osteomyelitis

Professor Dr Saima Ameer

Department of Diagnostic Radiology
Acute Osteomyelitis

 Age:
most commonly affects children
 Organism:

(a) Newborns:
S. aureus,
group B streptococcus,
Escherichia coli
Acute Osteomyelitis
(b) Children:
 S. aureus (blood cultures in 50% positive)

c) Adults:
 S. aureus (60%)
 enteric species (29%)
 Streptococcus (8%)
Acute Osteomyelitis
(f) Diabetics:
often multiple organisms like
 S. aureus
 Streptococcus
 E. coli
 Klebsiella
 Clostridia
 Pseudomonas (in soil+ sole of shoes
Acute Osteomyelitis
(d) Drug addicts:
 Pseudomonas (86%)
 Klebsiella,
 Enterobacteriae; (57 days average delay in diagnosis)

(e) Sickle cell disease:

 S. aureus
 Salmonella
Acute Osteomyelitis
 Cause:
(1) Genitourinary tract infection (72%)

(2) Lung infection (14%)

(3) Dermal infection (14%)

Acute Osteomyelitis
Location:
 Lower extremity (75%) over pressure points in diabetic

foot
 Vertebrae (53%)

lumbar (75%) >thoracic> cervical(= infectious

spondylitis)
 Radial styloid (24%)
 Sacroiliac joint (18%)
Acute Osteomyelitis
Diagnosis
Radiograph
 Insensitive; initial radiographs often normal

(notoriously poor in early phase of infection for as long

as 10-14 days)
 Localized soft-tissue swelling adjacent to metaphysis

with obliteration of usual fat planes (after 3-10 days)

 Permeative metaphyseal osteolysis (lags 7-14 days

behind pathologic changes)

Acute Osteomyelitis
 Endosteal erosion

 Intracortical fissuring

 Involucrum
cloak of laminated I spiculated periosteal reaction
(develops after 20 days)
Acute Osteomyelitis
 Button sequestrum
detached necrotic cortical bone(develops after 30 days)

 Cloaca formation
space in which dead bone reside
Erosion of
distal fibular
cortex on
lateral aspect
with soft
tissue swelling
Acute Osteomyelitis
MR
 82% sensitive,

 80% specific in diabetics

 Demonstrates extent of infection

Signal changes with different weightings
T1-weighting T2- weighting STIR
Normal
cortex ----------- Low signal Low signal Low signal

medull---------- Very bright Less bright Low signal

Oedematous
cortex----------- Low signal Bright Very bright

medulla------ Low signal Bright Very bright

enhancing with
gadolinium
Acute Osteomyelitis

 Periarticular bone marrow edema can be seen

adjacent to joints involved by noninfectious
inflammatory arthropathy I osteoarthritis and does not
reliably indicate osteomyelitis

 Subperiosteal infection =hyperintense halo

surrounding cortex on T2WI
Acute Osteomyelitis
 Sinus tract
communication of medullary fluid collection with soft-
tissue fluid collection through cortical disruption.

Hyperintense line on T2WI extending from bone to skin

surface+ enhancement of its borders
Acute Osteomyelitis
 Abscess characteristics:

 Hyperintense enhancing rim(= hyperemic zone) around

a central focus of low intensity(= necrotic Idevitalized
tissue) on contrast-enhanced TlWI
 Hyperintense fluid collection surrounded by

hypointense pseudocapsule on T2WI + contrast

 Enhancement of granulation tissue
Acute Osteomyelitis

 Sequestrum = central hypointense area on T2WI

Hyperintense adjacent soft tissues on T2WI

DDx:
 noninfectious inflammatory arthropathy(Charcot joint)
 osteoarthritis
 cellulitis
 Early osteomyelitis.
(A) There is a barely
discernible radiolucency
affecting the distal
shaft of the femur,
but an early periostitis
is demonstrated
medially and laterally.
B) The radioisotope
bone scan shows the extent
of the pathological change.
Acute Osteomyelitis
Complications
(I) Soft-tissue abscess

(2) Fistula formation

(3) Pathologic fracture

(4) Extension into joint

Acute Osteomyelitis
(5) Growth disturbance due to epiphyseal involvement

(6) Neoplasm

(7) Amyloidosis

(8) Severe deformity with delayed treatment

 X-ray
Neonate
circumcised since
25 days. right upper
medial tibial
metaphyseal lytic
lesion; thick
periostitis and
interrupted soft
tissues around
8 months old boy
with 10 day h/o wrist
swelling. show lucency
of the distal radial
metaphysis and marked
surrounding soft
tissue swelling
 T1 +C + fat sat

