The Daily Differential — Tuesday, May 5, 2026

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Osteomyelitis

Osteomyelitis is a high-morbidity infection where delayed diagnosis can lead to sepsis, chronic infection, amputation, or neurologic compromise. ED...

At the Bedside

Major pathways
Hematogenous spread: more common in children; in adults often vertebral osteomyelitis.
Contiguous spread: diabetic foot ulcers, pressure wounds, trauma, open fractures, hardware.
Vascular insufficiency: diabetic foot, peripheral arterial disease.
Key history
Diabetes, dialysis, IV drug use, immunosuppression, sickle cell disease, recent bacteremia, indwelling lines, prosthetic joints/hardware.
Local pain, swelling, nonhealing ulcer, drainage, fever; vertebral disease may present as persistent focal back pain with fever or risk factors.
Exam
Inspect ulcers: size, depth, drainage, exposed bone.
Probe-to-bone test in diabetic foot ulcers: positive test increases likelihood of osteomyelitis.
Check perfusion: pulses, cap refill, ABI if vascular disease suspected.
Full neuro exam for vertebral osteomyelitis/epidural abscess concern.
Diagnostics
CBC may be normal.
ESR/CRP: useful screening and trending; elevated values support diagnosis, especially diabetic foot or vertebral disease.
Blood cultures x2 before antibiotics if febrile, septic, vertebral osteomyelitis, or hematogenous concern.
Wound swabs are less useful; deep tissue/bone cultures are preferred when available.
Plain X-ray: first-line for diabetic foot/contiguous infection; may show cortical destruction, periosteal elevation, gas, foreign body, but early films can be normal.
MRI with contrast is best imaging for early osteomyelitis and vertebral disease; MRI also evaluates abscess and epidural extension.
CT if MRI unavailable/contraindicated; better for cortical bone but less sensitive early.
Management
If septic, unstable, necrotizing infection, or neurologic deficit: start broad-spectrum antibiotics immediately after blood cultures if feasible—do not delay.
If stable and definitive bone biopsy/culture is planned, discuss with admitting/ID/orthopedics before antibiotics because pre-treatment can reduce culture yield.
Diabetic foot: assess for necrotizing infection, abscess, ischemia, compartment issues; surgical consult for deep infection, gangrene, gas, abscess, exposed bone, or severe infection.
Vertebral osteomyelitis: evaluate for epidural abscess; urgent MRI and neurosurgery/spine consult if neurologic signs or bladder/bowel dysfunction.
Disposition
Admit most suspected osteomyelitis patients needing IV antibiotics, MRI, surgery, sepsis care, vascular evaluation, or inability to ambulate/follow up.
Carefully selected stable patients with mild chronic disease and close follow-up may be managed outpatient only after specialist plan.

A Classic Presentation

A 62-year-old man with poorly controlled diabetes presents with a chronic plantar ulcer and worsening foot pain. Exam shows a 3-cm ulcer under the first metatarsal head with purulent drainage and bone palpable with a sterile probe. ESR and CRP are elevated; X-ray shows cortical erosion of the metatarsal. Blood cultures are obtained, vancomycin plus piperacillin-tazobactam is started because he has systemic symptoms and severe infection, and he is admitted with podiatry/orthopedic consultation.

Study Directive

Make a one-page algorithm for diabetic foot infection: classify severity, probe-to-bone, X-ray, ESR/CRP, MRI, antibiotics, surgical consult.
Memorize common empiric severe osteomyelitis regimen: vancomycin + cefepime or pip-tazo, adjusted to source and renal function.
Review MRI findings of osteomyelitis and epidural abscess.
Practice disposition decisions with 5 cases: stable chronic ulcer, septic diabetic foot, vertebral back pain with fever, hardware infection, IV drug use with back pain.

Key Medications

Empiric regimens depend on source, MRSA risk, gram-negative risk, and local antibiogram.
Vancomycin: 15–20 mg/kg IV loading/initial dose, then pharmacy-guided AUC/trough dosing. Use actual body weight; adjust for renal function.
Cefepime: 2 g IV q8–12h, adjust for renal function.
Piperacillin-tazobactam: 4.5 g IV q6h or extended infusion per protocol; adjust for renal function.
Ceftriaxone: 2 g IV q24h for selected vertebral/hematogenous coverage when Pseudomonas risk is low.
Metronidazole: 500 mg IV/PO q8h when anaerobic coverage needed and not using pip-tazo/carbapenem.
Common ED empiric examples:
- Severe diabetic foot/contiguous infection: vancomycin + piperacillin-tazobactam.
- MRSA + Pseudomonas risk: vancomycin + cefepime, add metronidazole if anaerobic coverage needed.
- Vertebral osteomyelitis with sepsis/neuro concern: vancomycin + cefepime often reasonable; tailor to local protocol.
Pediatrics: Pathogens and dosing differ significantly; hematogenous osteomyelitis often S. aureus. Use pediatric weight-based references.

