%l.

\Ruhh,

I()70

EARLY
By MARIE A.

ROENTGEN OBSERVATIONS ACUTE OSTEOMYELITIS*

CAPITANIO, M.D..
PHILADELPHIA,

IN
M.D.

and

JOHN

A. KIRKPATRICK,

PENNSYLVANIA

H
nc

EMATOGENEOUS tinues to be
age group. a Ihe
means

osteoni

eli

tis

conillis

may

take

place or

if not

interrupted by tilerapeutic

b
in

body
melt-

endemic
litiVent for c-tire

in
ofantibiotics

the
but

pediattherap

defenses
sores.
rate of

altered

Initially

provided

bloot!
ant!

there is an increase flow to tile region

dilata
increased

tile an

with Capillar perme-

must be instituted to prevent the osteomyelitis. of paramount

signs
are

early serious Early

to be effective complications is When therefore the

osteomvelitis

and of classic heat the

associated

arteriolar

dilatation

tion. capillar capillaries

diagnosis
of acute

ability pouring the slowing b the

then of surrount!ing

ensue fluid

with from tissues.

a subsequent the

out-

importance.
symptoms

into followed cells into

and
present tenderness,

There

is eventual

(i.e., may difficult. of

local
fever

pain,
anti

swelling, leukocvtosis) by there

tile clinician

and

or stasis appearance

of the bloot! flow of white blood

diagnosis without

be

made

However, antibiotics

since has

the

inbeen

troduction an apparent
osteomvelitis.2

the inflammatory focus. The suppurative process results in local destruction of trabeculae anti eventually, if unabated, ma\ spread nal trabeculae. throughout producing The in the through tracts and osteomyelitis During the may pus the the widespread intramedullary cortex
via

change
This number of
subacute or

in

the

character
by with

of an
an inin-

in tramedullarv destruction accumulating canal

caof under ma multiple

is manifest patients illness anti

creasing

presenting frequently

with
sidious

a milt!
onset

pressure rupture sinus Chronic point. cal stilt

of

symptoms

no associated systemic reaction. It is difficult to make the diagnosis of osteomvelitis in tilese patients on clinical evidence alone, and other necessary. cia ted means for rile changes early that c-ally before are of the
LOGY

elevate tile periosteum. is established lit that destructive phase cortidevitalized

of sequestra.
is

diagnosis
can

are early

be apprethe

bone in

become
formation
is formeti

and

reAn
pro-

the b the

roentgenographi

in

involucrum

stages of osteom elitis, ble bone destruction, assistance in making

PA1HO

there is visiconsiderable diagnosis.

t!uced is the

elevatet!
of
may

when bone periosteum.

periosteum anti there
process.

Rarely
violated may be

integrity
suppurative
effusion

the occur

early

b
joint

the

A sympathetic process into is unusual.

Hematogeneous flammatory process

osteomyelitis that begins

is in the

an

inbone

extension the joint,

of the although
ROENTGEN

suppurative the latter

OBSERVATIONS

marrow. primary of the of the

physis,

Almost without site of involvement long bones where

rich blood supply
vessels

exception the is at the ends growth is most

and
at

Tile

roentgen

observations primarily before bone bone after in

soft
and

tiescri

bed

rapid. The

the nature

here will be limited changes that are seen tion or periosteal the
of
Hospital for

to those destrucis

structure

of

tile

the

metato the

new first
3 days

formation

end-arteries,

pret!ispose

lodgment
this
region.8

of bacteria within Once the nidus

an integrated
of Radiology

the
of series
and

vessels
illfection of
Pediatrics,

in
is

visible. \Vithin symptoms,

appearance

the
the

onset
roentgen

of
tile

alterations
tile
Children

established,
*

events
St.

tissues
lemple

about
University School

From

the

Departments

Christophers

of

Medicine,

Philadelphia,

Pennsylvania.

488

I-ic.

i. This

12

year

old Negro

male

presented

with

local

pain

and

tenderness

over

the distal

metaphysis

of

the right femur. (4) He had no systemic local deep soft tissue swelling in relation (C). The left knee (B and D) is normal.

symptoms. The displacement of the deep lucent planes by the to the medial metaphysis is best seen in the oblique projection

490

Marie

A.

Capitanio

and

John

A.

Kirkpatrick

MARCH,

1970

11G.

