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Radiological manifestations of chronic osteomyelitis - Dr. Olanipekun Babatunde J.
- 1. RADIOLOGICAL MANIFESTATIONS OF OSTEOMYELITIS By Dr. Babatunde J. OLANIPEKUN MB;BS Registrar, Department of Family Medicine. RADIOLOGY ROTATION 01/02/2020 – 29/02/2020 2/11/2021 1
- 2. OUTLINE • INTRODUCTION • EPIDEMIOLOGY • BONE ANATOMY OVERVIEW • AETIOLOGY • PATHOPHYSIOLOGY • CLINICAL FEATURES • IMAGING MODALITIES • TREATMENT • COMPLICATIONS • ROLE OF FAMILY PHYSICIAN • CONCLUSION 2/11/2021 2 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 3. INTRODUCTION • “OSTEO” – Bone • “MYEL” – Marrow • “ITIS” – Inflammation • Plural: osteomyelitides • First coined by Auguste Nelaton in 1844. • Can either be Acute, Subacute or Chronic. 2/11/2021 3 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 4. EPIDEMIOLOGY • Omololu et al. [2010] – Acute Osteomyelitis Female:Male 1:1.3, mean age 6-12 years, commonest organism – Staphylococcus Aureus [47.1%]. • Omoke N.I. et al.[2018] ] – Osteomyelitis Female:Male 1:1.7, mean age 9.9 +/- 5.9 years, commonest organism – Staphylococcus Aureus. Presentations – acute[21.1%], subacute[13.2%], chronic [65.8%] 2/11/2021 4 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 5. BONE ANATOMY • Diaphysis • Epiphysis • Epiphyseal plate • Metaphysis • Articular Cartilage • Periosteum • Medullary Cavity • Endosteum 2/11/2021 5
- 6. AETIOLOGY • Staphylococcus Aureus – Commonest • Others – E. Coli, Psedomonas, Klebsiella, Salmonella, Hemophilus Influenza, Group B Streptococcus • Spread can either be Hematogenous (commonest), direct contiguous, direct implantation, post operative. 2/11/2021 6 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 7. PATHOPHYSIOLOGY – 1 • Pathogen gets Implanted • Vascular and cellular response • Suppurative intramedullary edema • Mechanical compression of capillaries and sinusoids • Infarction of marrow tissue and bone • Focal osteolysis and inflammatory exudate • Inflammatory process penetrates inner cortex- PERIOSTEAL ELEVATION 2/11/2021 7 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 8. PATHOPHYSIOLOGY – 2 • Loss of blood supply to cortical bone (cortical bone necrosis) • Cortical and medullary infarct –SEQUESTRUM (Dead bone in situ) • As exudates lifts periosteum, periosteal new bone formation occurs (INVOLUCRUM) • Cloaca: Cortical defect • Marjolin ulcer: occasional malignant transformation of the normal squamous cells lining the sinus tract from the cloacae 2/11/2021 8 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 9. CLINICAL FEATURES • Symptoms and signs include: Fever, chills, pain, swelling usually with extensive loss of limb function. • Common Locations: Lower limbs (commonest), Vertebra, radial styloid, sacroiliac joints. 2/11/2021 9 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 10. IMAGING MODALITIES • PLAIN RADIOGRAPH is the initial imaging of choice • Magnetic resonance imaging • Computed tomography • Bone scintigraphy • Ultrasonography 2/11/2021 10 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 11. PLAIN RADIOGRAPH • Radiographic latent period is 10 days for extremities and 21 days for spine. • Signs include: – Soft tissue swelling and obliterated fat planes seen @ 7-10 days – Regional osteopenia seen as lucencies – Moth eaten or permeative cortical and medullary destruction seen as patchy lucencies in the medullary and cortical regions – Periosteal reaction (laminated) seen 10-14 days – Destruction of adjacent cortex seen 10-14 days – Involucrum – 3 weeks – Sequestrum – 4 weeks – Cloaca – Loss of joint spaces and healing by ankylosis in the vertebrae. 2/11/2021 11 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 12. PLAIN RADIOGRAPH PLAIN RADIOGRAPH OBLIQUE VIEW SHOWING DESTRUCTION OF THE RIGHT 2ND MTPJ Harmer, James & Pickard, James & Stinchcombe, Simon. (2011). The role of diagnostic imaging in the evaluation of suspected osteomyelitis in the foot: A critical review. Foot (Edinburgh, Scotland). 21. 149-53. 10.1016/j.foot.2010.11.005. 