High-Yield Pearls

Bone destruction on X-ray is a late finding; early osteomyelitis can have normal radiographs.
In stable patients, bone culture before antibiotics improves microbiologic yield—but sepsis, necrotizing infection, or neurologic compromise mandates immediate antibiotics.
Vertebral osteomyelitis plus neurologic deficit is an epidural abscess until proven otherwise.

Board Question

Which imaging test is most sensitive for early osteomyelitis in a diabetic foot ulcer when plain radiographs are nondiagnostic?

AMRI
BRepeat plain radiograph in 24 hours
CNoncontrast head CT
DBone scan only after antibiotics are completed

Reveal answer

Correct: A

MRI is the preferred imaging test for early osteomyelitis and for defining soft tissue abscess or extent of infection. Plain radiographs are useful initially but can be normal early.

Recent Literature

Review or guideline Clinical Practice Guideline by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America: 2021 Guideline on Diagnosis and Management of Acute Hematogenous Osteomyelitis in Pediatrics
J Pediatric Infect Dis Soc, 2021 · cited 262×
Recent clinical Synergistic sonodynamic and ion-interference therapy effectively treats osteomyelitis and promotes neural and osteogenic regeneration
Biomaterials, 2026 · cited 1×

3 of 4

Spinal Cord Injuries

Spinal cord injury can cause permanent paralysis, respiratory failure, and shock physiology. ED care focuses on preventing secondary cord injury through...

At the Bedside

Initial approach
ATLS primary survey with spinal motion restriction.
Maintain cervical immobilization in trauma until cleared clinically or radiographically.
Avoid hypotension and hypoxia—both worsen secondary spinal cord injury.
Check glucose if altered; assess for associated head, chest, abdominal, and pelvic trauma.
Neuro exam
Motor strength by myotomes, sensation by dermatomes, reflexes.
Assess rectal tone, perianal sensation, bulbocavernosus reflex when indicated.
Document neurologic level and whether deficits are complete or incomplete.
Look for:
Neurogenic shock: hypotension + bradycardia from loss of sympathetic tone, typically cervical/high thoracic injury.
Spinal shock: transient areflexia/flaccidity below lesion after acute cord injury.
Priapism may suggest severe cord injury.
Syndromes
Central cord: upper extremity weakness > lower; often hyperextension in older patient with cervical stenosis.
Anterior cord: motor loss + pain/temp loss; preserved dorsal column function.
Brown-Séquard: ipsilateral motor/vibration/proprioception loss + contralateral pain/temp loss.
Posterior cord: loss of vibration/proprioception; rare.
Conus medullaris/cauda equina: saddle anesthesia, bladder/bowel dysfunction; cauda often LMN findings.
Imaging
CT cervical spine for most adult blunt trauma patients requiring imaging.
Image entire spine if high-energy mechanism, multiple injuries, altered, distracting injury, or one spinal fracture found.
MRI if neurologic deficit, suspected ligamentous injury, spinal cord compression, epidural hematoma, or persistent symptoms with negative CT.
Resuscitation
Airway: high cervical injuries can impair diaphragm/intercostals; prepare for early intubation if declining respiratory mechanics.
Breathing: monitor FVC/NIF if feasible in cervical injury.
Circulation: fluids initially if hypovolemic possible, but neurogenic shock often needs vasopressors.
Target MAP commonly 85–90 mmHg in acute traumatic SCI per many spine protocols; duration often ICU-driven. In ED, avoid even brief hypotension.
Definitive management
Emergent spine/neurosurgery consult for neurologic deficits, unstable fracture, cord compression, epidural hematoma, penetrating injury with deficit, or progressive symptoms.
High-dose methylprednisolone is not routine standard ED care; controversial and generally not recommended by many current protocols because benefit is limited and complications exist. Use only if institutional spine protocol specifically directs it.
Transfer to trauma/spine center if needed.
Disposition
ICU/trauma admission for confirmed SCI, neurogenic shock, respiratory compromise, unstable injury, or MAP augmentation.
Spine service admission/observation for concerning neuro symptoms even with initially negative CT if MRI needed.

A Classic Presentation

A 24-year-old man dives into shallow water and arrives awake with neck pain, weak grip bilaterally, and inability to move his legs. BP is 82/45 with HR 48. CT shows cervical fracture-dislocation. He is kept immobilized, oxygenated, given cautious fluids, started on norepinephrine for suspected neurogenic shock with MAP augmentation, and spine surgery is consulted emergently for decompression/stabilization.

