Osteomyelitis In Children: A Race Against Time

Poster No.: C-1439

Congress: ECR 2019
Type: Educational Exhibit
Authors: 1 2
C. Astor Rodriguez , R. Giovanetti González , P. Calvo Azabarte ,
1

1 1 3
S. Dieguez Tapias , C. Villaespesa , A. Palomares Morales ;
1 2 3
Toledo/ES, Córdoba/ES, Toledo, Ci/ES
Keywords: Infection, Diagnostic procedure, Ultrasound, MR, Conventional
radiography, Paediatric, Bones, Inflammation
DOI: 10.26044/ecr2019/C-1439

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Learning objectives

To illustrate the imaging findings of acute childhood osteomyelitis.

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Images for this section:

Fig. 1: Childhood Osteomyelitis: A Race Against Time

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Background

The term osteomyelitis refers to inflammation of the bone caused by a bacterial or

fungal organism and principally affects the most vascularized regions of the growing
skeleton.

It is considered an acute process when it lingers less than two weeks.

Pediatric bone infections peak at a rate of 80 per 100,000, being higher in boys than
in girls. Almost one third of children with osteomyelitis have previous trauma. The most
frequent pathogens include: Staphylococcus aureus, Kingella Kingae, Streptococcus
pyogenes and Streptococcus pneumoniae.

Knowing the anatomy of the growing skeleton is important to understand the

distribution of osteomyelitis. The most affected site is the metaphysis due to its
abundant vascularization; during the first 18 months there is vascular communication
between the metaphysis and the epiphysis which facilitates the extension of the infection
to the epiphysis.

The periosteum is formed of two layers: a fibrous superficial layer and an inner
vascularized level called the cambium. Infection can reach the periosteum by direct
seeding or from a metaphyseal focus.

The lower extremities account for 75% of the infections in children, with the femur (27%),
tibia (26%), pelvis (9%) and feet being the most common locations.

Early diagnosis is imperative to prevent possible complications and long-term

morbidity.

Children with osteomyelitis may present with pain with deambulation, fever, focal
tenderness or redness, and these symptoms tend to worse rapidly. Clinical suspicion
should be followed by radiological assessment.

Imaging of infection must depict the location of single or multiple foci and the presence
of drainable collections. The main imaging techniques include: conventional radiology,
ultrasound, and magnetic resonance. Other less preferred possibilities include computed
tomography and skeletal scintigraphy.

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Antibiotic therapy should be used empirically while awaiting imaging, especially if the
child demonstrates symptoms consistent with sepsis. Surgical intervention in OM is
performed to obtain microbiologic cultures, control the primary source of infection, and
preserve maximal function.

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Images for this section:

Fig. 2: Background

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

Fig. 3: Growing bone vascularization

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© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Findings and procedure details

Once osteomyelitis (OM) is clinically suspected, imaging should be performed to confirm

the diagnosis and depict infected collections and complications.

The first imaging approach is conventional radiology. Allows the clinician and
radiologist to depict other diagnoses including acute fractures and tumors. Less than 20%
of the radiographs are diagnostic of OM and abnormalities usually appear 10 or more
days after the onset of the infection. Early radiological findings may show deep soft tissue
swelling and visible elevation of the periosteum.

Magnetic resonance imaging (MRI) is the predominant modality for the evaluation
of bone infections. MRI protocol should include T1-weighted images (WI), STIR, T2-
WI fat-saturated (FS), and additionally gadolinium enhanced T1FS series. Gadolinium
enhancement does not increase the sensitivity or specificity for diagnosis of osteomyelitis.
If T2FS and STIR series are normal, gadolinium enhancement has no added value,
except for infection of the epiphyseal cartilage in which unenhanced images can be
negative. Gadolinium enhancement may increase the confidence in the diagnosis of an
abscess. MRI findings may show low signal intensity on T1, high signal on T2FS and
greater enhancement relative to the adjacent normal bone marrow.

MRI allows radiologist to identify soft tissue, intraosseous and subperiosteal collections:
an intraosseous abscess is seen as an area of high signal intensity in the bone on STIR
or T2-weighted images. On gadolinium-enhanced images, the typical appearance is a
nonenhanced center surrounded by a rim of enhanced tissue. Subperiosteal collections
are recognized by an elevated fibrous layer of the periosteum (hypointense linear
structure), which is separated from the underlying bone cortex by pus (high signal
intensity on T2-WI or STIR). A "V" form could be identified at the perichondrium where
the detached periosteum and cortex converge.