12 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 13. PLAIN RADIOGRAPH PLAIN RADIOGRAPH AP/OBLIQUE/LATERAL VIEWS SHOWING OSTEOMYELITIS OF LEFT DISTAL RADIUS http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal-trauma/musculoskeletal/suspected-acute- osteomyelitis#images 13 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 14. PLAIN RADIOGRAPH http://www.learningradiology.com/archives05/COW%20140-Discitis/discitiscorrect.htm 2/11/2021 14 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 15. PLAIN RADIOGRAPH https://radiopaedia.org/articles/bony-sequestrum 2/11/2021 15 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 17. MAGNETIC RESONANCE IMAGING • Sensitivity in detecting Osteomyelitis is high. • Bone marrow edema seen as surrounding bone marrow of lower signal intensity on T1 which changes to bright signal on T2 2/11/2021 17 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 18. MAGNETIC RESONANCE IMAGING https://www.orthobullets.com/spine/2025/adult-pyogenic-vertebral-osteomyelitis 2/11/2021 18 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 22. BONE SCINTIGRAPHY • Commonly used radioisotopes (tracers) include Technetium labeled methylene diphosphonate and Gallium-67 citrate • There is increased uptake (hot spot) due to increased osteoblastic activity as a response to inflammation and bone destruction 2/11/2021 22 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 24. BONE SCINTIGRAPHY https://pubs.rsna.org/doi/pdf/10.1148/rg.323115110 2/11/2021 24 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 25. COMPUTED TOMOGRAPHY • 3-Dimensional multi-planar imaging with improved bone margins visualization. 2/11/2021 25 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 29. Liane Heale et al. CMAJ 2015;187:433-435 ©2015 by Canadian Medical Association POT PUFFY TUMOR 2/11/2021 30 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 30. COMPUTED TOMOGRAPHY https://radiologykey.com/musculoskeletal-infections/ 2/11/2021 31 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 31. ULTRASONOGRAPHY • Good for visualization of effusions and fluid collection 2/11/2021 32 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 32. ULTRASONOGRAPHY 2/11/2021 33 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 33. SINOGRAPHY • PERFORMED IF SINUS TRACT IS PRESENT • As adjunct to surgical plan • Helpful in localizing focus of infection in chronic osteomyelitis 2/11/2021 34 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 34. SINOGRAPHY Pineda, Carlos & Pena, Angelica. (2009). Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy. Seminars in plastic surgery. 23. 80-9. 10.1055/s-0029-1214160. 2/11/2021 35 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 35. TREATMENT • Parenteral antibiotics or oral antibiotics with good bioavailability for extended periods, usually about 6 weeks • Choice of antibiotics based on bone biopsy microscopy, culture and sensitivity results • Empirical choice include the B-lactam antibiotics, clindamycin and vancomycin • If sequestrum and involucrum present, surgical drainage and debridement (saucerization, sequestrectomy/osteotomy/decortication) often necessary • Amputation may be perormed for failed medical and surgical therapies 2/11/2021 38 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 36. COMPLICATIONS • Growth plate arrest • Pathologic fracture • Pyogenic arthritis • Sinus tract formation • Marjolin ulcer • Neural compression • Epidural/prevertebral abscess • Endocarditis • Sepsis • Secondary amyloidosis • Amputation 2/11/2021 39 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 37. Role of Family Physician • Prompt identification of signs and symptoms and high index of suspicion for diagnosis. • Request for baseline laboratory and appropriate radiological investigations • Appropriate referrals involving coordinated and comprehensive care with other specialties including but not limited to the Orthopedic surgeon, Radiologist, Physiotherapist e.t.c. 2/11/2021 40 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 38. CONCLUSION • Osteomyelitis is a common diagnosis in our environment. • Appropriate choice of radiological investigations, prompt diagnosis and treatment options are important indices in preventing