Osteomyelitis refers to inflammation of bone that is almost always due to infection, typically

bacterial. This article primarily deals with pyogenic osteomyelitis, which may be acute or
chronic.
Other non-pyogenic causes of osteomyelitis are discussed separately:

tuberculous osteomyelitis

skeletal syphilis

fungal osteomyelitis

Epidemiology
Osteomyelitis can occur at any age. In those without specific risk factors, it is particularly
common between the ages of 2-12 years of age and is more common in males (M:F of 3:1) 6.
Pathology
In most instances, osteomyelitis results from haematogenous spread, although direct extension
from trauma and/or ulcers is also relatively common (especially in the feet of diabetic patients).
In the initial stages of infection, bacteria multiply setting up a localised inflammatory reaction
and resulting in localised cell death. With time, the infection becomes demarcated by a rim of
granulation tissue and new bone deposition.
Although no organisms are recovered in up to 50% of cases 1, when one is isolated
Staphylococcus aureus is by far the most common agent. Different organisms are more common
in specific clinical scenarios 1,4:

Staphylococcus aureus: 80-90% of all infections

Escherichia coli: IVDU (intravenous drug users) and genitourinary tract infection

Pseudomonas spp: IVDU and genitourinary tract infection

Klebsiella spp: IVDU and genitourinary tract infection

Salmonella spp: sickle cell disease

Haemophilus influenzae: neonates

group B streptococci: neonates

Location

Frequency in descending order by location 18:

lower limb (most common)

vertebrae: lumbar > thoracic > cervical

radial styloid

sacroiliac joint

The location of osteomyelitis within a bone varies with age, on account of changing blood supply
1,4
:

neonates: metaphysis and/or epiphysis

children: metaphysis

adults: epiphyses and subchondral regions

Variants

emphysematous osteomyelitis

Radiographic features
In some instances, radiographic features are specific to a region or a particular type of infection,
for example:

subperiosteal abscess

Brodie's abscess

Pott's puffy tumour

sclerosing osteomyelitis of Garr

Below are general features of osteomyelitis.

Plain film

The earliest changes are seen in adjacent soft tissues +/- muscle outlines with swelling and loss
or blurring of normal fat planes. An effusion may be seen in an adjacent joint.

In general, osteomyelitis must extend at least 1 cm and compromise 30 to 50% of bone mineral
content to produce noticeable changes in plain radiographs. Early findings may be subtle, and
changes may not be obvious until 5 to 7 days in children and 10 to 14 days in adults. After this
time a number of changes may be noted:

regional osteopaenia

periosteal reaction/thickening (periostitis): variable, and may appear aggressive including

formation of a Codman's triangle 6

focal bony lysis or cortical loss

endosteal scalloping 8

loss of bony trabecular architecture

new bone apposition

eventual peripheral sclerosis

In chronic or untreated cases eventual formation of a sequestrum, involucrum or cloaca may be

seen.
CT

CT is superior to both MRI and plain film in depicting the bony margins and identifying a
sequestrum or involucrum. The CT features are otherwise similar to plain films. The overall
sensitivity and specificity of CT even in the setting of chronic osteomyelitis is low and according
to one study was 67% and 50%17.
MRI

MRI is most sensitive and specific and is able to identify soft-tissue/joint complications 5,14.

T1
o intermediate to low signal central component (fluid)
o surrounding bone marrow of lower signal than normal due to oedema
o cortical bone destruction

T2
o bone marrow oedema

o central high signal (fluid)

T1 C+
o post contrast enhancement of bone marrow, abscess margins, periosteum and
adjacent soft tissue collections

Ultrasound

Although ultrasound excels as a fast and cheap examination of the soft tissues, and allows soft
tissue collections to be drained it has little direct role in the assessment of osteomyelitis, as it is
unable to visualise within bone.
It does, however, have a role to play in the assessment of soft tissues and joints adjacent to
infected bone, able to visualise soft tissue abscesses, cellulitis, subperiosteal collections and joint
effusion.
Ultrasound also is useful in assessing the extra-osseous components of orthopaedic
instrumentation as it is not affected by metal artefact 3.
Nuclear medicine

A number of techniques may be employed to detect foci of osteomyelitis. These include 2:

Bone scintigraphy (Tc99m)

Increased osteoblastic activity results in increased levels of radiotracer uptake in the surrounding
bone usually both on blood pool and delayed views. It is highly sensitive but not particularly
specific.
In111 labelled WBC and Gallium67 scintigraphy

May be useful in:

diabetic osteomyelitis, especially combined with Tc99m-phosphonate imaging. 2,7

However MRI is now generally used in conjunction with plain films 14,15

orthopaedic implants

vertebral osteomyelitis (Ga67 is best) 2

ulcers in bedridden patients with potential underlying osteomyelitis (In111 with Tc99mphosphonate)

Gallium67 scintigraphy

radiogallium attaches to transferrin, which leaks from the bloodstream into areas of
inflammation showing increased isotope uptake in infection, sterile inflammatory
conditions, and malignancy.

imaging is usually performed 18 to 72 hours after injection and is often performed in

conjunction with radionuclide bone imaging.

one difficulty with gallium is that it does not show bone detail particularly well and may
not distinguish well between bone and nearby soft tissue inflammation.

Gallium scans may reveal abnormal accumulation in patients who have active
osteomyelitis when technetium scans reveal decreased activity (cold lesions) or perhaps
normal activity.

