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Bacterial Osteomyelitis: Findings on Plain Radiography, CT,

MR, and Scintigraphy
Richard H. Gold,1 Randall A. Hawkins,1 and Robert D. Katz2

Early detection of osteomyelitis is essential if appropriate ther- ment of bone become sequestrated, a thick sheath of pen-
apy is to be started before bone devitalization. Although the osteal new bone, or involucrum, may surround it. The infection
“Tc-methyIene diphosphonate (MDP) bone scan may signify the
possibility of osteomyelitis days or weeks before osseous
changes are apparent on standard radiographs, the radiographic
American Journal of Roentgenology 1991.157:365-370.

changes may provide important diagnostic clues. The 67Ga-citrate

scan augments the diagnostic value of the “Tc-MDP scan, and
the 1111n-labeled WBC scan is useful for detecting abscesses. CT
aids in the detection of sequestra, and MR imaging is useful in
defining the extent of the inflammatory process and in distin-
guishing osteomyelitis from cellulitis. In this article, we review
and correlate the changes of bacterial osteomyelitis shown by
these imaging methods.

Advances in imaging patients with bacterial osteomyelitis

have improved the prognosis of the disease. In this article,
we review and correlate the changes of bacterial osteomyelitis
shown by various methods of imaging.

Plain Radiography
Because the clinical course of acute hematogenous osteo-
myelitis is rapid, early detection is essential if therapy is to be
started before bone devitalization. Although changes on plain
films occur relatively late in comparison with scintigraphic
changes, plain radiography usually is the initial imaging ex-
amination and may provide important clues, such as the
Fig. 1.-Anteroposterior radiographs show penosteal new bone: osteo-
appearance of periosteal new bone (Fig. 1) and widening of myelitis vs malignancy.
the joint (Fig. 2). In infants, sonography is useful in confirming A, Acute hematogenous staphylococcal osteomyelitis of humerus in a
7-year-old boy. Destructive changes are present in metaphysis. When
the presence of excess joint fluid, that, if drained early,
activated by benign stimuli such as pus, blood, or edema, the inner layer
obviates vascular tamponade and resultant osteonecrosis of of displaced periosteum produces uninterrupted new bone of uniform
the epiphysis. In childhood, the vascular metaphysis is the density.
B, Ewing sarcoma of humerus in 18-year-old man. Periosteal new bone
usual site of infection. After infancy, the physis prevents the stimulated by undenying malignancy tends to be interrupted and not
spread of infection to the epiphysis (Fig. 3). Should the space- uniform, and may exhibit multiple delicate longitudinal layers or perpendic-
occupying exudate increase the intramedullary pressure and ular spicules. The latter are reflected in fuzzy-appearing margins of mid
shaft. Longitudinal layers (“onion skinning”) terminate in Codman triangles
strip the peniosteum, vascular thrombosis is followed by bone (arrows), which commonly occur in association with Ewing sarcoma, but
necrosis and formation of sequestra. Should an entire seg- are uncommon with benign disease.

Received January 15, 1991 ; accepted after revision March 1 1 , 1991.

I Department of Radiological Sciences, University of California, School of Medicine, 1 0833 Le Conte Ave., Los Angeles, CA 90024. Address reprint requests to
A. H. Gold.
2 Department of Radiology, Beverly Hills Medical Center, 1177 5. Beverly Dr., Los Angeles, CA 90035.

AJR 157:365-370, August 1991 0361-803x/91/1572-0365 C American Roentgen Ray Society

 are foci for continued infection, their detection and excision
are essential. Tomography or CT may be required to detect
small sequestra. Ring sequestra may complicate pin-tract
infections (Fig. 4) [1].
The onset of subacute hematogenous osteomyelitis (Brodie
abscess) is insidious, and systemic manifestations are mild on
absent (Fig. 5) [2]. Chronic osteomylitis results when there is
continuation of the inflammatory process over many years,
which leads to sclerosis and deformity.
Disorders associated with multifocal bacterial osteomyelitis
include chronic granulomatous disease of childhood, immune
deficiency disorders, sickle cell anemia and its variants (Fig.
6), IV drug abuse (Fig. 7), diabetes mellitus, and subacute
bacterial endocarditis. Other predisposing factors are long-
term indwelling urinary on vascular catheters and immunosup-
pressive therapy.
In contrast to nontuberculous osteomyelitis of the spine,
tuberculous osteomyelitis has a more insidious onset and
progression, and produces greater destruction and anterior
wedging of the vertebral bodies. Tuberculous infection pro-
duces the larger soft-tissue (“cold”) abscess (Fig. 8A). Tuber-
Fig. 2.-Anteroposterior radiograph of hematogenous osteomyelitis of culosis of the spine may give rise to the aneurysmal syndrome
humerus in a 10-month-old girl. In infants and children, osteomyelitis near (Fig. 8B) and calcific debris. Joint tuberculosis, unlike pyogenic
end of a bone may cause joint to fill with a sympathetic effusion or exudate,
leading to an increase in articular interspace. This phenomenon is uncom- infection, progresses very slowly, and is associated with the
American Journal of Roentgenology 1991.157:365-370.