2. (4 and Negro male

surgery

C) The
are

right enlarged
pus

subperiosteai

leg is normal. (B and D) The deep soft tissues of the left leg of this 6 year old and there is fluid in the ankle joint. No alteration in the bones is evident. At uilder tension was found and cultures of the aspirate and blood grew out Staphv-

lococcus

aurcus,

coagu lase positive.

metaph\-sis Cilailge tissue

physis.3

are noteti swelling Ihe tissues The with

OD

visible. is
in

The local,
region

first of
and

definite deep, soft tile metaremain-

deep
witil

soft
tile

tissue

swelling
tile tile

correlates

well

a small,
tile structures

osseous

occurring inflamnlatorv deep is

is

time that tluring tissue when observes,

is than thickenet! usual. grow stage
of

response.

vascular changes are early events of the \\hen the local, is

frequently

ing soft grapilicallv.

contiguous
apparent

are tleep
tile

normal
soft tissue

roentgenoswelling bone and

soft present

swelling
tilere

visible
will

OD

tile

roentgenogram,

be

no

adjacent

pus surgeon
osteum

the

bone
and

is drilled. that
tilat

Tile penis

tile

roentgenogram

by
the
tile

virtue
deep

however, Cultures the an offend!ing

exutiate, of osteomvelitis,

the
bleeding

of zl-D). plane

the

tlisplacement plane
File

of from
to

lucent

muscle

away
tlegree

bone
tile

(Fig. lucent
tissue soft

i,

greater often

of the

aspirate organism. before

tile

which the deep

anti

will

is displaced is
opposite

by
unless extremity

Ihis
of
aS a

early

swelling
be tile

fretluentl\

small
in

will

not pro-

accumulation
metaphvsitis.

is

referred

to

appreciated

roentgenograms identical

Treatment
appropriate

at
antibiotics

this

stage
lilld

with rest
process

surgery, will usually

with no

jections roentgen

are availal)le observation

for of

comparison.

he

abort
subsequent

the

inflammatory
significant

tile

metaphysea!

bone

OL.

io8,

No.

Acute

Osteomvelitis

491

destruction

resulting. may show

anti

Follow-up a mild rarefaction peniosteal to

ill

roentgen1fl tile

muscles be alteretl, of the planes cutaneous soft J-D).

of

anti more (Fig.

lucent followed

planes later

are b\

the

first
lucent

to

ograms
metaphysis

involvement
sub-

slight is secondar\cllange

reaction,
tile soft occurs surgical

part

of

which

superficial 2, 4-D).

muscles and Superficial

procedure.

soft

tissue
to the
great

edema
be observetl
stage

is

the

last

The
apparent the of the first

seconti
few

tile

tissues
lifter onset

roentgenographicallv days following

tissue change Early 111 tiliS

enlargement of

second

(Fig. 3, the tlegree may

on

the

of
not cal

tleep
to

muscles
detect

symptoms.
muscles

Ihis
an(l

is manifested
obliteration

by
of the

swelling lucent

be sufficientl
examination,

phsican

although
roen

the change

planes

between

the

muscles.4_6,10

The

deep

be

visualized

tgenographicall

(Fig.

492

\llinie

A.

(apitanio

lint!

John

A.

Kirkpatrick

RCH,

1970

3:-

-&.--

I-

3-

I..

I-u;.

4. tissue

(4) (B)

There
The

is acute in relation

osteomvelitis to tile medial

of

the right
femoral

knee
metaphysis

of

this

74 year
was

old

Negro

swelling

not

as obvious

male. The clinically

degree as that

of

soft

at

the

wrist.

left

knee

is normal.

1-1-F).

\Vhen

the

bone as

is dnilletl

lit

this

destruction mation
tile

anti

peniosteal

new

bone

for-

time, phase
sitlerable

pus is obtained, is well established.

bone destruction

tile suppurative Although conis present dii ring roentgenographithat may

is not seen until 10 or 1 2 days lifter onset of symptoms or after treatment (Fig. 3, E anti I; antI 4, G-K). The amount bone
destruction

this c-ally.

