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Osteomyelitis
Updated:Sep13,2016
Author:StephenKishner,MD,MHAChiefEditor:HarrisGellman,MDmore...

OVERVIEW

Background
Osteomyelitisisinflammationofthebonecausedbyaninfectingorganism.Althoughboneisnormally
resistanttobacterialcolonization,eventssuchastrauma,surgery,thepresenceofforeignbodies,or
theplacementofprosthesesmaydisruptbonyintegrityandleadtotheonsetofboneinfection.
Osteomyelitiscanalsoresultfromhematogenousspreadafterbacteremia.Whenprostheticjointsare
associatedwithinfection,microorganismstypicallygrowinbiofilm,whichprotectsbacteriafrom
antimicrobialtreatmentandthehostimmuneresponse.
Earlyandspecifictreatmentisimportantinosteomyelitis,andidentificationofthecausative
microorganismsisessentialforantibiotictherapy.[1]Themajorcauseofboneinfectionsis
Staphylococcusaureus.Infectionswithanopenfractureorassociatedwithjointprosthesesand
traumaoftenmustbetreatedwithacombinationofantimicrobialagentsandsurgery.Whenbiofilm
microorganismsareinvolved,asinjointprostheses,acombinationofrifampinwithotherantibiotics
mightbenecessaryfortreatment.

Anatomy
Thebonyskeletonisdividedintotwoparts:theaxialskeletonandtheappendicularskeleton.The
axialskeletonisthecentralcoreunit,consistingoftheskull,vertebrae,ribs,andsternumthe
appendicularskeletoncomprisesthebonesoftheextremities.Thehumanskeletonconsistsof213
bones,ofwhich126arepartoftheappendicularskeleton,74arepartoftheaxialskeleton,andsix
arepartoftheauditoryossicles.
Hematogenousosteomyelitismostcommonlyinvolvesthevertebrae,butinfectionmayalsooccurin
themetaphysisofthelongbones,pelvis,andclavicle.Vertebralosteomyelitisinvolvestwoadjacent
vertebraewiththecorrespondingintervertebraldisk.(Seetheimagebelow.)Thelumbarspineismost
commonlyaffected,followedbythethoracicandcervicalregions.

OsteomyelitisofT10secondarytostreptococcaldisease.PhotographybyDavidEffronMD,FACEP.

ViewMediaGallery
Posttraumaticosteomyelitisbeginsoutsidethebonycortexandworksitswayintowardthemedullary
canal,typicallyfoundinthetibia.Contiguousfocusosteomyelitisoftenoccursinthebonesofthefeet
inpatientswithdiabetesmellitusandvascularcompromise.
Formoreinformationabouttherelevantanatomy,seeSkeletalSystemAnatomyinAdultsand
Osteology(BoneAnatomy).

Pathophysiology
Boneisnormallyresistanttoinfection.However,whenmicroorganismsareintroducedintobone
hematogenouslyfromsurroundingstructuresorfromdirectinoculationrelatedtosurgeryortrauma,
osteomyelitiscanoccur.Boneinfectionmayresultfromthetreatmentoftrauma,whichallows
pathogenstoenterboneandproliferateinthetraumatizedtissue.Whenboneinfectionpersistsfor
months,theresultinginfectionisreferredtoaschronicosteomyelitisandmaybepolymicrobial.
Althoughallbonesaresubjecttoinfection,thelowerextremityismostcommonlyinvolved.[1,2]
Someimportantfactorsinthepathogenesisofosteomyelitisincludethevirulenceoftheinfecting
organism,underlyingdisease,immunestatusofthehost,andthetype,location,andvascularityofthe
bone.Bacteriamaypossessvariousfactorsthatmaycontributetothedevelopmentofosteomyelitis.
Forexample,factorspromotedbySaureusmaypromotebacterialadherence,resistancetohost
defensemechanism,andproteolyticactivity.[3]

Hematogenousosteomyelitis
Inadults,thevertebraearethemostcommonsiteofhematogenousosteomyelitis,butinfectionmay
alsooccurinthelongbones,pelvis,andclavicle.[4]

