Osteomyelitis

Bones Most Commonly Affected by Osteomyelitis

Osteomyelitis can target a variety of bones, and the location often depends on the age of the patient. In children, we most often see the infection in the long bones of the arms and legs—especially the femur (thigh bone) and tibia (shin bone). These bones are more susceptible due to their rich blood supply, which makes it easier for germs circulating in the bloodstream to settle and cause an infection.

For adults, osteomyelitis tends to show up in different places. The vertebrae of the spine and the hips are the most typical hotspots. Adults with skin wounds, trauma, or who have had orthopedic surgeries are also at risk for bone infections in the extremities—like the arms, legs, wrists, or ankles. Some cases, particularly those involving the hip or spine, might not show many outward symptoms beyond persistent pain. But regardless of where it occurs, prompt diagnosis and care are key to preventing complications.

Bone Infection Causes

The majority of cases of osteomyelitis are caused by Staphylococcus bacteria, which are types of germs that are commonly found on the skin or in the noses of even healthy people. When germs enter a bone, they do so through a variety of channels, including:

• The circulatory system. Germs from other parts of the body, such as pneumonia in the lungs or a urinary tract infection in the bladder, can travel through the bloodstream to a weakened spot in a bone.
• Injuries. Germs can enter the body through severe puncture wounds. If such an injury becomes infected, the germs can spread to a nearby bone. Also, germs can enter the body if your child has a broken bone that protrudes through the skin.
• Surgery. Germ contamination can occur during surgeries to replace joints or repair fractures.

Certain bacteria, like staphylococcus aureus, are especially adept at evading the immune system and adhering to hardware such as joint replacements or bone screws, making infections more difficult to treat,  Other potential causes are as follows:

• Recently fractured (broken) a bone
• Been hurt or have a wound
• A prosthetic hip or a bone screw
• Have had recent bone surgery
• A weakened immune system
• Previously had osteomyelitis
• Diabetes
• A blood infection

Osteomyelitis Symptoms

• Swelling, warmth, and redness over the infection site.
• Pain at the infection site.
• Water drainage (yellow pus).
• Irritability or sluggishness.
• Restricted, painful movement
• Appetite loss.
• Lower back discomfort.
• Vomiting and nausea
• Excessive sweating or chills.

Sometimes, osteomyelitis has no symptoms, or the existing symptoms are difficult to distinguish from other problems. For example, this may occur with infants, children, the elderly, and people with weakened immune systems.

In other cases, symptoms may develop more clearly and can vary depending on the patient’s age and the bones involved. In children and teens, the long bones of the arms and legs—especially the femur and tibia—are most often affected. Adults, on the other hand, are more likely to experience infection in the vertebrae of the spine or hips, though extremities can also be involved, especially after trauma, skin wounds, or surgery.

Osteomyelitis can result from a variety of sources, including a previous trauma, puncture wound, surgery, bone fracture, or even an abscessed tooth or an infection of nearby soft tissue, the ear, or sinuses. In children, infection most commonly settles in the metaphysis—the narrow part of long bones. If infection spreads from the metaphysis through the bone cortex and into a joint, it can lead to septic arthritis, particularly in joints like the knee, wrist, hip, ankle, and shoulder.

Other typical symptoms can include:

• Several days of fever, sometimes with temperatures as high as 104–105°F (40–40.5°C)
• Deep, localized bone pain and swelling
• Redness (erythema) and warmth over the affected area
• Chills, excessive sweating, and a general feeling of illness (malaise)
• Painful or restricted movement in nearby joints
• Pus buildup or drainage near the infection site
• In severe cases, loss of calcium, tissue destruction (necrosis), or bone deformity

However, when osteomyelitis affects the hip, vertebrae, or pelvis, the most prominent or sometimes only symptom may be pain, making diagnosis more challenging.

