Acute Osteomyelitis

Clinical Description

Hematogenous spread of bacteria from a primary source. The commonest causative agent is staphylococcus aureus. Other organisms, which may be responsible, include streptococcus, pneumococcus, Haemophilus and sometimes salmonella in sickle cell disease. Commonly involved bones are proximal tibia, distal femur and distal humerus.

Signs and Symptoms

• Pain is the major presenting symptom with progressive severity with time.
• Commonly accompanying fever, and the patient becomes toxic.
• Main physical signs are swelling, localized tenderness and pseudoparalysis
• A high index of suspicion and proper history is important

Investigations

• FBC: A leucocytosis will be demonstrated.
• X−ray of affected limb may not show any changes in the early stages − periosteal elevation is a late feature (2−3 weeks).
• Blood cultures and sensitivity, ESR, CRP

Adults and Children

• Refer to the hospital
• Admit to hospital for rest
• Splint the affected limb as required
• Give analgesics- refer to acute pain management

If pain is severe:

• Give Pethidine 1mg/kg IM (Refer to acute pain management)
• Repeat every 6 hours for a maximum 4 doses
• Drain pus surgically from the bone and send for culture and sensitivitytesting
• Do not await culture results before starting antibiotic treatment

Children Over 2 years:

• Give Flucloxacillin 50 mg/kg up to a maximum of 500 mg 6 hourly, initially IV, then orally from 48 hours after fever has settled

Alternatively:

• Give Cloxacillin 50-100mg/kg 6 hourly X 6weeks, initially IV, then orally from 48 hours after fever has settled
• Clindamycin 15-40mgs/kg (4 divided doses)

Children Under 2 years:

• Give Ceftriaxone 50mg/kg once a day or (Especially if staphylococcal infection is very likely)
• Give Flucloxacillin 50 mg/kg every 6hrs, initially IV, then orally from 48 hours after fever has settled

Note: Antibiotic treatment should be continued for 4 weeks under hospital supervision.