Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Osteomyelitis


Related Terms

  • Bone Infection
  • Central Osteitis
  • Contiguous Inoculation Osteomyelitis
  • Direct Inoculation Osteomyelitis
  • Hematogenous Osteomyelitis
  • Vertebral Osteomyelitis

Differential Diagnosis

Specialists

  • Emergency Medicine Physician
  • Infectious Disease Internist
  • Orthopedic (Orthopaedic) Surgeon

Comorbid Conditions

Factors Influencing Duration

The location of the infection, mechanism of infection, effectiveness of treatment, severity of pain, and availability of home intravenous (IV) therapy, as well as whether the individual has had an amputation, will influence the length of disability. The presence of chronic underlying disease and the development of complications (particularly those requiring surgery) may greatly increase the disability period, perhaps to a permanent status. Osteomyelitis frequently requires lengthy hospitalizations.

Medical Codes

ICD-9-CM:
730.00 - Acute Osteomyelitis, Site Unspecified
730.01 - Acute Osteomyelitis, Shoulder Region
730.02 - Acute Osteomyelitis, Upper Arm
730.03 - Acute Osteomyelitis, Forearm
730.04 - Acute Osteomyelitis, Hand
730.05 - Acute Osteomyelitis, Pelvic Region and Thigh
730.06 - Acute Osteomyelitis, Lower Leg
730.07 - Acute Osteomyelitis, Ankle and Foot
730.08 - Acute Osteomyelitis, Other Specified Site
730.09 - Acute Osteomyelitis, Multiple Sites
730.10 - Chronic Osteomyelitis, Site Unspecified
730.11 - Chronic Osteomyelitis, Shoulder Region
730.12 - Chronic Osteomyelitis, Upper Arm
730.13 - Chronic Osteomyelitis, Forearm
730.14 - Chronic Osteomyelitis, Hand
730.15 - Chronic Osteomyelitis, Pelvic Region and Thigh
730.16 - Chronic Osteomyelitis, Lower Leg
730.17 - Chronic Osteomyelitis, Ankle and Foot
730.18 - Chronic Osteomyelitis, Other Specified Site
730.19 - Chronic Osteomyelitis, Multiple Sites
730.20 - Unspecified Osteomyelitis, Site Unspecified
730.21 - Unspecified Osteomyelitis, Shoulder Region
730.22 - Unspecified Osteomyelitis, Upper Arm
730.23 - Unspecified Osteomyelitis, Forearm
730.24 - Unspecified Osteomyelitis, Hand
730.25 - Unspecified Osteomyelitis, Pelvic Region and Thigh
730.26 - Unspecified Osteomyelitis, Lower Leg
730.27 - Unspecified Osteomyelitis, Ankle and Foot
730.28 - Unspecified Osteomyelitis, Other Specified Site
730.29 - Unspecified Osteomyelitis, Multiple Sites

Overview

Osteomyelitis is an acute inflammatory process within bone, bone marrow, and surrounding soft tissue that develops secondary to infection with bacterial organisms (and, rarely, fungi). The disease may be either current, requiring immediate treatment (acute), or long term (chronic); acute cases may become chronic (or recurrent) if treatment is delayed or unsuccessful. Chronic osteomyelitis tends to persist regardless of its initial cause and despite aggressive treatment.

Osteomyelitis is differentiated into two primary categories based on how the infective organisms enter the bone (mechanism of infection). In hematogenous osteomyelitis, bacteria enter directly through the bloodstream.

In direct inoculation or contiguous inoculation osteomyelitis, secondary infection is caused by bacteria coming into contact with bone during surgery or trauma. In individuals with lack of sufficient blood supply (vascular insufficiency), direct-inoculation osteomyelitis may result from bacteria entering through a specific route such as infected nail beds.

The causative bacteria will vary in people of different ages and according to the mechanism of infection. The most common cause of hematogenous osteomyelitis is pus-forming (pyogenic) bacteria, including the tuberculosis bacterium.

In direct-inoculation osteomyelitis, multiple organisms from the site of surgery or trauma may cause secondary local infection in the involved bone. Organisms may be introduced into the bone during surgery, from a compound or open fracture, from a contaminated wound over exposed bone, or from a foreign object penetrating the skin and bone, such as puncture of the foot. Hardware or prosthetic implants may carry infection into a bone where bacteria multiply rapidly, causing it to become a focus of infection. Because the metal is not affected by circulating blood, antibiotics may not have any effect on that type of infection.

