ROENTGENOGRAPHY AS DIAGNOSTIC TECHINIQUE MORONIKE OLUBUKOLA AJOKE GROUP: 501 FACULTY: IMF DEPARTMENT: RADIOLOGICAL MEDICINE

Defining Osteomyelitis

Whats in a Name?
Osteomyelitis (Osteo- bone, Myelo- Marrow, and itis -Inflammation)

Defining Osteomyelitis

What is it?
It is an infection of the of the bone or bone marrow which leads to a subsequent Inflammatory process.

TYPES OF OSTEOMYELITIS
Acute, subacute and chronic Pediatric and adulthood Hematogenous, by direct spread, contigous,

associated with disease Traumatic and post traumatic

Acute Osteomyelitis

Types of Acute Osteomyelitis

I. Hematogenous Osteomyelitis II. Direct Inoculation Osteomyelitis

Acute Osteomyelitis
Hematogenous Osteomyelitis:

Bacterial seeding from the blood. Seen primarily in Children. The most common site is the Metaphysis at the growing end of Long Bones in Children, and The Vertebrae and pelvic in Adults.

Acute Osteomyelitis Direct Inoculation Osteomyelitis

Direct contact of the tissue and bacteria as a result of an Open Fracture or Trauma. Tend to involve multiple organisms.

Acute Osteomyelitis
Causative Organisms:

Staphylococcus aureus (Mainly) Streptoccous pyogens or pneumoniae. (Less) H.Influenzae (Young Children) Salmonella (Sickle-Cell)

Acute Osteomyelitis

Imaging:

First 10 days X-Rays Show No Abnormality. By the end of the 2nd Week signs of rarefaction of Metaphysis and New Bone Formation. With Healing there is Sclerosis and thickening of Cortex. MRI may help to distinguish between Bone and Soft-Tissue Infection.

 Joint involvement common Septic arthritis X-ray findings Initial radiographs often normal for as long as 7-10 days Localized soft-tissue swelling adjacent to metaphysis with

obliteration of usual fat planes (after 3-10 days) Area of bone destruction (lags 7-14 days behind pathologic changes) 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

Radiological studies
X-Ray:
First sign is soft-tissue edema at 3-5 days after infection. Bony changes are not evident for 14-21 days:
1. early radiographic signs of rarefraction (thining of bony

tissue sufficient to cause decreased density of bone) of the metaphysis and periosteal new bone formation

2. increasing ragged if treatment is delayed 3. sclerosis and thickening of the bone at healing

 Plain-film radiograph showing

osteomyelitis of the second metacarpal (arrow). Periosteal elevation, cortical disruption and medullary involvement are present.

Osteomyelitis of index finger metacarpal head secondary to clenched fist injury

Osteomyelitis of elbow

Septic arthritis of right hip

The above X-ray of the left ankle of a 10-year-old boy shows lucency in the tibial metaphysis secondary to acute hematogenous osteomyelitis (AHO).

The above X-ray of the

right ankle of a 10-year-old boy shows lucency in the tibial metaphysis secondary to acute hematogenous

Here is an X-ray of an AHO lesion extending into the growth plate.

Streptococcal osteomyelitis in a 3-yearold patient presenting with periosteal new-bone formation of the tibia

Subacute Osteomyelitis
Results from a less virulent Microorganism, or

a patient with an elevated resistance. Occurs Mostly at the Distal Femur or Proximal Tibia On X-Ray we See Brodies Abcess: Small and Oval in shape It is surrounded by sclerotic bone May be mistaken for Ostieoid Osteoma

A Brodie abscess
is a subacute osteomyelitis with a predilection for the ends of long bones and the carpus and tarsus. Plain radiographic findings include the following: (1) a central area of radiolucency with a surrounding thick rim of reactive bone sclerosis, which may persist for months; (2) pathognomonic tortuous parallel lucent channels extending toward the growth plate; (3) a variable degree of periosteal newbone formation; and (4) associated soft-tissue swelling.

Treatment of Brodies abscess in the metaphysis includes surgical curettage

Brodies abscess, a localised radiolucency usually seen in the metaphyses of long bones. It is sometimes difficult

Subacute Osteomyelitis
An image depicting subacute osteomyelitis

Chronic Osteomyelitis

Chronic osteomyelitis
is a severe, persistent, and sometimes incapacitating infection of bone and bone marrow. It is often a recurring condition because it is difficult to treat definitively.

This disease may result from (1) inadequately treated acute OSM (2) a hematogenous type of osteomyelitis; (3) trauma, (4) iatrogenic causes such as joint replacements and the internal fixation of fractures; (5) compound fractures; (6) infection with organisms, such as Mycobacterium tuberculosis and Treponema species (syphilis); and (7) contiguous spread from soft tissues, as in diabetic ulcers or ulcers in peripheral vascular disease

Radiography Findings Plain radiographic findings in acute or sub acute osteomyelitis are deep soft-tissue swelling, a periosteal reaction, cortical irregularity, and demineralization. The chronic phase of the disease is characterized by thick, irregular, sclerotic bone interspersed with radiolucency, an elevated periosteum, and chronic draining sinuses. Sclerosing osteomyelitis of Garr most commonly affects the mandible and appears with a focal sclerosing periosteal reaction on radiologic studies. Chronic recurrent osteomyelitis is benign self-limiting condition that primarily affects long bones in children and adolescents. The metaphysis of long bones are usually affected, and changes may be symmetrical. The appearances are those of confluent areas of bone lysis. . False Positives/Negatives Stress fractures, osteoid osteomas, and other causes of periosteitis may mimic acute or chronic osteomyelitis.

Osteomyelitis, chronic. Sequestrum of the lower tibia

Osteomyelitis, chronic. Sclerosing osteomyelitis of the lower tibia. Note the bone expansion and .marked sclerosis

Sequelae of :Osteomyelitis Chronic Sinus Intermittent drainage Sequestrum Dead bone (sclerotic) Failure to resorb Involucrum New bone envelope Pathologic fracture

Tuberculous osteomyelitis of sternum

References
American Diabetes Association, Consensus Reports

http://care.diabetesjournals.org/content/vol28/suppl_1 / Reese RE, Belts RF: A Practical Approach to Infectious Diseases, 3rd Ed.,Boston: Little, Brown and Company;1991:464-498 Resnick D: Diagnosis of Bone and Joint Disorders, 3rd Ed., Philadelphia:W.B. Saunders Company;1995:Vol. 4,2323-2558. Weinstein SL, Buckwalter JA: Turks Orthopedics Principles and their Application,5th Ed.,Philadelphia:J.B.Lippincott Company;1994. http://emedicine.medscape.com/article/785020workup#a0720