2.

0 CONTACT HOURS

JOYCE SEABOLT, LPN

Progression Unit Brightwood Center Lutherville, Md.
The author has disclosed that she has no significant relationship with or financial
interest in any commercial companies that pertain to this educational activity.

Osteomyelitis is an inflammation of bone

tissue that affects approximately 2 in
10,000 people in the United States. Caring
for a patient with osteomyelitis can be
challenging because the signs and symptoms often mimic other health problems.
Find out what you can do to recognize this
serious condition and help guide your
patient through diagnosis and recovery.
OSTEOMYELITIS IS AN infectious process in the bone that
usually starts in the spongy medullary bone. Osteomyelitis
literally means inflammation of the bone and is usually caused
by bacteria. The infection that causes osteomyelitis often
starts in another part of the body and spreads to the bone
through the bloodstream. Affected bone is often vulnerable
to infection because of recent trauma, such as a fracture or
surgery. Osteomyelitis is most common in children and
adults over age 50, affecting men more often than women.
It can be acute or chronic.
Bone can become infected in one of the following ways:
as an extension of soft-tissue infection from an incision or pressure ulcer
by direct contamination from bone surgery, open fracture, or traumatic injury
via the blood (hematogenous) from other sites of infection (tonsils, boils, teeth, upper respiratory tract).
Staphylococcus aureus causes between 70% and 80% of
osteomyelitis cases. Other frequent causes include
Pseudomonas and Escherichia coli. Some infections involve
multiple infectious agents.
Acute osteomyelitis usually occurs in children as a
result of infection with Gram-negative bacteria, and the
long bones (tibia, humerus, and femur) are commonly
affected. Infection spreads quickly in children. It can
damage bones and joints, impairing function, growth,
and mobility.
Osteomyelitis in adults is most commonly a chronic
condition that can last several months to years and lead to

bone death. The development of sinus tracts between

bone and skin is common in chronic cases. The pelvis and
vertebrae are most often affected; about half of the cases of
vertebral osteomyelitis are due to S. aureus, and the other
half are due to tuberculosis. Chronic osteomyelitis of the
spine is dangerous because it can damage the nerves. Sites
of chronic osteomyelitis can evolve into skin cancer or
gangrene, and possibly lead to limb amputation.
Risky business
People who are at high risk for osteomyelitis include
those who are poorly nourished, elderly, or obese. Others at risk include those with impaired immune systems;
those with chronic illnesses such as diabetes or rheumatoid arthritis; and those receiving long-term corticosteroid therapy or immunosuppressive agents. People
with diabetes have an increased risk of getting osteomyelitis for many reasons:
They have impaired circulation, which causes wounds
to heal slowly.
If they have neuropathy, an injury may go undetected
for a long time.
Impaired vision or impaired mobility can lead to injuries.
Chronic diseases such as sickle-cell anemia, cancer,
hemophilia, rheumatoid arthritis, and HIV also put people at high risk for infections. All these problems can lead
to osteomyelitis. Weakness and impaired mobility from
these diseases increase the potential for injuries. These
patients also have impaired ability to heal after an injury,
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Direct contamination
Infectious organisms can enter the
bone directly through an open fracture, a traumatic injury such as a
gunshot wound, and during surgery.
Postoperative surgical wound infections occur within 30 days after
surgery. They are classified as incisional (superficial, located above the
deep fascia layer) or deep (involving
tissue beneath the deep fascia).
If the patient received a bone
implant, a deep postoperative infection may affect the site within a year.
Deep sepsis after arthroplasty may
be classified as follows:
Stage 1, acute fulminating: occurring during the first 3 months after
orthopedic surgery; frequently associated with hematoma, drainage, or
superficial infection
Stage 2, delayed onset: occurring between 4 and 24 months after surgery
Stage 3, late onset: occurring 2 or
more years after surgery, usually as
a result of hematogenous spread.
Bone infections are more difficult
to wipe out than soft tissue infections
because blood vessels dont supply
the infected bone to provide access
to the bodys natural immune
response. Penetration by antibiotics
is decreased as well, so osteomyelitis
may become chronic and affect the
patients quality of life.
Before we get to what can be done
to treat osteomyelitis, its time to
take a look at the common signs and
symptoms.
Signs and symptoms
Children under the age of 3 are
common targets for osteomyelitis
because they fall frequently and
their immune systems are not yet
developed. Instruct parents to monitor a childs injury site (especially
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Volume 4, Number 2