Infection may also spread from a soft tissue injury caused by trauma, pressure ulcers, or burns. The bone itself is not initially injured, but the infection spreads through the layers of soft tissue into the bone. This type of osteomyelitis is more common in the elderly.

Bones may also become predisposed to infection in individuals with peripheral vascular disease, which is characterized by formation of blood clots that may block the blood supply to a given area. Other diseases and conditions may also predispose individuals to secondary bone infection, including diabetes, sickle cell anemia, AIDS, intravenous drug abuse, alcoholism, chronic use of steroids, immunosuppression, and chronic joint disease. Individuals on hemodialysis and those who have had orthopedic surgery or open fracture or who have a prosthetic orthopedic device are also more susceptible to developing osteomyelitis.

In acute osteomyelitis, bacteria lodge in bones, where circulation is sluggish. The bacteria then multiply, resulting in secondary infection, abscess formation, and eventual bone destruction. Because the abscess deprives the bone of its blood supply, the bone will die (necrosis). As the disease progresses, areas of healthy bone may become isolated by the infection and areas of necrotic bone. Chronic osteomyelitis may develop when these necrotic areas of bone form islands or segments (sequestra) that remain infected, becoming a source of recurrent infection and, often, draining wounds (sinus tracts). The infection can also spread to other areas of the body. This pattern of recurring infection results in failure of the bone to heal. When some areas of the bone die, circulation throughout the bone stops, maintaining the cycle of infection and bone destruction.

The osteomyelitis that develops from direct inoculation with vascular insufficiency is most common in diabetics and occurs in adults over age 45 (King).

The target bones in osteomyelitis are primarily the spine and pelvis; children most often have their long bones affected.

Incidence and Prevalence: The incidence of osteomyelitis in the US is under 2% a year (Paluska). Incidence increases with every decade of life. Acute hematogenous osteomyelitis is most commonly seen in children, with 85% of affected individuals usually under the age of 1; the prevalence among children is 1 in 5,000 (King). Among individuals who have been treated for an episode of acute osteomyelitis, the prevalence of chronic osteomyelitis is about 5% to 25% in the US (Khan). Prevalence can be as high as 30% to 40% in individuals with diabetes and 16% after foot puncture (King).

In developing countries, the overall incidence is higher (King).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Osteomyelitis can affect individuals of all ages and all races. The risk of developing osteomyelitis is higher in individuals with diabetes, sickle cell disease, AIDS, immunosuppression, and chronic joint disease. Alcoholism, chronic use of steroids, and the use of intravenous drugs are also risk factors. Orthopedic surgery, open fracture, or the presence of a prosthetic orthopedic device increase risk. Men are twice as likely as women to develop osteomyelitis (King).

Source: Medical Disability Advisor



Diagnosis

History: In individuals with acute osteomyelitis, the main complaint is pain in the bone or bone tenderness, localized swelling and warmth, and perhaps redness of the area. The individual may avoid using or have a reduced ability to use the affected body part. In acute cases, individuals may report a generalized feeling of illness (malaise), loss of appetite, fatigue, nausea, irritability, and fever. There may be a history of recent trauma, surgery, or infection of another organ (i.e., lungs, bladder). Individuals with chronic osteomyelitis will have a history of an acute episode (if it was recognized initially), and often have a recurrence of pus draining out through the skin, pain, and swelling. They may also have generalized complaints of fever, loss of appetite, and fatigue. Additional symptoms may include excessive sweating (diaphoresis), chills, and low back pain. These individuals may have an underlying immune system disease or peripheral vascular disease. Individuals must be questioned about IV drug abuse and alcoholism. A complete health history is obtained, including all current and prior illnesses and injuries.

Physical exam: An examination will reveal local pain and tenderness. Redness over the area (erythema), swelling (edema), draining wounds, draining sinuses, or chronic skin ulcers may also be evident. Fever, signs of dehydration, or other signs of blood infection (sepsis) may be evident. Range of motion of joints may be reduced. Generally, direct inoculation osteomyelitis presents more local signs, whereas hematogenous osteomyelitis presents more generalized signs and symptoms that tend to progress slowly.

