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Osteomyelitis in Emergency Medicine

Sections Osteomyelitis in Emergency Medicine
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Workup

Approach Considerations

The studies below are indicated in patients with osteomyelitis.

The Infectious Diseases Society of America (IDSA) issued new guidelines on vertebral osteomyelitis in 2015.^{[11, 12]}

Laboratory Studies

The studies below are indicated in patients with osteomyelitis.

CBC count

The WBC count may be elevated, but it is frequently normal.

A leftward shift is common with increased polymorphonuclear leukocyte counts.

C-reactive protein

The C-reactive protein level is usually elevated and nonspecific; this study may be more useful than the erythrocyte sedimentation rate (ESR) because it reveals elevation earlier.

ESR/CRP

The ESR is usually elevated (90%); however, this finding is clinically nonspecific.

CRP and ESR have limited roles in the setting of chronic osteomyelitis and are often normal.

Elevated ESR and CRP may suggest vertebral osteomyelitis.^{[11, 12]}

Procalcitonin

Procalcitonin elevation: This can potentially be useful in diagnosis because it is relatively specific; however, it lacks sensitivity.^[13]

Culture

Superficial wound or sinus tract cultures often do not correlate with the bacteria that is causing osteomyelitis and have limited use. Blood culture results are positive in approximately 50% of patients with hematogenous osteomyelitis. However, a positive blood culture may preclude the need for further invasive procedures to isolate the organism. Bone cultures from biopsy or aspiration have a diagnostic yield of approximately 77% across all studies.^[2]

Radiography

Radiographic evidence of acute osteomyelitis is first suggested by overlying soft-tissue edema at 3-5 days after infection. Examples of radiographic evidence of osteomyelitis are presented in the images below.

Osteomyelitis of the elbow. Photography by David Effron MD, FACEP.

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Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.

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Osteomyelitis of the great toe. Photography by David Effron MD, FACEP.

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Osteomyelitis of T10 secondary to streptococcal disease. Photography by David Effron MD, FACEP.

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Osteomyelitis. Radiography of diabetic foot showing osteomyelitis with gas. Photography by David Effron MD, FACEP.

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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.

In patients in whom TB is of concern, chest radiography may demonstrate lesions characteristic of TB.

Plain radiographs of the spine are not sensitive for early diagnosis of vertebral osteomyelitis.^{[11, 12]}

MRI

The MRI is effective in the early detection and surgical localization of osteomyelitis.^{[14, 15]}

Studies have shown its superiority compared with plain radiography, CT, and radionuclide scanning and is considered to be the imaging of choice.

Sensitivity ranges from 90-100%.

Patients with back pain and with elevated ESR and CRP levels should undergo MRI to distinguish infection from disc herniation or other structural cause of back pain.^{[11, 12]}

Positron emission tomographic scanning

Positron emission tomographic (PET) scanning has accuracy similar to MRI.

Radionuclide bone scanning

Three phase bone scan, gallium scan and tagged WBC scan are considerations in patients who are unable to have MRI imaging. A three phase bone scan has high sensitivity and specificity in adults with normal findings on radiograph. Specificity is dramatically decreased in the setting of previous surgery or traumatized bone.

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 is not recommended for routine use for diagnosing osteomyelitis but is often the imaging of choice when MRI is not available

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.

Procedures

The probe to bone (PTB) test may be a useful rapid adjunct in the evaluation of the diabetic foot. The procedure involves inserting a blunt probe into the suspected ulceration on the plantar surface of the foot. A "click" (solid or gritty end point) indicates a positive finding. Note that location of the ulcer and the performer’s expertise may affect reliability.^[16]. A positive PTB test finding in a high-risk patient indicates a high probability of osteomyelitis. A negative PTB test result in a low-risk patient indicates a low probability of osteomyelitis.^[17]

Treatment & Management

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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.

Sections Osteomyelitis in Emergency Medicine
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Osteomyelitis in Emergency Medicine Workup

Approach Considerations