Imaging of Osteomyelitis in the Mature Skeleton

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Osteomyelitis continues to be a common condition in clinical practice. The clinical diagnosis in the late stages of infection is easily achieved. Detecting early infection when complete resolution is still possible, however, is a challenge to clinicians and radiologists. The clinical picture may be confusing, and laboratory findings, including an elevated erythrocyte sedimentation rate and leukocytosis, are not specific for bone infection in its early stage. Serial blood cultures are positive in 50% to 60% of cases.42, 69 Cultures of blood and material obtained by needle aspiration of the involved bone yield positive findings in up to 87% of cases.25, 34

Because delay in the treatment of osteomyelitis significantly diminishes the cure rate and increases the rate of complications and morbidity,55 several imaging modalities have been used for early detection of osteomyelitis, including conventional radiography, several scintigraphic techniques, CT, and MR imaging.31

Osteomyelitis may result from hematogenous seeding, spread from adjacent soft tissue infection, or direct inoculation. Hematogenous osteomyelitis spread is most common in children, especially in the tubular bones. In contrast, hematogenous osteomyelitis in mature skeleton more commonly affects the spine, pelvis, and small bones.23, 50

Direct inoculation may occur in the setting of trauma or surgery. Osteomyelitis caused by adjacent soft tissue infection is commonly associated with neurotrophic foot ulcers in diabetic patients and decubitus ulcers in bedridden patients. In neonates and adults, vascular communications are present between the epiphysis and metaphysis. Between the ages of 1 and 16 years, the epiphyseal plate separates the metaphysis from the epiphysis and acts as a barrier to the vascular supply and spread of infection.50

Hematogenous osteomyelitis is usually caused by gram-positive organisms, the most common being Staphylococcus aureus (Table 1).17

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Conventional Radiography

In the early stage of osteomyelitis, the findings on conventional radiography may be normal for 10 to 21 days after the onset of infection because a 30% to 50% loss of bone density must occur before a radiograph becomes abnormal.7, 69 In osteomyelitis, the earliest radiographic finding is deep soft tissue swelling that may cause obliteration of the tissue planes. Localized osteoporosis and bone resorption caused by infection in the medullary space with hyperemia, edema or abscess formation, and

SUBACUTE AND CHRONIC OSTEOMYELITIS

Subacute osteomyelitis may occur in abnormal bone or after inadequate antibiotic therapy. This commonly appears as a well-defined osteolytic metaphyseal lesion. This discrete Brodie's abscess (Figs. 14 and 15) has a sclerotic margin that fades peripherally and creates a fuzzy sclerotic margin. Occasionally, the Brodie's abscess appears as a serpiginous lucency (Fig. 15) in the metaphysis of the long bones. These features are often pathognomonic on plain radiographs. Lower extremity involvement

CHRONIC RECURRENT MULTIFOCAL OSTEOMYELITIS

This rare form of osteomyelitis of unknown cause predominantly affects children and young adults between the ages of 19 months and 27 years. The multifocal metaphyseal lesions are often, but not invariably, symmetric and often exhibit bouts of exacerbation and remission. The tibia is most frequently involved, followed by the femur, clavicle, and fibula. Other sites include the short bones of the hands and feet, sternum, and axial skeletal.15 The erythrocyte sedimentation rate is elevated in

DIABETIC FOOT OSTEOMYELITIS

Early diagnosis of osteomyelitis in patients with diabetes is particularly important in preventing progression of the disease and prompt treatment has been noted to decrease the rate of amputation in this patient population.3, 19 Plain films (Figs. 2, 23 and 24) have a lower sensitivity than other methods, but a specificity that is comparable with bone scan. False-positive radiographs are often associated with neuropathic joints or degenerative or inflammatory arthritis.14, 57 Neuropathic

VERTEBRAL OSTEOMYELITIS

Vertebral osteomyelitis is the most common form of hematogenously acquired osteomyelitis in adults. Spinal infection is discussed elsewhere in this issue.

CRANIAL OSTEOMYELITIS

Cranial osteomyelitis (Fig. 29) arises from complications of paranasal sinus infection, trauma, dental extractions, chronic periodontal disease, chronic mastoiditis, necrotizing otitis externa, and various surgeries. Imaging diagnosis of osteomyelitis is difficult when there is concurrent bone destruction or repair because of a nonifectious process. In a study involving 25 cases evaluating the diagnosis of cranial osteomyelitis using different modalities, including111In-WBC and 99mTC-MDP bone

PRESENCE OF HEMOGLOBINOPATHY

Vaso-occlusive crisis with infarction of bone marrow or cortex is typically characterized by pain of various severity and duration at one or more sites. In some instances, swelling, erythema, fever, and leukocytosis develop, raising the possibility of osteomyelitis. It must be mentioned that the serious consideration of infection, prompted by moderate or marked fever and localized signs of inflammation, occurs in only 10% to 15% of patients who come to the emergency room for visits for sickle

SUMMARY

Diagnosis of acute osteomyelitis is often challenging but can be made by plain radiograph, bone scan, or MR imaging. This diagnosis may be more problematic in small bones, in diabetic or immunocompromised patients, those partially treated, post-traumatic, previous surgery, or with pre-existing marrow conditions and associated soft tissue infections. CT is the modality of choice for revealing sequestra and cortical erosions in chronic osteomyelitis. Nonenhanced and enhanced STIR or fat-saturated

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    Address reprint requests to Jamshid Tehranzadeh, MD, Department of Radiological Sciences (R-140), University of California, Irvine Medical Center, 101 The City Drive, Orange, CA 92868ā€“3298, e-mail: [email protected]

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