mon In more constrained joints of adufts. In infancy, transphyseal blood diagnostic triad of Phemister (Fig. 9). Tuberculosis in children
vessels may transmit infection from metaphysis to epiphysis, with second-
ary Involvement of joint. A widened joint is obvious in this patient, as are
tends toward multifocality and involvement of the short tu-
destruction of humeral head and exuberant uniform periosteal new bone. bular bones (Fig. i 0).

CT and MR Imaging
may perforate the involucrum in the form of a cloaca, leading
to soft-tissue abscesses and sinus tracts. Because sequestra MR imaging is superior to CT for evaluating the extent of

I
Fig. 3.-Tomograms show effect of physis as a barrier to spread of infection. Fig. 4.-Radiograph shows ring se-
A, Staphylococcal osteomyelitis of femur in a 12-year-old girl. Serpentine foci of osteolysis in metaphysis questrum of pin-tract osteomyelitis com-
and diaphysis represent abscess cavities. Disappearance of transphyseal blood vessels after infancy has plicating skeletal fixation of tibial frac-
allowed physis to prevent spread of infection to epiphysis. tures in a 25-year-old man. Diagnostic of
B, Tuberculosis of the femur in a 7-year-old boy. As shown here, physis of older children is frequently a major pin-tract infection, necrotic ring
breached by tuberculous infection. Alternatively, since metaphysis of hip joint is intracapsular, the infection of sclerotic bone (arrow) is separated
might have spread to epiphysis by way of joint itself. from surrounding viable bone by exudate
or granulation tissue. It is easily distin-
guished from clinically insignificant ther-
mal osteonecrosis caused by high-speed
drilling of a pinhole, which is character-
ized by a broad zone of sclerosis around
the pin tract, but not by a separated ring;
nor should it be confused with fluffy re-
parative bone in tract seen after pin re-
moval.
 1

Fig. 6.-Anteroposterior radiograph shows changes of salmonellal Os-

teomyelitis in tibias of a 3-year-old giri with sickle cell anemia. Suscepti-
bility to hematogenous osteomyelitis is increased manyfold in patients
Fig. 5.-Brodie abscess in distal tibia of a 16-year-old girl. Oblique with sickle cell anemia and related disorders. Approximately 50% of cases
radiograph shows sharply marginated cavity. Sometimes cavity is sur- are caused by Salmonella. Osteomyelitis may occur within a region that
rounded by sclerosis. Soft-tissue swelling, while usually present, may be has been previously devitalized by infarction. As in this case, multiple
absent. Sequestra are uncommon and periosteal new bone inconspicuous bones are frequentiy affected and lesions may be bilaterally symmetric.
(arrow). Abscess is characteristically found in lower tibial metaphysis in Thick and occasionally layered periosteal new bone (arrows) and longitu-
children and adolescents, and metaphysis or diaphysis of femur or tibia in dinal intracortical fissures may parallel extent of lesion. These findings,
adults. Staphylococcus aureus is the usual cause. however, are not specific for osteomyelitis, and may accompany infarction
alone.
American Journal of Roentgenology 1991.157:365-370.

infection. CT is superior to MA imaging for detection of

sequestra and cloacae and can also depict intraos-
(Fig. 1i )
seous gas, an infrequent but reliable sign of osteomyelitis.
However, in a collapsed vertebral body, a linear streak of gas
merely signifies an intraosseous vacuum resulting from post-
traumatic osteonecrosis (KUmmell disease). MR imaging aids
in planning surgery by delineating sinus tracts and soft-tissue
abscesses, by differentiating osteomyelitis from cellulitis, and
by disclosing the extent of intramedullary involvement. MR is
particularly helpful in the evaluation of the diabetic foot (Fig.
1 2) [3]. MA should be used only when it might provide
information unavailable from less expensive imaging methods
and when the results might affect management significantly.
For evaluation of osteomyelitis, MR is as specific as or more
specific and more sensitive than the three-phase 9Tc-meth-
ylene diphosphonate (MDP) bone scan (Fig. 13). The specific- Fig. 7.-Pseudomonas infection of left stemoclavicular joint in a 30-
ity of MR is increased by plain radiographic correlation and year-old male heroin addict. Anteroposterior tomogram shows erosions
and joint widening. An increased frequency of infection in IV drug abusers
by obtaining both Ti and T2-weighted - images. The edema results from hematogenous spread from contaminated hypodermic
and exudate of active infection have a low-intensity signal on needles. Spine, sacrolliacjolnt, stemoclavicularjoint, and symphysis pubis,
Ti-weighted images and a high-intensity signal on T2- sites most commonly Involved in order of decreasing prevalence, represent
the four S’s of osteomyelitis associated with IV drug abuse. In some series,
weighted images. Gram-negative organisms such as Pseudomonas and Kiebsiella have pro-
dominated, while in others Staphylococcus aureus has been the organism
most frequently cultured.

