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| | __NOTOC__ |
| | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| {{Infobox Disease | | | {{Infobox Disease | |
| Name = Osteomyelitis | | | Name = Osteomyelitis | |
| Image = Ostermyelitis Tibia.jpg | | | Image = Ostermyelitis Tibia.jpg | |
| Caption = Osteomyelitis of the [[tibia]] of a young child. Numerous [[abscess]]es in the bone show as [[radiolucency]]. | | | Caption = Osteomyelitis of the [[tibia]] of a young child. Numerous [[abscess]]es in the bone show as radiolucency. | |
| ICD10 = {{ICD10|M|86||m|86}} |
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| ICD9 = {{ICD9|730}} |
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| ICDO = |
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| OMIM = |
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| DiseasesDB = 9367 |
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| MedlinePlus = 000437 |
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| eMedicineSubj = ped |
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| eMedicineTopic = 1677 |
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| MeshID = D010019 |
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| }} | | }} |
| {{Search infobox}} | | {{Osteomyelitis}} |
| {{CMG}} | | {{CMG}}; {{AE}} {{MehdiP}},{{NRM}} |
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| '''Associate Editor-In-Chief:''' {{CZ}}
| | {{SK}} OM |
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| {{Editor Join}}
| | ==[[Osteomyelitis overview|Overview]]== |
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| ==Overview== | | ==[[Osteomyelitis historical perspective|Historical Perspective]]== |
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| '''Osteomyelitis''' is an [[infection]] of [[bone]] or bone marrow, usually caused by [[pyogenic]] [[bacterium|bacteria]] or mycobacteria. It can be usefully subclassifed on the basis of the causative organism, the route, duration and anatomic location of the infection.<ref name="Robbins"> Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; & Mitchell, Richard N. (2007). ''Robbins Basic Pathology'' (8th ed.). Saunders Elsevier. pp. 810-811 ISBN 978-1-4160-2973-1</ref>
| | ==[[Osteomyelitis classification|Classification]]== |
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| == Etiology == | | ==[[Osteomyelitis pathophysiology|Pathophysiology]]== |
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| {| class="wikitable"
| | ==[[Osteomyelitis causes|Causes]]== |
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| | '''Age group'''
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| | '''Most common organisms'''
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| | Newborns (younger than 4 mo)
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| | ''[[Staphylococcus aureus|S. aureus]]'', ''[[Enterobacter]]'' species, and [[Group A streptococcal infection|group A]] and [[Group B streptococcal infection|B]] ''Streptococcus'' species
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| | Children (aged 4 mo to 4 y)
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| | ''[[Staphylococcus aureus|S. aureus]]'', [[Group A streptococcal infection|group A]] ''Streptococcus'' species, ''[[Haemophilus influenzae]]'', and ''[[Enterobacter]]'' species
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| | Children, adolescents (aged 4 y to adult)
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| | ''[[Staphylococcus aureus|S. aureus]]'' (80%), [[Group A streptococcal infection|group A]] ''Streptococcus'' species, ''[[Haemophilus influenzae|H. influenzae]]'', and ''[[Enterobacter]]'' species
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| | Adult
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| | ''[[Staphylococcus aureus|S. aureus]]'' and occasionally ''[[Enterobacter]]'' or ''[[Streptococcus]]'' species
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| |}
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| In children, the [[long bone]]s are usually affected. In adults, the vertebrae and the [[pelvis]] are most commonly affected.
| | ==[[Osteomyelitis differential diagnosis|Differentiating Osteomyelitis from other Diseases]]== |
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| Acute osteomyelitis almost invariably occurs in children. When adults are affected, it may be because of compromised host resistance due to debilitation, [[intravenous]] drug abuse, infectious root-canaled teeth, or other disease or drugs (''e.g.'' [[immunosuppressive]] therapy).
| | ==[[Osteomyelitis epidemiology and demographics|Epidemiology and Demographics]]== |
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| Osteomyelitis is a secondary [[complication (medicine)|complication]] in 1-3% of patients with pulmonary [[tuberculosis]]<ref name="Robbins" />. In this case, the bacteria generally spread to the bone through the [[circulatory system]], first infecting the [[synovium]] (due to its higher [[oxygen]] concentration) before spreading to the adjacent bone<ref name="Robbins" />. In tubercular osteomyelitis, the long bones and vertebrae are the ones which tend to be affected<ref name="Robbins" />.
