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Osteomyelitis






What is osteomyelitis?


Osteomyelitis is infection in the bone. Osteomyelitis can occur in infants, children , and adults. Different types of bacteria typically affect the different age groups. In children, osteomyelitis most commonly occurs at the ends of the long bones of the arms and legs, affecting the hips, knees, shoulders, and wrists. In adults, it is more common in the bones of the spine (vertebrae), feet, or in the pelvis.


What causes osteomyelitis?


There are several different ways to develop the bone infection of osteomyelitis. The first is for bacteria to travel through the bloodstream ( bactermia) and spread to the bone, causing an infection. This most often occurs when the patient has an infection elsewhere in the body, such as pneumonia  or a urinary tract infection , that spreads through the blood to the bone.


An open wound over a bone can lead to osteomyelitis. This happens most commonly with underlying peripheral vascular disease , peripheral neuropathy, or diabetes. With an open fracture (compound fracture), the bone that punctures through the skin is exposed to bacteria.


A recent surgery or injection around a bone can also expose the bone to bacteria and lead to osteomyelitis.


Patients with conditions or taking medications that weaken their immune system are at a higher risk of developing osteomyelitis.



Risk factors include cancer, chronicsteroid use,human immunodeficiency virus (HIV), diabetes, hemodialysis, intravenousdrug users, and the elderly.



What are osteomyelitis symptoms and signs?


In children, osteomyelitis most often occurs more quickly. They develop pain or tenderness over the affected bone, and they may have difficulty or inability to use the affected limb or to bear weight or walk due to severe pain. They may also have fever, chills, and redness at the site of infection.


In adults, the symptoms often develop more gradually and include fever, chills, irritability, swelling or redness over the affected bone, stiffness, andnausea. In people with diabetes, peripheral neuropathy, or peripheral vascular disease, there may be no pain or fever. The only symptom may be an area of skin breakdown that is worsening or not healing.


Acute osteomyelitis occurs with a rapid onset and is usually accompanied by the symptoms of pain, fever, and stiffness. It generally occurs after a break in the skin from injury, trauma, surgery, or skin ulceration from wounds.


Chronic osteomyelitis is insidious (slow) in onset. It may be the result of a previous infection of osteomyelitis. Despite multiple courses of antibiotics, it may reoccur. Symptoms of chronic osteomyelitis are subtle but may include fever, pain, redness, or discharge at the site of infection.



In adults, the symptoms often develop more gradually and include fever, chills, irritability, swelling or redness over the affected bone, stiffness, andnausea. In people with diabetes, peripheral neuropathy, or peripheral vascular disease, there may be no pain or fever. The only symptom may be an area of skin breakdown that is worsening or not healing.




Acute osteomyelitis : occurs with a rapid onset and is usually accompanied by the symptoms of pain, fever, and stiffness. It generally occurs after a break in the skin from injury, trauma, surgery, or skin ulceration from wounds.


Chronic osteomyelitis : is insidious (slow) in onset. It may be the result of a previous infection of osteomyelitis. Despite multiple courses of antibiotics, it may reoccur. Symptoms of chronic osteomyelitis are subtle but may include fever, pain, redness, or discharge at the site of infection.


How is osteomyelitis diagnosed?


The diagnosis of osteomyelitis begins with a complete medical history and physical examination. During the medical history, the doctor may ask questions about recent infections elsewhere in the body, past medical history, medication usage, and family medical history.


The physical examination will look for areas of tenderness, redness, swelling, decreased or painful range of motion, and open sores.


The doctor may then order tests to help diagnose osteomyelitis. Several blood tests can be used to help determine if there is an infection present. These include a complete  blood count (CBC), the erythrocytesedimentation rate (ESR), C-reactive protein (CRP), and blood cultures. None of these is specific for osteomyelitis but they can suggest that there may be some infection in the body.


Imaging studies may be obtained of the involved bones. These can include plain radiographs (X-rays), bone scans,computed tomography (CT) scans,magnetic resonance imaging (MRIs), and ultrasounds. These imaging studies can help identify changes in the bones that occur with osteomyelitis.


