Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
I feel it in my bones: Osteomyelitis
Case presentation
A 13-year-old male is referred to the Emergency Department by his primary care provider. The patient has had left hip pain for the past week, which has progressively interfered with his daily activities, such as sports, and now has made ambulation difficult. He has had subjective fever but no recent illness and denies any trauma. There has been no back pain, abdominal pain, incontinence, weakness, or numbness. The pain radiates from his left hip to the superior aspect of his left knee.
On examination, the patient is a pleasant teenager in no distress. He has a temperature of 100.2 degrees Fahrenheit, a heart rate of 112 beats per minute, a respiratory rate of 20 breaths per minute, and a blood pressure of 120/76 mm Hg. His physical examination reveals no obvious abnormalities, as he is sitting up on the hospital bed. His leg lengths are equal. He is able to ambulate but when doing so states that this produces left lateral hip pain, pointing to the anterior-lateral aspect of the superior iliac crest. When his left leg is examined, he has good range of motion of the leg at the hip joint; he is able to flex and extend the leg without difficulty, but when the knee is flexed and the leg (at the hip joint) is either abducted or adducted, pain is produced at the superior aspect of the left hip. There is no erythema, swelling, warmth, or signs of trauma. He has no abdominal pain or back pain and has a normal genital examination.
Imaging considerations
Plain radiography
This imaging modality is most commonly employed in patients with musculoskeletal complaints, given the low ionizing radiation exposure relative to other modalities and general availability. Plain radiography is useful in investigating alternative causes of pain in patients with suspected osteomyelitis, such as fractures. For osteomyelitis, however, radiography is less useful in the acute period. Changes associated with osteomyelitis will not be evident on plain radiography immediately. Associated soft tissue swelling may be seen approximately 3–4 days into the course of the illness and cortical destruction may not be evident for 10–14 days after onset of the infection. Osteopenia may generally be seen after 30%–50% loss of mineralization. Osseous radiographic findings of osteomyelitis initially include subperiosteal resorption, followed by bone lucencies, then irregular destruction with new periosteal bone formation.
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