Osteomyelitis: The Daily PANCE Blueprint
A 62-year-old man with a history of diabetes mellitus presents to the clinic with worsening pain in his left foot for the past 3 weeks. He has a chronic ulcer on the plantar surface of the foot that now appears to probe to the bone. He denies fever or chills. Laboratory tests reveal elevated erythrocyte sedimentation rate and C-reactive protein. White blood cell count is within normal limits. Plain radiographs of the foot are inconclusive. What is the most appropriate next step in the management of this patient?
A. Start empiric antibiotics immediately
B. Obtain blood cultures and start empiric antibiotics
C. Proceed to magnetic resonance imaging (MRI) of the foot
D. Perform bone biopsy for culture and histology
E. Refer the patient for surgical debridement
Answer and topic summary
The answer is C. Proceed to magnetic resonance imaging (MRI) of the foot
In patients with suspected osteomyelitis and less than 2 weeks of symptoms or inconclusive plain radiographs, advanced imaging modalities like MRI are recommended. This is especially true for patients with diabetes, localized symptoms, and abnormal laboratory results. MRI is highly sensitive and specific for osteomyelitis and can help guide further diagnostic and therapeutic steps, such as bone biopsy or surgical debridement.
Incorrect Answer Explanations:
- A. Start empiric antibiotics immediately: Starting antibiotics without a confirmed diagnosis can make it difficult to later establish the diagnosis of osteomyelitis through culture.
- B. Obtain blood cultures and start empiric antibiotics: Blood cultures are generally not useful in cases of nonhematogenous osteomyelitis, which is more likely in this patient given his diabetic foot ulcer.
- D. Perform bone biopsy for culture and histology: While bone biopsy is the gold standard for diagnosing osteomyelitis, it is generally performed after imaging studies have suggested the presence of osteomyelitis.
- E. Refer the patient for surgical debridement: Surgical debridement is a therapeutic option but should be based on confirmatory diagnostic tests like MRI and bone biopsy.
View blueprint lesson
Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Musculoskeletal ⇒ ⇒