complications. • Sufficient Clinical history is Important in guiding the radiologists to make an approriate diagnosis 2/11/2021 41 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 39. REFERENCES • https://emedicine.medscape.com/article/1348767-overview ; Retrieved 20 February 2020 • Winters JL, Cahen I. Acute hematogenous osteomyelitis: a review of sixty-six cases. J Bone Joint Surg Am 1960;42:97 • A.B. Omololu and T.O. Alonge S.O. Ogunlade Acute osteomyelitis in children in Ibadan, Nigeria. Is surgical decompression necessary?; African Journal of Biomedical Research (ISSN: 1119-5096) Vol 7 Num 3, 2010 • Omoke NI. Childhood Pyogenic Osteomyelitis in Abakaliki, South East Nigeria. Niger J Surg [serial online] 2018 [cited 2020 Feb 22];24:27-33. from: http://www.nigerianjsurg.com/text.asp?2018/24/1/27/227621 • https://www.macpeds.com/documents/11LongChap78-osteomyelitis.pdf ; Retrieved 19 February 2020 • Ferri, Fred F. (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 924. ISBN 9780323529570 • Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; & Mitchell, Richard N. (2007). Robbins Basic Pathology (8th ed.). Saunders Elsevier. pp. 810–811 • ACR Criteria for Suspected Osteomyelitis, Septic Arthritis, or Soft-Tissue Infection (Excluding Spine and Diabetic Foot) • http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/musculoskeletal- trauma/musculoskeletal/suspected-acute-osteomyelitis#images ; Retrieved 23 February 2020 • Pineda, Carlos & Pena, Angelica. (2009). Radiographic Imaging in Osteomyelitis: The Role of Plain Radiography, Computed Tomography, Ultrasonography, Magnetic Resonance Imaging, and Scintigraphy. Seminars in plastic surgery. 23. 80-9. 10.1055/s-0029-1214160. 2/11/2021 42 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
- 40. 2/11/2021 43 RADIOLOGICAL MANIFESTATION OF OSTEOMYELITIS
Editor's Notes
- It is the inflammation of the soft tissues of the bone marrow spaces {of the spongiosa}, harversian system of the cortex and the periosteum
- Hilal M. K. et al {2015} retrospective study reviewing between 1969 and 2009, annual global incidence was found to be about 21.8 per 100,000 population with high male to female ratio and commonest organism isolated was S. Aureus (44%) Omololu et al. A retrospective study of 17 children at the orthopedic and trauma unit of Uch with osteomyelitis Omoke N.I. et al. A retrospective study on chidren 18 years and below with Childhood Pyogenic Osteomyelitis at Federal Teaching Hospital, Abakaliki
- 5 types of bones – long bones, flat bones, short bones, irregular bones, sesamoid bones. Using the long bone as a prototype Diaphysis – Long shaft of the bone Epiphysis – Ends of the bone Epiphyseal plate – Growth plate Metaphysis – Between epiphysis and diaphysis Articular Cartilage – Covers epiphysis Periosteum – Bone Covering (pain sensitive) Sharpey’s fibers – via which periosteum attaches to the underlying bone Medullary Cavity – Hollow chamber in the bone Endosteum – Thin layer lining the medullary cavity Medullary Cavity – Red marrow produces red blood cells, yellow marrow produces adipose Whole marrow filled with red marrow at birth, gradually vhanges to yellow marrow with advancing age. Adults have more of yellow marrow with red marrows found in flat bones and distal ends of long bones Blood Supply 1.) Nutrient Artery – supplies marrow and inner cortex 2.) Periosteal vessels - supplies outer cortex 3.) Metaphyseal and epiphyseal vessels Blood supply crosses groth plate in infants and adults. In children 2-16 years, the cartilaginous growth plate prevents the crossover Implication: spread to epiphysis and joint less common in children with exception of humerus at shoulder joint and femur at hip joints which both have their metaphysis in the joint capsule
- Hematogenous spread focus usually at the metaphysis. Post traumatic/direct implantation usually at the diaphysis( common with tibia), direct contigous e.g in DM foot. Post operative e.g external fixator, intramedullary nails placement May also rarely be fungal, skeletal syphilis, tuberculous or non suppurative (i.e. Sclerosing type). Pyogenic by far still the commonest.