After an area of bone is identified with possible osteomyelitis, a biopsy of the bone may be obtained to help determine precisely which bacteria are involved, and the culture of this can indicate the best choice for antibiotic treatment.




What is the treatment for osteomyelitis?


In many cases, osteomyelitis can be effectively treated with antibiotics and pain medications. If a biopsy is obtained, this can help guide the choice of the best antibiotic. The duration of treatment of osteomyelitis with antibiotics is usually four to eight weeks but varies with the type of infection and the response to the treatments. In some cases, the affected area will be immobilized with a brace to reduce the pain and speed the treatment.


Sometimes, surgery may be necessary. If there is an area of localized bacteria ( abscess), this may need to be opened, washed out, and drained. If there is damaged soft tissue or bone, this may need to be removed. If bone needs to be removed, it may need to be replaced with bone graft or stabilized during surgery.


What is the prognosis for osteomyelitis?


With early diagnosis and appropriate treatment, the prognosis for osteomyelitis is good. Antibiotics regimes are used for four to eight weeks and sometimes longer in the treatment of osteomyelitis depending on the bacteria that caused it and the response of the patient. Commonly, patients can make a full recovery without longstanding complications.


However, if there is a long delay in diagnosis or treatment, there can be severe damage to the bone or surrounding soft tissues that can lead to permanent deficits or make the patient more prone to reoccurrence. If surgery or bone grafting is needed, this will prolong the time it takes to recover.


Chronic osteomyelitis is often a result of complication of treatment with open fractures, therefore, prevention of infection is highly important . Since the role of nutrition is vital in cases of infection, patient need to be properly educated on proper nutrition in early post-surgical intervention due to the fact that most infections occur in the immediate post-operative period. Individuals who are at risk for developing osteomyelitis should also be taught proper preventative measures and be aware of early warning signs that infection may be present such as, excessive pus present coming from incision line, redness, extreme tenderness, increased skin temperature near area of injury or surgical procedure, and symptoms of nausea or vomiting.



Physical Therapy Management :




  • If treated surgically for osteomyelitis, physical therapy may be indicated post-operatively to address any impairments in :

  • Strength

  • ROM

  • Proprioception

  • treatment for any functional limitations or disabilities secondary to the infection.

  • maintain function and enhance mobility

  • Active range of motion physical therapy initially helps maintain flexibility


As strength continues to progress, endurance becomes a focus in the individual's rehabilitation program for osteomyelitis. Aerobic exercises that increase cardiovascular fitness are recommended. The American Heart Association recommends 30 to 60 minutes of aerobic activity 3 or 4 times a week.



Learning how to avoid injury is another important intervention in the rehabilitation of progressive osteomyelitis.

Occupational therapy helps individuals arrange their homes and organize their lives in ways that support their physical and mental well-being. Activities are also provided to relieve the mental boredom of inactivity. Devices and techniques that help the individual communicate are invaluable in maintaining peace of mind. The rehabilitation program varies among individuals with progressive osteomyelitis as the intensity and progression of the exercise depends on the stage of the disease and individual's overall health.


The type of rehabilitation for osteomyelitis depends on the location of the infected bone
and the underlying cause of infection. For rehabilitation purposes, osteomyelitis is subdivided into five types. Depending on the type of osteomyelitis (ranging from type I to type V, according to the degree of tibia and fibula involvement and the bone’s ability to withstand functional loads), the rehabilitation time required varies.


Type I osteomyelitis (in which both tibia and fibula are intact and can withstand functional loads), the rehabilitation time is from 6 to 12 weeks.


Type II osteomyelitis (in which the tibia is intact, but a bone graft is needed), the rehabilitation
time required is from 3 to 6 months.


Type III osteomyelitis (in which the fibula is intact, but there is a tibial defect of no more than 6 cm), 6 to 12 months of rehabilitation are needed.


Type IV osteomyelitis (in which the fibula is intact, but there is a tibial defect of more than 6 cm), 12 to 18 months of rehabilitation are required.


Type V osteomyelitis (in which there is no usable intact fibula, and there is a tibial defect of more than 6 cm), 18 months or longer are required for rehabilitation.