Spencer McClelland, HMS III

Gillian Lieberman, MD
March, 2011

Osteomyelitis:
The Role of Radiography in Diagnosis

Spencer McClelland, HMS III

Gillian Lieberman, MD
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Let us begin with a patient presentation.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Our Patient: History

• 51 yo M with a history of hypertension who
presents with right foot swelling of two months’
duration
• The process began with a “callus” that he noticed on
the underside of his right foot, which flaked off to
reveal an ulcerated surface
• Over the intervening two months, his foot became
progressively swollen, but not painful
• His PCP had tried him on courses of Doxycycline
and Ciprofloxacin, with some improvement, but
without resolution
• On the day prior to admission, he underwent a foot
X-ray which showed findings concerning for
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osteomyelitis
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Our Patient:
Foot X-ray

Source: BIDMC PACS

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Having introduced our patient and

looked briefly at his presenting X-ray,
let us talk about osteomyelitis.

We will return to his X-ray shortly.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: Overview
• Infection of bone
• Can occur by:
• Contiguous spreading (i.e. from an ulcer)
• Hematogenous seeding (i.e. in bacteremia)
• Direct inoculation (i.e. from trauma)
• Organisms responsible can be
monomicrobial or polymicrobial
• Hematogenous is usually monomicrobial
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Jeffcoate, WJ, et al. Clin Infec Dis. 2004
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: Diagnosis
• Diagnosis of osteomyelitis requires one of the
following:
• Isolation of bacteria from a bone biopsy sample
obtained via sterile technique, together with
histologic findings of inflammation and osteonecrosis
• Positive radiologic finding beneath a foot ulcer
• Positive radiologic finding with positive blood
cultures
• Probing to bone in a diabetic foot ulcer
• Diabetic foot ulcer greater than 2 X 2 cm

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Jeffcoate, WJ, et al. Clin Infec Dis. 2004; Grayson, ML, et al, JAMA, 1995
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: Diagnosis
• Diagnosis of osteomyelitis requires one of the
following:
• Isolation of bacteria from a bone biopsy sample
obtained via sterile technique, together with
histologic findings of inflammation and osteonecrosis
• Positive radiologic finding beneath a foot ulcer
• Positive radiologic finding with positive blood
cultures
• Probing to bone in a diabetic foot ulcer
• Diabetic foot ulcer greater than 2 X 2 cm

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Jeffcoate, WJ, et al. Clin Infec Dis. 2004; Grayson, ML, et al, JAMA, 1995
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Having introduced the concept of

osteomyelitis and the ways to diagnose
it, let us discuss the specific radiologic
findings that support a diagnosis.

We will start with X-ray.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: X-ray Findings

• Sensitivity 43-75%, specificity 75-83%
• Timing
• Soft tissue changes visible in 3 days
• Bone changes visible in 1-2 weeks
• Early findings
• Bone: osteopenia
• Late findings
• Bone: cortical erosion, mixed lucency and sclerosis,
periosteal reaction
• Soft tissue: swelling

Pineda, C, et al. Infect Dis Clin North Am. 2006 10

 Spencer McClelland, HMS III
Gillian Lieberman, MD

Now let us return to our patient’s foot

X-ray to look for some of the specific
findings suggestive of osteomyelitis.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Our Patient:
Foot X-ray
• Marked bone lysis of the
distal first metatarsal, first
proximal phalanx, and first
distal phalanx
• Mild cortical lucency and
sclerosis of the medial aspect
of the distal second
metatarsal
• Marked soft tissue swelling
along the medial foot and
surrounding the first toe
joints
• Solid periosteal reaction of
the first metatarsal
Source: BIDMC PACS
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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Having discussed the findings of

osteomyelitis on X-ray and examined
our patient’s foot X-ray, let us
continue with a discussion of findings
on MRI that are suggestive of
osteomyelitis.