Gallium accumulation may correlate more closely with activity in cases of osteomyelitis
than does technetium uptake

Others
FDG-CT/PET

PET-CT systems are relatively novel techniques that are being applied. FDG-PET may have the
highest diagnostic accuracy for confirming or excluding chronic osteomyelitis in comparison
with bone scintigraphy, MRI, or leukocyte scintigraphy. It is also considered superior to
leukocyte scintigraphy in detecting chronic osteomyelitis in the axial skeleton 9.
Treatment and prognosis
Treatment is typically with intravenous antibiotics, usually for extended periods. If a collection,
sequestrum or involucrum is present then drainage and/or surgical debridement is often
necessary. Amputation is performed with failure of medical therapy or when the infection is lifethreatening.
Complications include 1:

sinus track formation with occasional superimposed squamous cell carcinoma (Marjolin
ulcer)

secondary sarcoma (e.g. osteosarcoma): rare

pathological fracture

secondary amyloidosis

Differential diagnosis

General imaging differential considerations include:

Charcot joint

metastases

primary bone neoplasm

o Ewing sarcoma
o osteosarcoma
o lymphoma
o multiple myeloma

Langerhans cell histiocytosis (LCH)

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radiography, CT, MR, and scintigraphy. AJR Am J Roentgenol. 1991;157 (2): 365-70.
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Infect. Dis. Clin. North Am. 2006;20 (4): 789-825. doi:10.1016/j.idc.2006.09.009 Pubmed citation

10. Averill LW, Hernandez A, Gonzalez L et-al. Diagnosis of osteomyelitis in

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Dr Henry Knipe and A.Prof Frank Gaillard et al.
http://radiopaedia.org/articles/osteomyelitis

Osteomyelitis

Age
o Usually affects children

Septic arthritis more common in adults; osteomyelitis in children

Hallmark characteristics
o Destruction of bone
o Periosteal new bone formation

Organisms
o Newborns

S. aureus

Group B streptococcus

E. coli

o Children

o Adults

S. aureus

S. aureus (most common)

Enteric species

Streptococcus

o Drug addicts

Pseudomonas (most common)

Klebsiella

o Sickle cell disease

Salmonella

Pathogenesis
o Hematogenous spread
o Direct implantation from a traumatic / iatrogenic source
o Extension from adjacent soft-tissue infection

Location
o Lower extremity (most common)

Over pressure points in diabetic foot

o Vertebrae

Lumbar > thoracic > cervical

o Radial styloid
o Sacroiliac joint

ACUTE NEONATAL OSTEOMYELITIS

Age

o Onset <30 days of age

Little or no systemic disturbance

Multicentric involvement more common

o Often joint involvement

Bone scan falsely negative / equivocal in 70%

ACUTE OSTEOMYELITIS IN INFANCY

Age
o <18 months of age

Pathomechanism
o Spread to epiphysis through blood vessels

Marked soft-tissue component

Subperiosteal abscess with extensive periosteal new bone formation

Complications
o Frequent joint involvement

Prognosis
o Rapid healing
ACUTE OSTEOMYELITIS IN CHILDHOOD

Age
o 2-16 years of age

Pathomechanism

o Trans-physeal vessels closed

o Primary focus of infection is in metaphysis

Findings
o Sequestration frequent
o Periosteal elevation
o Small single / multiple osteolytic areas in metaphysis
o Extensive periosteal reaction parallel to shaft (after 3-6 weeks)
o Shortening of bone with destruction of epiphyseal cartilage
o Growth stimulation by hyperemia and premature maturation of adjacent epiphysis
ACUTE OSTEOMYELITIS IN ADULTHOOD

Delicate periosteal new bone

Joint involvement common

o Septic arthritis

X-ray findings
o Initial radiographs often normal for as long as 7-10 days
o Localized soft-tissue swelling adjacent to metaphysis with obliteration of usual fat
planes (after 3-10 days)
o Area of bone destruction (lags 7-14 days behind pathologic changes)

Bone destruction of head of 2nd metatarsal

with periosteal new bone formation
characteristic of osteomyelitis

Involucrum = cloak of laminated /spiculated periosteal reaction (develops after 20 days)

Sequestrum = detached necrotic cortical bone (develops after 30 days)

Cloaca formation = space in which dead bone resides

MR findings
o Bone marrow hypointense on T1WI + hyperintense on T2WI (= water-rich
inflammatory tissue)

DDx
o Neuropathic osteoarthropathy
o Aseptic arthritis
o Acute fracture
o Recent surgery
o Ewings sarcoma

Findings
o Focal / linear cortical involvement hyperintense on T2WI
o Hyperintense halo surrounding cortex on T2WI = subperiosteal infection
o Hyperintense line on T2WI extending from bone to skin surface and enhancement
of borders (= sinus tract)

Nuclear Medicine (accuracy approx. 90%):

o Ga-67 scans

100% sensitivity

Increased uptake 1 day earlier than for Tc-99m MDP

o Gallium helpful for chronic osteomyelitis

Static Tc-99m diphosphonate

o 83% sensitivity
o 5-60% false-negative rate in neonates and children

Complications of osteomyelitis
o Abscess in soft-tissue
o Fistula or sinus formation
o Pathologic fracture
o Extension into joint producing septic arthritis
o Growth disturbance due to epiphyseal involvement
o Severe deformity with delayed treatment

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