Similar Conditions That Can Mimic Osteomyelitis

Because osteomyelitis shares symptoms with several other disorders, it can sometimes be tricky to diagnose. Some conditions that may look like osteomyelitis include:

• Soft tissue infections: These affect areas like muscles, tendons, or skin around the bone. Infections that won’t heal, especially in people with diabetes, should be checked for possible bone involvement.
• Charcot arthropathy: Sometimes called Charcot joint, this is a progressive joint problem often seen in people with diabetes. It can cause redness, warmth, and swelling, much like osteomyelitis. When Charcot’s joint is suspected and doesn’t improve with rest and elevation, further testing may be needed.
• Osteonecrosis (avascular necrosis): This condition, often related to steroid or radiation use, causes bone death but is usually distinguishable from osteomyelitis.
• Gout and pseudogout: Both can cause joint inflammation and pain, but gout will show uric acid crystals in the joint fluid. Osteomyelitis tends to present more gradually.

Additional Conditions

• Bone fractures: A healing fracture may mimic osteomyelitis on imaging, especially if there was no clear injury or if the fracture isn’t healing as expected.
• Malignancy (bone cancer): Like osteomyelitis, cancers can cause bone pain and changes on X-rays. Sometimes a biopsy is needed to tell the difference.
• Bursitis: This is the inflammation of the fluid-filled sacs near joints and can resemble osteomyelitis, but the infection is localized to the bursa, not the bone.
• Rheumatoid arthritis: An autoimmune disease that causes painful, swollen joints, fatigue, and sometimes appetite loss. Symptoms may linger for weeks or longer, much like chronic osteomyelitis.
• Rheumatic fever: Often following untreated strep throat, this can cause joint swelling, fever, and fatigue, potentially mimicking a bone or joint infection.
• Infectious (septic) arthritis: This joint infection causes rapid-onset pain, swelling, redness, and fever, sometimes making it hard to distinguish from bone infection.

Additional Conditions

• Cellulitis: A skin infection that causes redness, swelling, and pain. If left untreated, it can spread deeper and even reach the bone.
• Giant cell tumors: Rare tumors in the long bones can cause bone pain and swelling, resembling infection.
• Sickle cell disease: This inherited blood disorder can cause bone pain during “crisis” periods, sometimes alongside infections.
• Secondary amyloidosis: This metabolic disorder can develop as a complication of chronic osteomyelitis, leading to organ dysfunction.

Because these conditions can overlap in symptoms, doctors may use imaging, joint fluid tests, and sometimes a bone biopsy to confirm the diagnosis and ensure the right treatment.

Types of Osteomyelitis

Acute:

This infection appears unexpectedly. For example, your child may develop a fever followed by pain in the infected area days later.

Chronic osteomyelitis: 

Chronic osteomyelitis refers to a bone infection that does not respond to treatment. For instance, it causes bone pain and persistent drainage (pus). Chronic osteomyelitis does not always have symptoms. For months or even years, the infection may go undetected. Diagnosing chronic osteomyelitis can be particularly challenging when prosthetic material, skin or soft tissue ulcers, or poor blood flow are present. However, the presence of a draining sinus tract—an abnormal channel that creates a pathway for pus to escape from the infected bone to the skin—is almost always a clear sign of chronic osteomyelitis. Other signs include fractures that fail to heal and a specific form called Brodie’s abscess, which typically develops after an acute infection when the body and the bacteria are equally matched in strength. Brodie’s abscess is sometimes referred to as a distinct form of subacute osteomyelitis.

Vertebral:

A type of infection that affects the spine. It causes chronic back pain that worsens with movement, and treatments such as rest, heating, and pain relievers are ineffective. However, it rarely causes a fever. For this type of spinal bone infection, people living in nursing homes, abusing intravenous drugs, or being on dialysis are at a higher risk of developing spinal bone infections. Vertebral osteomyelitis is more common in adults over 50 and may be linked to prior injuries, urinary tract infections, or heart valve infections (endocarditis). Patients can experience localized tenderness, muscle spasms, and limited movement, and those with unexplained fever, weight loss, or bacteremia who develop new or worsening back pain should be evaluated for this condition.