We will then look at an example from

a patient with recurrent pubic
symphysis osteomyelitis. 13
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: MRI Findings

• Sensitivity 82-100%, specificity 75-96%
• Can detect early (i.e. within 3-5 days)
Acute/Active Chronic
• Medullary space: • Low signal on T1 and T2
• Fat is replaced by edema, so: • Bone sclerosis with cortical
• Low signal on T1 thickening
• High signal on T2, STIR, or • Sequestra on gadolinium-
fat-suppressed sequences enhanced T1
• Possible cortical disruption • Narrow transition zone
• Wide transition zone
• Soft tissue: edema, abscess, sinus
tract, ulcer, cellulitis
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Pineda, C, et al. Infect Dis Clin North Am. 2006; Sammak, B, et al, Eur Radiol, 1999
 Spencer McClelland, HMS III
Gillian Lieberman, MD
Companion Patient #1:
Axial T1
Axial T2 Fat Suppression
MRI Pelvis
• Areas of low signal intensity
• Soft tissue irregularity
Source: BIDMC PACS
• Areas of high signal intensity
• Soft tissue irregularity
• Superficial hyperintensity
consistent with cellulitis
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Source: BIDMC PACS
 Spencer McClelland, HMS III
Gillian Lieberman, MD
Companion Patient #1:
MRI Pelvis
• Sinus tract

Axial Pre-Contrast Coronal Post-Contrast

Source: BIDMC PACS Source: BIDMC PACS

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Having discussed the findings of

osteomyelitis on MRI, let us continue
with a discussion of findings on CT
that are suggestive of osteomyelitis.

We will then look at an example from

a patient with osteomyelitis involving
the left hip joint.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: CT Findings
• Superior spatial resolution compared to MRI,
but lower sensitivity and specificity
• Useful when MRI is contraindicated or
unavailable, or for surgical planning
• Bone findings: cortical breakdown, trabecular
changes, periosteal reaction, intraosseous gas
• Soft tissue findings: sinus tract projection
• Particularly good for showing sequestra and
involucra (discussed later)
Pineda, C, et al. Infect Dis Clin North Am. 2006; Sammak, B, et al, Eur Radiol, 1999 18
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Companion Patient #2:

CT Hip
• Intraosseous gas • Intraosseous gas • Intraosseous gas
• Cortical thinning • Cortical thinning • Deep tissue
• Soft tissue edema • Soft tissue edema emphysema

Axial C- Coronal C- Sagittal C-

Source: BIDMC PACS Source: BIDMC PACS Source: BIDMC PACS 19
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Having looked at the findings of

osteomyelitis on X-ray, MRI, and CT,
let us look briefly at some findings
specific to osteomyelitis that are
visible on all three modalities.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis: Additional Findings

• Sequestrum
• Large devascularized fragment of bone
separated from healthy bone after undergoing
ischemic necrosis
• Involucrum
• New bone deposited around a sequestrum,
resulting from cortical damage stimulating
the periosteum to lay down new bone and
surround the sequestrum
• Brodie’s abscess
• Subacute form of osteomyelitis
• Common in children, especially boys
• Focal abscess most commonly found in the
metaphyses of long bones, particularly the
tibia
Pineda, C, et al. Infect Dis Clin North Am. 2006; Sammak, B, et al, Eur Radiol, 1999
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All photos courtesy of Sergio Fernández Tapia, MD, Tampico, Mexico, from Pineda, C, et al, Infect Dis Clin North Am. 2006
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Now let us discuss the role of nuclear

medicine in diagnosing osteomyelitis.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis
Nuclear Medicine: Bone Scan Findings
• Three-phase bone scan with radiolabeled marker like
Technetium-99
• Flow phase: immediately after injection
• Shows areas of increased blood flow, i.e. inflammation
• Pooling phase: 15 minutes after injection
• Shows areas of vascular permeability
• Delayed phase: 4 hours after injection
• Shows areas of retained uptake, most specific for osteomyelitis
• Sensitivity/Specificity
• If positive in three phases, sensitivity 73-100%
• Metanalysis: sensitivity 61%, specificity 25%
• Sensitivity decreases with coexisting conditions, like trauma,
surgery, orthopedic hardware, diabetes
Pineda, C, et al. Infect Dis Clin North Am. 2006 23
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Now we will see an example of a

three-phase bone scan, showing
increased uptake in the right foot in all
three phases, consistent with a
diagnosis of osteomyelitis.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Companion Patient #3
Foot Bone Scan: Flow Phase

R L
Courtesy of Dr. Kevin Donohoe

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Companion Patient #3
Foot Bone Scan: Flow Phase

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Courtesy of Dr. Kevin Donohoe
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Companion Patient #3
Foot Bone Scan: Flow Phase

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Courtesy of Dr. Kevin Donohoe
 Spencer McClelland, HMS III
Gillian Lieberman, MD

