Nursing Care of Osteomyelitis

Cellulitis and osteomyelitis are common infections that can appear to be similar. For a review of cellulitis, review this lesson. If you want to review osteomyelitis on the go, tune in to episode 363 of the Straight A Nursing podcast wherever you listen to podcasts, or from the website here.

Osteomyelitis overview

Osteomyelitis is an infection that occurs when a pathogen invades the bone. This can be secondary to surgery, a bone fracture, a bloodstream infection, or as a result of untreated cellulitis. Unlike cellulitis which is solely bacterial in origin, osteomyelitis can be caused by fungi as well as bacteria. The most common pathogen responsible for osteomyelitis is staphylococcus aureus, and the prevalence of MRSA is increasing. Other pathogens include Mycobacterium tuberculosis (which can spread from the lungs to the spine), e-coli, and salmonella (and yes, there are others!). Osteomyelitis can be acute or chronic, with acute being the more common type.

Risk factors for osteomyelitis include cellulitis, prosthetic joints, smoking, renal failure and hemodialysis, endocarditis, orthopedic surgery, diabetes, vascular insufficiency, chronic pressure ulcers, and bone fractures.

Osteomyelitis complications include osteonecrosis (which may lead to amputation), slow bone growth in children, bone deformity, septic arthritis, abscesses, and sepsis.

Now that you’ve got some background information on osteomyelitis, let’s learn how to care for these patients using the Straight A Nursing LATTE method.

L:  How does the patient LOOK?

In osteomyelitis, the skin overlying the infected bone may be normal or it may appear red, warm and swollen, which is what can make it resemble cellulitis. However, the patient will complain of pain or tenderness in the area that is typically more pronounced than the pain of cellulitis. 

Other signs and symptoms include difficulty moving nearby joints, difficulty bearing weight on the affected area, fever, chills, tachycardia, and malaise. If the infection is near a surgical incision or wound, purulent drainage may also be present. In patients with osteomyelitis of the vertebrae, back pain is a common symptom.

A: How do you ASSESS the patient?

Assessments for osteomyelitis includes:

• Monitor vital signs – The patient with acute osteomyelitis will usually have a fever and may also have an elevated heart rate (tachycardia). If sepsis occurs, the patient will experience hypotension as the body mounts an overwhelming immune response to the infection. 
• Assess pain – The bone pain associated with osteomyelitis is generally more painful than cellulitis and is often described as a dull pain.
• Assess the skin over the affected area for warmth, tenderness, erythema, and edema. 
• Monitor for safety concerns, especially in regards to weight-bearing. Osteomyelitis of a lower extremity can put the patient at high risk for falls. Ensure patients understand not to put weight on an affected extremity and assess for proper use of assistive devices.

T: What TESTS are used to evaluate cellulitis and osteomyelitis?

Tests utilized for a patient with osteomyelitis include:

• WBC – will be elevated due to infection
• CRP and/or ESR – these are specific markers that are elevated when inflammation is present
• Blood cultures – may be positive as the infection moves through the bloodstream
• Imaging – X-ray and MRI are commonly used to diagnose osteomyelitis. Of the two, MRI is much more specific and sensitive, and can detect the infection within three to 5 days of onset (whereas it may take up to 14 days for infection to show on X-ray.) Note that MRI is not able to be utilized in patients with surgical hardware, such as those used to correct a fracture. Patients with metal hardware may undergo nuclear imaging instead (you may see this referred to as bone scintigraphy or a bone scan). 
• CT scan – computed tomography may be utilized in those unable to undergo MRI and in those with vertebral osteomyelitis. 
• Bone biopsy – biopsies are helpful in identifying the pathogen and are more useful than wound cultures in targeting antibiotic therapy

T: What TREATMENTS are utilized for osteomyelitis?

Treatment for osteomyelitis typically involves a two-pronged approach which involves surgery and anti-infective therapy. This is because anti-infectives do not penetrate bone readily, so the area must be debrided, which removes diseased tissue and bone. If a patient with a prosthetic joint develops osteomyelitis as a result, that joint may need to be surgically removed. Note that patients receiving anti-infective therapy are generally receiving these medications through the IV route for 4 to 6 weeks as the infections are difficult to treat.

Other treatments include:

• NSAIDs to reduce inflammation and pain. Acetaminophen may also be added if NSAIDs are not sufficient in treating pain.
• Elevate the affected area.
• Vacuum-assisted wound closure devices (wound vac) may be used to treat large wounds that occur due to extensive surgical debridement.
• Wound care, which can be prolonged and extensive. This may be done via home health or the patient may visit a wound care clinic multiple times a week.

E: How do you EDUCATE the patient/family?

Key things to teach regarding osteomyelitis include:

• If MRSA is present, teach the patient and caregivers how to avoid transmission by following contact precautions and avoiding sharing personal items.
• Since cellulitis can progress to osteomyelitis, teach at-risk patients and caregivers how to prevent cellulitis. Learn more in this lesson.
• The importance of adhering to lengthy anti-infective therapy and to finish the entire course even if feeling better.
• The need for diligent wound care, which likely will involve a home-health nurse or frequent visits to a wound-care clinic.
• Keep the affected limb elevated and supported with pillows.
• No weight-bearing on the affected limb.
• Teach the patient how to utilize assistive devices as needed.
• Isometric exercises can help maintain joint function and muscle strength.

Does this LATTE framework help you remember the key things you need to know? Get your free LATTE Method template here.

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References:

Cleveland Clinic. (2024a, May 9). How Is Osteomyelitis Cured? Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/osteomyelitis-bone-infection

Cleveland Clinic. (2024b, May 9). Osteomyelitis (Bone Infection): Causes, Symptoms & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/osteomyelitis-bone-infection

Mayo Clinic. (2022, November 8). Osteomyelitis – Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-20375913

Momodu, I. I., & Savaliya, V. (2024). Osteomyelitis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK532250/

NHS.UK. (2017, November 21). Osteomyelitis. Nhs.Uk. https://www.nhs.uk/conditions/osteomyelitis/

Victoria Department of Health. (2013, August 27). Osteomyelitis. BetterHealth Channel. http://www.betterhealth.vic.gov.au/health/conditionsandtreatments/osteomyelitis

Last Updated on September 5, 2024 by Maureen Osuna, MSN, RN