Anaerobic osteomyelitis:

This form often affects the lower jaw (mandible), skull, or feet. It is typically marked by ulceration, swelling, redness, and foul-smelling drainage from the affected area.

Diabetic foot osteomyelitis:

In people with diabetes or vascular disease, particularly those over 50, skin ulcerations can progress into bone infections, most commonly in the toes and small bones of the feet. This type often presents with pain, redness (erythema), swelling, chronic ulcers, and pus drainage. It is especially challenging to treat due to poor blood supply, which can hinder the effectiveness of antibiotics.

Each type of osteomyelitis has distinct risk factors and symptoms, so prompt recognition and treatment are vital to prevent complications and promote recovery.

Subacute Osteomyelitis (Brodie Abscess)

Subacute osteomyelitis, often known as a Brodie abscess, is a localized, slow-growing infection that frequently affects children and adolescents. Unlike acute osteomyelitis, its onset is insidious, and symptoms may be subtle.

Clinical Features

Children with a Brodie abscess often present with dull, persistent pain in a limb, most commonly in the long bones of the legs, without a preceding trauma. Swelling and redness are often mild or absent, and fever is uncommon. In some cases, a child may simply limp or avoid using the affected limb due to discomfort.

Diagnostic Approaches

Diagnosing a Brodie abscess requires a thorough physical exam and a combination of laboratory and imaging studies.

• Blood tests: Markers of inflammation, such as ESR or CRP, may be slightly elevated, but white blood cell counts are often normal.
• Imaging: X-rays might reveal a small, well-circumscribed area of bone lucency surrounded by a rim of sclerosis. MRI is especially helpful for detecting the extent of infection and differentiating it from other conditions, while CT scans can provide detailed information about the bony changes.
• Bone biopsy: In select cases, a doctor may obtain a sample from the lesion to confirm the diagnosis and rule out tumors.

Treatment Considerations

Treatment typically focuses on long-term antibiotics to eradicate the infection. Oral or intravenous antibiotics may be used for several weeks, depending on the organism involved and the child’s clinical response. In some cases, minor surgical intervention is required to drain the abscess or remove infected tissue, especially if symptoms persist or the diagnosis is uncertain.

Early detection and tailored therapy are key to full recovery while minimizing the risk of complications or chronic infection.

Osteomyelitis Diagnosis

Our Pediatric Orthopedic Specialists may order one or more of the following tests after assessing your child’s symptoms and performing a physical exam:

• Blood tests: Tests on the blood: A complete blood count (CBC) detects inflammation and infection. Additionally, a blood culture examines the bloodstream for bacteria.
• Imaging tests: X-rays, MRIs, CT scans, and ultrasounds all produce images of bones, muscles, and tissues.
• Bone scan: A bone scan refers to an imaging scan that uses a small amount of safe, radioactive material to detect infections or fractures.
• Biopsy: Needle biopsy is performed by our doctors to obtain samples of fluid, tissue, or bone. Then, the biopsy is examined for signs of infection.

Diagnosis typically begins with a thorough physical exam and a review of your child’s symptoms and medical history. If osteomyelitis is suspected, blood tests may reveal signs of infection and inflammation. In some cases, doctors may use blood cultures to identify the specific bacteria present. Imaging studies such as X-rays, MRI, CT scans, and ultrasounds help visualize changes in bone and surrounding tissue. However, in early stages, X-rays may not show changes, so more sensitive imaging like MRI is sometimes preferred.

A bone scan, which uses a small amount of safe, radioactive material, can help pinpoint areas of infection or bone damage when other imaging might be inconclusive.