What osteomyelitis looks like

JAKE PALMER

so their acute osteomyelitis is more

likely to evolve into chronic
osteomyelitis.

fractures and puncture wounds)

long after they seem to be healed.
Osteomyelitis is one complication
they can help prevent.
Signs and symptoms of acute
osteomyelitis include:
pain in the affected area
redness, swelling, and warmth
over the area of infection
fever
irritability
malaise.
In children, many of these symptoms may mistakenly be attributed to
other causes, such as the flu. Children
frequently have scrapes, falls, punctures, and fractures and experience
pain, swelling, redness, or drainage
after those injuries, and a diagnosis of
osteomyelitis can be overlooked.
Signs and symptoms of chronic
osteomyelitis include:
redness, swelling, and warmth over
the area of infection
pain or tenderness in the affected
area
drainage from an open wound in
the area of infection
fever (in some cases).
Because bone infections in adults
commonly follow an injury or
surgery, the symptoms may erroneously be attributed to the injury or

surgery and osteomyelitis can be

overlooked.
Once osteomyelitis is suspected,
its time to perform some tests to
make a definitive diagnosis. Heres
what you need to know about the
current tests available.
Testing, testing
Because diagnosing osteomyelitis
can be difficult, assessment requires
a complete medical history, physical
examination, and diagnostic testing.
This testing may include blood
work, bone biopsy, X-rays, bone
scans, computed tomography (CT)
scans, and magnetic resonance
imaging (MRI).
Blood work typically includes a
complete blood cell (CBC) count,
erythrocyte sedimentation rate
(ESR), blood cultures, and Creactive protein (CRP) level. The
CBC count will show an elevated
white blood cell count when infection is present. The ESR is almost
always elevated in the presence of
inflammation. The CRP helps detect
inflammation and infection.
A bone biopsy is the gold standard
for diagnosing osteomyelitis. It will
identify the infection and can be performed through surgery (an open

biopsy) or by deep needle aspiration.

X-rays can detect osteomyelitis
only after it has reached an advanced
stage, but common findings in chronic osteomyelitis include bone sclerosis
and periosteal new bone formation.
Bone scans are done after dye has
been injected and absorbed by bone
tissue. They can detect areas of
increased or decreased bone metabolism, even in the early stages of
infection.
CT scans can show abnormal calcification (the buildup of calcium in
body tissues) and ossification (when
cartilage is turned into bone).
MRIs are most useful to evaluate
vertebral lesions and can distinguish
between soft tissue infection and
bone infection.
Treatment options
Once your patient has been diagnosed with osteomyelitis, his treatment will depend on the bacteria
involved, the site of infection, and
the type of osteomyelitis (acute or
chronic). Antibiotic therapy, bed
rest and opioid analgesia, nutritional
support, and surgery are options;
lets take a look at what each can do
to help your patient.
Intravenous antibiotic therapy is
administered after blood cultures or
aspiration cultures identify the cause
of the infection. Bacterial infections
usually require 2 to 6 weeks of
antibiotic therapy (unless vertebrae
are infected, when treatment lasts 6

to 8 weeks). Fungal infections may

require several months of treatment,
and chronic infections may require
treatment indefinitely.
Antibiotic therapy usually begins
in the hospital and continues at
home, either intravenously (I.V.) or
orally. Common antibiotics used
include ciprofloxacin (Cipro), nafcillin (Unipen), clindamycin
(Cleocin), vancomycin, flucloxacillin
(Floxapen), and gentamicin
(Genoptic). Remind your patient to
take his antibiotics exactly as prescribed and to call his health care
provider if any problems occur.
Bed rest and opioid analgesia may
be indicated to manage pain. Bed
rest is especially important when
osteomyelitis affects weight-bearing
bones (those in the spine, hip, knees,
and foot) because standing puts pressure on the infection site.
Nutritional support, which
includes a high-protein diet unless
its contraindicated, can help aid
wound healing.
Surgery is considered when:
antibiotic therapy fails
the patient develops neurologic
deficits
the bone becomes deformed.
Surgery may be as simple as draining a bone abscess. Abscesses must
be drained because they can impair
the blood supply to the affected area
and cause bone death (osteonecrosis). Sometimes, the surgery may be
as complicated as a spinal recon-