Young infants and neonates may show very low signal intensity on T1 WI and higher
in STIR due to abundant hematogenous tissue. Therefore, fat saturated series may not
help and contrast enhanced T1 non-FS should be obtained in these patients.

Ultrasound (US) could be the second imaging approach when MRI is not available.
The earliest manifestation of osteomyelitis is juxtacortical soft tissue swelling with early
periosteal thickening. Inflammatory changes are depicted as areas of hyperemia on
power Doppler or color Doppler imaging. US is especially valuable for the diagnosis of
subperiosteal abscesses; the fibrous layer of the periosteum appears as an echogenic
line the subperiosteal fluid is of low or mixed echogenicity.

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Nuclear medicine imaging techniques may help to detect osseous involvement
(scintigraphy) and for distinguishing between active infection and healing in treated
children (PET-CT).

We present a collection of cases demonstrating the different radiological findings of acute

osteomyelitis.

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Images for this section:

Fig. 4: Findings and Procedure Details

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Fig. 5: 3 yo boy with right ankle tenderness and pain. Fig. 1, 2 and 3 show the initial
plain film and US, with soft tissue collection and rarefaction of the distal metaphysis of
the tibia. Fig. 4, 5 and 6 show poor evolution with pathological fractures.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

Fig. 6: 6 yo girl with left ankle tenderness and pain. Fig. 1 US showing subperiosteal
collection on the distal fibula. Fig. 2, 3, 4 and 5 T1, T2 and T1 contrast enhaced weighted
images show abnormal edema and enhancement on fibula metaphysis with subperiosteal
abscess.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Fig. 7: 1 yo boy with left ankle swelling. Fig. 1 US shows slight asymmetry on the
calcaneus metaphysis. Fig. 2, 3 and 4: T1, T2 and T1 contrast enhaced weighted images
show abnormal bone edema and enhancement on the calcaneus and surrounding soft
tissues.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Fig. 8: 13 month boy with fever and functional impotence of the left arm. Fig. 1: Plain
film shows epiphyseal erosion with sclerotic changes. Fig. 2, 3 and 4: T1, STIR and
T1 contrast enhaced weighted images show abnormal bone edema and intraosseous
abscess.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

Fig. 9: 2 yo boy with right wrist tenderness. Fig. 1: No bone rarefaction or cortical
permeation is revealed. Fig. 2, 3 and 4: US shows subperiosteal collection with soft tissue
edema and high vascularity.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Fig. 10: 9 yo boy with right arm tenderness and fever. Fig. 1, 2: Subperiosteal abscess
with increased vascularity. Fig. 3 Coronal T2 WI: increased signal and well defined
intraosseus liquid collection Fig 4: Contrast-enhanced T1WI demonstrates intraosseous
abscess.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Fig. 11: 13 yo boy with left hip pain with deambulation and fever. Fig. 1: Metaphyseal
radiolucency (thin arrow) and soft tissue swelling (thick arrow) Fig. 2 and 3: T1 and T2FS
WI shows bone signal loss, effusion and soft tissue oedema. Fig 4 and 5: CE T1FS shows
intraosseous abscess and fistulous tract.

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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Conclusion

Imaging assessment of osteomyelitis, particularly MRI, has a substantive impact on

clinical decisions and surgical approach. It should be performed shortly after clinical
suspicion.

Identifying drainable collections such as intraosseous abscess and subperiosteal

collections is essential to pose surgical management.

Radiologists must be familiar with the different presentations of childhood osteomyelitis

to establish an early diagnosis and therefore avoid possible complications.

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Images for this section:

Fig. 12: Conclusion

© COMPLEJO HOSPITALARIO DE TOLEDO - Toledo/ES

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References

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Changing Disease. Radiology. 2017;283(3):629-643.

Guillerman RP. Osteomyelitis and beyond. Pediatr Radiol. 2013; 43: S193-S203.

Jaramillo D. Infection: musculoskeletal. Pediatr Radiol. 2011; 41: S127-S134.

Arnold JC et al. Osteoarticular Infections in Children. Infect Dis Clin N Am. 2015;
29:557-574.

Karmazyn B. Imaging Approach to Acute Hematogenous Osteomyelitis in Children: An

Update. Semin Ultrasound CT MRI. 2010; 31:100-106.

Pruthi S et al. Infectious and Inflammatory Disorders. Radiol Clin N Am. 2009; 47:
911-926.

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