Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Sepsis, compression or threatened structure
Bone disease with shock, rapidly progressive neurological deficit, spinal cord compression, impending pathological fracture or a large collection requires immediate multidisciplinary action.
Action: Resuscitate, obtain cultures when safe, involve orthopaedics and the relevant infection or tumour service, and arrange urgent targeted MRI or CT without delaying time-critical treatment.
Synopsis
Differentiate imaging patterns of bone infection and tumour, select tests that map marrow and soft-tissue extent, and escalate sepsis, neurological compression or suspected malignancy without unsafe biopsy.
Start with age, site, symptom duration, fever, cancer history, immune status, surgery or hardware and whether pain is focal, nocturnal or progressive.
Radiographs assess location, pattern of destruction, cortex, periosteal response, matrix, fracture and joint involvement but may be normal early in infection.
MRI is the preferred modality for marrow, abscess, soft-tissue extension, neurovascular relationship and skip lesions; protocol the whole relevant compartment.
Key red flags
Fever, focal bone pain, raised inflammatory markers and inability to bear weight can represent osteomyelitis despite a normal early radiograph.
Progressive night pain, enlarging mass, pathological fracture or an aggressive radiographic lesion requires urgent specialist tumour referral.
In an adult with suspected spinal infection, vertebral destruction with a new neurological deficit, bladder or bowel dysfunction or epidural disease needs emergency MRI and spinal escalation.
Do not biopsy a suspected primary bone tumour outside the specialist sarcoma pathway because the tract can contaminate future surgical compartments.
Acute osteomyelitis
Marrow oedema and enhancement may precede radiographic change; adjacent soft-tissue inflammation, subperiosteal collection and abscess strengthen suspicion but require microbiological correlation.
Aggressive bone lesion
An ill-defined transition zone, permeative destruction, cortical breakthrough, interrupted periosteal reaction or soft-tissue mass requires urgent specialist assessment.
Investigation priorities
01
Plain radiographyFirst step
Characterise lesion location, destruction, cortex, periosteal response, matrix and fracture as the initial structural examination.
Management branches
Infection pathwayMap and sample suspected osteomyelitis
A child has focal bone pain, fever or inflammatory markers raising concern for acute musculoskeletal infection.
Assess sepsis and limb or neurological threat, obtain blood cultures promptly when this does not delay emergency treatment.
Obtain initial radiographs and use MRI to define marrow, joint and soft-tissue extent when available and appropriate.
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.
ACR suspected spine infection criteriaRevised 2021; adult suspected spine infection variants read 13 September 2026. MRI of the area without and with contrast or without contrast is usually appropriate when a new neurological deficit or cauda equina syndrome accompanies suspected epidural abscess, discitis or osteomyelitis; US imaging guidance, not antimicrobial or surgical policy.
NICE NG12 suspected cancer recommendationsLive recommendations updated 2026 read 13 September 2026; symptom-triggered radiography and urgent referral boundaries for bone sarcoma.
UK guidelines for bone sarcomasPeer-reviewed UK professional guideline published 2024; diagnostic imaging, specialist referral, biopsy and staging sections; specialist sarcoma population.