Imaging of Osteomyelitis with Special Reference to Children

Infection of bone in children represents a diagnostic and therapeutic challenge to the pediatrician, the surgeon, the radiologist, and the pathologist. The pattern of manifestation varies and is dependent on the site of involvement, the initiating event, the infecting organism, and the acute or chronic nature of the illness. Early diagnosis allows prompt treatment, which can prevent many of the dreaded complications of this disease. Plain radiographs remain the initial imaging modality used in the diagnosis and differential diagnosis of osteomyelitis. However, with the advent of newer imaging techniques such as scintigraphy, ultrasonography, computed tomography, and magnetic resonance imaging, a higher degree of accuracy in diagnosis and definition of the extent of the disease has been achieved. The time interval between the onset of symptoms and diagnosis has also been significantly reduced. Although magnetic resonance imaging has the additional advantage of multiplanar capability, greater anatomic detail, and excellent soft tissue resolution, it is a relatively expensive technique, which somewhat limits its use. Following a brief review of the classification and pathophysiology of osteomyelitis, we have tried to elucidate the utility of various imaging modalities in the diagnosis of osteomyelitis in children, outlining their relative strengths and weaknesses. Certain entities specific to children and a brief review of differential diagnosis are also presented.

KEYWORDS

Pediatric musculoskeletal imaging - osteomyelitis - septic - arthritis

REFERENCES

• 1 Griffin P P. Bone and joint infections in children.  Pediatr Clin North Am. 1967;  14 533-548
• 2 Cole W G. The management of chronic osteomyelitis.  Clin Orthop. 1991;  264 84-89
• 3 Oudjhane K. Infection. In: Reed Martin H. Pediatric Skeletal Radiology Baltimore; Williams & Wilkins 1992: 393-425
• 4 David R, Barron B J, Modewell J E. Osteomyelitis, acute and chronic.  Radiol Clin North Am. 1987;  25 1171-1201
• 5 Murray I PC. Photopenia in skeletal scintigraphy of suspected bone and joint infection.  Clin Nucl Med. 1982;  7 13-16
• 6 Maurer A H, Chen D C, Camargo E E, Wong D F, Wagner Jr H N, Alderson P O. Utility of three-phase skeletal scintigraphy in suspected osteomyelitis: concise communication.  J Nucl Med. 1981;  22 941-949
• 7 Alazraki N, Dries D, Datz F, Lawrence P, Greenberg E, Taylor jr A. Value of a 24-hour image (four phase scan) in assessing osteomyelitis in patients with peripheral vascular disease.  J Nucl Med. 1985;  26 711-717
• 8 Turpin S, Lambert R. Role of scintigraphy in musculoskeletal and spinal infections.  Radiol Clin North Am. 2001;  39 169-189
• 9 Sullivan D C, Rosenfield N S, Ogden J, Gottschalk A. Problems in the scintigraphic detection of osteomyelitis in children.  Radiology. 1980;  135 731-736
• 10 Borman T R, Johnson R A, Sherman F C. Gallium scintigraphy for diagnosis of septic arthritis and osteomyelitis in children.  J Pediatr Orthop. 1986;  6 317-325
• 11 Lewin J S, Rosenfield N S, Hoffer P B, Downing D. Acute osteomyelitis in children: combined Tc-99m and Ga-67 imaging.  Radiology. 1986;  158 795-804
• 12 Lantto T, Kaukonen J P, Kokkola A, Laitninen R, Vorne M. Tc99m HMPAO labeled leukocytes superior to bone scan in the detection of osteomyelitis in children.  Clin Nucl Med. 1992;  17 7-10
