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__NOTOC__
'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
'''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}} |
ICD9 = {{ICD9|730}} |
ICDO = |
OMIM = |
DiseasesDB = 9367 |
MedlinePlus = 000437 |
eMedicineSubj = |
eMedicineTopic = |
MeshID = D010019 |
}}
}}
{{Search infobox}}
{{Osteomyelitis}}
{{CMG}}'''; Associate Editor(s)-In-Chief:''' {{CZ}}
{{CMG}}; {{AE}} {{MehdiP}},{{NRM}}
 
==Overview==
'''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>
 
 
==Complete Differential Diagnosis of the Causes of Osteomyelitis==
 
==Most common==
 


==By organ system==
{{SK}} OM


{|style="width:80%; height:100px" border="1"
==[[Osteomyelitis overview|Overview]]==
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Arterial insufficiency ulcer]], [[Polyarteritis nodosa]], [[Thrombophlebitis]]
|-
|-bgcolor="LightSteelBlue"
| '''Chemical / poisoning'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dermatologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Ear Nose Throat'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Environmental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Genetic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Hematologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Iatrogenic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Musculoskeletal / Ortho'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Neurologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Nutritional / Metabolic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Obstetric/Gynecologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Oncologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Opthalmologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Overdose / Toxicity'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Psychiatric'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Pulmonary'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Renal / Electrolyte'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Rheum / Immune / Allergy'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Sexual'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Trauma'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Urologic'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Dental'''
|bgcolor="Beige"| No underlying causes
|-
|-bgcolor="LightSteelBlue"
| '''Miscellaneous'''
|bgcolor="Beige"| No underlying causes
|-
|}


==By alphabetical order==
==[[Osteomyelitis historical perspective|Historical Perspective]]==


== Etiology ==
==[[Osteomyelitis classification|Classification]]==


{| class="wikitable"
==[[Osteomyelitis pathophysiology|Pathophysiology]]==
|-
| '''Age group'''
| '''Most common organisms'''
|-
| Newborns (younger than 4 mo)
| ''[[Staphylococcus aureus|S. aureus]]'', ''[[Enterobacter]]'' species, and [[Group A streptococcal infection|group A]] and [[Group B streptococcal infection|B]] ''Streptococcus'' species
|-
| Children (aged 4 mo to 4 y)
| ''[[Staphylococcus aureus|S. aureus]]'', [[Group A streptococcal infection|group A]] ''Streptococcus'' species, ''[[Haemophilus influenzae]]'', and ''[[Enterobacter]]'' species
|-
| Children, adolescents (aged 4 y to adult)
| ''[[Staphylococcus aureus|S. aureus]]'' (80%), [[Group A streptococcal infection|group A]] ''Streptococcus'' species, ''[[Haemophilus influenzae|H. influenzae]]'', and ''[[Enterobacter]]'' species
|-
| Adult
| ''[[Staphylococcus aureus|S. aureus]]'' and occasionally ''[[Enterobacter]]'' or ''[[Streptococcus]]'' species
|}


In children, the [[long bone]]s are usually affected. In adults, the vertebrae and the [[pelvis]] are most commonly affected.
==[[Osteomyelitis causes|Causes]]==


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 differential diagnosis|Differentiating Osteomyelitis from other Diseases]]==


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 epidemiology and demographics|Epidemiology and Demographics]]==


== Pathogenesis ==
==[[Osteomyelitis risk factors|Risk Factors]]==


''[[Staphylococcus aureus]]'' is the organism most commonly isolated from all forms of osteomyelitis.<ref name="Robbins" />
==[[Osteomyelitis natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
 
Bloodstream-sourced osteomyelitis is seen most frequently in children, and nearly 90% of cases are caused by ''[[Staphylococcus aureus]]''. In infants, ''S. aureus'', [[Group B streptococcal infection|Group B streptococci]] (most common<ref name="CBC">{{cite encyclopedia|url=http://www.healthline.com/galecontent/streptococcal-infections-1|title=Streptococcal Infections|first=Maureen|last=Haggerty|encyclopedia=Gale Encyclopedia of Medicine|publisher=The Gale Group|year=2002|accessdate=2008-03-14}}</ref>) and ''[[Escherichia coli]]'' are commonly isolated; in children from 1 to 16 years of age, ''S. aureus'', ''[[Streptococcus pyogenes]]'', and ''[[Haemophilus influenzae]]'' are common. In some subpopulations, including intravenous drug users and [[splenectomy|splenectomized]] patients, [[Gram-negative bacteria]], including enteric bacteria, are significant pathogens.<ref name="carek">{{cite journal|last=Carek|first=P.J.|coauthors=L.M. Dickerson; J.L. Sack|title=Diagnosis and management of osteomyelitis.|journal=[[American Family Physician|Am Fam Physician]]|date=2001-06-15|volume=63|issue=12|pages=2413-20}}</ref>
 
The most common form of the disease in adults is caused by injury exposing the bone to local infection. ''Staphylococcus aureus'' is again the most common organism seen in osteomyelitis seeded from areas of contiguous infection, but [[anaerobe]]s and Gram-negative organisms, including ''[[Pseudomonas aeruginosa]]'', ''E. coli'', and ''[[Serratia marcescens]]'', are also common, and mixed infections are the rule rather than the exception.<ref name="carek" />
 
Systemic [[mycotic]] (fungal) infections may also cause osteomyelitis. The two most common pathogens involved in such infections are [[Blastomyces dermatitidis]] and [[Coccidioides immitis]].
 
