ZSFG Intern Report Pearls 6.8.17: Upper Extremity Swelling Secondary to Osteomyelitis

Thanks to Mike Incze for presenting an amazing case of a really gnarly right upper extremity that was ultimately found to be a case of osteomyelitis with a key learning point of going for bone biopsy prior to antibiotics if patient is clinically stable.

 

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Top Learning Pearls:

  1. When osteomyelitis is suspected, bone biopsy should be obtained (and it yield a positive finding in 87% of cases).
  2. Cessation of antibiotics 48-72 hours prior to bone biopsy can help increase microbiological yield, although some authors argue that bone biopsy can still be positive since osteomyelitis often occurs in areas of poor vascularization.
  3. Complex regional pain syndrome can be considered when other etiologies have been ruled out and can include symptoms of pain, sensory changes (although typically more pain instead of less pain), motor loss, as well as edema

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Differential Of Large, Swollen Upper Extremity:

High Acuity (“Can’t Miss”)

  • Necrotizing fasciitis
  • Compartment Syndrome
  • Tenosynovitis (especially of hand)
  • Osteomyelitis
  • Other skin & soft tissue infection

 

Moderate Acuity:

  • DVT of upper extremity (spontaneous rare)
  • Septic thrombophlebitis
  • Acute gout
  • Lymph obstruction
  • Atypical infections (TB, Nocardia)
  • Charcot arthropathy
  • Fracture
  • Bursitis
  • Malgnancy
  • SAPHO (Synoviitis, Acne, Pustulosis, Hyperostitis, Osteitis)

 

Lower Acuity (Dx of Exclusion):

  • Complex Regional Pain Syndrome

 

Work-Up of Osteomyeltis:

Exam:

-“Probe to Bone” as a screening – (recommended to do w/ metal object, if hit hard, gritty substance, that’s bone) – Sensitivity 0.87, Specificity 0.83.

 

Labs:

-CBC, ESR, CRP, blood cultures (only positive in about ½ of cases of acute osteo)

-Bone Biopsy is needed to tailor treatment

 

Imaging:

–Start with X-ray of the area, advanced imaging is patient, location, and situation dependent

 

For more information on A Systematic Approach to The Swollen Extremity: Click here

 

 

 

 

 

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