ORTHOPEDICS■ CT, MRI, and radionuclide bone scan are more sensitive than X-ray for
early detection.
TREATMENT
■ Early antibiotics
■ Penicillinase-resistant synthetic penicillin (PRSP) and third-generation
cephalosporin
■ If MRSA is suspected, use vancomycin or clindamycin instead of PRSP.
■ If sickle cell–related, start a fluoroquinolone to cover Salmonella. Do not
use fluoroquinolones in children—use third generation cephalosporin.
■ If puncture through the sole of a shoe, cover Pseudomonaswith cef-
tazidime or ciprofloxacin.
■ Antibiotic bead implants
■ Hyperbaric oxygen
■ Surgical debridement of wound or removal of bone may be necessary
COMPLICATIONS
Sepsis, bone abscess, pathological fracture, nonhealing wound
DISORDERS OF THE SPINELow Back Pain
The causes of low back pain are varied and often impossible to pinpoint in the
emergency department. It is more important to determine if an emergency
existsthat requires neurosurgical intervention or a condition, eg, osteomyelitis
that requires specific treatment. Patients at high risk for a serious cause of back
pain include injection drug users, the elderly, immunocompromised, and those
with a history of cancer or recent trauma.
SYMPTOMS
Symptoms that indicate a potential neurosurgical emergency include:
■ Fever
■ Severe pain, which may be radicular
■ Neurological impairment
■ Bladder or bowel retention or incontinence
EXAM
■ Fever
■ Findings that indicate a neurosurgical emergency, including:
■ Motor weakness
■ Loss of perianal/perineal sensation
■ Loss of deep tendon reflexes
■ Straight leg raise test (SLR):A positive SLR is back pain that radiates past
the knee at an elevation <60°.A positive contralateral SLR is highly spe-
cificfor sciatica.
■ Decreased rectal tone
DIFFERENTIAL
■ Back strain
■ Herniated disc
■ Osteomyelitis
A straight leg raise test is
positive when it elicits back
pain that radiates past the
knee at an elevation <60°. A
positive contralateral
straight leg raise is highly
specificfor sciatica.