDLINE Link].
Harwood PJ, Talbot C, Dimoutsos M, et al. Early experience with linezolid for infections in orthopaedics. Injury. 2006 Sep. 37(9):818-26. [QxMD MEDLINE Link].
Henry NK, Rouse MS, Whitesell AL, McConnell ME, Wilson WR. Treatment of methicillin-resistant Staphylococcus aureus experimental osteomyelitis with ciprofloxacin or vancomycin alone or in combination with rifampin. Am J Med. 1987 Apr 27. 82(4A):73-5. [QxMD MEDLINE Link].
Hollmig ST, Copley LA, Browne RH, Grande LM, Wilson PL. Deep venous thrombosis associated with osteomyelitis in children. J Bone Joint Surg Am. 2007 Jul. 89(7):1517-23. [QxMD MEDLINE Link].
Hsu LY, Koh TH, Tan TY. Emergence of community-associated methicillin-resistant Staphylococcus aureus in Singapore: a further six cases. Singapore Med J. 2006 Jan. 47(1):20-6. [QxMD MEDLINE Link].
Kabak S, Tuncel M, Halici M, Tutus A, Baktir A, Yildirim C. Role of trauma on acute haematogenic osteomyelitis aetiology. Eur J Emerg Med. 1999 Sep. 6(3):219-22. [QxMD MEDLINE Link].
Kaiser S, Jorulf H, Hirsch G. Clinical value of imaging techniques in childhood osteomyelitis. Acta Radiol. 1998 Sep. 39(5):523-31. [QxMD MEDLINE Link].
Karamanis EM, Matthaiou DK, Moraitis LI, Falagas ME. Fluoroquinolones versus beta-lactam based regimens for the treatment of osteomyelitis: a meta-analysis of randomized controlled trials. Spine (Phila Pa 1976). 2008 May 1. 33(10):E297-304. [QxMD MEDLINE Link].
Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011 Feb 1. 52(3):285-92. [QxMD MEDLINE Link].
Mandracchia VJ, Sanders SM, Jaeger AJ, Nickles WA. Management of osteomyelitis. Clin Podiatr Med Surg. 2004 Jul. 21(3):335-51, vi. [QxMD MEDLINE Link].
Martinez-Aguilar G, Hammerman WA, Mason EO. Clindamycin treatment of invasive infections caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children. Pediatr Infect Dis J. 2003 Jul. 22(7):593-8. [QxMD MEDLINE Link].
Martínez-Aguilar G, Avalos-Mishaan A, Hulten K, Hammerman W, Mason EO Jr, Kaplan SL. Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children. Pediatr Infect Dis J. 2004 Aug. 23(8):701-6. [QxMD MEDLINE Link].
Moumile K, Merckx J, Glorion C, Pouliquen JC, Berche P, Ferroni A. Bacterial aetiology of acute osteoarticular infections in children. Acta Paediatr. 2005 Apr. 94(4):419-22. [QxMD MEDLINE Link].
Nguyen S, Pasquet A, Legout L, Beltrand E, Dubreuil L, Migaud H. Efficacy and tolerance of rifampicin-linezolid compared with rifampicin-cotrimoxazole combinations in prolonged oral therapy for bone and joint infections. Clin Microbiol Infect. 2009 Dec. 15(12):1163-9. [QxMD MEDLINE Link].
Nicolau DP, Nie L, Tessier PR, Kourea HP, Nightingale CH. Prophylaxis of acute osteomyelitis with absorbable ofloxacin-impregnated beads. Antimicrob Agents Chemother. 1998 Apr. 42(4):840-2. [QxMD MEDLINE Link]. [Full Text].
Perron AD, Brady WJ, Miller MD. Orthopedic pitfalls in the ED: osteomyelitis. Am J Emerg Med. 2003 Jan. 21(1):61-7. [QxMD MEDLINE Link].
Rao N, Ziran BH, Hall RA, Santa ER. Successful treatment of chronic bone and joint infections with oral linezolid. Clin Orthop Relat Res. 2004 Oct. 67-71. [QxMD MEDLINE Link].
Rasmont Q, Yombi JC, Van der Linden D, Docquier PL. Osteoarticular infections in Belgian children: a survey of clinical, biological, radiological and microbiological data. Acta Orthop Belg. 2008 Jun. 74(3):374-85. [QxMD MEDLINE Link].
Restrepo CS, Lemos DF, Gordillo H, et al. Imaging findings in musculoskeletal complications of AIDS. Radiographics. 2004 Jul-Aug. 24(4):1029-49. [QxMD MEDLINE Link].
Roberts DE. Femoral osteomyelitis after tooth extraction. Am J Orthop (Belle Mead NJ). 1998 Sep. 27(9):624-6. [QxMD MEDLINE Link].
Sadat-Ali M. The status of acute osteomyelitis in sickle cell disease. A 15-year review. Int Surg. 1998 Jan-Mar. 83(1):84-7. [QxMD MEDLINE Link].
Sammak B, Abd El Bagi M, Al Shahed M, et al. Osteomyelitis: a review of currently used imaging techniques. Eur Radiol. 1999. 9(5):894-900. [QxMD MEDLINE Link].
Schauwecker DS. The scintigraphic diagnosis of osteomyelitis. AJR Am J Roentgenol. 1992 Jan. 158(1):9-18. [QxMD MEDLINE Link].
Segev S, Yaniv I, Haverstock D, Reinhart H. Safety of long-term therapy with ciprofloxacin: data analysis of controlled clinical trials and review. Clin Infect Dis. 1999 Feb. 28(2):299-308. [QxMD MEDLINE Link].