Primaryhematogenousosteomyelitisismorecommonininfantsandchildren,usuallyoccurringinthe
longbonemetaphysis.However,itmayspreadtothemedullarycanalorintothejoint.Wheninfection
extendsintosofttissue,sinustractsmayeventuallyform.Secondaryhematogenousosteomyelitisis
morecommonandoccurswhenachildhoodinfectionisreactivated.Inadults,thelocationisalso
usuallymetaphyseal.[4]
Saureusisthemostcommonpathogenicorganismrecoveredfrombone,followedbyPseudomonas
andEnterobacteriaceae.Lesscommonorganismsinvolvedincludeanaerobegramnegativebacilli.
Intravenousdrugusersmayacquirepseudomonalinfections.Gastrointestinalorgenitourinary
infectionsmayleadtoosteomyelitisinvolvinggramnegativeorganisms.Dentalextractionhasbeen
associatedwithviridansstreptococcalinfections.Inadults,infectionsoftenrecurandusuallypresent
withminimalconstitutionalsymptomsandpain.Acutely,patientsmaypresentwithfever,chills,
swelling,anderythemaovertheaffectedarea.[2,5]

Contiguousfocusandposttraumaticosteomyelitis
Theinitiatingfactorincontiguousfocusosteomyelitisoftenconsistsofdirectinoculationofbacteria
viatrauma,surgicalreductionandinternalfixationoffractures,prostheticdevices,spreadfromsoft
tissueinfection,spreadfromadjacentsepticarthritis,ornosocomialcontamination.Infectionusually
resultsapproximatelyonemonthafterinoculation.
Posttraumaticosteomyelitismorecommonlyaffectsadultsandtypicallyoccursinthetibia.Themost
commonlyisolatedorganismisSaureus.Atthesametime,localsofttissuevascularitymaybe
compromised,leadingtointerferencewithhealing.Comparedwithhematogenousinfection,
posttraumaticinfectionbeginsoutsidethebonycortexandworksitswayintowardthemedullary
canal.Lowgradefever,drainage,andpainmaybepresent.Lossofbonestability,necrosis,andsoft
tissuedamagemayleadtoagreaterriskofrecurrence.[4,5]
Septicarthritismayleadtoosteomyelitis.Abnormalitiesatthejointmarginsorcentrally,whichmay
arisefromovergrowthandhypertrophyofthesynovialpannusandgranulationtissue,mayeventually
extendintotheunderlyingbone,leadingtoerosionsandosteomyelitis.Onestudydemonstratedthat
septicarthritisinelderlypersonsmostcommonlyinvolvesthekneeandthat,despitemostofthe
patientshavingahistoryofsurgery,38%developedosteomyelitis.Septicarthritisismorecommonin
neonatesthaninolderchildrenandisoftenassociatedwithmetaphysealosteomyelitis.Althoughrare,
gonococcalosteomyelitismayariseinaboneadjacenttoachronicallyinfectedjoint.[6,7]
Patientswithvascularcompromise,asindiabetesmellitus,arepredisposedtoosteomyelitisowingto
aninadequatelocaltissueresponse.[4]
Infectionismostoftencausedbyminortraumatothefeetwithmultipleorganismsisolatedfrombone,
includingStreptococcusspecies,Enterococcusspecies,coagulasepositiveandnegative
staphylococci,gramnegativebacilli,andanaerobicorganisms.Footulcersallowbacteriatoreachthe
bone.Patientsmaynotexperienceanyresultingpain,becauseofperipheralneuropathy,andmay
presentwithaperforatingfootulcer,cellulitis,oraningrowntoenail.
Physicalexaminationmayrevealdecreasedsensation,poorcapillaryrefill,anddecreaseddorsalis
pedisandposteriortibialpulses.Treatmentisaimedatsuppressinginfectionandimproving
vascularity.However,mostpatientsdeveloprecurrentornewboneinfections.Resectionor
amputationoftheaffectedtissueissometimesnecessary.Debridement,incisionanddrainage,and
tendonlengtheningareattemptedfirst.

Vertebralosteomyelitis

Theincidenceofvertebralosteomyelitisgenerallyincreasesprogressivelywithage,withmost
affectedpatientsbeingolderthan50years.Althoughdevastatingcomplicationsmayresultfroma
delayindiagnosis,vertebralosteomyelitisisrarelyfatalsincethedevelopmentofantibiotics.The
infectionusuallyoriginateshematogenouslyandinvolvestwoadjacentvertebraewiththe
correspondingintervertebraldisk.Thelumbarspineismostcommonlyaffected,followedbythe
thoracicandcervicalregions.[4,1]
Potentialsourcesofinfectionincludeskin,softtissue,respiratorytract,genitourinarytract,infected
intravenoussites,anddentalinfections.Saureusisthemostcommonisolatedorganism.However,
Pseudomonasaeruginosaismorecommoninintravenousdrugusers.
Mostpatientswithvertebralosteomyelitispresentwithlocalizedpainandtendernessoftheinvolved
vertebraewithaslowprogressionover3weeksto3months.Fevermaybepresentinapproximately
50%ofpatients.Fifteenpercentofpatientsmayhavemotorandsensorydeficits.Laboratorystudies
mayrevealperipheralleukocytosisandanelevatederythrocytesedimentationrate.Extensionofthe
infectionmayleadtoabscessformation.[4]

