Osteomyelitis is an infection of the bone, caused usually by bacteria but occasionally by fungi. Several forms of osteomyelitis exist. Hematogenous osteomyelitis, which occurs most often in children, generally develops in bones with a good blood supply and rich marrow. Vertebral osteomyelitis begins as a gradually developing back pain. Post-traumatic osteomyelitis commonly occurs in patients with infected prostheses.

Once established in the bone, the infections can spread outward to the adjacent soft tissue, where it causes abscesses. Antibiotics are first line treatment. Unsuccessful treatment can result in chronic osteomyelitis. While often symptom-free for long periods, this condition causes bone pain, recurring infections, and constant or intermittent drainage of pus through the skin. The drainage creates sinus tracts between the bone and the skin. It affects children more than adults.

The infection is most commonly caused by Staphylococcus aureus but consider other microorganisms such as Mycobacterium tuberculosis. It starts in soft tissue adjacent to bone or enters the body from external sources. It reaches the bone via several routes (including the bloodstream, open wounds, surgery on bones) and causes the bone marrow to swell. As it presses against the bone's rigid outer wall, the marrow compresses blood vessels, reducing the supply of blood to the bone or cutting it off entirely. Without treatment, parts of the bone may die. Prosthetic devices may be source of irritation.

• Open bone fracture
• Bone surgery
• Attachment of metal to a bone
• Kidney dialysis
• Intravenous use of illegal drugs
• Implanted prosthesis
• Foot ulcers
• Diabetes
• Trauma

Symptoms can be acute or chronic, depending on etiology.

• Intense pain and a sensation of heat at the site of the affected bone
• Tenderness and swelling
• Persistent back pain, unrelieved by rest, heat, or analgesics
• Abscesses in tissue surrounding the painful bone
• Fever, in some cases
• Fatigue, irritability, malaise
• Inflammation, generally localized with or without drainage

• Infectious arthritis
• Charcot's joint (neuropathic joint disease)
• Bone tumors
• Cellulitis
• Other systemic infection
• Gout
• Other sources of localized inflammation

Patient typically looks sick, particularly children. They report tenderness when palpated above the affected area of the bone. Fever is not necessarily an indicator of osteomyelitis; patients may show minimal fever or no fever. Check patient's TB status. Consider old chest X rays and family history.

Samples of blood, pus, joint fluid and, if necessary, the bone itself serve to diagnose the infection and to identify the bacteria or fungi responsible.

• An elevated white blood cell count typifies osteomyelitis in children, but rarely in adults.
• ESR is typically high in both children and adults, particularly in cases of vertebral osteomyelitis.
• Blood cultures indicate the pathogen that caused infection, most commonly S. aureus. Fungal and tubercular infections are almost impossible to diagnose without cultures.

Pyogenic bacteria

Radionuclide bone scans that use technetium phosphate give positive indications of the condition, but they are less useful when osteomyelitis stems from infected prostheses, because the technetium phosphate accumulates in fracture sites, new bone, overlying areas of cellulitis, and aseptic loosened areas of the prostheses. In these cases, conventional X rays reveal changes. Computed tomography can help define the amount of bone destruction and indicate the presence of complications of the infection, such as abscesses. Magnetic resonance imaging serves to distinguish infection in soft tissue alone from that in the bone.

• Palpate areas of apparent infection for signs of warmth and tenderness.
• Carry out blood tests for white blood cell count and ESR.
• Perform blood culture to identify cause of infection.
• Biopsy the bone, where necessary, by needle aspiration or open surgery.
• Needle biopsy of the infected bone itself, or open surgical biopsy, is generally required to diagnose vertebral osteomyelitis. Aspiration applies to the intervertebral disk space that appears infected.

A three-week course of antibiotics forms the first line of treatment of osteomyelitis. Choice of antibiotic depends on identification of the infectious agent. Bed rest should frequently accompany the treatment. Surgery is necessary when detection and treatment of the infection occur too late to halt its spread.

Extended bed rest and immobilization of the affected bones are recommended in conjunction with antibiotics or antimicrobials.

Courses of antibiotics lasting several weeks should clear up infections identified early. If diagnostic techniques identify the nature of the infection precisely, antibiotic specific to that infection should be prescribed. Antimicrobials are recommended for chronic osteomyelitis and forms of the condition caused by fractures or infections in sites adjacent to the bone.

