Presentation Title

Osteomyelitis

Dr. Abeer Maghawry

Professor of Diagnostic Radiology

Fakeeh collage for medical sciences



Osteomyelitis

Osteomyelitis refers to inflammation of bone and bone marrow that is

almost always due to infection, typically bacterial (pyogenic osteomyelitis)

which may be acute or chronic. Staphylococcus

Non-pyogenic causes of osteomyelitis are: aureus

fungal osteomyelitis

skeletal syphilis

tuberculous osteomyelitis

Epidemiology

Osteomyelitis can occur at any age.

It is particularly common between the ages of 2-12 years and is more common in males (M: F of 3:1) .

Pathology

In most instances, osteomyelitis results from hematogenous spread, although direct extension from
trauma and/or ulcers is relatively common (especially in the feet of diabetic patients).

Staphylococcus aureus is by far the most common pathogen.

In the initial stages of infection, bacteria multiply, triggering a localized inflammatory reaction that

results in localized cell death.

With time, the infection becomes demarcated by a rim of granulation tissue and new bone deposition.
Location
Frequency by location, in descending order :
lower limb (most common)
vertebrae: lumbar > thoracic > cervical
radial styloid
sacroiliac joint
The location of osteomyelitis within a bone varies with age:
Neonates: metaphysis and/or epiphysis
Children: metaphysis
Adults: epiphyses and subchondral regions
Acute infection occurs in less than 2 weeks.
Subacute infection occurs within weeks to months.
Chronic infection occurs after 3 months.
Radiographic features 5 (S)

DSUPPURATIVE FOCUS
SUBPERIOSTEAL ABCESS
SEQUESTRUM (devitalised
bone that separated from
surrounding bone)
SINUS (CLOACA)
SCLEROSIS OF PERIOSTIUM
(INVOLUCRUM)>>>>NEW
BONE FORMATION
 Acute Pyogenic Osteomyelitis

Clinical Presentation
A 10-year-old girl presented with a 3-week history of thigh pain.
Her blood work showed a mildly elevated erythrocyte sedimentation
rate and elevated white cell count.
Plain radiograph
Early findings may be subtle, and changes may not be obvious until 5
to 7 days from the onset in children and 10 to 14 days in adults.
On radiographs taken after this time period:
regional osteopenia
periosteal reaction/thickening (periostitis)
In chronic or untreated cases, the eventual formation of
a sequestrum, involucrum, and/or cloaca may be seen.
Plain radiograph
00
 MRI:
MRI is the most sensitive and specific and can identify soft-tissue/joint complications .
Bone marrow edema is the earliest feature of acute osteomyelitis seen on MRI and can
be detected as early as 1 to 2 days after the onset of infection.
MRI Coronal fast inversion recovery
shows extensive high signal bone
marrow edema in the proximal femoral
meta-diaphysis with a small spherical
central ringlike low signal intensity
consistent with very early abscess
formation (arrow).
A trace of fluid is also present in the peri
osseous soft tissues(arrowheads).
 It has little role in the
direct assessment of
osteomyelitis, as it is
unable to visualize within
the bone.
It does, however, have a
Ultrasound role in the assessment of
soft tissues and joints
adjacent to infected bone,
as it can be used to
visualize soft tissue
abscesses , cellulitis,
subperiosteal collections,
and joint effusion.
Longitudinal sonogram shows a small
fluid collection (arrows) in the deep
soft tissues adjacent to the proximal
femur with a rim of hyperemia seen on
color Doppler.
The fluid collection was aspirated using
ultrasound guidance, and subsequent
cultures grew Staphylococcus aureus.
Subperiosteal pus on ultrasound
Bone scan: 7-year-old boy with reluctance to weight bear on the left leg.
Generally unwell with low grade fever.
 BONE SCAN:

Dynamic flow phase: there is increased blood flow (hyperemia) in the

region of the left distal femoral metaphysis.
Blood pool phase: increased uptake in the same region.
Delayed phase: increased uptake in the same region.
Chronic osteomyelitis:
The classic radiographic appearance is thickened cortex and variable mixtures
of lucency and density.
Sequestrum is necrotic bone, isolated from living bone by granulation tissue. It
appears relatively dense because it has no blood supply.
Involucrum is a shell of bone that surrounds a sequestrum.
Cloaca is a cortical and periosteal defect through which pus drains from an
infected medullary cavity.
Sinus: chronic osteomyelitis of the tibia or femur is often associated with a
chronically draining sinus tract.
If the drainage occurs over many years (usually decades), the tract may develop
a squamous cell carcinoma.
 Lateral radiograph of a proximal ulna
shows osteomyelitis that has developed
following an open fracture.
There is permeative bone destruction,
as well as an H-shaped dense fragment
of necrotic bone (arrow), termed a
sequestrum.
Lateral radiograph in a
diabetic patient with
neuropathic foot shows
a round sequestrum
(arrow) in the posterior
calcaneus.
Age: 15 years
Gender: Male
A sclerotic bony fragment
surrounded by lucent rim
(sequestrum is seen in the
distal femoral diaphysis
with posterior cortical
defect (cloaca) and marked
thickening of adjacent
cortex (involucrum).
A bony sequestrum is a
piece of devascularised
bone that becomes
separated from the
remainder of the bone in
chronic osteomyelitis
and acts as a nidus for
ongoing infection.
CT coronal plane of left
humeral bone showing
features of chronic
osteomyelitis.
Central bony cavity
surrounded by bony
sclerosis (involucrum)
with sinus formation
(cloaca).
CT of the lower femur
showing features of chronic
osteomyelitis.
Central bony cavity with
overlying thickened cortex
Sinus (cloaca)
Chronic osteomyelitis.
A sinogram enhanced
by magnification
shows a draining
sinus typical of
chronic
osteomyelitis.
 subacute
Subacute

Is a distinct form of
Subacute osteomyelitis in a
child.
Usually found in the
metaphysis and may present
in epiphysis.
Geographic lytic lesion with
a well defined, often broad
sclerotic margin.
Oval, with the long axis
parallel to the long axis of the
bone.
Borders the growth plate
 Take Home Message

Plain radiography is the initial imaging modality of choice but may be normal in the
early stages of disease.
Normal plain radiographs do not exclude osteomyelitis.
MRI is considered the optimal imaging modality in the evaluation of osteomyelitis
and associated soft tissue abnormalities.
Nuclear medicine studies are an alternative to MRI when there are no localizing
signs or symptoms in suspected osteomyelitis, when MRI is contraindicated or
unavailable or in cases of suspected peri-prosthetic infection.
They can also monitor response to treatment.
Thank you