For a more definitive diagnosis, a bone biopsy may be performed. This involves using a needle to collect a small sample of bone, fluid, or tissue, which is then examined for signs of infection. If a bacterial culture from the biopsy is positive, it helps guide targeted antibiotic therapy. In certain cases, such as when blood cultures reveal bacteria like Staphylococcus aureus or Pseudomonas aeruginosa and imaging findings indicate infection, a bone biopsy may not be required.

Special Considerations in Chronic Osteomyelitis

Diagnosing chronic osteomyelitis can sometimes be more challenging, especially if your child has prosthetic material, skin or soft tissue ulcers, or poor blood supply to the area. The presence of a draining sinus tract is usually a clear sign of chronic infection. Other clues may include fractures that are slow to heal or a Brodie’s abscess—a localized pocket of infection that may follow an acute attack.

Ultimately, a combination of clinical exam, blood work, imaging, and, when needed, biopsy helps our specialists confirm the diagnosis and plan the most effective treatment for your child.

Osteomyelitis Complications

• Abscesses:  Abscesses can form when an infection spreads to muscles and soft tissue. In brief, these pus pockets can seep through the skin. Furthermore, chronic osteomyelitis patients are more likely to develop recurring abscesses. Unfortunately, treatment to drain these abscesses may increase the risk of skin cancer slightly.
• Bone death, also known as osteonecrosis, can occur when infection-related swelling cuts off blood flow to a bone. Incidentally, this may, on rare occasions, result in limb loss or amputation.
• Osteomyelitis:  Osteomyelitis can slow bone growth in a growing child.
• Septic arthritis: Arthritis is caused by bacteria. Infection within bones can sometimes spread to a nearby joint. When this happens, pus can accumulate inside the joint space, leading to septic arthritis. This condition typically causes severe pain, swelling, warmth, and redness in the affected joint, often accompanied by fever, chills, fatigue, and an inability to move the limb due to discomfort. Children or adults with inflammatory joint diseases, those experiencing overwhelming systemic bacterial infection (sepsis), and people who use injection drugs are at higher risk of developing septic arthritis.
• Hampering Growth:  If osteomyelitis occurs in the softer areas called growth plates at either end of the long bones of the arms and legs, normal bone or joint growth in children can stop.
• Cancer of the skin:  If your child’s osteomyelitis causes an open sore that drains pus, the skin around it may have a higher risk of developing squamous cell cancer.

Osteomyelitis associated with poor blood flow, such as in children with certain vascular conditions, can be particularly persistent. In these cases, the infection may resist standard treatments and necessitate special therapeutic considerations, as described in clinical reviews.

Conditions that necessitate the Use of Intravenous Lines or Catheters can Cause Problems.

A variety of conditions necessitate the use of medical tubing to connect the outside world to internal organs.  However, this tubing can also serve as a pathway for germs to enter the body, increasing your child’s risk of infection in general, which can lead to osteomyelitis. Examples of applications for this type of tubing include:

• Tubing for dialysis machines.
• Urine catheters.
• Long-term intravenous tubing, also known as central lines.

Immune System Deficiency Conditions

Your child is more likely to develop osteomyelitis if their immune system becomes compromised by a medical condition or medication. Briefly, some of the factors that may suppress an immune system are as follows:

• Cancer therapy
• Uncontrolled diabetes
• The need for corticosteroids or tumor necrosis factor inhibitors
•  Illicit drugs

Because addicts may use non-sterile needles and are less likely to sterilize their skin before injections, people who inject illegal drugs are more likely to develop osteomyelitis, too.