Osteomyelitisinchildren
Acutehematogenousosteomyelitisusuallyoccursafteranepisodeofbacteremiainwhichthe
organismsinoculatethebone.ThemostcommonorganismsisolatedinthesecasesincludeS
aureus,Streptococcuspneumoniae,andHaemophilusinfluenzatypeb(lesscommonsincetheuseof
vaccineforHinfluenzatypeb).
AcutehematogenousSaureusosteomyelitisinchildrencanleadtopathologicfractures.Thiscan
occurinabout5%ofcaseswitha72daymeantimefromdiseaseonsettofracture.[8]
Inchildrenwithsubacutefocalosteomyelitis(seetheimagebelow),Saureusisthemostcommonly
isolatedorganism.

Rarefactionandperiostealnewboneformationaroundtheleftupperfibulaina12yearoldpatient.Thiswas
causedbysubacuteosteomyelitis.

ViewMediaGallery
GramnegativebacteriasuchasPseudomonasspeciesorEscherichiacoliarecommoncausesof
infectionafterpuncturewoundsofthefeetoropeninjuriestobone.Anaerobescanalsocausebone
infectionafterhumanoranimalbites.
Osteomyelitisintheneonateresultsfromhematogenousspread,especiallyinpatientswithindwelling
centralvenouscatheters.Thecommonorganismsinosteomyelitisoftheneonateincludethosethat
frequentlycauseneonatalsepsis,namelygroupBStreptococcusspecies,andEcoli.Infectionsinthe
neonatecaninvolvemultipleosseoussites,andapproximatelyhalfofthecasesalsoinvolveeventual
developmentofsepticarthritisintheadjacentjoint.
Childrenwithsicklecelldiseaseareatanincreasedriskforbacterialinfections,andosteomyelitisis
thesecondmostcommoninfectioninthesepatients.Themostcommonorganismsinvolvedin
osteomyelitisinchildrenwithsicklecellanemiaincludeSalmonellaspecies,Saureus,Serratia
species,andProteusmirabilis.

Etiology
Posttraumaticosteomyelitisaccountsforasmanyas47%ofcasesofosteomyelitis.Othermajor
causesofosteomyelitisincludevascularinsufficiency(mostlyoccurringinpersonswithdiabetes
34%)andhematogenousseeding(19%).
Motorvehicleaccidents,sportsinjuries,andtheuseoforthopedichardwaretomanagetraumaalso
contributetotheapparentincreaseinprevalenceofposttraumaticosteomyelitis.Osteomyelitismay
complicatepuncturewoundsofthefoot,occurringin1.8%6.4%ofpatientsfollowinginjury.[9,10,11,
12,13]

Epidemiology
Approximately20%ofadultcasesofosteomyelitisarehematogenous,whichismorecommonin
malesforunknownreasons.[4]
Theincidenceofspinalosteomyelitiswasestimatedtobe1in450,000in2001.Insubsequentyears,
however,theoverallincidenceofvertebralosteomyelitisisbelievedtohaveincreasedasa
consequenceofintravenousdruguse,increasingageofthepopulation,andhigherratesof
nosocomialinfectionduetointravasculardevicesandotherinstrumentation.[14,15]Theoverall
incidenceofosteomyelitisishigherindevelopingcountries.

Prognosis
Inadequatetherapymayleadtorelapsinginfectionandprogressiontochronicinfection.Becauseof
theavascularityofbone,chronicosteomyelitisiscurableonlywithradicalresectionoramputation.
Thesechronicinfectionsmayrecurasacuteexacerbations,whichcanbesuppressedbydebridement
followedbyparenteralandoralantimicrobialtherapy.Rarecomplicationsofboneinfectioninclude
pathologicfractures,secondaryamyloidosis,andsquamouscellcarcinomaatthesinustract
cutaneousorifice.
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