MRI reveals the additional

presence of adjacent soft
tissue collection and wrist
joint synovitis
At presentation
12 year old with
osteomyelitis
of the distal
radius(lucency)
with followup x-
rays
1 month later
6 months later
4 years later

Early diagnosis no bone shortening

occur complete resolution
Periarticular osteopenia
involving 2nd to 5th MTP
joints.
Lytic area in 5th
metatarsal head – neck
with cortical breach
Soft tissue swelling with
air foci in mid foot laterally
 T1+C+FAT SAT
Charcot arthropathy
with destruction of
the cuneiform bones,
metatarsal bases,
and parts of the
cuboid and talus.
excessive edema.
After contrast an
abscess at the
tarso-metaatarsal
junction. Bone necroses
at the talar head .
Cutaneous fistula at
the hindfoot
 Chronic Osteomyelitis

 Thick irregular sclerotic bone with radiolucencies,

elevated periosteum

 Chronic draining sinus

 Chronic Osteomyelitis

cavity with organized

periosteal reaction
sugestive of chronic
osteomyelitis involving
4th metatarsal bone
 Chronic Osteomyelitis

right thumb shows

erosions involving
tuft of distal phalanx
and in distal articular
surface of proximal
phalanx of thumb.
Diffuse soft tissue
swelling seen involving
thumb. Osteomyelitis
of distal phalax and
septic arthritis of
interphalangeal joint.

patient presented with recurrent swelling and

discharge from tip of right thumb.
 Chronic Osteomyelitis

sinography.
right femur demonstrates
several radiodense,
sharply marginated foci
within lucent cavities
suggestive of sequestration.
(B) Oblique view showing
retrograde opacification
of a sinus tract defining
the course and extent of
the fistula and confirming
the communication with
an abscess in the bone
Sclerosing Osteomyelitis of Garre

STERILE OSTEOMYELITIS
low-grade nonnecrotic nonpurulent infection
 This condition is manifested by gross sclerosis in

the absence of apparent bone

 Location:

mandible (most commonly)

Sclerosing Osteomyelitis of Garre

focal bulge of thickened cortex (sclerosing

periosteal reaction)

DDx: osteoid osteoma, stress fracture

Sclerosing Osteomyelitis
of Garre

focal bulge of thickened cortex

Sclerosing Osteomyelitis of Garre

•Persistent pain in the

left knee and lower leg.
• Diffuse marrow
patchy hypointense
areas on T1WI
•Hyperintense on STIR
Post contrast patchy
enhancemant
Right shoulder, ankle and knee pain
Dense sclerosis of the medial right clavicle.
Hyperostosis.
On the right, diffuse cortical thickening, a thick, lamellated
periosteal reaction and hyperostosis.
Hyperostosis of the lateral
malleolus.Presentation radiograph
Dense sclerosis, hyperostisis
and thickening of the cortex
. The periosteal reaction is
now broken, suggesting
an underlying aggressive
process
 Extensive cortical thickening of the distal diaphysis of femur, extending
into the metaphyseal region, particularly medially. Bone and soft
tissues show mild degree enhancement d/t edema. enhancement of
the synovium consistent with synovitis.
The marrow signal remains intact. Moderate joint effusion.
Mild loss of cartilage over the medial femoral condyle anteriorly. an
area of defect seen within the medial femoral condyle anteriorly and
posteriorly
After 2 years
Brodie Abscess

 Subacute pyogenic osteomyelitis (smoldering indolent

infection)
Organism:
 S. aureus (most common); cultures often negative

Age:
more common in children; M > F
Brodie Abscess
Location:
 Predilection for ends of tubular bones (proximal Idistal

tibial metaphysis most common);

 carpal+ tarsal bones
Brodie Abscess
Site:
 metaphysis,
 rarely traversing the open growth plate;
 epiphysis (in children +infants)
Brodie Abscess
On X -ray
 Lytic lesion often in an oval configuration that is

oriented along the long axis of the bone

 Surrounded by thick dense rim of reactive sclerosis

that fades imperceptibly into surrounding bone

Brodie Abscess
 lucent tortuous channel extending toward growth
plate prior to physeal closure (PATHOGNOMONIC)
 Periosteal new-bone formation

±adjacent soft-tissue swelling

 may persist for many months
' Tunnelling' in
osteomyelitis.
A finger-like process of
osteomyelitic bone
destruction
extends from the main
focus. This is
tunnelling,which usually
indicates the presence of
chronic infection
Lytic lesion in an oval
configuration oriented
along the long axis of the
bone Surrounded by
thick dense rim of
reactive sclerosis
Double line" effect

high signal intensity of

granulation tissue
surrounded by low signal
intensity of bone sclerosis
Brodie abcess with
surrounding
marrow edema