Study Directive

Draw and memorize the 4 classic incomplete cord syndromes with motor/sensory findings.
Practice documenting a focused spinal neuro exam: myotomes, dermatomes, rectal/perianal findings, reflexes, and level.
Review neurogenic shock management and write a MAP augmentation order set from memory.
Run one airway simulation for high cervical SCI emphasizing in-line stabilization and hypotension prevention.

Key Medications

Norepinephrine: start 0.05–0.1 mcg/kg/min IV, titrate to MAP goal. Preferred in many neurogenic shock cases.
Phenylephrine: 0.1–1 mcg/kg/min IV titrated; may worsen reflex bradycardia, so less ideal if bradycardic.
Atropine for symptomatic bradycardia: 1 mg IV q3–5 min, max 3 mg.
Fentanyl analgesia: 25–100 mcg IV q5–10 min titrated; monitor ventilation/BP.
Hydromorphone: 0.2–1 mg IV titrated carefully.
Ketamine analgesia: 0.1–0.3 mg/kg IV sub-dissociative; dissociative dose 1–2 mg/kg IV if needed for RSI/sedation context.
RSI induction considerations: avoid hypotension; etomidate 0.3 mg/kg IV or ketamine 1–2 mg/kg IV commonly used. Paralytic choice depends on timing and contraindications.
Methylprednisolone: If used by protocol, dosing is complex and time-dependent; check institutional/spine protocol. Not routine.

High-Yield Pearls

Neurogenic shock = hypotension + bradycardia; spinal shock = temporary areflexia/flaccidity below the lesion.
The ED treatment of SCI is prevention of secondary injury: oxygenation, immobilization, normocapnia, and aggressive avoidance of hypotension.
Central cord syndrome often affects arms more than legs due to cervical cord somatotopy and is classically seen after hyperextension in older patients with stenosis.

Board Question

A trauma patient with suspected high cervical spinal cord injury is hypotensive and bradycardic with warm extremities. After excluding hemorrhage as best as possible, what is the most appropriate vasopressor?

ANorepinephrine
BNitroglycerin
CFurosemide
DAdenosine

Reveal answer

Correct: A

Neurogenic shock results from loss of sympathetic tone, causing vasodilation and bradycardia. Norepinephrine provides alpha vasoconstriction and some beta support to maintain spinal cord perfusion.

Recent Literature

Review or guideline Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury
J Neurol Phys Ther, 2020 · cited 373×
Recent clinical Cuproptosis in spinal cord injury: emerging mechanisms and immunological relevance
Ann Med, 2026

Full text · open access

4 of 4

Spinal Fractures

Spinal fractures range from stable compression injuries to unstable fracture-dislocations with devastating neurologic risk. ED clinicians must identify who...

At the Bedside

Initial approach
ATLS primary survey; maintain spinal motion restriction when indicated.
Assume multisystem trauma in high-energy mechanisms.
Treat hypotension as hemorrhage until proven otherwise; neurogenic shock is a diagnosis after considering bleeding.
Who needs imaging
Use validated rules for alert blunt trauma patients:
NEXUS C-spine: no midline tenderness, no intoxication, normal alertness, no focal neuro deficit, no distracting injury.
Canadian C-spine Rule: age ≥65, dangerous mechanism, paresthesias, inability to rotate neck, etc.
Thoracolumbar imaging for midline pain/tenderness, neuro deficit, high-energy mechanism, altered/intoxicated patient, distracting injuries, or known cervical fracture.
Exam
Midline tenderness, step-off, deformity.
Complete motor/sensory/reflex exam.
Check perineal sensation/rectal tone if neurologic complaints, bowel/bladder symptoms, or suspected cord/cauda injury.
Evaluate for abdominal injury with Chance fracture mechanism; lap-belt injuries are associated with bowel/mesenteric trauma.
Imaging
CT is the primary ED imaging modality for adult traumatic spinal fractures.
Plain films have limited sensitivity, especially cervical spine.
MRI for neurologic deficit, suspected ligamentous injury, epidural hematoma, cord compression, or persistent severe pain with negative CT when concern remains.
If one spinal fracture is found, consider imaging the rest of the spine due to noncontiguous fractures.
Important fracture patterns
Compression fracture: anterior column failure; often osteoporotic, may be stable if isolated.
Burst fracture: axial load with vertebral body retropulsion; risk of canal compromise.
Chance fracture: flexion-distraction injury; unstable; associated intra-abdominal injury.
Fracture-dislocation: highly unstable, high cord injury risk.
Odontoid fracture: C2 dens; type II has high nonunion risk.
Hangman fracture: traumatic spondylolisthesis of C2, often hyperextension.
Clay-shoveler fracture: spinous process avulsion; usually stable.
Management
Maintain immobilization until injury characterized and spine recommendations obtained.
Analgesia, antiemetics, careful logrolls.
Spine/neurosurgery consult for unstable patterns, cervical fractures, burst fractures with retropulsion, neurologic deficit, ligamentous injury, pathologic fractures, or uncertain stability.
Open fractures/penetrating trauma: antibiotics/tetanus as indicated; avoid blind probing.
Osteoporotic compression fracture: pain control, assess neurologic status, consider brace, outpatient spine follow-up if stable and ambulatory; admit if uncontrolled pain, neuro deficit, unsafe discharge, malignancy/infection concern.
Disposition
Discharge may be reasonable for stable compression fractures or isolated stable transverse/spinous process fractures with good pain control, no neuro deficit, and clear follow-up.
Admit/transfer for unstable fracture, neuro deficit, need for MRI, operative management, polytrauma, elderly unable to mobilize, or inadequate outpatient support.