| | ==[[Osteomyelitis risk factors|Risk Factors]]== |
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| == Presentation == | | ==[[Osteomyelitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Generally, microorganisms may infect bone through one or more of three basic methods: via the [[bloodstream]], contiguously from local areas of infection (as in [[cellulitis]]), or penetrating [[Physical trauma|trauma]], including [[iatrogenic]] causes such as [[joint replacement]]s or internal fixation of [[Bone fracture|fracture]]s or [[endodontic therapy|root-canaled]] teeth.<ref name="Robbins" /> Once the bone is infected, [[leukocyte]]s enter the infected area, and in their attempt to [[phagocytosis|engulf]] the infectious organisms, release [[enzyme]]s that [[Lysis|lyse]] the bone. [[Pus]] spreads into the bone's blood vessels, impairing their flow, and areas of devitalized infected bone, known as ''[[sequestra]]'', form the basis of a chronic infection.<ref name="Robbins" /> Often, the body will try to create new bone around the area of [[necrosis]]. The resulting new bone is often called an [[involucrum]].<ref name="Robbins" /> On [[histology|histologic]] examination, these areas of necrotic bone are the basis for distinguishing between ''[[Acute (medicine)|acute]] osteomyelitis'' and ''[[wikt:chronic|chronic]] osteomyelitis''. Osteomyelitis is an infective process which encompasses all of the bone ([[wikt:osseous|osseous]]) components, including the bone marrow. When it is chronic it can lead to bone [[sclerosis]] and deformity.
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| In [[infant]]s, the infection can spread to the [[joint]] and cause [[arthritis]]. In [[child]]ren, large [[subperiosteal]] [[abscess]]es can form because the [[periosteum]] is loosely attached to the surface of the bone.<ref name="Robbins" />
| | ==Diagnosis== |
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| Because of the particulars of their blood supply, the [[tibia]], [[femur]], [[humerus]], [[vertebra]], the [[maxilla]], and the mandibular bodies are especially susceptible to osteomyelitis.<ref>{{cite web
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| | url = http://www.emedicine.com/emerg/topic349.htm
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| | title = Osteomyelitis
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| | accessdate = 2007-11-11
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| | author = King MD, Randall W.
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| | coauthors = David Johnson, MD, FACEP
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| | date = 2006-07-13
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| | work = [[eMedicine]]
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| | publisher = [[WebMD]]
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| }}</ref> However, abscesses of any bone may be precipitated by trauma to the affected area. Many infections are caused by ''[[Staphylococcus aureus]]'', a member of the normal [[flora (microbiology)|flora]] found on the [[skin]] and [[mucous membrane]]s.
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| ==Complete Differential Diagnosis of Associated Conditions==
| | [[Osteomyelitis history and symptoms|History and Symptoms]] | [[Osteomyelitis physical examination|Physical Examination]] | [[Osteomyelitis laboratory findings|Laboratory Findings]] | [[Osteomyelitis x ray|X Ray]] | [[Osteomyelitis CT|CT]] | [[Osteomyelitis MRI|MRI]] | [[Osteomyelitis other imaging findings|Other Imaging Findings]] | [[Osteomyelitis other diagnostic studies|Other Diagnostic Studies]] |
| *[[Bacteroides]]
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| *Decubitus
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| *Diabetic angiopathy
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| *[[E.Coli]]
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| *Gastrointestinal infection
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| *[[Klebsiella]]
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| *[[Otitis]]
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| *[[Pneumonia]]
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| *[[Pseudomonas]]
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| *[[Serratia]]
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| *[[Sinusitis]]
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| *Skin infection
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| *[[Staphylococcus aureus]]
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| *[[Staphylococcus epidermidis]]
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| *[[Streptococcus pyogenes]]
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| *[[Streptococcus pneumoniae]]
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| *[[Tonsilitis]]
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| *[[Urinary tract infection]]
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| *[[Vasculitis]] <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| ==Diagnostic Findings==
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| *Conventional radiographic evaluation of acute osteomyelitis is insufficient because bone changes are not evident for 14–21 days after the onset of infection.
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| *Although MR imaging is the accepted modality of choice for the early detection and surgical localization of osteomyelitis, in the emergency department, CT is usually more readily available for establishing the diagnosis. <ref>Laura M. Fayad, John A. Carrino, and Elliot K. Fishman. [http://radiographics.rsnajnls.org/cgi/content/abstract/27/6/1723 Musculoskeletal Infection: Role of CT in the Emergency Department.] RadioGraphics 2007 27: 1723-1736.</ref>
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| *At CT, features of bacterial osteomyelitis include overlying soft-tissue swelling, periosteal reaction, medullary low-attenuation areas or trabecular coarsening, and focal cortical erosions.