phase lile
local

it is not only on
rarefaction in part
to

visible bone the

to

of

that

is
enti

visible of

roent-

change

be

appreciliteti
mild

which
ellt as

is titie

roentgenogram is a at tile metaph\sis the il\peremia presactual early t!estruc, 11--D). Treatment,

genographically week is considerably of actual bone

b-

the less

thlin present. RY

tile seconti tile amount

destruction
S

tion
maSSive

well as of trabeculae
destruction

tile (Fig.
in

U MMA

The helpful
osteonlyelitis.

roentgen in making

examination

can

be

very

if institutetl
com

early

this
of

stage,
bone

can
and

prevent
serious

the
the

\Vithin

early first soft

tiiagnosis 3 tla\s tissue A

of after local

ph c-a tions.
The classic
roentgell

the picture of bone are

onset visible

of symptoms, roentgenographically.

changes

I
I

Fic.

(C and

E)

Osteomyelitis

of

the right

wrist.

(D and F) Normal

left wrist.

LL 1-ic.
4.

__

k
3 weeks following treatment, show periosteal new bone,

(1

and

K) Roentgenograms

of the right wrist, but no visible

bone

destruction.

\OL.

108,

No.

Acute

Osteomvelitis

495

i-ic.

This
of the

year oiti white

roentgenographic
right leg

female

gave
and

a history
(4
is an there

prior

to the
Fluid

examination.
ankle joint.

of a sore throat and D) Swelling

area of bone

week prior to onset of limping anti 2 weeks of both the deep and superficial soft tisat the metaphysis of the distal

sues
tibia.

is present in the

destruction

is present

(B

and

C) The normal
material

left leg is shown

indicative of a chronic

for comparison.
infection.

At surgery

the

periosteum

was

distended

by a granulomatous

496
deep soft metaphysis superficial
ogist to the

Marie
tissue of edema swelling a
possibility growing

A. Capitanio
adjacent
bone

and
the

John

A. Kirkpatrick
Medical Publishers, Changed Inc., character
255-256.

MARCH,

t9#{243}

to
without

Chicago, of

1967.

2. Editorial.

osteomyelitis.

should

alert
of

the
osteomyelitis.

radio!-

Brit.
3.
FERGUSoN,

M. 7.,

1967,3,

The also
days

diagnosis is almost local tenderness

after the
planes

certain clinically.

if there is Several
swelling 4.

Infancy Williams 1963.

GIEDI0N,

A. B., JR. Orthopedic Surgery in and Childhood. Second edition. & Wilkins Company, Baltimore,
radiologic

onset
between

of symptoms,

of the
lucent

deep

muscles

and

visible
the

roentgenographically,
enlargement of the

obliteration of the the muscles are even though

deep muscles may
.

A. Soft tissue changes and early diagnosis of acute osteomyelitis childhood. Fortschr. a. d. Geb. d. strah/en ii. d. Nuk/earmedizin, 1960, 466.
P. 533-548. P. Bone and joint
children.
14,

in early R#{246}ntgen93, 455in

1967,

GRIFFIN,

infections

not be appreciated clinically. In order to appreciate the soft tissue changes that occur early in osteomyelitis it is most important that the normal as well as the abnormal sitle be examined roentgenographically.
Marie A. Capitanio, M.D.
Children Department of Radiology St. Christophers Hospital for 2600 North Lawrence Street

Pediat.

C/in.

North

4merica,

6. JORUP, S., and KJELLBERG, S. R. Early diagnosis of acute septic osteomyelitis, periostitis and

arthritis
jicta 7. 8.

and

its

importance

in

treatment.
W.
1967.

radio/., 1948, 30, 316-325. Roiiius, S. L. Pathology. Third Saunders Company, Philadelphia,
SCHINZ, UEH

edition.
FRIEDL,

B.

H. R.,
LINGER,

BAENSCH,

W. E.,

i,

Skeleton.
1951.

E. Roengten Grune &

Diagnostics. Stratton,
of bones.

E., and Volume Inc.,

New

Philadelphia,

Pennsylvania
REFERENCES

York, 9.
JO.

19133

STEINBACH,

Roentgenol.,
SURRATT,

H. I. Infections 1966, I, 337-369.

Seminars

i.

CAFFEY,

J.,

and

SILVERMAN,

F.
edition.

N.

Pediatric
Year Book

X-Ray

Diagnosis.

Fifth

acute sissippi

R. R. Radiologic seminar hematogenous osteomyeiitis. M. 4., 1965, 6, 350-351.

XLI: early 7. Mis-