Osteomyelitis Treatment

A bone infection can be difficult to treat. If your child begins treatment within three to five days of first noticing symptoms, the infection may clear up faster.  Treatment options include:

• Antibiotics: Antibiotics are drugs that kill bacteria that cause infections. Meanwhile, our doctors may prescribe antibiotics for four to eight weeks, beginning with intravenous (IV) antibiotics in the hospital for a week or two. Also, your child will then take medications orally for several weeks. Finally, chronic infections may necessitate months of antibiotic treatment.
• Antifungals: Your child may need to take antifungal medications orally for months to treat fungal infections.
• Needle aspiration: Doctors use a fine needle to drain fluid and pus from the abscess.
• NSAIDs: Pain and inflammation are treated with nonsteroidal anti-inflammatory drugs (NSAIDs).
• Surgery: Sometimes our doctors will recommend surgery to treat bone infections. After the surgery, patients will take antibiotics. Surgeries can include the following:
  • Bone surgery: Our doctors may remove infected, dead tissue and bone (debride).
  • Spine surgery: Children suffering from vertebral osteomyelitis may require spine surgery. Moreover, this procedure prevents vertebrae from collapsing and damaging the spinal cord, nerves, and other nervous system components.

Early diagnosis and tailored therapy are critical, especially in cases where the infection is complicated by poor circulation, multiple organisms, or resistance to standard antibiotics. Treatment regimens are individualized based on the severity, the affected bone, the causative organism, and the child’s overall health.

Osteomyelitis Surgery

If the following occurs to your child, our doctor may recommend surgery:

• A pus buildup (abscess) develops in the bone. Doctors will drain the pus from an abscess.
• The infection presses up against something else, such as the spinal cord.
• The infection has been present for a long time and has caused bone damage.

If the infection has damaged the bone, surgery (known as debridement) may occur to remove the damaged portion. Debridement can leave a gap in the bone that gets filled with antibiotics. To treat an infection, surgeons may operate more than once. Furthermore, other parts of the body’s muscles and skin near the affected bone may need repair, too.

With modern approaches combining surgery, targeted antibiotic therapy, and multidisciplinary care, most cases of osteomyelitis can be managed effectively, greatly reducing the risk of long-term disability.

How Can I Prevent My Child from Getting Osteomyelitis?

All doctors will tell you to clean and treat wounds to keep bacteria and infections at bay. If your child has had a bone break or surgery, call us at the first sign of infection. Therefore, the earlier we begin treatment, the less chance of osteomyelitis beginning.

Osteomyelitis Prognosis

The majority of patients who get osteomyelitis recover with treatment. Thus, the earlier you detect the infection and begin treatment, the better the prognosis. Chronic or untreated infections can permanently damage bones, muscles, and tissues.

When Should Your Child See a Doctor?

If your child’s bone pain gets worse and he or she has a fever, you should call to make an appointment with one of our doctors. If your child becomes at risk of infection or there are signs and symptoms of infection due to a medical condition, recent surgery, or injury, please see one of our doctors as soon as possible.

Prevention:

Finally, if you’ve been told that your child has a higher risk of infection, talk to your doctor about ways to avoid infections. Reducing the risk of infection reduces the chances of developing osteomyelitis. In general, avoid cuts, scrapes, and animal scratches or bites, which allow germs easy access to your child’s body. If your child sustains a minor injury, clean the wound right away and apply a clean bandage. In conclusion, inspect wounds for signs of infection regularly, and if you are worried about your child’s health, call us for an appointment.

See Great Children’s Doctors

When you need a doctor who specializes in children, the doctors at Medical City Children’s Orthopedics and Spine Specialists are among the best in the world.  Finally, our physicians are trained in children’s growing bones and the infections they may get. So, we have five offices to choose from, and they are located in Dallas, Arlington, Flower Mound, Frisco, and McKinney, TX.  Also, we make sure we have at least one office ready for urgent care daily for those children who need to immediately visit a children’s Doctor.

That said, this way you can avoid the ER, those long wait times, big bills, and the doctor will see your child right away. Regardless, we try to think as parents do and always have an option for care. Therefore, this way you and your child can receive on-the-spot care and have a diagnosis and treatment plan to get your child to feel better.

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Footnote:

National Organization of Rare Disorders: Osteomyelitis