No rim
enhancement after IV
Gd-chelate
Tuberculous Osteomyelitis

 Incidence:
16% of skeletal tuberculosis
 Age:

children <5 years (0.5-14%), rare in adults

Tuberculous Osteomyelitis
Location:
 Femur,
 Tibia,
 Small bones of hand+ foot (most common);
 any bone may be involved
Tuberculous Osteomyelitis
Site :
(a) metaphysis
 (TYPICALLY) with transphyseal spread (in

child)
DDx:
pyogenic infections usually do not extend across physis
Tuberculous Osteomyelitis
(b) epiphysis with spread to joint I spread from adjacent
affected joint

(c) diaphysis (<1%)

 initially round I oval poorly defined lytic lesion with

minimal I no surrounding sclerosis

 varying amounts of eburnation +periostitis
Tuberculous Osteomyelitis

 advanced epiphyseal maturity I overgrowth (due to

hyperemia) ±limb shortening from premature physeal
fusion
 cystic tuberculosis

well-marginated round I oval

radiolucent lesions with variable amount of sclerosis
Tuberculous Osteomyelitis
(a) in children (frequent)

 in peripheral skeleton

 symmetric distribution

 no sclerosis
Tuberculous Osteomyelitis
(b) in adults (rare):
 in skull
 shoulder
 pelvis
 spine
 with sclerosis
Tuberculous Osteomyelitis
DDx:
 eosinophilic granuloma,
 sarcoidosis,
 cystic angiomatosis,
 plasma cell myeloma,
 chordoma,
 fungal infections,
 metastases
Tuberculous Osteomyelitis
tuberculous dactylitis (spina ventosa)
 "wind-filled sail"
 ballooning dactylitis
 The term spina ventosa derives from spina = short

bone and ventosa = expanded with air

 forming an enlarging cystlike cavity with erosion of

endosteal cortex (end-stage disease)

 (children>> adults):
 Tuberculous Osteomyelitis
Poorly defined lytic
change with
medullary expansion,
cortical erosion and
mild periosteal
reaction in the mid
and distal aspect of
the right middle finger
in a patient with TB
dactylitis
Tuberculous Osteomyelitis

spina ventosa
of the
proximal
phalanx of the
forefinger.
Tuberculous Osteomyelitis
 DDx:
 pyogenic osteomyelitis
o (no transphyseal spread)
 syphilitic dactylitis
o bilateral symmetric involvement,
o less soft-tissue swelling
o sequestration
Tuberculous Osteomyelitis

 Sarcoidosis
 hemoglobinopathies
 hyperparathyroidism
 leukemia
initially round to oval
poorly defined lytic
lesion with no
surrounding sclerosis
with follow up X –rays
At presentation
At 3 months
At6 months
At 9 months
Tuberculous Osteomyelitis

Xray - Sternum -
No bony
abnormality
noted.
OSTEOMYELITIS OF VERTEBRA

Prevalence:
 2-10% of all cases of osteomyelitis

Cause:
(1)
 direct penetrating trauma (most common)
 surgical removal of nucleus pulposus
OSTEOMYELITIS OF VERTEBRA

(2) hematogenous:
 associated with urinary tract infections
 following GU surgery
 instrumentation
 Diabetes mellitus
 drug abuse
OSTEOMYELITIS OF VERTEBRA

Organism:
 Staphylococcus aureus,
 Salmonella

Peak age:
5th-7th decade
OSTEOMYELITIS OF VERTEBRA

Radiographic signs
 Disk space narrowing (earliest radiographic sign)

 Demineralization of adjacent vertebral endplates

 Bulging of paras pinal I lines

OSTEOMYELITIS OF VERTEBRA

Radioneucloide scan
tracer uptake in adjacent portions of two vertebral
bodies
MRI
 decreased marrow signal on T1WI
 iso- I hyperintense marrow signal on T2WI
OSTEOMYELITIS OF VERTEBRA

Cx:
 secondary infection of intervertebral disk is frequent

Rx:
>4 weeks course of IV antibiotics
DDx:
diskitis
OSTEOMYELITIS OF VERTEBRA
extremely advanced discitis
osteomyelitis with septic
arthritis of facet joints and
extensive adjacent abscess
formation.

the L2 and L3 vertebra have

been eroded such that they
occupy only the height of one
vertebra.
 OSTEOMYELITIS OF VERTEBRA