Seligson D, Klemm K. Adult posttraumatic osteomyelitis of the tibial diaphysis of the tibial shaft. Clin Orthop Relat Res. 1999 Mar. 30-6. [QxMD MEDLINE Link].
Shedek BK, Nilles EJ. Community-associated methicillin-resistant Staphylococcus aureus pyomyositis complicated by compartment syndrome in an immunocompetent young woman. Am J Emerg Med. 2008 Jul. 26(6):737.e3-4. [QxMD MEDLINE Link].
Shih HN, Shih LY, Wong YC. Diagnosis and treatment of subacute osteomyelitis. J Trauma. 2005 Jan. 58(1):83-7. [QxMD MEDLINE Link].
Sonnen GM, Henry NK. Pediatric bone and joint infections. Diagnosis and antimicrobial management. Pediatr Clin North Am. 1996 Aug. 43(4):933-47. [QxMD MEDLINE Link].
Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2012 Feb 1. 54(3):393-407. [QxMD MEDLINE Link].
Steer AC, Carapetis JR. Acute hematogenous osteomyelitis in children: recognition and management. Paediatr Drugs. 2004. 6(6):333-46. [QxMD MEDLINE Link].
Stengel D, Bauwens K, Sehouli J, Ekkernkamp A, Porzsolt F. Systematic review and meta-analysis of antibiotic therapy for bone and joint infections. Lancet Infect Dis. 2001 Oct. 1(3):175-88. [QxMD MEDLINE Link].
Trobs R, Moritz R, Buhligen U, et al. Changing pattern of osteomyelitis in infants and children. Pediatr Surg Int. 1999 Jul. 15(5-6):363-72. [QxMD MEDLINE Link].
Tsukayama DT. Pathophysiology of posttraumatic osteomyelitis. Clin Orthop Relat Res. 1999 Mar. 22-9. [QxMD MEDLINE Link].
US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when linezolid (Zyvox®) is given to patients taking certain psychiatric medications. Available at http://www.fda.gov/Drugs/DrugSafety/ucm265305.htm. Accessed: July 27, 2011.
Vuagnat A, Stern R, Lotthe A, et al. High dose vancomycin for osteomyelitis: continuous vs. intermittent infusion. J Clin Pharm Ther. 2004 Aug. 29(4):351-7. [QxMD MEDLINE Link].
Waagner DC. Musculoskeletal infections in adolescents. Adolesc Med. 2000 Jun. 11(2):375-400. [QxMD MEDLINE Link].
Walenkamp GH, Kleijn LL, de Leeuw M. Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1-12 years. Acta Orthop Scand. 1998 Oct. 69(5):518-22. [QxMD MEDLINE Link].
Walters HL, Measley R. Two cases of Pseudomonas aeruginosa epidural abscesses and cervical osteomyelitis after dental extractions. Spine (Phila Pa 1976). 2008 Apr 20. 33(9):E293-6. [QxMD MEDLINE Link].
Yun HC, Branstetter JG, Murray CK. Osteomyelitis in military personnel wounded in Iraq and Afghanistan. J Trauma. 2008 Feb. 64(2 Suppl):S163-8; discussion S168. [QxMD MEDLINE Link].
Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res. 2004 Oct. 86-93. [QxMD MEDLINE Link].

Media Gallery

Osteomyelitis of the elbow. Photography by David Effron MD, FACEP.
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.
Osteomyelitis of the great toe. Photography by David Effron MD, FACEP.
Osteomyelitis of T10 secondary to streptococcal disease. Photography by David Effron MD, FACEP.
Osteomyelitis of diabetic foot. Photography by David Effron MD, FACEP.
Osteomyelitis. Radiography of diabetic foot showing osteomyelitis with gas. Photography by David Effron MD, FACEP.

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Author

Randall W King, MD, FACEP Assistant Clinical Professor of Emergency Medicine, University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Department of Emergency Medicine, Chief Medical Information Officer, Chief of Staff Elect, Mercy St Vincent Medical Center

Randall W King, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Residency Directors in Emergency Medicine, American Medical Association, Ohio State Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

David Johnson, MD Assistant Clinical Professor, Department of Surgery, University of Toledo College of Medicine; Chairman, Department of Emergency Services, St Vincent's Mercy Medical Center, Toledo

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

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 Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Dana A Stearns, MD Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital; Associate Director, Undergraduate Clerkship in Surgery, Massachusetts General Hospital/Harvard Medical School; Assistant Professor of Surgery, Harvard Medical School

Dana A Stearns, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.