Teaching facts
Patients with osteomyelitis need to take care of themselves to improve their
chances of fighting infection. Teach your patients to:
Eat a variety of fruits and vegetables, which can provide the body with the nutritional support it needs to fight infection and stay healthy.
Stop smoking. Smoking slows blood flow to the hands and feet, making it more
difficult for the body to fight infection. Provide your patient with smoking cessation
materials if he needs help.
Continue antibiotic treatment as prescribed. Advise him to call his health care
provider to report any adverse effects before discontinuing the drug on his own. The
success of antibiotic treatment depends on following the complete regimen.

struction. It all depends on the infection, the site, the symptoms, and the
surgeon. Many surgeries involve
bone scraping. Once the infected
area is debrided, the bone should
regenerate rapidly.
If a prosthesis (such as a total knee
replacement) is the site of osteomyelitis, it is removed. Sometimes,
the empty space is packed with
antibiotic-impregnated materials.
Other times, a new prosthesis is
implanted immediately and I.V.
antibiotics are given.
Unless there is nerve damage,
surgery isnt recommended for
patients with spinal osteomyelitis.
Other approaches for treating
osteomyelitis include:
splinting and cast immobilization to
prevent further trauma or to help
the bone and joint heal (usually
used in children)
two different types of external fixators: static fixators hold bones in
place; dynamic fixators adjust to
compress, angle, or lengthen bones
free tissue transfers, in which tissue
(with its blood supply) is attached to
new vessels in the wound
bone grafts to replace infected bone
cells with healthy bone (usually
from the patients pelvis)
hyperbaric oxygen therapy, along
with antibiotics, to inhibit the
growth of anaerobic organisms
amputation when a new prosthesis
will function better than the chronically infected limb.
Chronic osteomyelitis resists
treatment, especially if multiple
microbes or a fungus are the cause.
Chronic types usually require a combination of antibiotics and surgery.
Caring for your patient
Caring for a patient with osteomyelitis includes managing immediate problems and making sure his
ongoing treatment is safe and effective. Your goals should be to:
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tions. See Teaching facts for more

information.
It can be prevented
Because osteomyelitis is a preventable disease, inform all your patients,
especially those with risk factors,
about the causes of osteomyelitis and
how preventive measures can help
(see An ounce of prevention). Educated
patients may succeed in preventing
or minimizing the pain that accompanies osteomyelitis. LPN
Selected references
American Academy of Orthopaedic Surgeons. Infections. http://orthoinfo.aaos.org/topic.cfm?
topic=A00197. Accessed December 10, 2007.
Cierny III G. Guest editorial. http://www.
osteomyelitis.com Accessed January 1, 2007.

Normal bone
hyaline cartilage
epiphysis
cancellous bone
epiphyseal plate

medullary cavity

diaphysis

compact bone
epiphysis
epiphysis

The Cleveland Clinic. Osteomyelitis. http://www.

clevelandclinic.org/health/health-info/docs/2700/
2702.asp?index=9495. Accessed January 17, 2007.
The Mayo Clinic. Osteomyelitis. http://www.
mayoclinic.com/health/osteomyelitis/DS00759.
Accessed November 29, 2006.

An ounce of prevention
When patients have an increased risk of infection, educate them about ways to prevent infections and help prevent osteomyelitis. If they do get cuts and scrapes, the
American Association of Orthopaedic Surgeons recommends these simple steps to
prevent infections in skin wounds:
First, control the bleeding, then clean the wound with soap and water.
Keep all foreign matter out of the wound but dont try to remove matter embedded
in the wound.
Use sterile materials for the first dressing.
See your primary care provider for a final, definitive cleaning of the wound.

The Merck Manual of Geriatrics. Osteomyelitis.

http://www.merck.com/mrkshared/mmg/sec7/
ch50/ch50a.jsp. Accessed February 11, 2007.
National Institutes of Health. Malignant otitis externa. http://www.nlm.nih.gov/medlineplus/
ency/article/000672.htm. Accessed February 17,
2007.
Sheff EK. Solving the mystery of osteomyelitis.
Nursing2005. 35(7):32hn1-32hn3, July 2005.
Smeltzer SC, et al. Brunner and Suddarths Textbook
of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007.

Earn CE credit online:

Go to http://www.nursingcenter.com/ce/lpn and receive a
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INSTRUCTIONS

Overcoming osteomyelitis
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48

LPN2008

Volume 4, Number 2

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Your certificate is valid in all states.