• 13 Connolly L P, Connolly S A, Drubach L A, Jaramillo D, Treves S T. Acute hematogenous osteomyelitis of children: assessment of skeletal scintigraphy-based diagnosis in the era of MRI.  J Nucl Med. 2002;  43 1310-1316
• 14 Kaiser S, Jorulf H, Hirsch G. Clinical value of imaging techniques in childhood osteomyelitis.  Acta Radiol. 1998;  39 523-531
• 15 Jaramillo D, Hoffer F A. Cartilaginous epiphysis and growth plate: normal and abnormal MR imaging findings.  AJR Am J Roentgenol. 1992;  158 1105-1110
• 16 Beltran J, Noto A M, McGhee R B, Freedy R M, McCalla M S. Infections of the musculoskeletal system: high field strength MR imaging.  Radiology. 1987;  164 449-454
• 17 Modic M T, Pflanze W, Feiglin D H, Belhobek G. Magnetic resonance imaging of musculoskeletal infections.  Radiol Clin North Am. 1986;  24 247-258
• 18 Unger E, Moldofsky P, Gatenby R, Hartz W, Broder G. Diagnosis of osteomyelitis by MR imaging.  AJR Am J Roentgenol. 1988;  150 605-610
• 19 Morrison W B, Schweitzer M E, Bock G W et al.. Diagnosis of osteomyelitis: utility of fat suppressed contrast-enhanced MR imaging.  Radiology. 1993;  189 251-257
• 20 Erdman W A, Tamburro F, Jayson H T, Weatherall P T, Ferry K B, Peshock R M. Osteomyelitis: characteristics and pitfalls of diagnosis with MR imaging.  Radiology. 1991;  180 533-539
• 21 Tang J SH, Gold R H, Basset L W, Seeger L L. Musculoskeletal infection of the extremities: evaluation by MR imaging.  Radiology. 1988;  166 205-209
• 22 Poyhia T, Azouz E M. MR imaging evaluation of subacute and chronic bone abscesses in children.  Pediatr Radiol. 2000;  30 763-768
• 23 Dangman B C, Hoffer F A, Rand F F, Rourke E J. Osteomyelitis in children: gadolinium enhanced MR imaging.  Radiology. 1992;  182 743-747
• 24 Gold R H, Hawkins R A, Katz R D. Bacterial osteomyelitis: findings on plain radiography, CT, MR and scintigraphy.  AJR Am J Roentgenol. 1991;  157 365-370
• 25 Veillard E, Guggenbuhl P, Morcet N et al.. Prompt regression of paravertebral and epidural abscesses in patients with pyogenic discitis. Sixteen cases evaluated using magnetic resonance imaging.  Joint Bone Spine. 2000;  67 219-227
• 26 Harcke H T, Grissom L E, Finkelstein M S. Evaluation of the musculoskeletal system with sonography.  AJR Am J Roentgenol. 1988;  150 1253-1261
• 27 Steiner G M, Sprigg A. The value of ultrasound in the assessment of bone.  Br J Radiol. 1992;  65 589-593
• 28 Hoffer F A, Emans J. Percutaneous drainage of subperiosteal abscess: a potential treatment for osteomyelitis.  Pediatr Radiol. 1996;  26 879-881
• 29 Rubaltelli L, De Gerone E, Caterino G. Echographic evaluation of tubercular abscesses in lumbar spondylitis.  J Ultrasound Med. 1990;  9 67-70
• 30 Dinc H, Onder C, Turhan A U et al.. Percutaneous catheter drainage of tuberculous and nontuberculous psoas abscesses.  Eur J Radiol. 1996;  23 130-134
• 31 Hernandez R J. Visualization of small sequestra by computerized tomography: report of 6 cases.  Pediatr Radiol. 1985;  15 238-241
• 32 Ram P C, Martinez S, Korobkin M, Breiman R S, Galluis H R, Harrelson J M. CT detection of intraosseous gas: a new sign of osteomyelitis.  AJR Am J Roentgenol. 1981;  137 721-723
• 33 Rafii M, Firooznia H, Golimbu C, McCauley D I. Hematogenous osteomyelitis with fat-fluid level shown by CT.  Radiology. 1984;  153 493-494
• 34 Bissonnette R T, Connell D G, Fitzpatrick D G. Preoperative localization of low density foreign bodies under CT guidance.  Can Assoc Radiol J. 1988;  39 286-287
