What are the symptoms and treatment options for a patient with suspected bony osteomyelitis, particularly one with a history of diabetes and recent trauma or surgery?

Symptoms of Bony Osteomyelitis

Osteomyelitis presents with localized bone pain, swelling, erythema, and warmth over the affected area, often accompanied by fever and systemic signs of infection in acute cases, while chronic osteomyelitis may have subtle, non-specific symptoms that make diagnosis challenging. 1, 2

Clinical Presentation

Acute Osteomyelitis

• Localized bone pain is the most consistent symptom, present in the majority of cases 2
• Fever and systemic symptoms including malaise and elevated temperature, though the typical triad of fever, pain, and diminished mobility is present in only slightly above 50% of pediatric cases 3
• Visible swelling and erythema over the affected bone, with an erythematous and indurated "sausage" appearance particularly in finger osteomyelitis 3
• Warmth and tenderness on palpation of the affected area 1, 2
• Reduced range of motion or reluctance to use the affected limb 3

Chronic Osteomyelitis

• Non-specific symptoms that are often subtle and may delay diagnosis 1, 2
• Persistent, dull bone pain that may be less severe than acute presentations 2
• Draining sinus tracts through the skin, which are highly suggestive of chronic bone infection 1
• Non-healing wounds despite appropriate care, particularly in diabetic patients 3
• Absence of systemic symptoms in many cases, especially in diabetic patients with neuropathy who may not experience typical pain 1

High-Risk Clinical Findings

Diabetic Foot Osteomyelitis

• Probe-to-bone test positive - visible or palpable bone through a wound has a positive likelihood ratio of 9.2 for osteomyelitis 3, 4
• Deep ulcers extending to bone, particularly in the presence of peripheral neuropathy 1
• Elevated inflammatory markers with ESR >60 mm/hour or CRP >3.2 mg/dL combined with clinical findings 3, 4

Post-Surgical or Post-Traumatic Osteomyelitis

• Pain and swelling at the site of previous hardware or surgery 1
• Persistent wound drainage or failure of surgical site to heal 1
• Cellulitis associated with hardware sites 1

Laboratory and Imaging Findings That Support Clinical Diagnosis

Initial Laboratory Assessment

• Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are useful when clinical examination is equivocal 1, 3
• Procalcitonin (PCT) may be assessed in diagnostically uncertain cases 1
• Blood cultures should be obtained in suspected hematogenous osteomyelitis before starting antibiotics 3

Imaging Findings

• Plain radiographs may show cortical erosion, periosteal reaction, mixed lucency and sclerosis, sequestrum, or involucrum, though sensitivity is low in early disease 1, 4, 2
• MRI findings of low signal intensity on T1 images and high signal intensity on fluid-sensitive images indicate osteomyelitis 4
• Soft-tissue involvement including abscesses, joint effusions, and inflammatory changes in adjacent tissues 1

Critical Pitfalls to Avoid

• Do not rely solely on systemic symptoms - diabetic patients with neuropathy may have minimal pain and no fever despite significant bone infection 1
• Do not dismiss chronic, subtle symptoms - chronic osteomyelitis often lacks dramatic presentation but can cause persistent morbidity 1, 2
• Do not overlook draining sinuses - these should prompt high clinical suspicion for chronic bone infection 1
• Do not delay imaging when clinical suspicion is high, even if initial radiographs are negative, as early osteomyelitis may not show radiographic changes for 10-14 days 4, 2