Scintigraphy
Aadionuclide studies useful in examining patients with sus- “flow” or “angiogram” images, blood-pool images, and 2- to
pected osteomyelitis include the 99mTc-MDP scan, 1In-la- 5-hr delayed images (Fig. i 3). Cellulitis is characterized by an
beled WBC scan, and 67Ga-citrate scan [4]. The mTcMDP initially high soft-tissue uptake in the flow phase, and pro-
bone scan may signify the possibility of osteomyelitis days or gressively lower uptake compared with bone uptake in later
weeks before osseous changes are apparent on standard phases. In contradistinction, osteomyelitis gives rise to pro-
radiographs. “Tc-MDP bone scans are sensitive indicators gressively increasing bone uptake over the course of the
of altered osteoblastic activity, but local disturbances in vas- study. The combination of cellulitis and osteomyelitis pro-
cular perfusion, clearance rate, permeability, and chemical duces increased bone and soft-tissue uptake in all three
binding also affect imaging. On standard 99mTc-MDP scans it phases. The 99mTc-MDP scan is not specific for osteomyelitis,
sometimes may be difficult to differentiate soft-tissue uptake and in the appropriate clinical setting may suggest but cannot
from bone uptake in patients with known cellulitis and possible conclusively establish the diagnosis. A fourth phase (imaging
underlying osteomyelitis. To address this problem, the three- 24 hr after infection) may be useful in patients with equivocal
phase “Tc-MDP scan was developed, consisting of dynamic results at the end of three phases, as osteomyelitis usually
 368 GOLD ET AL. AJR:157, August 1991

Fig. 8.-Tuberculosis of spine.

A, CT scan shows erosion of right ilium by a
cold iliopsoas abscess that extended from spine
to pelvis. Patient was a 23-year-old man with a
7-month history of pain and weakness of right
lower limb.
B, Lateral radiograph of lumber spine in a 45-
year-old man shows aneurysmal syndrome due
to tuberculosis. Although narrowing of interver-
tebral disk usually is earliest radiographic fea-
ture of both nontuberculous and tuberculous os-
teomyelitis, scalloping of anterior (and some-
times lateral) margin (arrows) of vertebral bodies
(aneurysmal syndrome) is associated only with
tuberculous infection. Aneurysmal syndrome is
so-called because concavities simulate those
caused by transmitted pulsations of an aortic
aneurysm. Scalloped vertebrae lie within an ab-
5005$ cavity.

Fig. 9.-Anteroposterior radiograph of tuber-

culosis ofthe kneeln a 46-year-old man. Tending
to have a more insidious onset than nontuber-
culous septic arthritis, tuberculous arthritis is
American Journal of Roentgenology 1991.157:365-370.

also associated with profound osteoporosis,

marginal erosions, and long-standing preserva-
tion of contacting articular cartilage, the diag-
nostic triad of Phemister. Rarefactions in sub-
chondral bone of tibia reflect undermining by
tuberculous pannus.

Fig. 10.-Radiograph of tuberculous dactylitis

in a 1-year-old boy. In children, tuberculosis has
a tendency toward multifocality and involvement
of short tubular bones. Lesion of tuberculous
dactylitis, unlike tuberculosis of long bones,
tends not to invade adjacent joints. In proximal
phalanx of index finger, shown here, slow dab-
oration of periosteal new bone that accompanied
gradual resorption of inner surface of cortex led
to a typically expanded fusiform appearance
called spina ventosa (literally, a wind-filled pro-
jection, such as a finger).