Tests: Blood tests include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and a test for C-reactive protein. Samples of blood and wound drainage (or samples taken directly from the infected bone or sinus tract) may be cultured to identify the causative organism and determine antibiotic (or antifungal) sensitivities, although causative bacteria are identified in only about 35% to 40% of cases (King). Other possible tests include needle aspiration (lumbar puncture) within the vertebral space for culture, tuberculin skin test, open bone biopsy, bone culture, Doppler studies in cases of peripheral vascular disease, plain x-rays, ultrasound (in soft tissue abnormalities), gallium bone scan, CT scan, and MRI. Specialized tests may be ordered to evaluate the individual for the presence of a primary underlying illness or monitor ongoing treatment for a known chronic illness.

Source: Medical Disability Advisor



Treatment

The treatment goal is to eliminate the infection and prevent the development of a chronic infection. Because early treatment is critical, high-dose antibiotic intravenous (IV) therapy is usually started immediately, before test results are known. Antibiotics can be changed later, depending upon results of cultures. Hospitalization is necessary, at least during the early stages of treatment. The IV antibiotics continue for 4 to 6 weeks and may be followed with oral treatment for several months (the usual treatment duration for acute osteomyelitis is about 6 weeks, but the duration is longer for chronic and vertebral osteomyelitis). Analgesics are prescribed as needed. Wound care, if applicable, may include removal of dying or dead tissue (débridement) and frequent dressing changes. Bed rest and immobilization of the infected body part are essential. If improvement is not evident after 24 hours of antibiotic treatment, surgery may be done to relieve pressure in the bone (surgical decompression) by drilling into the bone and removing pus. Open spaces left by the removed bone will be filled with bone graft, or left with packing material in to promote regrowth of new bone tissue. If a prosthetic implant or hardware is suspected as the cause, the device may be removed; the infection should be eradicated before a replacement device is inserted. In cases in which there is reduced oxygen tension or vascular supplies, hyperbaric oxygen therapy may be used, but it is not recommended for routine use. In vertebral osteomyelitis, if the infection persists, it might be necessary to perform surgery, such as vertebral fusion.

Chronic osteomyelitis will require surgical removal of the sequestra (sequestrectomy) and surrounding tissue, followed by antibiotic therapy. In severe cases, amputation may be necessary. Dehydration, protein deficiency, and anemia caused by draining wounds require nutritional supplementation. Education is very important to ensure compliance with long-term therapy. Home care services are necessary when patients require IV medication administration and wound care after discharge from the hospital.

Source: Medical Disability Advisor



Prognosis

Acute episodes have a good prognosis with timely diagnosis and aggressive antibiotic treatment. Chronic cases often have a poor outcome, especially when chronic underlying illness (e.g., diabetes, peripheral vascular disease, sickle cell disease, or chronic bone disease) is present. In vertebral osteomyelitis, approximately 10% to 15% develop neurological deficits (King). Mortality rates associated with osteomyelitis are generally low unless serious or chronic concomitant illness is present.

Source: Medical Disability Advisor



Rehabilitation

The type of rehabilitation for osteomyelitis depends on the location of the infected bone and the underlying cause of infection. For rehabilitation purposes, osteomyelitis is subdivided into five types. Depending on the type of osteomyelitis (ranging from type I to type V, according to the degree of tibia and fibula involvement and the bone’s ability to withstand functional loads), the rehabilitation time required varies. For type I osteomyelitis (in which both tibia and fibula are intact and can withstand functional loads), the rehabilitation time is from 6 to 12 weeks. In type II osteomyelitis (in which the tibia is intact, but a bone graft is needed), the rehabilitation time required is from 3 to 6 months. For type III osteomyelitis (in which the fibula is intact, but there is a tibial defect of no more than 6 cm), 6 to 12 months of rehabilitation are needed. In type IV osteomyelitis (in which the fibula is intact, but there is a tibial defect of more than 6 cm), 12 to 18 months of rehabilitation are required. Finally, for type V osteomyelitis (in which there is no usable intact fibula, and there is a tibial defect of more than 6 cm), 18 months or longer are required for rehabilitation.

In general, rehabilitation is aimed at restoring normal range of motion, flexibility, strength, and endurance. The goal of rehabilitation for progressive osteomyelitis is to maintain function and enhance mobility.

Active range of motion physical therapy initially helps maintain flexibility and strength and relieves the musculoskeletal pain associated with muscular weakness, paralysis, and immobility. As the therapy progresses, passive range of motion exercises are preferable to avoid overexertion or possible damage to the muscles. In the event of muscle weakness to the legs, balance exercises may be utilized.