A Classic Presentation

A 35-year-old restrained driver in a high-speed MVC presents with severe thoracolumbar pain and a lap-belt sign. CT shows a horizontal fracture through the L2 vertebral body and posterior elements consistent with a Chance fracture. He remains neurologically intact, but because the injury is unstable and associated with intra-abdominal injury, he receives spine precautions, CT abdomen/pelvis evaluation, aggressive analgesia, and spine/trauma admission.

Study Directive

Create flashcards for compression, burst, Chance, odontoid, hangman, and fracture-dislocation patterns.
Practice applying NEXUS and Canadian C-spine Rule to 10 sample trauma cases.
Review CT images of common cervical and thoracolumbar fractures.
Build a disposition checklist: stability, neuro exam, pain control, MRI need, spine consult, associated injuries, safe ambulation.

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Mechanism Pearl of the Day: Whether the insult is opioid-induced hypoventilation, vertebral infection, cord compression, or traumatic fracture, neurologic outcome depends heavily on oxygen delivery and perfusion under pressure-sensitive anatomy. The ED move is to rapidly reverse systemic threats—hypoxia, hypotension, sepsis—while preventing local secondary injury from compression, instability, or delayed source control.

Key Medications

Acetaminophen: 1,000 mg PO/IV q6–8h, max usually 3,000–4,000 mg/day depending on liver risk/institution.
Ibuprofen: 400–600 mg PO q6h; avoid/limit in renal disease, GI bleed risk, anticoagulation, certain fractures per surgical preference.
Ketorolac: 15 mg IV/IM q6h PRN commonly used; max daily and duration vary by age/renal function—check protocol.
Fentanyl: 25–100 mcg IV q5–10 min titrated for severe acute pain.
Morphine: 4 mg IV, repeat/titrate every 10–15 min as needed.
Hydromorphone: 0.2–1 mg IV titrated carefully.
Ketamine analgesia: 0.1–0.3 mg/kg IV sub-dissociative.
Ondansetron: 4 mg IV/ODT for nausea.
Tetanus
- Tdap/Td 0.5 mL IM if indicated.
- Tetanus immune globulin 250 units IM for dirty wounds with incomplete/unknown immunization.

High-Yield Pearls

CT is far more sensitive than plain radiographs for adult traumatic spinal fractures.
A single spinal fracture increases risk of noncontiguous fractures—consider imaging the entire spine in high-energy trauma.
Neurologic deficit with a spinal fracture requires urgent MRI/spine consultation to evaluate cord compression, ligamentous injury, or epidural hematoma.

Board Question

A patient has a flexion-distraction injury through the vertebral body and posterior elements after a lap-belt MVC. Which associated injury should be specifically considered?

AMesenteric or hollow viscus injury
BIsolated radial head fracture
CSpontaneous pneumothorax only
DAchilles tendon rupture

Reveal answer

Correct: A

Chance fractures are caused by flexion-distraction forces and are classically associated with lap-belt mechanisms. They have significant association with intra-abdominal injuries, especially bowel and mesenteric trauma.

Recent Literature

Review or guideline Vertebral compression fractures: Still an unpredictable aspect of osteoporosis
Turk J Med Sci, 2021 · cited 118×

Full text · open access
Recent clinical Is strict use of denosumab or zoledronate Beneficial to patients with bone metastatic Disease?
J Bone Oncol, 2026

Full text · open access

TheDaily Differential

Opioid Toxicity and Poisoning

At the Bedside

Study Directive

Recent Literature

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