L1-L2 disc height loss

and endplate sclerosis
 OSTEOMYELITIS OF VERTEBRA

Discitis Osteomyelitis T1 C+
At C6-C7 complete destrusion
of vertebra with intervening
disc and paraspinal
component compressing the
cord posteriorly
OSTEOMYELITIS OF VERTEBRA
endplate osteomyelitis
- ie a destructive
process centered on
the disc with secondary
bone collapse and a
large paravertebral
cuff-like soft tissue
mass containing fluid
(rim enhancing)
consistent with pus.
OSTEOMYELITIS OF VERTEBRA
 Rather than a malignant mass, there are features
typical of endplate osteomyelitis .
 Neutrophils utilise glucose at a similarly increased rate

to malignant cells so they are highly FDG avid thus a

potential false positive for malignancy
D/D pyogenic spondylitis
 pyogenic
 History
long
 Short

 Presence of active  Not present

pulmonary disease---60 %

 Most common location

thoracic spine, then  Lumbar spine
thoracolumbar
tubercular
D/D pyogenic spondylitis

 >3 contiguous vertebral  19% mostly involve 1 spinal

body involvement is segment---2 vertebrae and
common--42% intervening disc
 21%
 Vertebral collapse --67%
 48%
 Bone destruction---73%
 Rare
 Porterior element
 rare
involvement---common
tubercular
Skip lesions----common pyogenic
D/D pyogenic spondylitis

 Disc is involved with less  Disc destruction is most

frequency and severity. Disc often seen in pyogenic
spared in central type TB. osteomyelitis.

 Paraspinal and epidural

abscesses-60%
 large involving many
 30%
 Rare
contiguous vertebral bodies
level.
tubercular pyogenic
D/D pyogenic spondylitis

 calcification if present is
pathognomic.  Not seen.

 Heterogenous enhancement.
 Smooth rim enhancement - Thick irregular Rim
74% enhancement only 9% cases.

TO SUMMARISE: atypical
tubercular
features + abscess character pyogenic
 Gibbus deformity rare.

 Smaller paraspinal abscesses

 Facet joint involvement

BONE TRAUMA
 Fracture
 is a discontinuity in a bone (or cartilage) resulting from

mechanical forces which exceed the bone's ability to

withstand them.
 Terminology
 A fracture is often written as # in medical short hand ,

i.e. the hash symbol, although it is still pronounced as

fracture, e.g. "neck of femur fracture", may be written
as "#NOF".
 Diagnosis
 The diagnosis of a fracture is mainly based on typical

radiographic criteria proving the bony discontinuity.

 Fractures are generally imaged using
 plain radiographs,
 CT,
 MRI,
 bone scans
 ultrasound
 when 3D anatomy is complex (e.g. joints, wrists, feet, the

base of skull, spine)

 when plain films are insensitive to non-displaced fractures

(e.g. base of skull, spine, sacrum, or proximal neck of

femur)
 Traumatic fractures
 Most commonly fractures occur in the setting of a
normal bone with acute overwhelming force, usually in
the setting of trauma.

 Insufficiency fractures
 Entire skeleton may be weak due to metabolic (e.g.
osteoporosis) or less frequently genetic abnormalities
(e.g. osteogenesis imperfecta) and thus prone to
fractures from forces that would be insufficient to cause
fractures in normal bones.
 Fatigue fractures
 chronic application of abnormal stresses (e.g. running)

can result in the accumulation of microfractures faster

than the body can heal, eventually resulting in
macroscopic failure.
 Stress fractures
 insufficiency and fatigue fractures are often grouped to

 Pathalogical fracture

The bone may have many a lesion that focally

weakens it (e.g metastasis , bone cyst, etc) gether
 Location
 which bone is fractured
 which part of the bone is affected

◦ general:
◦ epiphysis,
◦ physis,
◦ metasphysis,
◦ disphysis
◦ specific features: e.g. tubercle, epicondyle, etc...
Radiograhic findings x- ray
 Stress fractures radiographically show the following
signs:
 osteal bone

◦ endosteal or periosteal callus formation without fracture line

◦ circumferential periosteal reaction with fracture line through
one cortex
◦ frank fracture
 cancellous bone
◦ flake-like patches of new bone formation (2-3 weeks)
◦ cloudlike area of mineralized bone
◦ focal linear area of sclerosis, perpendicular to the trabeculae
 On the left a 42-year old female who walks long
distances and has been experiencing forefoot pain for
a month.
On the initial radiograph no fracture is seen.
After 4 weeks, a follow up radiograph clearly marks
callus formation at the site of the stress fracture
 MRI
 MRI has surpassed bone scintigraphy as the imaging