- Pathogen gets Implanted into medullary tissue Vascular and cellular response SUPPURATIVE EDEMA(INCREASED INTRAMEDULLARY PRESSURE) Mechanical compression of capillaries and sinusoids Infarction of marrow tissue and bone Focal osteolysis and inflammatory exudate Inflammatory process penetrates inner cortex, enters haversian canal and lacunar systems to reach the subperiosteal space (PERIOSTEAL ELEVATION)
- Loss of blood supply to cortical bone (cortical bone necrosis) Cortical and medullary infarct –SEQUESTRUM (DEAD BONE IN SITU) As exudates lifts periosteum, periosteal new bone formation occurs (INVOLUCRUM) CLOACA: Cortical defect with continuous discharge via a sinus tract Marjolin ulcer: occasional malignant transformation of the normal squamous cells lining the sinus tract from the cloacae
- Vertebra: Lumber>thoracic>cervical It can occur in any of the bones in the body, these are just the commonest sites
- According to the American college of Radiology, plain radiograph is the initial imaging of choice PLAIN RADIOGRAPH is the initial imaging of choice MAGNETIC RESONANCE IMAGING has better soft tissue resolution, is highly sensitive to low grade infections and specific. COMPUTED TOMOGRAPHY with 3-dimensional multiplanar imaging and well-defined bone margins compared to plain radiograph. Shows intraosseous fistula if present. Good for pre-operative evaluation, BONE SCINTIGRAPHY is the earliest means of diagnosis. Shows positive findings as early as 48 hours from onset of symptoms hot spots- malignancies, arthritis, healing fracture line due to increases osteoblastic activity, Cold spot, multiple myeloma, bone infarction/necrosis Not useful in late stages when vascular suplly has been compromised. SENSITIVE BUT NOT SPECIFIC ULTRASONOGRAPHY useful in accessing joint effusions, periosteal elevation and fluid collection adjacent to bone
- Osteolytic lesions from destruction of bones not usually visible until about 50% bone demineralization
- Plain Radiograph, oblique view of the right foot coned down, show the medial 3 digits It shows areas of soft tissue swelling, laminated radio opacities along the periosteum as periosteal reaction in the distal shaft of 2nd metatarsal bone more on the lateral periosteum Diffuse area of lucencies over the distal 2nd metatarsal bone, 2nd Mtpj and proximal aspect of the 2nd proximal phalanx
- Plain radiagrograph AP/Oblique/LAT views of the left fore arm, wrist and hand coned down to the left distal radial and ulnar bone ,wrist joints carpal and metarcarpal bones. It shows areas of diffuse focal lucencies in the distal metaphysis of the left distal radius, indicative of bony destruction
- Plain radiograph Lateral view of the spine coned down to L3 – L4 vertebrae and proximal 2/3rd of the sacral spine It shows Straigthening of the normal lumbar lordosis, however alignment preserved lucencies in the lower magins of L4 vertebral body and upper margins of L5 vertebral body suggestive of destruction of the normal endplates of the vertebra There is narrowing of the intervening intervertebral disc space between L4 an L5 Features suggestive of spondylodiscitis
- Plain radiograph AP and Lateral of the right lower limb coned down to the right distal 2/3rd of femur, knee joint and proximal tibia and fibula It shows Obliteration of the soft tissue planes, increase linear opacities along the outer length of the cortex with slightly irregular margins suggestive of the involucrum A small spindle shape radio opacity surrounded by a rim of lucency in the medullary cavity of the diaphysis suggestive of sequestrum There is a small oval radiolucent defect in the metaphysis of the right femur suggestive of a cloaca
- Plain radiograph AP View of the right tibia and fibula, It shows soft tissue swelling with Obliteration of the fat planes Linear radio opacities along the outer cortical margins of the proximal tibial diaphysis suggestive of involucrum Oval shaped lucency surround by a radio opaque rim seen in the medullary cavity of the proximal tibial diaphysis suggestive of an intraosseous abscess call Brodies abscess in keeping with subacute osteomyelitis
- Excellent soft tisse resolution MRI CI: prosthetic cardiac valves, cochlear implants, claustrophobia, unavailability
- A T2, T1 and T1 post contrast Sagittal View MRI Image of the lumbosacral spine showing a wedged shaped hyperintensity in the L4-L5 disc space with collapse of the adjacent vertebral plateus and herperintense accumulation in the adjoining epidural and prevertebral space This is suggestive of L4-L5 Spondylodiscitis with epidural and prevertebral abscess. The T1 shows similar lesions as hypodense and there is modrate enhancement post contrast Acute spondylodiscitis (Staphylococcus aureus). Sagittal (a) T2-W TSE, (b) T1-W SE and (c) gadalinium-enhanced T1-w MR images of lumbar spie show fluid in L4-L5 disc space, destruction vertebral plateus adjacent to L4-L5 disc and epidural abcess and paravertebral soft tissue.
