Osteomyelitis in Emergency Medicine Clinical Presentation

  • Author: Randall W King, MD, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jul 27, 2011
 

History

Hematogenous osteomyelitis usually presents with a slow insidious progression of symptoms. Direct osteomyelitis generally is more localized, with prominent signs and symptoms. General symptoms of osteomyelitis include the following:

  • Hematogenous long-bone osteomyelitis
    • Abrupt onset of high fever (fever is present in only 50% of neonates with osteomyelitis)
    • Fatigue
    • Irritability
    • Malaise
    • Restriction of movement (pseudoparalysis of limb in neonates)
    • Local edema, erythema, and tenderness
  • Hematogenous vertebral osteomyelitis
    • Insidious onset
    • History of an acute bacteremic episode
    • May be associated with contiguous vascular insufficiency
    • Local edema, erythema, and tenderness
    • Failure of a young child to sit up normally[6]
  • Chronic osteomyelitis
    • Nonhealing ulcer
    • Sinus tract drainage
    • Chronic fatigue
    • Malaise
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Physical

Findings at physical examination may include the following:

  • Fever (present in only 50% of neonates)
  • Edema
  • Warmth
  • Fluctuance
  • Tenderness to palpation
  • Reduction in the use of the extremity (eg, reluctance to ambulate, if the lower extremity is involved or pseudoparalysis of limb in neonates)
  • Failure of a young child to sit up normally
  • Sinus tract drainage (usually a late finding or one that occurs with chronic infection)
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Causes

Note that responsible pathogens may be isolated in only 35-40% of infections. Bacterial causes of acute and direct osteomyelitis include the following:

  • Acute hematogenous osteomyelitis (Note increasing reports of other pathogens in bone and joint infections including community-associated methicillin-resistant Staphylococcus aureus [MRSA],[7]Kingella kingae,[8] and others.)
    • Newborns (younger than 4 mo): Saureus, Enterobacter species, and group A and B Streptococcus species
    • Children (aged 4 mo to 4 y): S aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species
    • Children, adolescents (aged 4 y to adult): S aureus (80%), group A Streptococcus species, H influenzae, and Enterobacter species
    • Adult - S aureus and occasionally Enterobacter or Streptococcus species
  • Direct osteomyelitis
    • General - S aureus, Enterobacter species, and Pseudomonas species
    • Puncture wound through an athletic shoe - S aureus and Pseudomonas species
    • Sickle cell disease -S aureus and Salmonellae species

Also see Medscape's Infectious Diseases Resource Center.

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Contributor Information and Disclosures
Author

Randall W King, MD, FACEP  Assistant Clinical Professor of Emergency Medicine, The University of Toledo College of Medicine; Director, Emergency Medicine Residency Program, Associate Chair, Department of Emergency Medicine, St Vincent Mercy Medical Center

Randall W King, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Ohio State Medical Association, and Society for Academic Emergency Medicine

Disclosure: Challenger corporation None Physician Advisory Board; Ohio ACEP Consulting fee Editor Rivers review text Emergency Medicine

Coauthor(s)

David Johnson, MD  Assistant Clinical Professor, Department of Surgery, University of Toledo College of Medicine; Chairman, Department of Emergency Services, St Vincent's Mercy Medical Center, Toledo

Disclosure: Nothing to disclose.

Specialty Editor Board

Dana A Stearns, MD  Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital

Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eric L Weiss, MD, DTM&H  Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Progressor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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Osteomyelitis of the elbow. Photography by David Effron MD, FACEP.
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.
Osteomyelitis of index finger metacarpal head secondary to clenched fist injury. Photography by David Effron MD, FACEP.
Osteomyelitis of the great toe. Photography by David Effron MD, FACEP.
Osteomyelitis of T10 secondary to streptococcal disease. Photography by David Effron MD, FACEP.
Osteomyelitis of diabetic foot. Photography by David Effron MD, FACEP.
Osteomyelitis. Radiography of diabetic foot showing osteomyelitis with gas. Photography by David Effron MD, FACEP.
 
 
 
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