UMEM Educational Pearls

Category: Infectious Disease

Title: Diabetes and Osteomyelitis

Keywords: diabetes, osteomyelitis, temperature, white blood cell count (PubMed Search)

Posted: 7/1/2008 by Mike Winters, MD (Updated: 2/28/2020)
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Does this Patient with Diabetes have Osteomyelitis?

  • Diagnosis of lower extremity osteomyelitis in the diabetic patient remains challenging
  • Bone biopsy with culture remains the gold standard for diagnosis but is not always obtainable
  • What clinical features, therefore, raise the likelihood of osteomyelitis?
  • In this review, an ulcer size > 2 cm2 (LR 7.2), ability to probe to bone using a sterile stainless steel probe (LR 6.4), and an ESR > 70 mm/h were found to be useful in predicting the presence of osteomyelitis
  • Clinical features NOT found to be useful included fever (sensitivity 19%), presence of erythema, swelling, or purulence (LR 1), elevated white blood cell count (sensitvity 14%-54%), and superficial swab culture
  • A note about radiographic studies:
    • bony changes on plain films may take up to 2 weeks to develop
    • plain films alone are only marginally useful if positive (LR 2.3)
    • MRI is more accurate than bone scan or plain films
    • If you are going to order a radiographic study, your best bet is the MRI


Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008;299:806-13.