Internal Medicine

0521779407-16 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

1104 Osteomyelitis

■Cellulitis, pain, drainage and an open wound seen in osteomyelitis

associated with vascular insufficiency or a contiguous infection

■Chronic osteomyelitis associated with chronic draining sinus tract

tests

■In febrile patient, blood cultures may reveal etiologic agent.

■Cultures of sinus tracts, open wounds or ulcers unreliable in predict-

ing pathogen and are not recommended

■WBC and sedimentation rate may be elevated; will decrease with

successful therapy and can be used to monitor therapy

■Periosteal reaction and destructive lesions on bone films accurate in

making diagnosis, but may take 2 weeks or longer to appear

■Technetium radionuclide scan positive as early as 2–3 days after

onset of infection, but false-positive scans can occur if adjacent soft

tissue infection present; negative scan helpful in excluding diagnosis

■CT and MRI may be useful in making diagnosis and defining extent of

disease; correlation of abnormalities with pathologic confirmation

of osteomyelitis has not been done and overinterpretation of scans

is a concern

■Definitive diagnosis made by biopsy and culture

differential diagnosis

■Acute hematogenous osteomyelitis must be differentiated from

tumor; osteomyelitis associated with diabetes or vascular insuffi-

ciency confused with Charcot joint, osteoarthritis, disuse osteope-

nia

management

■Since therapy prolonged, attempt to define bacteriology

■Blood cultures in febrile patient

■Bone biopsy or surgical debridement encouraged to isolate causative

organism(s) and aid in choosing best antibiotic regimen

specific therapy

■IV antibiotic therapy for 4–6 weeks; use of oral antibiotics not well

studied for acute osteomyelitis in adults

■Debride necrotic tissue

■Obliteration of dead space and revascularization of bone often

accomplished with myocutaneous flaps

■Role of hyperbaric oxygen therapy for chronic osteomyelitis or

osteomyelitis associated with vascular insufficiency unclear; dra-

matic successes anecdotally reported