Rosen & Barkin's 5-Minute Emergency Medicine Consult (497 page)

Emergent stabilization if septic or if neurologic deficits from spine involvement

• Empiric antibiotic treatment in ED
  
• Cultures should guide subsequent antibiotic regimen.
  
• Antibiotics: Depend on patient’s age and organism (see Medications section)
  
• Orthopedic and infectious disease consultation
  
• Surgical intervention may be needed to optimize treatment (e.g., infected fracture or hardware, bone necrosis).
  
• Parenteral antibiotic treatment for 4–6 wk
  

• Newborn–4 mo: Penicillinase-resistant synthetic penicillin (e.g., nafcillin: 37 mg/kg IV q6h) plus a 3rd-generation cephalosporin (e.g., ceftriaxone: 50–75 mg/kg/d IV); if suspect methicillin-resistant
  S. aureus
  (MRSA) then vancomycin (40–60 mg/kg IV q6h) plus a 3rd-generation cephalosporin. (Note: Doses are based on age >28 days)
  
• Children (>4 mo): Penicillinase-resistant synthetic penicillin (e.g., nafcillin: 37 mg/kg IV q6h to max. 8–12 g/d). If suspect MRSA, then vancomycin (40–60 mg/kg IV q6h to max. 2–4 g/d). Add 3rd-generation cephalosporin if suspicion for gram-negative rods, or presence on Gram stain noted (e.g., ceftriaxone: 50–75 mg/kg IV per day to max. 2–4 g/d)
  
• Adult: Penicillinase-resistant synthetic penicillin (e.g., nafcillin: 2 g IV q4h); if suspect MRSA, vancomycin (15 mg/kg IV q12h)
  
• Gram-negative (including pseudomonas) chronic OM: Ciprofloxacin 750 mg PO BID or Levofloxacin 750 mg PO QD
  
• Sickle cell anemia with OM: Ciprofloxacin 400 mg IV q12h, or levofloxacin 750 mg IV q24h (
  not
  in children); alternative: 3rd-generation cephalosporin
  
• Post nail puncture through tennis shoe: Ciprofloxacin 750 mg PO BID or Levofloxacin 750 mg PO q24h; alternative: Ceftazidime 2 g IV q8h
  
• Involving orthopedic prosthesis or hardware: Add rifampin (10 mg/kg/d PO/IV to max. of 600 mg/d) to regimen for
  S. aureus
  . Hardware removal generally required.
  
• Post-traumatic OM: Vancomycin and ceftazidime
  
• If vancomycin-resistant enterococcus present: Linezolid 600 mg IV q12h × 6 wk
  

Children with hematogenous OM may undergo short-course IV antibiotics and then be changed to oral for additional 1–2 mo.

FOLLOW-UP

• Patients with acute OM should be admitted.
  
• Patients with chronic OM usually require admission for surgical procedures, débridement, and obtaining bone cultures and histology.
  

Subacute or chronic OM patients may be considered for outpatient management if home IV antibiotics arranged, bone specimens obtained, and necrotic bone débrided.

• Cases refractory to débridement and antibiotics benefit from hyperbaric oxygen as an adjunct to standard treatment.
  
• ∼2/3 of these cases will demonstrate benefit.
  

• WBC may be normal in many cases.
  
• Radiographs may be normal in the 1st 2–3 wk of symptoms.
  
• Wound cultures are low yield in guiding antibiotic therapy.
  

• Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity?
  JAMA
  . 2008;299(7):806–813.
  
• Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis.
  Am Fam Physician.
  2011;84(9):1027–1033.
  
• Lalani T, Sexton D. Overview of osteomyelitis in adults. In: Rose BD, ed.
  UpToDate
  . Waltham, MA: UpToDate, 2013.
  
• Weichert S, Sharland M, Clarke NM, et al. Acute haematogenous osteomyelitis in children: Is there any evidence for how long we should treat?
  Curr Opin Infect Dis
  . 2008;21:258–262.
  
• Winters ME, Kluetz P, Zilberstein J. Back pain emergencies.
  Med Clin North Am
  . 2006;90:505–523.
  

CODES

• 730.00 Acute osteomyelitis, site unspecified
  
• 730.10 Chronic osteomyelitis, site unspecified
  
• 730.20 Unspecified osteomyelitis, site unspecified
  

BASICS

• Overall decrease in skeletal mass, generally diffuse
  
• Trabecular bone (especially vertebrae and femur) affected more commonly and earlier
  
• Disease begins in adolescence, but fractures do not usually manifest until age ≥50
  
• Females affected much more commonly than males, especially after menopause
  

• Overall increase in resorption over formation of new bone
  
• Advanced age is the most important risk factor
  
• Inadequate dietary calcium an important factor, especially early in life
  
• Sedentary lifestyle is a risk factor (weight bearing on bone favors new bone formation)
  
• Decrease in estrogen with menopause key factor in women
  
• Other risk factors include long-term steroid use, alcoholism, methotrexate, tobacco use, low body weight
  
• Familial or hereditary factor may coexist
  

Although disease appears to start in adolescence, pediatric patients are asymptomatic.

DIAGNOSIS

• Usually asymptomatic until pathologic fractures occur
  
• Fractures with insignificant mechanism or recurrent fractures are hallmark
  
• Vertebral column most commonly involved
  
• Multiple compression fractures of vertebral column often lead to kyphosis and scoliosis
  
• Hip fractures (femoral neck and intertrochanteric fractures) also common
  

• A suspected fracture with a relatively minor mechanism or a history of multiple fractures suggests osteoporosis.
  
• A family history of osteoporosis is an important risk factor
  

Exam findings are related to the acute fracture rather than the disease itself.

• Fracture without significant mechanism and identification of risk factors is most important
  
• Careful neurovascular exam distal to femur or other extremity fracture
  
• Rectal tone and postvoid residual should be determined in patients with vertebral fractures
  
• Radiographs of suspected fracture may show osteopenia (late finding in disease)
  
• Spine films may show old compression fractures
  
• CT scan should be performed to better evaluate vertebral fractures:
  
  • Retropulsion, spinal canal compromise is not always apparent on plain films.
    
  • Make sure CT cuts extend full level above and below injuries on spine radiographs.
    

Serum chemistries—such as calcium, parathyroid hormone, and alkaline phosphatase—may help differentiate this from other illnesses.

• Plain films can identify fractures; however, age of each fracture may be difficult to determine
  
• Bone scan or CT can help determine age of fractures, especially in spine
  

Bone densitometry can provide prognostic information and help guide therapy. Dual-energy x-ray absorptiometry with BMD T-score ≤--2.5: Osteoporosis.

• Multiple myeloma or other metastatic tumor
  
• Osteogenesis imperfecta (usually apparent in childhood)
  
• Hyperparathyroidism
  
• Other demineralizing bone diseases
  

TREATMENT

Cautions:

• Obtain pre-hospital information on mechanism to help diagnose pathologic fracture
  
• Avoid aggressive manipulation or movement of patient, as this may exacerbate bony injury
  

Immobilize fractures

• Fractures are treated with expectation of delayed or incomplete healing
  
• Prevention is far more effective than treatment
  
• Long-term therapy is beneficial (see Medication)
  
• Use of orthotic back braces and vests should be arranged in conjunction with orthopedic spine consultation
  
• Exercise is also helpful
  
• Balance must be achieved between osteoporosis risk and steroid or methotrexate therapy