In osteomyelitis involving the vertebral bodies, about half the cases are due to ''Staphylococcus aureus'', and the other half are due to [[tuberculosis]] (spread hematogenously from the [[lung]]s). Tubercular osteomyelitis of the [[spine]] was so common before the initiation of effective antitubercular therapy that it acquired a special name, ''[[Pott's disease]]'', by which it is sometimes still known. The ''[[Burkholderia cepacia complex]]'' have been implicated in vertebral osteomyelitis in intravenous drug abusers. <ref>{{cite journal|url=http://www.jidc.org/issn1972-2680/current-issue/59-vol-2-no-1-february-2008/152-cervical-osteomyelitis-caused-by-burkholderia-cepacia-after-rhinoplasty
|title=Cervical osteomyelitis caused by Burkholderia cepacia after rhinoplasty|journal=[[Journal of Infection in Developing Countries|J Infect Developing Countries]]|first=Lenny|last=Weinstein|coauthors= Knowlton, Christin A.; Smith, Miriam A.|date=2007-12-16|volume=2|issue=1|pages=76-77|issn=1972-2680}}</ref>
 
Factors that may commonly complicate osteomyelitis are fractures of the bone, [[amyloidosis]], [[endocarditis]], or [[sepsis]]<ref name="Robbins" />.
 
== Presentation ==
 
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.
 
In [[infant]]s, the infection can spread to the [[joint]] and cause [[arthritis]]. In children, large subperiosteal abscesses can form because the [[periosteum]] is loosely attached to the surface of the bone.<ref name="Robbins" />
 
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
| url = http://www.emedicine.com/emerg/topic349.htm
| title = Osteomyelitis
| accessdate = 2007-11-11
| author = King MD, Randall W.
| coauthors = David Johnson, MD, FACEP
| date = 2006-07-13
| work = [[eMedicine]]
| publisher = [[WebMD]]
}}</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.
 
* Hematogenous long-bone osteomyelitis
:* Abrupt onset of high fever (fever is present in only 50% of neonates with osteomyelitis)
:* Fatigue
:* Irritability
:* Malaise
:* Restriction of movement (pseudoparalysis of limb in neonates)
:* Local edema, erythema, and tenderness
* 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 normally2
* Chronic osteomyelitis
:* Non-healing ulcer
:* Sinus tract drainage
:* Chronic fatigue
:* Malaise
 
==Complete Differential Diagnosis of Associated Conditions==
*[[Bacteroides]]
*Decubitus
*Diabetic angiopathy
*[[E.Coli]]
*Gastrointestinal infection
*[[Klebsiella]]
*[[Otitis]]
*[[Pneumonia]]
*[[Pseudomonas]]
*[[Serratia]]
*[[Sinusitis]]
*Skin infection
*[[Staphylococcus aureus]]
*[[Staphylococcus epidermidis]]
*[[Streptococcus pyogenes]]
*[[Streptococcus pneumoniae]]
*[[Tonsilitis]]
*[[Urinary tract infection]]
*[[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>


==Diagnosis==
==Diagnosis==


Diagnosis of osteomyelitis is often based on [[radiology|radiologic]] results showing a [[lytic]] center with a ring of [[sclerosis]], though bone cultures are normally required to identify the specific pathogen<ref name="Robbins" />.
==Diagnostic Findings==


*Conventional radiographic evaluation of acute osteomyelitis is insufficient because bone changes are not evident for 14–21 days after the onset of infection.
[[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]]
*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>
*At CT, features of bacterial osteomyelitis include overlying soft-tissue swelling, periosteal reaction, medullary low-attenuation areas or trabecular coarsening, and focal cortical erosions.
 
===MRI===
 
[http://www.radswiki.net Images courtesy of RadsWiki]
 
'''Patient #1 Extensive calcaneal osteomyelitis. Note soft tissue ulceration and [[cellulitis]]'''
 
<gallery>
Image:Osteomyelitis MRI 001.jpg|T1
Image:Osteomyelitis MRI 002.jpg|STIR
Image:Osteomyelitis MRI 003.jpg|T1
Image:Osteomyelitis MRI 004.jpg|STIR
Image:Osteomyelitis MRI 005.jpg|T1 fat sat contrast
Image:Osteomyelitis MRI 006.jpg|T1 fat sat contrast
</gallery>
 
===Bone Scan===
 
'''Patient #2'''
 
[http://www.radswiki.net Images courtesy of RadsWiki]
 
<gallery>
Image:Osteomyelitis-102.jpg|Blood pool
Image:Osteomyelitis-103.jpg|Delayed
</gallery>
<br clear="left"/>
 
<youtube v=X2ShDUfeso0/>
<br clear="left"/>
 
===Pathological Findings===
 
[[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"/>
 
==Osteomyelitis and Chondritis of Vertebrae==
 
<youtube v=KTfOwYS1ykY/>


==Treatment==
==Treatment==


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]]


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
| quotes = yes
| last=McKeever
| first=Duncan Clark
| year=2008|month=June
| title=The classic: maggots in treatment of osteomyelitis: a simple inexpensive method. 1933
| journal=Clin. Orthop. Relat. Res.
| volume=466
| issue=6
| pages=1329–35
| pmid = 18404291
| doi = 10.1007/s11999-008-0240-5
}}</ref>


[[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]]


==References==
==Related Chapters==
{{Reflist|2}}
 
==See also==
*[[Brodie abscess]]
*[[Brodie abscess]]
==External Links==
* [http://goldminer.arrs.org/search.php?query=Osteomyelitis Goldminer: Osteomyelitis]
==Additional Resources==
* {{MerckManual|5|54|b}}
* {{Chorus|00298}}


{{Diseases of the musculoskeletal system and connective tissue}}
{{Diseases of the musculoskeletal system and connective tissue}}
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Latest revision as of 23:27, 29 July 2020

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Osteomyelitis
Osteomyelitis of the tibia of a young child. Numerous abscesses in the bone show as radiolucency.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2],Nate Michalak, B.A.

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