• 35 Azouz E M, Greenspan A, Marton D. CT evaluation of primary epiphyseal bone abscess.  Skeletal Radiol. 1993;  22 17-23
• 36 Azouz E M. Computed tomography in bone and joint infections.  J Can Assoc Radiol. 1981;  32 102-106
• 37 Schlesinger A E, Hernandez R J. Diseases of the musculoskeletal system in children; imaging with CT, sonography and MR.  AJR Am J Roentgenol. 1992;  158 729-741
• 38 Sandrik K. PET/CT speeds up, moves beyond oncology imaging.  Diagn Imaging (San Franc). 2002;  , Nov 5-8
• 39 Boutin R D, Resnick D. The SAPHO syndrome: an evolving concept for unifying several idiopathic disorders of bone and skin.  AJR Am J Roentgenol. 1998;  170 585-591
• 40 Schultz C, Holterhus P M, Seidel A et al.. Chronic recurrent multifocal osteomyelitis in children.  Pediatr Infect Dis J. 1999;  18 1008-1013
• 41 Rosenberg Z S, Shankman S, Klein M, Lehman W. Chronic recurrent multifocal osteomyelitis.  AJR Am J Roentgenol. 1988;  151 142-144
• 42 Azouz E M, Jurik A G, Bernard C. Sternocostoclavicular hyperostosis in children: a report of eight cases.  AJR Am J Roentgenol. 1998;  171 461-466
• 43 Barton L L, Dunkle L M, Habib F H. Septic arthritis in childhood. A 13-year review.  Am J Dis Child. 1987;  141 898-900
• 44 Santos E, Boavida J E, Barroso A, Seabra J, Carmona da Mota H. Late osteoarticular lesions following meningococcemia with disseminated intravascular coagulation.  Pediatr Radiol. 1989;  19 199-202
• 45 Fernandez F, Pueyo I, Jimenez J R, Vigil E, Guzman A. Epiphysiometaphyseal changes in children after severe meningococcic sepsis.  AJR Am J Roentgenol. 1981;  136 1236-1238
• 46 Buchanan G R. Differentiation of bone infarct from infection in a child in sickle cell disease.  Pediatr Infect Dis J. 1996;  15 725
• 47 Mandell G A. Imaging in the diagnosis of musculoskeletal infections in children.  Curr Probl Pediatr. 1996;  26 218-237
• 48 Powars D R. Natural History of Disease: The First Two Decades. Sickle Cell Disease: Basic Principles and Clinical Practice. New York; Raven Press 1975: 395-412
• 49 Stark J E, Glasier C M, Blasier R D, Aronson J, Seibert J J. Osteomyelitis in children with sickle cell disease: early diagnosis with contrast-enhanced CT.  Radiology. 1991;  179 731-733
• 50 Rifai A, Nyman R. Scintigraphy and ultrasonography in differentiating osteomyelitis from bone infarction in sickle cell disease.  Acta Radiol. 1997;  38 139-143
• 51 Bonnerot V, Sebag G, de Montalembert M et al.. Gadolinium-DOTA enhanced MRI of painful osseous crises in children with sickle cell anemia.  Pediatr Radiol. 1994;  24 92-95
• 52 Merino A J, Carpintero M I, Marrero C M, Anso O S, Elvira P A, Iglesias E G. Acute osteomyelitis. Clinical, radiological and bacteriological features and outcome.  An Esp Pediatr. 2001;  55 20-24
• 53 Aroojis A J, Johari A N. Epiphyseal separations after neonatal osteomyelitis and septic arthritis.  J Pediatr Orthop. 2000;  20 544-549
• 54 Aigner R M, Fueger G F, Ritter G. Results of three-phase bone scintigraphy and radiography in 20 cases of neonatal osteomyelitis.  Nucl Med Commun. 1996;  17 20-28
• 55 Kumar S J, Harcke H T, MacEwan G D, Ger E. Osteoid osteoma of the proximal femur: new techniques in diagnosis and treatment.  J Pediatr Orthop. 1984;  4 669-672
• 56 Chu T, D'Angio G J, Favara B E, Ladisch S, Nesbit M, Pritchard J. Histiocytosis syndromes in children.  Lancet. 1987;  2 41-42