JAKE PALMER

control the patients pain with

prescribed analgesics and nonpharmacologic techniques
monitor his response to antibiotic
therapy
observe the patients I.V. site for
signs of complications
monitor the area of infection and
neurovascular status (if an extremity
is involved)
apply gentle range-of-motion
exercises to the joints above and
below the affected site
unless contraindicated, provide
nutritional support in the form of a
high-protein diet
teach your patient how to take
prescribed antibiotics and how to
recognize possible adverse reac-

2.0
CONTACT HOURS

Overcoming osteomyelitis
GENERAL PURPOSE: To provide the nurse with a comprehensive review of the diagnosis, management, and treatment of osteomyelitis.
LEARNING OBJECTIVES: After reading the preceding article and taking this test, you should be able to: 1. Discuss the infectious process causing osteomyelitis. 2. Identify the symptoms and tests used in diagnosing osteomyelitis. 3. Explain the options for treatment and prevention of
osteomyelitis.
1. Each of the following statements about
osteomyelitis is true except
a. it can be an acute or chronic infectious
process.
b. it affects men more than women.
c. it usually starts in the bone and spreads to
other parts of the body.
d. it usually starts in the spongy medullary
bone.

d. Osteomyelitis is rare in children.

2. Which bacteria cause 70% to 80% of

osteomyelitis cases?
a. Pseudomonas
b. Escherichia coli
c. multiple infectious agents
d. Staphylococcus aureus

8. A C-reactive protein test helps detect

a. increased white blood cells.
b. low hemoglobin levels.
c. inflammation and infection.
d. an elevated sedimentation rate.

b. vancomycin
c. levaquin
d. gentamicin (Genoptic)

7. Which of the following symptoms is present in acute osteomyelitis but may not be
present in chronic osteomyelitis?
a. redness and swelling
b. fever
c. warmth
d. pain

14. What level of activity is most likely to be

ordered for a patient with osteomyelitis of
the hip?
a. bed rest
b. standing with assistance
c. chair only
d. ambulation
15. Which treatment is usually used in children with osteomyelitis to prevent further
trauma?
a. surgery
b. external fixators
c. bone grafts
d. splinting and cast immobilization

9. The gold standard for diagnosing

osteomyelitis is
a. bone biopsy.
b. magnetic resonance imaging (MRI).
c. computed tomography (CT) scan.
d. bone scan.

3. Half the cases of vertebral osteomyelitis

in adults are caused by
a. tuberculosis.
c. Pseudomonas.
b. fungi.
d. E. coli.
4. People with diabetes are at increased
risk for osteomyelitis because of impaired
circulation and
a. impaired immune system.
b. poor nutrition.
c. neuropathy.
d. corticosteroid therapy.

10. Which test can detect osteomyelitis only

after its reached an advanced stage?
a. MRI
c. X-ray
b. bone scan
d. CT scan

17. Chronic osteomyelitis usually requires

treatment with
a. free tissue transfers and bone grafts.
b. hyperbaric oxygen therapy.
c. amputation.
d. a combination of antibiotics and surgery.

11. A patient with suspected vertebral osteomyelitis is best evaluated by

a. a CT scan.
c. an X-ray.
b. a bone scan.
d. an MRI.

5. A patient with deep sepsis 3 months after arthroplasty and a history of a postoperative hematoma would be classified as
a. stage 1.
c. stage 3.
b. stage 2.
d. stage 4.

12. A patient with fungal osteomyelitis may

require antibiotic therapy for
a. 2 to 4 weeks.
b. 6 to 8 weeks.
c. several months.
d. an indefinite amount of time.

6. What should parents of injured children

be taught about osteomyelitis?
a. Check for fever often.
b. Their active immune systems are an effective barrier against osteomyelitis.
c. Monitor the injury site even after apparent
healing.

16. Which treatment is used to inhibit the

growth of anaerobic organisms?
a. a bone graft
b. hyperbaric oxygen therapy
c. free tissue transfers
d. external fixators

18. To prevent infections in skin wounds,

you should advise a patient with a cut or
scrape to
a. dress the wound with sterile materials.
b. clean the wound with soap and water.
c. remove any embedded matter from the
wound.
d. see his primary care provider for final
cleaning.

13. Which antibiotic is not commonly used

for treatment of osteomyelitis?
a. ciprofloxacin (Cipro)

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