Oxacillin and nafcillin, effective against S. aureus, the most common source of infection, should be given intravenously to children when tests do not reveal a precise cause of infection. Start intravenously; change to oral administration within days. For children, intravenous administration should start as soon as the patient is diagnosed and hospitalized.

In cases of osteomyelitis that result from foot ulcers or diabetes, medical treatment should include such antimicrobial agents as cefoxitin, cefotetan, or a combination of aminoglycoside and clindamycin.

Surgery may be necessary when osteomyelitis is identified late. Surgery is an option more often in cases of chronic osteomyelitis, osteomyelitis caused by fractures and infections in soft tissue contiguous to the bone, and that originating in foot ulcers. Surgery can drain abscesses adjacent to the infected bone and remove all dead tissue and bone. Antimicrobial or antibiotic therapy should follow all cases of surgery.

Infected prostheses should be surgically removed, following several weeks of antibiotic treatment, to permit a new prostheses to be implanted at the same time.

Osteomyelitis requires immediate medical attention. Alternative therapies can be used concurrently to stimulate the immune system and optimize recovery.

For overall immune support and to enhance healing, use the following.

• Vitamin C (1,000 mg tid to qid)
• Zinc (30 to 50 mg/day for 1 month, then reduce to 25 mg/day)
• Vitamin E (400 to 800 IU/day)
• Vitamin A (10,000 to 15,000 IU/day) (avoid in pregnancy or women considering becoming pregnant)
• Acidophilus (1 to 3 capsules/day, or 1 to 5 million organisms/day)—to prevent antibiotic-induced diarrhea and yeast infections

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites, or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 10 to 60 minutes and drink 2 to 4 cups/day. Tinctures may be used singly or in combination.

Use one or more herbs from each category. Make a tincture using equal parts. Take 15 to 20 drops tid to qid.

• Immune support: coneflower (Echinacea purpurea), lomatium (Lomatium dissectum), astragalus (Astragalus membranaceus)
• Anti-microbials: goldenseal (Hydrastis canadensis), barberry (Berberis vulgaris), garlic (Allium sativum)
• Analgesics: valerian (Valeriana officinalis), St. John's wort (Hypericum perforatum)
• For improved circulation: Ginkgo biloba 120 mg bid

Alteratives are traditionally known as blood cleansers. Use the following herbs in combination as an infusion. Drink 2 to 3 cups a day.

• Red clover (Trifolium pratense), burdock root (Arctium lappa), yellowdock (Rumex crispus), yarrow (Achillea millefolium), cleavers (Galium aparine), and licorice root (Glycyrrhiza glabra). Licorice is contraindicated in hypertension.

Topical applications aid abscess healing: Make a paste from the powders of goldenseal root (Hydrastis canadensis) and slippery elm (Ulmus fulva). Apply as needed.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Arnica for use after trauma or injury, especially with bruising or a bruised, "beat up" feeling
• Ledum for puncture wounds that lead to abscesses, especially if they feel better with cold applications
• Silica for enlarged, suppurating glands or abscesses, especially in depleted individuals

May help stimulate immune response, reducing inflammation, pain, edema, and fever.

Careful monitoring is essential during antibiotic and antimicrobial treatments. Look for rapid responses—24 to 48 hours—to the administration of antibiotics and antimicrobials.

Avoid strenuous activity or weight-bearing exercise until healed.

Patients who do not receive treatment soon after the onset of infection and those with immune deficiency may develop chronic osteomyelitis. Infections that spread from foot ulcers to bones in the foot often involve several types of bacteria and are difficult to cure by antibiotics alone. Abscess may occur. Cure may require removal of the infected bone. Massage is contraindicated in osteomyelitis due to concerns of spreading infection.

Most patients respond well with no long-term problems. Chronic osteomyelitis can be quiescent for months to years.

Berkow R, ed. Merck Manual of Diagnosis and Therapy. 16th ed. Rahway, NJ: Merck Research Laboratories; 1992.

Dambro MR, ed. Griffith's 5 Minute Clinical Consult. New York, NY: Lippincott, Williams & Wilkins; 1998.

Larson DE, ed. Mayo Clinic Family Health Book. 2nd ed. New York, NY: William Morrow and Company; 1996.