Now let us turn to a brief discussion of

other nuclear modalities, with an
emphasis on the gallium scan.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis
Nuclear Medicine Findings: Gallium
Scan
• Uses radiolabeled gallium, which likely attaches to
acute phase reactant proteins
• Good sensitivity (25-80%)
• More specific than three-phase bone scan (67%)
• False positives due to fracture and neoplasm
• Scan occurs 24 hours after injection, so only useful
in the clinically stable patient

Pineda, C, et al. Infect Dis Clin North Am. 2006 29

 Spencer McClelland, HMS III
Gillian Lieberman, MD

Osteomyelitis
Nuclear Medicine: Other Studies
• Tagged WBCs
• Radiolabeled antibiotics
• Labeled immunoglobulins
• Streptavidin
• 111In-biotin

Pineda, C, et al. Infect Dis Clin North Am. 2006 30

 Spencer McClelland, HMS III
Gillian Lieberman, MD

Having completed our discussion of

the various imaging modalities used in
diagnosing osteomyelitis, we will now
return to our patient.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Our Patient: Surgery

• Given his foot ulcer with radiographic findings
consistent with osteomyelitis, he underwent surgical
exploration, debridement, and biopsy
• Grossly, there was very little necrotic or actively
infected tissue
• The biopsy result showed:
• “Fragments of granulation tissue with chronic inflammation,
bone with reparative changes and focal necrosis with
marrow space fibrosis and chronic inflammation; no
significant acute inflammation noted.”
• Wound culture grew Staphylococcus aureus, susceptible
to Methicillin

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Our Patient: Treatment

• Given a known Penicillin allergy, the patient was
started on IV Daptomycin, with a PICC line for
home therapy totaling six weeks
• At the time of last follow-up, he had finished his
Daptomycin course and, as his foot had showed
signs of improvement, he had been transitioned to
oral Moxifloxacin
• Follow-up with Infectious Disease and Podiatry is
ongoing

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

To end, we will look at an algorithm

for working up the possibility of
osteomyelitis in a patient with a foot
ulcer, highlighting our patient’s course
as previously described.

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

An Algorithm:
Putting It All Together

Source: Lipsky BA, et al. Clin Infect Dis. 2004

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 Spencer McClelland, HMS III
Gillian Lieberman, MD

Take-Home Points
• Osteomyelitis is an infection of bone
• The gold standard for diagnosis is a sterile surgical biopsy,
but imaging can play a great role in the absence of that
• X-ray is the first line for imaging, as it is fast and
inexpensive, but its sensitivity is only fair, since it takes
weeks for changes to become apparent
• MRI is the best modality, both in terms of sensitivity and
specificity, and in terms of its ability to detect changes
early on
• Nuclear medicine studies have good sensitivity, but mixed
specificity, as many other conditions can cause increased
focal uptake of radiolabeled markers
• Many algorithms exist for how to diagnose osteomyelitis
in different clinical scenarios… follow them!
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 Student Name, year
Gillian Lieberman, MD

Acknowledgments
• Dr. Jim Wu
• Dr. Kevin Donohoe
• Dr. David Glazier
• Dr. Mai-Lan Ho
• Dr. Monica Agarwal
• Dr. Gillian Lieberman
• Emily Hanson

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 Student Name, year
Gillian Lieberman, MD

References
• Grayson, ML, et al. Probing to bone in infected pedal ulcers. A clinical sign of
underlying osteomyelitis in diabetic patients. JAMA. 1995 Mar 1;273(9):721-3.
• Jeffcoate, WJ, et al. Controversies in Diagnosis and Management of
Osteomyelitis of the Foot in Diabetes. Clin Infect Dis. (2004) 39 (Supplement
2): S115-S122.
• Lipsky, BA, et al. Diagnosis and Treatment of Diabetic Foot Infections. Clin
Infect Dis. (2004) 39 (7): 885-910.
• Mader JT, et al. Update on the diagnosis and management of osteomyelitis.
Clin Podiatr Med Surg. 1996;13(4):701-24
• Pineda, C, et al. Imaging of Osteomyelitis: Current Concepts. Infect Dis Clin
North Am. 2006 Dec;20(4):789-825.
• Sammak, B, et al. Osteomyelitis: a review of currently used imaging
techniques. Eur Radiol. 9,894-900 (1999).

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Student Name, year
Gillian Lieberman, MD

THANK YOU!
And Happy Belated St. Patty’s Day,
from Brooklyn the Irish Croco-Dog!

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