How can you rule out or confirm the diagnosis of osteomyelitis

All chronic ulcers, particularly when their dimensions are more than 2 cm, can be complicated by osteomyelitis. Acute osteomyelitis manifests radiological findings two weeks after involvement of the bone. These consist of osteolysis or even a significant degree of bone absorption, with or without periosteal reaction (Figure 17.8). It is recommended

Osteomyelitis Pathophysiology
Figure 17.8. The X-ray of the patient with the ulcer (Figure 17.7). Osteolysis of the head of the 1st metatarsal and the proximal part of the last phalanx, with periosteal reaction due to osteomyelitis is seen.

that an X-ray is performed on all chronic ulcers (sensitivity in diagnosing osteomyelitis is in the order of 55 percent but increases more when the radiograph is repeated at a two weekly interval). In cases when the radiograph is negative and the clinical suspicion high, it is recommended to treat the infection as osteomyelitis and repeat the X-ray in two weeks. A complete blood count (CBC) may show anaemia of chronic disease. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are usually slightly elevated and are useful for disease monitoring and follow-up. Probing of bone with a metal object through the ulcer (probe-to-bone test) has a sensitivity of more than 90 percent for diagnosing acute osteomyelitis. Three-phase technetium bone scan scintigraphy is indicated when the radiograph is negative. Computed tomography (CT) can reveal more subtle damage than the simple radiograph (periosteal reaction, small cortex erosions) as well as damage of soft tissues. Magnetic resonance imaging (MRI) tomography can also help in cases where the other tests are non-diagnostic, because it has higher sensitivity and specificity for the diagnosis of osteomyelitis.

CASE STUDY 3

A patient with a relapsing neurotrophic ulcer at the head of his right 5th metatarsal presents for a follow-up visit. On examination, he has an ulcer 2 x 1.5 cm in diameter and 0.8 cm in depth, surrounded by a callus. The gauzes that the patient uses to cover the ulcer are impregnated with serosan-guinous fluid, but there are no clinical signs of infection. How will you manage the patient?

As mentioned above, surgical debridement of the ulcer border for removal of the hyperkeratotic rim is necessary. Adequate tissue should be removed, up to the point of mild bleeding from the ulcer rim. The surface of the ulceration is cleansed initially with ample NaCl 0.9 percent or 15 percent solution and then debrided with a scalpel, aimed at removing microbes and macrophage products (proteases), which act by suspending the action of fibroblasts and locally produced healing factors. The surgical debridement of the ulcer borders times to transform a chronic ulcer into an acute one that heals faster.

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