Fig. 11.-Chronic osteomyelitis with seques-

trum of proximal tibia. Six years earlier, this 30-
year-old man had a fracture of distal tibia that
became infected after fixation with an intramed-
ullary rod. Rod was subsequentiy removed. Cur-
rent radiographs disclosed sclerotic reactive
bone outlining track of former rod. Correspond-
ing “Tc-MDP bone scan revealed striking in-
crease in activity in proximal tibia.
A, CT scan of proximal tibia shows rod track
surrounded by a thick, sclerotic rim and contain-
Ing a central sequestrum. Adjacent marrow ap-
pears normal.
B, Axial MR image (SE 1500/56) shows a
bright, high-intensity abscess in rod track, with
a central low-intensity sequestrum and a rim of
low-intensity sclerotic bone. These findings, to-
gether with absence of high signal intensity in
adjacent marrow and soft tissues, Imply that
active infection is present only in rod track.

provokes further increase in activity. Single-photon emission 1111n-labeled WBC scan and the 67Ga scan are useful adjuncts,
CT bone scans provide additional anatomic information. and while usually no more sensitive than the combination of
Although the overall sensitivity of the 99mTc-MDP scan for Tc-MDP bone scans and plain radiographs in detecting
active osteomyelitis is high (approximately 95%), false-nega- osteomyelitis, they are more specific (Figs. 14 and 15). The
tive diagnoses may occur, particularly in neonates. Both the 111In-WBC scan, although positive in some noninfected frac-
 Fig. 12.-Differential diagnosis in this 84-year-old diabetic woman includes neuropathic osteoarthropathy, cellulitis, pyarthrosis, and osteomyelitis.
A, Anteroposterior radiograph of foot shows striking osteoporosis and possible erosion of medial margin of head of second metatarsal. Results of
three-phase Tc-MDP bone scan were equivocal.
B and C, Ti-weighted (SE 500/28, B) and T2-weighted (SE 1500/56, C) coronal MR images show normal signal intensity in bones and joints adjacent
to clinically suspicious areas, thereby excluding osteomyelitis and pyarthrosis. Neuropathic osteoarthropathy is also unlikely in absence of joint eftusions.
Soft tissues medial to first metatarsophalangeal joint (arrows) have decreased signal intensity on Ti-weighted image and increased intensity on T2-
weighted image, consistent with cellulitis.
American Journal of Roentgenology 1991.157:365-370.

i.
E1 1 ‘
s.’-

B C

Fig. 13.-Acute hematogenous osteomyelitis of lumbar spine in a 59-year-old man, proved by biopsy. Comparison of imaging techniques.
A, Lateral radiograph shows narrowing of L3-L4 disk, osteolytic foci next to endplates, and erosion of superior endplate of L4 (arrow).
B and C, Three-phase “Tc-MDP bone scan shows a corresponding gradual increase in activity in dynamic flow phase (B), which becomes even more
intense on 5-hr postinjection image (C).
0, PET scan in coronal plane, performed as part of an investigational study approved by the Human Subjects Protection Committee, shows a
corresponding mild increase in activity (arrow) due to a focus of leukocytes preferentially metabolizing glucose from lV-infused FDG.
E, TI-weighted sagittal MR image (SE 500/28) shows relatively high-intensity fatty marrow has been replaced by edema of intermediate intensity in
bodies of L4 and L5, and adjacent endplates have undergone central destruction.
F, T2-weighted sagittal image (SE 2000/84) shows involved vertebrae have a high-intensity signal. An even more intense focus centered at intervertebral
disk represents an abscess.
 370 GOLD ET AL. AJR:157, August 1991

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Fig. 14.-Usefulness of sequential ‘“Tc-MDP and 7Ga scans in evaluating suspected chronic Fig. 15.-Abscess, complicating total hip ar-
osteomyelitis. Eleven years earlier, a 34-year-old man had a fracture of the right femur that was throplasty, shown by 111ln-WBC scan. Fever and
stabilized with an intramedullary rod. One year later, fracture healed and rod was removed. Since thigh pain developed 10 years after surgery in a
then, he had had intermittent thigh discomfort that had increased during the past 6 months. New 62-year-old man. Aspiration of joint yielded Staph-
radiographs disclosed diffuse cortical thickening and mottled sclerosis of middle third of ylococcus aureus. 111In-WBC scan shows an in-
femur. tense focus of activity (arrow) in abscess.
American Journal of Roentgenology 1991.157:365-370.

A, A ‘“Tc-MDP four-phase scan shows progressively increasing bone and soft-tissue activity
throughout flow, blood-pool, and 4-hr phases, culminating in strikingly increased activity in femoral
shaft on this 24-hr delayed image.
B, Additional evidence of chronic osteomyelitis, as well as a soft-tissue abscess, is provided by
a ‘VGa scan showing focus of intense activity extending from medial soft tissues (arrow) to femur.

tunes, still tends to be preferred over the 67Ga scan because creases the specificity of PET. Osteomyelitis nevertheless
of its greater specificity for infection. The sensitivity of the may yield an abnormal finding on PET body scans (Fig. 13).
111In-WBC scan is greater for acute than for chronic infection,
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