Osteomyelitis — Complete History and Physical Examination — Clinical Pathway: Emergency and Inpatient

Osteomyelitis Clinical Pathway — Emergency Department and Inpatient

Complete History and Physical Examination

Osteomyelitis is an infection of the bone and typically presents with focal pain, often in an extremity, and fever. History and physical are paramount to guide differential, and to determine need for further labs and imaging.

History

Pain
  • Duration
  • Location
  • Referred pain
  • Quality
    • Increasing in severity
    • Awakens patient from sleep
    • Present at rest and with activity
Associated Symptoms
  • Fever
  • Focal erythema
  • Fatigue, poor appetite, irritability
  • Refusal to bear weight/use affected area
  • Recent, concurrent infectious symptoms or upper respiratory infection
    • Joint pain or swelling
Past Medical History
  • Immunocompromised state
    • Sickle cell disease or other hemoglobinopathy
    • Diabetes
    • Immunodeficiencies
    • Immunosuppressive medications
  • Recent antibiotic use
  • Recent immunization
  • Recent surgical intervention
  • History of previous skin infections or MRSA
Risk Factors
  • Recent trauma or wound at or near affected area
    • Timing
    • Mechanism
    • Penetrating
  • Incomplete immunization status
  • Family members with known MRSA positive status

Physical Exam

General
Use caretaker to console patient for better exam
  • Vital signs: fever, hypotension, tachycardia, tachypnea
  • Pulses and cording of vasculature
  • Rash
  • Presence of trauma
Musculoskeletal
  • Presence of joint effusion(s) — These findings are more suggestive of septic arthritis, reference Septic Arthritis Pathway.
  • Swelling, erythema, warmth
  • Tenderness to palpation
  • Micromotion tenderness (inability to tolerate < 10° of motion) — These findings are more suggestive of septic arthritis, reference Septic Arthritis Pathway.
Ambulation or Axial Loading
  • Limp (for hip or leg joint) or preference to remain supine (for vertebral involvement/discitis)
  • Refusal or inability to bear weight
Likely Absence
  • Mass

Citations