As strength continues to progress, endurance becomes a focus in the individual's rehabilitation program for osteomyelitis. Aerobic exercises that increase cardiovascular fitness are recommended. The American Heart Association recommends 30 to 60 minutes of aerobic activity 3 or 4 times a week.

Learning how to avoid injury is another important intervention in the rehabilitation of progressive osteomyelitis. Occupational therapy helps individuals arrange their homes and organize their lives in ways that support their physical and mental well-being. Activities are also provided to relieve the mental boredom of inactivity. Devices and techniques that help the individual communicate are invaluable in maintaining peace of mind. The rehabilitation program varies among individuals with progressive osteomyelitis as the intensity and progression of the exercise depends on the stage of the disease and individual's overall health.

Source: Medical Disability Advisor



Complications

An acute condition may become chronic. Soft tissue abscess formation, soft tissue cellulitis, bone abscess, septic arthritis, a prosthetic implant coming loose, the spread of a localized infection, chronic drainage (development of draining soft-tissue sinus tracts), toxic shock syndrome, joint contracture, and amputation can all result from acute or chronic osteomyelitis. Bone resorption can weaken bone and lead to fractures. Osteomyelitis of the spine can be complicated by paraplegia or inflammation of the membranes that surround the spinal cord and brain (meningitis). Untreated or inadequately treated osteomyelitis can lead to blood poisoning (septicemia), which can be fatal. Deep venous thrombosis (DVT) may occur in up to 30% of children with long-bone osteomyelitis, sometimes indicating disseminated infection (King).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals may be able to receive intravenous (IV) therapy at work if a clean space that permits privacy, equipment to handle infusion, and refrigeration of medication can be made available. A home health nurse may be brought to the workplace to assist in this treatment plan. The individual may require frequent breaks to rest and eat. Depending on the affected bone and whether the individual had an amputation, restrictions on weight lifting may be necessary. Other restrictions and accommodations relate to the specific body part involved.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis of osteomyelitis been confirmed?
  • What was the mechanism of infection?
  • Was the causative organism identified?
  • Were antibiotic (or antifungal) sensitivities determined?
  • Does individual have an underlying condition (e.g., disorders associated with a disabled immune system [organ transplantation, AIDS, cancer], diabetes, obesity, general debility, suboptimal nutrition, sleep dysfunction or apnea, tuberculosis, cardiovascular disease) that may affect recovery?

Regarding treatment:

  • Was treatment with broad-spectrum antibiotics initiated immediately once osteomyelitis was suspected?
  • Have antibiotic-resistant organisms been ruled out?
  • Did the initial therapy consist of oral or IV antibiotics?
  • Was antibiotic therapy discontinued before 4 to 6 weeks of treatment were completed?
  • Was surgical decompression required?
  • Is the osteomyelitis associated with some type of fixation device (screw, plate, prosthesis)? Has the device been removed?
  • Have home care services been employed to provide necessary intravenous medication administration and wound care?
  • Has individual received the education and support services necessary to ensure compliance with long-term therapy?

Regarding prognosis:

  • Did osteomyelitis result from a bone fracture? Has permanent bone damage occurred?
  • If the osteomyelitis is associated with some type of fixation device (screw, plate, prosthesis) and the device has been removed, how does that affect function?
  • Is the osteomyelitis considered chronic?
  • Has individual experienced complications related to the osteomyelitis?
  • Did the individual need an amputation? Is so, how did that affect overall function?
  • If the individual smoked or abused alcohol or IV drugs, was the individual instructed to stop these habits, and was the individual able to comply?
  • Is an underlying chronic illness being treated effectively?

Source: Medical Disability Advisor



References

Cited

Khan, Ali Nawaz, and Sumaira Macdonald. "Osteomyelitis, Chronic." eMedicine. Eds. Amilcare Gentili, et al. 10 Feb. 2009. Medscape. 28 Mar. 2009 <http://emedicine.medscape.com/article/393345-overview>.

King, Randall W., and D. L. Johnson. "Osteomyelitis." eMedicine. Eds. Dana A. Stearns, et al. 4 Nov. 2008. Medscape. 22 Nov. 2008 <http://emedicine.medscape.com/article/785020-overview>.

Paluska, Scott A. "Osteomyelitis." Clinics in Family Practice 6 1 (2004): MD Consult. Elsevier, Inc. 22 Nov. 2008 <http://home.mdconsult.com/das/journal/view/41461313-4/N/14529305?ja=407851&PAGE=1.html&sid=305356744&source=>.

Source: Medical Disability Advisor






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