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| ===MRI===
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| '''Patient #1 Extensive calcaneal osteomyelitis. Note soft tissue ulceration and [[cellulitis]]'''
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| <gallery>
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| Image:Osteomyelitis MRI 001.jpg|T1
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| Image:Osteomyelitis MRI 002.jpg|STIR
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| Image:Osteomyelitis MRI 003.jpg|T1
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| Image:Osteomyelitis MRI 004.jpg|STIR
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| Image:Osteomyelitis MRI 005.jpg|T1 fat sat contrast
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| Image:Osteomyelitis MRI 006.jpg|T1 fat sat contrast
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| </gallery>
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| ===Bone Scan===
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| '''Patient #2'''
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| [http://www.radswiki.net Images courtesy of RadsWiki]
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| <gallery>
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| Image:Osteomyelitis-102.jpg|Blood pool
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| Image:Osteomyelitis-103.jpg|Delayed
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| </gallery>
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| <br clear="left"/>
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| <youtube v=X2ShDUfeso0/>
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| <br clear="left"/>
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| ===Pathological Findings===
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| [[Image:Osteomyelitis in cancer.jpg|thumb|left|250px|Osteomyelitis in cancer. <br> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology]. ]] | |
| <br clear="left"/>
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| ==Osteomyelitis and Chondritis of Vertebrae==
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| <youtube v=KTfOwYS1ykY/>
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| ==Treatment== | | ==Treatment== |
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| Osteomyelitis often requires prolonged [[antibiotic]] therapy, with a course lasting a matter of weeks or months. A [[PICC line]] or [[central venous catheter]] is often placed for this purpose. Osteomyelitis also may require surgical [[debridement]]. Severe cases may lead to the loss of a limb. Initial first line antibiotic choice is determined by the patient's history and regional differences in common infective organisms. | | [[Osteomyelitis medical therapy|Medical Therapy]] | [[Osteomyelitis surgery|Surgery]] | [[Osteomyelitis prevention|Prevention]] | [[Osteomyelitis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Osteomyelitis future or investigational therapies|Future or Investigational Therapies]] |
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| Prior to the widespread availability and use of antibiotics, [[maggot|blow fly larvae]] were sometimes [[maggot therapy|deliberately introduced]] to the wounds to feed on the infected material, effectively scouring them clean.
| | ==Case Studies== |
| <ref>{{cite journal |last=Baer M.D. |first=William S. |year=1931 |title=The Treatment of Chronic Osteomyelitis with the Maggot (Larva of the Blow Fly) |journal=Journal of Bone and Joint Surgery |volume=13 |pages=438–475 |url=http://www.ejbjs.org/cgi/content/abstract/13/3/438 |accessdate= 2007-11-12}}</ref><ref>{{cite journal
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| | quotes = yes
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| | last=McKeever
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| | first=Duncan Clark
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| | year=2008|month=June
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| | title=The classic: maggots in treatment of osteomyelitis: a simple inexpensive method. 1933
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| | journal=[[Clin. Orthop. Relat. Res.]]
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| | volume=466
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| | issue=6
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| | pages=1329–35
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| | pmid = 18404291
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| | doi = 10.1007/s11999-008-0240-5
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| }}</ref>
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| [[Hyperbaric oxygen therapy]] has been shown to be a useful [[wikt:adjunct|adjunct]] to the treatment of [[wikt:refractory|refractory]] osteomyelitis.<ref>{{cite journal |author=Mader JT, Adams KR, Sutton TE |title=Infectious diseases: pathophysiology and mechanisms of hyperbaric oxygen |journal=J. Hyperbaric Med |volume=2 |issue=3 |pages=133–140 |year=1987 |url=http://archive.rubicon-foundation.org/4339 |accessdate=2008-05-16}}</ref><ref>{{cite journal |author=Kawashima M, Tamura H, Nagayoshi I, Takao K, Yoshida K, Yamaguchi T |title=Hyperbaric oxygen therapy in orthopedic conditions |journal=Undersea Hyperb Med |volume=31 |issue=1 |pages=155–62 |year=2004 |pmid=15233171 |url=http://archive.rubicon-foundation.org/4000 |accessdate=2008-05-16}}</ref> A treatment lasting 42 days is practiced in a number of facilities.<ref>Putland M.D, Michael S., Hyperbaric Medicine, [[Capital Regional Medical Center]], [[Tallahassee, Florida]], personal inquiry June 2008.</ref> | | [[Osteomyelitis case study one|Case #1]] |
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| ==References== | | ==Related Chapters== |
| {{Reflist|2}}
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| ==See also==
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| *[[Brodie abscess]] | | *[[Brodie abscess]] |
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| ==External Links==
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| * [http://goldminer.arrs.org/search.php?query=Osteomyelitis Goldminer: Osteomyelitis]
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| ==Additional Resources==
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| * {{MerckManual|5|54|b}}
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| * {{Chorus|00298}}
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| {{Diseases of the musculoskeletal system and connective tissue}} | | {{Diseases of the musculoskeletal system and connective tissue}} |
| [[Category:Orthopedics]]
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| [[Category:Bacterial diseases]]
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| [[Category:Skeletal disorders]]
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| {{SIB}}
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| [[de:Osteomyelitis]] | | [[de:Osteomyelitis]] |
| [[fr:Ostéomyélite]] | | [[fr:Ostéomyélite]] |
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