- A T1 and T1 post contrast Sagittal view MRI images of the Lumbosacral spine showning an hypointense band over both the lower margins of L3 and upper Margin of L5 with collapse of the intervetebral disc. There is enhanement of similar lesion post contrast Features are suggestive of L3-L4 spondylodiscitis
- Femoral condyles (C) and proximal tibia (T) also noted. A Coronal T1 post contrast Magnetic Resonance Image showing the distal 2/3rd of the right femur and proximal 3rd of the right tibia. It shows an oval shaped hypointense lesion with irregular outline and peripheral enhancement following contrast administration in the medullary cavity of the distal femoral metaphysis This is suggestive of Brodie’s Abscess.
- A sagittal view T1 post contrast MRI sequence showing the distal ½ of left thigh and proximal left knee joint, tibia and fibula. It shows an oval shaped hypointense lesion posterior to the distal femoral metaphysis with peripheral enhancement following contrast administration. This is suggestive of subperiosteal abscess collection
- Cold scan in both the angiographic and blood pool phase due to osteolysis as seen in thrombotic/ischemic necrosis e.g. in SCDx three phases: the angiographic, tissue and osseous phases
- An anterior and posterior radionuclide images of a 14 year old male adolescent with history of fever, right leg swelling and reduced limb function showing heterogenous radionuclide uptake over the right tibial diaphysis. This is suggestive of osteomyelitis (arrows) of the right tibia. The uptake at the epiphyseal plates are due to the normal osteoblastic activity in the growing bones.
- Anterior and posterior frog - leg view radionuclide images of a female neonate with history of fever and right thigh swelling showing increased uptake over the distal portion of the right femur. This is suggestive of distal metaphyseal osteomylitis of right femur.
- Provides better visualization of bone margins and useful for pre op evaluation to assess extent of disease before surgery
- A coronal reformatted CT scan Image Bone window coned down to the right humerus and elbow It shows Diffuse hyperdense thickening of the humeral shaft.. Also shows a small hyperdense sclerotic bone fragment seen within the medullary cavity in the distal epiphysis close to the lateral cortex (bony sequestrum).
- Saggital reformatted CT image coned down to the right humerus showing hyperdense Diffuse thickening of the humeral shaft. Small cloaca seen as an isodense defect in the posterior cortex at the distal humeral shaft. A small hyperdense sclerotic bone fragment seen within (bony sequestrum).
- Diffuse thickening and remodelling of the humeral shaft. Small healing cloaca at the distal humeral shaft. Another larger more distal surgical track, with a sclerotic bone fragment seen within (bony sequestrum).
- A Coronal reformatted CT image coned down to the right humerus showing hyperdense cortical thickening of proximal humerus (arrow) and an isodense defect in the lateral cortex in the proximal diaphysis just close to the metaphysis
- Contrast-enhanced computed tomography of the head of a five-year-old girl with headache and fever showing two large subgaleal abscesses (thick arrows) with osteomyelitis of the frontal bone (circled) and intracranial extension of the infection into an epidural empyema (thin arrows). Note: A = anterior, P = posterior. Pot puffy tumor
- Chronic osteomyelitis of the left femur in a 17-year-old boy.Radiograph (A) and computed tomography scan (B) demonstrate involucrum (arrow) that surrounds sequestrum (asterisk). Note air within the proximal femoral diaphysis related to abscess (arrowhead).
- Acute childhood osteomyelitis of the proximal humerus on ultrasound. Transverse (a) and longitudinal (b) ultrasound images of the proximal humerus. Note focal thinning of the humeral cortex (thin white arrow) on the axial images in keeping with a cortical penetration of the infection causing subperiosteal pus collection (asterisk). There is also increased Doppler signal (white arrow head) within the synovium of the long head of the biceps tendon (large white arrow)
- Roentgenogram made in two planes after injection of radio opaque liquid into sinus
- A sinogram of the right femur Anteroposterior view of the right femur demonstrates several radiodense, sharply marginated foci within lucent cavities suggestive of sequestration. (B) Oblique view shows retrograde opacification of a sinus tract defining the course and extent of the fistula and confirming the communication with an abscess in the bone.
- DESTRUCTION OF THE ADVANCING PERIOSTEAL REACTION BY THE GROWING TUMOR CARVES OUT THE CODMAN’S TRIANGLE