tool for stress fractures, showing equal sensitivity

(100%) but a higher specificity (85%), probably by
giving better anatomical detail and more precisely
depicting the tissues involved.
 STIR (short tau inversion recovery), T1-weighted
(T1WI) and T2-weighted images (T2WI) are used for
characterization and grading.
 Grading is based on signs seen at MRI:
 1- mild - moderate periosteal edema on STIR, no

marrow changes
 2- moderate - severe periosteal edema on STIR +

marrow changes on T2WI

 3- 2 + marrow changes on T1WI
 4 -fracture line visible
 a 27-year old soccer player in the highest league of amateur football.
He suffered from midfoot pain with a recent increase in complaints.
T1WI shows a definite fracture line in the navicular bone, indicating a
grade 4 stress fracture.
Corresponding CT shows a fracture line and sclerosis on the axial
images and coronal reconstructions.
Femoral neck fractures

 There are two types of stress fractures of the femoral neck:

 Compression fracture. These are located on the inner side of the
femoral neck.
They have a low risk of complicated healing with conservative
therapy, because the fracture parts are pressed together.
 Tension fracture. These are located on the outer side of the femoral
neck.
They have a high risk of complicated healing due to tension exerted
on the fracture elements. These fractures are at risk for complete
fracture and avascular necrosis.
If conservative therapy fails, open reduction and internal fixation is
recommended.
On the left we see a compression fracture of the
femoral neck.
The radiograph is normal, but MR depicts the
fracture and bone marrow edema (i.e.grade 4).
 A radiograph made one month later shows
evolvement to complete fracture.
Although this is a low-risk fracture, the follow-up
radiographs at 3 and 13 months did show poor
healing tendency.
 Type
 Fractures usually fall within a set number of patterns.
 Complete fracture: extends all the way across the bone

(most common)
◦ transverse fracture: perpendicular to the axis of the bone
◦ oblique fracture: oriented obliquely across the bone
◦ spiral fracture: helical fracture path usually in the diaphysis of
long bones
◦ comminuted fracture: more than two parts
 incomplete fracture: does not cross the bone
completely (usually encountered in children)
◦ bowing fracture;
◦ usually occur in the forearm. This is a bending deformity
without a grossly visible fracture in the tubular structure of
the bone.
◦ buckle fracture:
◦ the cortex is buckled, often in the distal radius
◦ greenstick fracture:
◦ the cortex is broken, but only on one side
bending deformity without a grossly visible
fracture in the radius
greenstick fracture: the cortex
is broken, but only on one side
◦ buckle fracture:
◦ the cortex is buckled, often in the distal radius
 Epiphysiolysis fracture
 These are usually Salter Harris type II epiphysiolysis

fractures.
Restorage of the anatomical situation is necessary to
prevent growth disturbances.
Redislocation is common after closed reduction.
In many cases they need percutaneous pinning.
 Displacement
 The relationship between fracture fragments can be

described using the following terms.

 fracture translation (a.k.a. translocation or

displacement)
◦ direction: usually of the distal part relative to the proximal
part
◦ amount: measurement or % width
 fracture angulation
◦ direction: usually of the distal part relative to the proximal
part
◦ amount: in degrees
 fracture rotation
◦ direction: terminology will depend on the location
◦ amount: in degrees
 fracture length
◦ distraction/impaction/shortening
 Complications
 Many of the aforementioned fracture types can also go

on to have additional complicating features, not to

mention many associated soft tissue injuries beyond
the scope of this article.
 compound fracture: extending through the skin
 joint involvement

◦ intracapsular
◦ articular
◦ dislocation
Posterior dislocation of shoulder

Anterior dislocation of shoulder

 Colles' fracture

 fracture of the distal metaphysis of the radius

with dorsal angulation and displacement
leading to a 'silver fork deformity'.

Colles' fracture is an extraarticular,

uncomplicated and stable fracture Colles' fracture with intraarticular extension
Serial radiographs of anterior rotational
trochanteric osteotomy from a 16-year-old
man with posttraumatic osteonecrosis of the
femoral head are shown
 Treatment and prognosis
 The fundamentals of fracture healing rely on alignment

and immobilization. Alignment may or may not be

necessary depending on the degree of displacement,
the importance of correct alignment (e.g. index finger
vs rib) and the particulars of the patient (e.g.
professional athlete vs debilitated elderly).
 Immobilization can be achieved in a variety of ways
depending on the location and morphology of the
fracture.
 none (e.g. most rib fractures)
 sling (e.g. many clavicular fractures)
 cast(e.g. many forearm fractures)
 internal fixation (e.g. most hip fractures): open vs

closed reduction
 external fixation
an intraarticular fracture of the distal radius with shortening of
the radius.
The ulna abutts the lunate.
External fixation was used to lengthen the radius.
Internal fixators